Golden Care of Northeast Pa, Inc.

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on review of agency policies/procedures and clinical records and based on interview with the Administrator/Clinical Manager (Admin/Cl Manager-Employee #13), the agency failed to ensure clinical notes retrievable two (2) of five (5) patients. (Patients #1 and #5) Findings include: On July 30, 2026 at approximately 3:19 PM, review of the agency policy 6-020, titled “Safeguarding/Retrieval of Clinical/Service Record”, revealed the following: Procedure...11. If electronic medical record computers/devices are utilized, access to information procedures should be followed...Safeguard procedures followed but not limited to: A minimum necessary information should be on the device... On July 30, 2026 at approximately 3:18 PM, review of the agency policy 6-043, titled “Assembly of Clinical Record”, revealed the following: Procedure: The contents of the record will be as follows (If utilizing electronic medical records, the following information would need to be retrievable.): Section III: Clinical Notes... Patient #1 (Discharge): Between July 27, 2026 at approximately 10:53 AM and July 28, 2026 at approximately 5:56 PM, review of the clinical record revealed the start of care (SOC) date was 05/28/2024 and that skilled nursing (SN) services were to be provided ten (10) hours per day Monday to Friday to cover parents work schedules as documented on the “Home Health Certification and Plan of Care for the recertification periods of 05/28/2024 through 07/26/2024; and 07/27/2024 through 09/24/2024. There was no documentation which provided evidence that routine SN clinical notes were retrievable on 07/27 and 07/28/2026 for the following recertification periods: -05/28/2024 through 07/26/2024; and -07/27/2024 through 09/24/2024. Patient #5: Between July 27, 2026 at approximately 2:19 PM and July 28, 2026 at approximately 5:46 PM, review of the clinical record revealed the SOC date was 10/31/2023 and that the following services were to be provided as documented on the “Home Health Certification and Plan of Care for the recertification periods of 12/30/2023 through 02/27/2024, 02/28/2024 through 04/27/2024, 04/28/2024 through 06/26/2024 and 06/27/2024 through 08/25/2024 -SN eight (8) hours per night, 7 nights per week for mother’s sleep and 4-8 hours additionally per week for extra household duties (EHHD) as needed at parent’s request; and -Home health aide services 8-16 hours per day, up to 7 days a week for care in the home or for accompaniment to medical appointments as necessary when no SN available for EHHD hours. There was no documentation which provided evidence the routine SN and home health aide clinical notes were retrievable on 07/27 and 07/28/2026 for the following recertification periods: -12/30/2023 through 02/27/2024; -02/28/2024 through 04/27/2024; -04/28/2024 through 06/26/2024; and -06/27/2024 through 08/25/2024. During interview conducted on July 27, 2026 at approximately 4:15 PM, the Admin/Cl Manager reported that the clinical notes for the above identified patients and above referenced certifications periods could not be retrieved because the email to reset the password for the agency’s prior software program is being forwarded to a staff member who is no longer affiliated with the agency. On July 28, 2026 at approximately 4:38 PM, review of agency email documentation dated 07/28/2026 revealed the Admin/Cl Manager documented that the developer from the previous (software) system is working on retrieving the archive in a readable format and that the agency was waiting for that task to be completed. During interview conducted on July 30, 2026 at approximately 3:35 PM, the Admin/Cl Manager confirmed that the clinical notes for the above referenced recertification periods were not retrievable on 07/27 nor 02/28/2026 for patients #1 and #5.”

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on review of agency policies/procedures and clinical records and based on interview with the Administrator/Clinical Manager (Admin/Cl Manager-Employee #13), the agency failed to ensure discharge planning was conducted in accordance with agency policy/procedures for two (2) of two (2) planned discharges. (Patients #1 and #3) Findings include: On July 27, 2026 at approximately 1:42 PM, review of agency policy 1-024, titled “Discharge Criteria and Process” revealed the following: Policy: When the patient’s plan of care changes and this change results in discharge or reduction in services, the patient or his/her representative...will be...involved in planning decisions. Procedure: 1. The organization will