Golden Age Home Health

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program for calendar year 2023, 2024 and 01/01/25 to 04/03/25 for all patients and employees. Findings: A review of governing body meeting minutes showed no governing body oversite of the conduction of a patient centered QAPI program for: 2023 during a meeting on 02/28/23.2024 during a meeting on 05/09/24.01/01/25 to 03/30/25 during a meeting on 04/03/25. On 01/08/26 at 3:30 p.m., Staff A stated the meeting minutes do not document oversite of the QAPI program.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to: 1. Educate the patient on potential health outcomes related to refusal of and/or missed visits prior to the patient’s discharge from HHA services for noncompliance. 2. Notify the physician of the patient’s continued refusal of and/or missed visits prior to the patient’s discharge from HHA services for noncompliance for one (Patient #8) of 15 patients. Findings: Patient #8 A review of a POC dated 12/29/24 to 02/26/25 showed a SN visit frequency of one time a week for nine weeks. A review of visit notes showed missed SN visits on 02/13/25, 02/18/25 and on 02/21/25 and showed a desk discharge for patient refusal of visits on 02/26/25. The clinical record showed no communication or education attempts to the patient for potential health outcomes related to refusal of and/or missed SN visits and showed no follow up communications to the physician of the patient’s continued refusal of and/or missed SN visits prior to the patient’s discharge from the HHA. On 01/08/26 at 2:35 p.m., Staff A stated the clinical record showed no: 1. Attempts to educate the patient of potential health outcomes related to refusal of and/or missed SN visits. 2. Physician notification of the patient’s continued refusal of and/or missed SN visits prior to the patient’s discharge from the agency.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POC included: Pain reporting parameters to report to the physician or pain management goal for three (Patients #1, 5 and #6) of 15 patients.Weight management goal for one (Patient #1) of 15 patients.Wound management goal for one (Patient #2) of 15 patients. Findings: Patient #1 A review of the POC dated 11/08/25 to 01/06/26 showed orders for SN to assess and instruct the patient’s pain level and weight every visit. The POC showed no physician reporting parameters for the patient’s pain levels and showed no goals for the management of the patient’s pain and weight. The clinical record showed no physician notifications and no change in orders. On 01/08/26 at 1:45 p.m., Staff A stated the POC had no reporting parameters for the patients’ pain and had no goals for pain and weight management. Patient #2 A review of the POC dated 11/26/25 to 01/24/26 showed orders for SN to assess, instruct and conduct wound care interventions to the right lower extremity every visit. The POC showed no goals for wound management. The clinical record showed no physician notifications and no change in orders. On 01/08/26 at 1:55 p.m., Staff A stated the POC had no goals related to the wound care interventions. Patient #5 A review of the POC dated 11/30/25 to 01/28/26 showed orders for SN to assess and instruct the patient’s pain level every visit. The POC showed no physician reporting parameters for the patient’s pain levels. The clinical record showed no physician notifications and no change in orders. On 01/08/26 at 2:25 p.m., Staff A stated the POC had no reporting parameters for the patients’ pain. Patient #6 A review of the POC dated 11/14/25 to 01/12/26 showed orders for SN to assess and instruct the patient’s pain level every visit. The POC showed no physician reporting parameters for the patient’s pain levels. The clinical record showed no physician notifications and no change in orders. On 01/08/26 at 2:28 p.m., Staff A stated the POC had no reporting parameters for the patients’ pain.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: SN performed a foot assessment for one (Patient #1) of 15 patients.SN performed assessment of patient’s response to the medication for one (Patient #4) of 15 patients.SN monitored patient’s weight and reported weight greater than 125 pounds to the physician for one (Patient #6) of 15 patients. Findings: Patient #1 A review of the POC dated 11/08/25 to 01/06/26 showed orders for SN to perform an assessment of the patient’s feet every visit. A review of SN visit notes dated 11/12/25, 11/21/25, 12/08/25 and 12/15/25 showed no assessment of the patient’s feet and showed no patient or caregiver refusal, no physician notification and no changes in orders. On 01/08/26 at 1:45 p.m., Staff A stated the SN visit notes dated 11/12/25, 11/21/25, 12/08/25 and 12/15/25 did not document assessment of the patient’s feet. Patient #4 A review of the POC dated 12/06/25 to 02/03/26 showed orders for SN to assess the patient’s response to the medication Journavx (pain receptor inhibitor) every visit. A review of SN