verbally notify the patient of the decision to terminate or reduce services within one (1) visit prior to the time of the change in services is to occur (i.e. prior to the last scheduled visit). On July 27, 2026 at approximately 4:55 PM, review of agency policy 1-010, titled “Discharge Planning” revealed the following: Policy: Discharge planning will be initiated for every patient upon admission to the organization. Patients will not be discharged without appropriate preparation. The patient’s continuing care needs will be assessed on an ongoing basis, as well as at discharge. Information will be provided to assist the patient in planning his or her discharge... Patient #1 (Discharge): Between July 27, 2026 at approximately 10:53 AM and July 28, 2026 at approximately 5:56 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/18 through 07/16/2026: The start of care (SOC) date was 05/28/2024, the patient is four (4) years old, the primary diagnosis was Other Anophthalmos (congenital absence or failure to develop an eye), that other diagnoses included dysphagia (difficulty swallowing) and feeding difficulties and that skilled nursing (SN) services were to be provided up to 10 hours per day Monday through Friday for parents’ work schedule. Review of pediatric SN visit assessment documentation revealed a licensed practical nurse (LPN-Employee #9) provided SN services between 05/28 and 06/26/2026. There was no documentation in the clinical record which provided evidence a SN visit was performed after 06/26/2026. Review of physician order documentation dated 06/29/2026 revealed the patient was admitted to a facility for inpatient physical therapy services for the time period of 06/29 through 07/17/2026. Review of “Coordination Note” documentation dated 06/30/2026 revealed the patient’s parent notified the agency that a gastric (feeding) tube (GT) was scheduled to be inserted and that the parent inquired about the LPN’s competency to provide GT maintenance and care and agency’s methods to determine competency to provide GT maintenance and care. Review of “Coordination Note” documentation date 07/09/2026 revealed the following: Discussed the parents’ concerns regarding the care of the patient light of the patient ongoing changes in acuity (insertion of a gastric (feeding) tube) with the clinical supervisor and agency leadership. After careful review, the team determined that it would be in the patient’s best interest to discharge the patient from the agency and to assist the family with identifying another agency that can provide the level of care, oversight, and clinical support needed to meet the patient’s current needs. Review of physician order documentation dated 07/19/2026 revealed the discharge process had been completed by a registered nurse/case manager (RN/CM-Employee #2) on 07/19/2026. There was no documentation on the “Coordination Note” which provided evidence the patient’s parent had been involved in the case conference conducted on 07/09/2026 during which a decision was made by the agency to discharge the patient. There was no documentation in the clinical record which provided evidence discharge planning was conducted during the SN visit performed on 06/26/2026 nor was documentation present which provided evidence agency verbally notified the patient’s parent of the decision to terminate or reduce services within one (1) visit prior to the time of the change in services is to occur (i.e. prior to the last scheduled visit). Patient #3 (Discharge): Between July 27, 2026 between the approximate times of 1:02 PM and 1:52 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 07/11 through 09/09/2026: The SOC date was 07/16/2025, the patient is eight (8) years old, the primary diagnosis was presence of cerebral spinal fluid drainage device, that other diagnoses included other seizures and that SN services were to be provided up to eight (8) hours per day Monday through Friday for school and home assistance. Review of pediatric SN visit assessment documentation revealed an LPN (Employee #10) provided SN services on 07/13 and 07/14/2026. There was no documentation in the clinical record which provided evidence a SN visit was performed after 07/14/2026. Review of physician order documentation dated 07/24/2026 revealed the patient was discharged by the agency effective 07/23/2026 due to lack of staff. There was no documentation in the clinical record which provided evidence discharge planning was conducted during the SN visit performed on 07/14/2026 nor was documentation present which provided evidence agency verbally notified the patient’s parent of the decision to terminate or reduce services within one (1) visit prior to the time of the change in services is to occur (i.e. prior to the last scheduled visit). During interview conducted on July 30, 2026 at approximately 3:35 PM, the Admin/Cl Manager confirmed there was no documentation in the clinical record which provided evidence discharge planning had been conducted in accordance with agency policies/procedures for the patients #1 and #3.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records and based on interview with the Administrator/Clinical Manager (Admin/Cl Manager-Employee #13), the Governing Body failed to ensure the appointed Administrator signed the “Home Health Certification and Plan of Care” as the Administrator for two (2) of five (5) patients. (Patients #1 and #5) Findings include: On July 30, 2026 at approximately 3:17 PM, review of the agency policy 8-002, titled “Governing Body”, revealed the following: Policy: The Governing Body will assume full legal authority, responsibility and accountability for the overall management and operations, the provision of services... Procedure: The Governing Body will appoint a qualified Executive Director/Administrator... On July 30, 2026 at approximately 3:16 PM, review of the agency policy 8-007, titled “Executive Director/Administrator”, revealed the following under “Policy”: The Executive Director/Administrator position will be responsible for the direction, coordination and general supervision of all home health services. On July 27, 2026 at approximately 3:56 PM, review of agency documentation revealed the following: Employee #1: The date a contract was established with the Consultant was 09/25/2024 and that the Consultant was licensed as a registered nurse (RN) in Illinois. Patient #1 (Discharge): Between July 27, 2026 at approximately 10:53 AM and July 28, 2026 at approximately 5:56 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/18 through 07/16/2026: The start of care (SOC) date was 05/28/2024, the patient is four (4) years old, the primary diagnosis was Other Anophthalmos (congenital absence or failure to develop an eye), that other diagnoses included dysphagia (difficulty swallowing) and feeding difficulties and that skilled nursing (SN) services were to be provided. Review of Home Health Certification and Plan of Care (POC) for the recertification period of 07/27 through 09/24/2024 revealed a registered nurse (RN-Employee #14-Former Employee) obtained verbal orders for recertification from the primary care provider and that the Consultant (Employee #1) signed the POC the Administrator on 07/25/2024 which was prior to establishment of the Consultant’s contract. Patient #5: Between July 27, 2026 at approximately 2:19 PM and July 28, 2026 at approximately 5:46 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 06/18 through 08/15/2026: The SOC date was 10/31/2023, the patient is 20 years old, the primary diagnosis is chromosomal abnormality and that SN and home health aide services are to be provided. Review of Home Health Certification and Plan of Care (POC) for the recertification period of 08/26 through 10/24/2024 revealed an RN (Employee #6) obtained verbal orders for recertification from the primary care provider (PCP) and that the Consultant (Employee #1) signed the POC the Administrator on 08/25/2024 which was prior to establishment of the Consultant’s contract. On July 27, 2026 at approximately 3:50 PM, review of Governing Body meeting minutes revealed the following: 07/19/2024: A registered nurse (RN-Employee #15-Former Employee) was appointed as Administrator. 02/18/2025: A registered nurse (RN-Employee #16) was appointed as Administrator. There was no documentation which provided evidence the Governing Body had appointed the Consultant (Employee #1) as Administrator, nor was documentation present with provided evidence the Governing Body authorized the Consultant to sign the POC as the Administrator for patients #1 and #5. During interview conducted on July 30, 2026 at approximately 3:35 PM, the Admin/Cl Manager confirmed there was no documentation which provided evidence the Governing Body had appointed the Consultant (Employee #1) as Administrator nor was documentation present with provided evidence the Governing Body authorized the Consultant to sign the POC as the Administrator for patients #1 and #5.