visit notes dated 12/09/25 and 12/31/25 showed no assessment of the patient’s response to the medication Journavx and showed no patient or caregiver refusal, no physician notification and no changes in orders. On 01/17/25 at 2:20 p.m., Staff A stated the SN visit notes dated 12/09/25 and on 12/31/25 did not document assessment of the medication. Patient #6 A review of the POC dated 11/14/25 to 01/12/26 showed orders for SN to assess and instruct the patients’ weight on every visit and report to the physician weight greater than 125 pounds. A review of SN visit notes showed on: 11/19/25 weight of 128.1 pounds12/03/25 weight of 127.8 pounds12/15/25 weight of 127.2 pounds12/22/25 weight of 127.8 pounds The SN visit notes showed no physician notification and no changes in orders. On 01/08/26 at 2:28 p.m., Staff A stated the SN visit notes dated 11/19/25, 12/03/25, 12/15/25 and 12/22/25 did not weight notifications to the physician.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure certified home health aide supervisory visits were completed every 14 days for three (Patients #1, 2 and #4) of 15 patients. Findings: Patient #1 A review of the POC dated 11/08/25 to 01/06/26 showed orders for a CHHA visit frequency of one time a week for nine weeks. A review of the clinical record showed a CHHA supervisory visit was due on 12/29/25 and completed on 01/02/26 (18 days between supervisory visits) for CHHA visits on 12/16/25, 12/22/25 and 12/29/25. The supervisory visit notes showed no patient refusal of supervisory visits, no physician notification and no change in orders. On 01/08/26 at 1:45 p.m., Staff A stated the CHHA supervisory visit on 01/02/26 was late. Patient #2 A review of the POC dated 11/26/25 to 01/24/26 showed orders for showed a CHHA visit frequency of one time a week for nine weeks. A review of the clinical record showed a CHHA supervisory visit was due on 12/31/25 and completed on 01/02/26 (16 days between supervisory visits) for CHHA visits on 12/22/25 and 12/29/25. The supervisory visit notes showed no patient refusal of supervisory visits, no physician notification and no change in orders. On 01/08/26 at 1:55 p.m., Staff A stated the CHHA supervisory visit on 01/02/26 was late. Patient #4 A review of the POC dated 12/06/25 to 02/03/26 showed orders for showed a CHHA visit frequency of one time a week for eight weeks. A review of the clinical record showed a CHHA supervisory visit was due on 12/17/25 and completed on 12/23/25 (20 days between supervisory visits) for CHHA visits on 12/09/25 and 12/16/25. The supervisory visit notes showed no patient refusal of supervisory visits, no physician notification and no change in orders. On 01/08/26 at 2:20 p.m., Staff A stated the CHHA supervisory visit on 12/23/25 was late.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical visit note documentation was accurate for one (Patients #2) of 15 patients. Findings: Patient #2 A review of the POC dated 11/10/24 to 01/08/25 showed orders for SN to assess and conduct wound care interventions to right lower extremity wound sites each visit. SN visit notes dated 12/09/25 and 01/03/26 showed wound site interventions to left lower extremity were conducted during the visits. On 01/08/26 at 1:55 p.m., Staff A stated the SN visit notes on 12/09/25 and 01/03/26 documented wound site interventions to the left leg.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure completed transfer/discharge summaries were provided to receiving providers for four (Patients #8, 9, 11 and #12) of 15 patients. Findings: Patient #8 A review of the clinical record showed discharge from the agency on 02/26/25. The clinical record showed the discharge summary was provided to the ordering physician on 03/06/25 (8 days after discharge). On 01/08/26 at 2:25 p.m., Staff A stated the discharge summary was sent to the physician late. Patient #9 A review of the clinical record showed discharge from the agency on 08/18/25 to hospice services. The clinical record showed the discharge summary was not provided to the hospice provider. On 01/08/26 at 2:40 p.m., Staff A stated the discharge summary was not sent to the hospice provider. Patient #11 A review of the clinical record showed discharge from the agency on 12/16/25 to hospice services. The clinical record showed the discharge summary was not provided to the hospice provider. On 01/08/26 at 2:50 p.m., Staff A stated the discharge summary was not sent to the hospice provider. Patient #12 A review of the clinical record showed transfer with discharge from the agency on 12/05/25 to hospital services. The clinical record showed the transfer with discharge summary was completed on 12/17/25 and was not provided to the hospital provider. The transfer with discharge summary was sent to the ordering physician on 01/05/26 (19 days after discharge). On 01/08/26 at 2:55 p.m., Staff A stated the transfer with discharge summary was not sent to the hospital provider and was not sent to the physician late.”