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on review of agency policies/procedures and clinical records and based on interview with the Administrator/Clinical Manager (Admin/Cl Manager-Employee #13), the agency failed to ensure a comprehensive assessment was conducted at discharge for three (3) of three (3) patients who were discharged from the agency. (Patients #1, #2 and #3) Findings include: On July 27, 2026 at approximately 1:42 PM, review of agency policy 1-024, titled “Discharge Criteria and Process” revealed the following: Procedure: 3. An update to the comprehensive assessment...will be completed as required by regulations. On July 27, 2026 at approximately 4:55 PM, review of agency policy 1-010, titled “Discharge Planning” revealed the following: Policy...The patient’s continuing care needs will be assessed on an ongoing basis, as well as at discharge. Patient #1 (Discharge): Between July 27, 2026 at approximately 10:53 AM and July 28, 2026 at approximately 5:56 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/18 through 07/16/2026: The start of care (SOC) date was 05/28/2024, the patient is four (4) years old, the primary diagnosis was Other Anophthalmos (congenital absence or failure to develop an eye), that other diagnoses included dysphagia (difficulty swallowing) and feeding difficulties and that skilled nursing (SN) services were to be provided up to 10 hours per day Monday through Friday for parents’ work schedule. Review of pediatric SN visit assessment documentation revealed a licensed practical nurse (LPN-Employee #9) provided SN services between 05/28 and 06/26/2026. Review of physician order documentation dated 07/19/2026 revealed the discharge process had been completed by a registered nurse/case manager (RN/CM-Employee #2) on 07/19/2026. There was no documentation in the clinical record which provided evidence that an RN completed a comprehensive assessment at discharge. Patient #2 (Discharge): Between July 27, 2026 at approximately 12:22 PM and July 30, 2026 at approximately 3:30 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/28 through 07/26/2026: The start of care (SOC) date was 01/27/2026, the patient is fifteen (15) years old, the primary diagnosis was autistic disorder and that home health aide services were to be provided 40 hours per week. Review of pediatric staff notes documentation revealed home health aide services were provided between 05/28 through 07/15/2026. Review of physician order documentation dated 07/23/2026 revealed an RN/CM (Employee #3) documented that the patient was discharged from the agency at the request of per family request and that the patient had transferred to a different home health agency. There was no documentation in the clinical record which provided evidence that an RN completed a comprehensive assessment at discharge. Patient #3 (Discharge): Between July 27, 2026 between the approximate times of 1:02 PM and 1:52 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 07/11 through 09/09/2026: The SOC date was 07/16/2025, the patient is eight (8) years old, the primary diagnosis was presence of cerebral spinal fluid drainage device, that other diagnoses included other seizures and that SN services were to be provided up to eight (8) hours per day Monday through Friday for school and home assistance. Review of pediatric SN visit assessment documentation revealed an LPN (Employee #10) provided SN services on 07/13 and 07/14/2026. Review of physician order documentation dated 07/24/2026 revealed an RN/CM (Employee #4) documented that the patient was discharged from the agency due to lack of staff and that the patient’s care had been transferred to a different home health agency. There was no documentation in the clinical record which provided evidence that an RN completed a comprehensive assessment at discharge. During interview conducted on July 30, 2026 at approximately 3:35 PM, the Admin/Cl Manager confirmed a comprehensive assessment had not been completed at discharge for patients #1, #2 nor #3.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on review of agency policies/procedures, documentation, clinical records and personnel files and based on skilled nursing (SN) staff interview (Employee #10) and interview with the Administrator/Clinical Manager (Admin/Cl Manager-Employee #13), the clinical managers (Employees #13 and #16) failed to ensure gastric (feeding) tube (GT) and gastric/jejunal (GJ) tube competency assessment had been completed in accordance with agency policies/procedures for two (2) of six (6) current SN staff. (Employees #10 and #12) Findings include: On July 30, 2026 at approximately 3:23 PM, review of the agency policy 3-003, titled “Competency Assessment”, revealed the following: Policy: Competency assessments will be documented with the name of the personnel, topic, date completed and record of satisfactory performance. Competency of supervisors...will be assessed by the individual’s immediate supervisor... Procedure...Orientation and Probationary Period: 2. Using a Competency Skills Performance Checklist...the preceptor/Clinical Supervisor will observe new personnel performing the required skills and activities... Ongoing Assessments: 1. Competency assessments will be completed at least one (1) time per year. On July 30, 2026 at approximately 3:25 PM, review of the agency policy 3-006, titled “Competency Requirements for Supervisors/Preceptors”, revealed the following: Policy: Supervisory personnel...will have demonstrated knowledge/experience appropriate to their assigned responsibilities and complete a skills competency on a defined, regular basis. On July 30, 2026 at approximately 3:23 PM, review of the “Skilled Nursing Skills Checklist” revealed columns were present to document if the SN performance of a skill was satisfactory, needs reinforcement or unsatisfactory and that SN skills to be assessed included, but were not limited to, GT/GJT feeding and medications and GT changes. On July 27, 2026 at approximately 3:54 PM, review of the organizational chart revealed the employee #13 served as Administrator and Director of Nursing (Clinical Manager). On July 27, 2026 at approximately 3:50 PM, review of Governing Body meeting minutes revealed the following: - 02/10/2025: Employee #16 was appointed as Administrator effective 02/18/2025. -06/15/2026: Employee #3 was appointed as Administrator/Director of Nursing effective 06/29/2026. On July 30, 2026 at approximately 3:59 PM, review of July 2025 organizational chart revealed employee #16 served as the Admin/Cl Manager. Patient #4: Between July 27, 2026 between the approximate times of 1:57 PM and 3:38 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” (POC) for the initial certification period of 07/15 through 09/12/2026: The SOC date was 07/15/2026, the patient is three (3) years old, the primary diagnosis is Downs Syndrome, that SN services are to be provided and that the POC included the following orders: Clean GT site daily and as needed with soap and water and flush GT with 10 to 15 milliliters (ml) sterile water post GT feeds, oral medications to be administered via GT and that Alfamino junior oral powder (feeding)-Administer 155 ml 5 times daily as directed through feeding tube via feeding pump. Review of SN visit assessment documentation revealed a licensed practical nurse (LPN-Employee #10) provided GJT site care, administered GT feeding and performed medication administration and performed GT flushes on 07/24/2026. Patient #5: Between July 27, 2026 at approximately 2:19 PM and July 28, 2026 at approximately 5:46 PM, review of the clinical record revealed the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 06/18 through 08/15/2026: The SOC date was 10/31/2023, the patient is 20 years old, the primary diagnosis is chromosomal abnormality, that SN services are to be provided and that the POC includes the following orders: Administer prescribed pain medications as ordered and monitor for effectiveness and side effects, Water Flush / Jejunal Tube (portion of tube inserted into small intestine) Administer 30 ml via J port of GJ (gastric/jejunal) tube after medication administration and Nystatin Powder- Apply a small amount topically at GJ tube site 2-3 times per day as needed for irritation and that enteral feedings (feedings via a tube) are to be administered via a pump. Review of SN visit assessment documentation revealed an LPN (Employee #12) provided GJT site care, administered GT feeding and performed medication administration and performed GT flushes on 07/24/2026. Between July 27, 2026 at approximately 3:56 PM and July 30, 2026 at approximately 2:22 PM, review of personnel file documentation revealed the following: Employee #10: The date of hire of the LPN was 03/24/2025. There was no documentation in the personnel file which provided evidence a “Skilled Nursing Skills Checklist” had been completed; therefore, there was no documentation in the personnel file which provided evidence competency assessment to provide GT site care and flushes had been completed. During telephone interview conducted on July 30, 2026 at approximately 2:36 PM, the LPN reported that a registered nurse/case manager (RN/CM-Employee #4) determined competency to provide care to patients for whom GT orders are included on the “Home Health Certification and Plan of Care” during an onsite visit for an unnamed patient while the LPN was providing care in the home. Employee #12: The date of hire of the LPN was 11/14/2023. There was no documentation in the personnel file which provided evidence a “Skilled Nursing Skills Checklist” had been completed; therefore, there was no documentation in the personnel file which provided evidence competency assessment to provide GJT site care and flushes had been completed. During interview conducted on July 30, 2026 at approximately 3:35 PM, the Admin/Cl Manager confirmed there was no documentation in the personnel files which provided evidence a “Skilled Nursing Skills Checklist” had been completed; therefore, there was no documentation in the personnel file which provided evidence competency assessment to provide the above referenced GT or GJT interventions had been completed for the employees #10 and #12.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on review of agency documentation, policies/procedures, clinical records, personnel files and tuberculosis (TB) screening guidance issued by the Centers for Disease Control (CDC), and based on interview with the current Administrator (Admin)-Director of Nursing (DON) (Employee #1-who previously served as the Alternate Admin-DON) and the current Alternate Admin (Employee #9-who previously served as the Admin-DON), the Alternate Admin (Employee #9) failed to ensure documentation was maintained in the personnel file which provided evidence TB screening had been completed in accordance with agency policies/procedures and CDC recommendations for one (1) of six (6) agency staff members. (Employee #3) Findings include: On July 1, 2026 at approximately 9:14 AM, review of agency email documentation dated 05/09/2026 revealed employee #9 was served as the agency Administrator and DON. On July 2, 2026 at approximately 3:25 PM, review of agency policy 1-004, titled “Categories/Qualifications of Personnel”, revealed the following: Qualifications of Organization Personnel-Health Requirements: 1. Personnel with Patient Contact: All new personnel who will be in contact with patients...personnel must have TB skin test (TST) or show that there is no active TB in the past 12 months... On July 2, 2026 at approximately 4:15 PM, review of the initial TB screening guidance from the CDC (https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/baseline-testing.html) for prospective staff without a history of a positive TB test revealed the following: All health care personnel should be screened for TB upon hire (preplacement). The TB screening process for health care personnel includes: -A baseline individual TB risk assessment; -TB symptom evaluation; and -A TB test (TB blood test or a TB skin test (TST)... Two-step TB skin test process... Patient #1 (Discharge): Review of the clinical record between 07/01/2026 at approximately 12:06 PM and July 2, 2026 at approximately 11:05 AM revealed a registered nurse (RN-Employee #3) provided SN services between 05/22 and 06/12/2026. Review of personnel file documentation on 07/02/2026 between the approximate times of 11:40 AM and 3:05 PM revealed the following: Employee #3: The date of hire of the RN was 05/11/2026. There was no documentation in the personnel file which provided evidence a baseline individual TB risk assessment nor a TB symptom evaluation had been completed upon hire. During interviews conducted on July 2, 2026 between the approximate times of 3:10 PM and 3:40 PM, employee #9 reported that due to the recent departure of a human resource staff member, complete personnel file contents may not be available for presentation/review. Employees #1 and #9 confirmed there was no documentation in the personnel file which provided evidence that the aforementioned TB screenings had been completed for employee #3 upon hire.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records and based on interview with the current Administrator/Direct of Nursing (Admin/DON-Employee #1 who previously served as the Alternate Admin/Alternate DON) and the current Alternate Admin (Employee #9-who previously served as the Admin/DON), the agency failed to ensure the parents of three (3) of three (3) patients were involved in the care planning (coordination) process. (Patient #1, #2 and #3) Findings include: On July, 2026 at approximately 3:26 PM, review of agency policy 1-004, titled “Care/Service Coordination” revealed the following: Policy: Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/services provided... Procedure: 4. Care Coordination will include, but not be limited to: F. Appropriate involvement of the patient and caregivers...J. Coordination of care delivery to meet the patient’s needs, and involve the patient representative, and caregivers, as appropriate, in the coordination of care activities... Patient #1 (Discharge): Review of the clinical record between 07/01/2026 at approximately 12:06 PM and July 2, 2026 at approximately 11:05 AM revealed the start of care date was 08/08/2022, that the patient is 20 years old, that the primary diagnosis was other seizures, and that skilled nursing (SN) services were to be provided 10.25 hours per day Monday through Friday for school, transportation accompaniment, extended school year (ESY), accompaniment to medical appointments as needed and home assistance for parent’s work schedule and 10 hours per night for five (5) days a week for parents’ sleep as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/20 through 07/18/2026. Review of SN documentation revealed a registered nurse/Case Manager (RN/CM-Employee #2) completed SN recertification visits on 11/20/2025, 01/16/2026, 03/16/2026 and 05/19/2026. Review of “Case Conference” notes dated 11/20/2025, 01/16/2026 and 03/16/2026 revealed there was no documentation which provided evidence a parent was present during the SN recertification visits. There was no documentation in the clinical record which provided evidence the parent of the patient was notified that SN recertification visits were scheduled to be conducted on 11/20/2025, 01/16/2026, 03/16/2026 and 05/19/2026. Patient #2: Review of the clinical record between 07/01/2026 at approximately 1:14 PM and July 2, 2026 at approximately 12:28 PM revealed the start of care date was 08/26/2024, that the patient is 10 years old, that the primary diagnosis is autistic disorder, and that home health aide (HHA) services are to be provided 40 hours per week, up to 8 hours per day Monday through Friday for school assistance, ESY, and home assistance as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/01 through 06/29/2026. Review of SN documentation revealed an RN/CM (Employee #2) completed a SN supervisory visit on 02/26/2026 and that the SN completed recertification visits on 02/27, 04/29 and 06/25/2026. Review of “Case Conference” notes dated 02/27, 04/29 and 06/25/2026 revealed there was no documentation which provided evidence a parent was present during the SN recertification visit. There was no documentation in the clinical record which provided evidence the parent of the patient was notified that SN recertification visits were scheduled to be conducted on 02/27, 04/29 and 06/25/2026. Patient #3: Review of the clinical record and SN text documentation between 07/01/2026 at approximately 1:45PM and July 2, 2026 at approximately 3:17 PM revealed the start of care date was 07/08/2022, that the patient is 17 years old, that the primary diagnosis is other seizures, that SN services are to be provided 12.5 hours per day Monday through Thursday and 9 hours per day every Friday for home and school assistance and accompaniment on school transportation and medical appointments and that HHA services are to be provided 8 hours per night for 5 nights a week for parent sleep as documented on the “Home Health Certification and Plan of Care” for the recertification period of 06/24 through 08/22/2026. Review of SN documentation revealed the current Admin/DON (Employee #1) completed SN supervisory visits 03/05, 03/23, 05/18 and 06/01/2026. There was no documentation in the clinical record nor on the SN texts which provided evidence the parent of the patient was notified that SN supervisory visits were scheduled to be conducted on 03/05, 03/23, 05/18 and 06/01/2026. During interview conducted on July 2, 2026 at approximately 3:40 PM, employees #1 and #9 confirmed that there was no documentation in the clinical record nor SN text messages which provided evidence that the he parents of the above identified patients were notified that SN recertification and/or supervisory visits were scheduled to be conducted on the above referenced dates.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on review of agency documentation, policies/procedures and personnel files and based on interview with the current Administrator (Admin)-Director of Nursing (DON) (Employee #1-who previously served as the Alternate Admin-DON) and the current Alternate Admin (Employee #9-who previously served as the Admin-DON), the former Admin (Employee #9-current Alternate Admin) failed to ensure employment separation procedures or communications were authorized or issued by the Administrator (Employee #9) for two (2) of two (2) staff members who submitted letters of resignation.(Employees #7 and #8) and the agency failed to ensure patient confidentiality was maintained in accordance with agency policy/procedure for one (1) of three (3) patients. (Patient #2) Findings include: EMPLOYMENT SEPARATION PROCEDURES AND COMMUNICATIONS FINDINGS: On July 1, 2026 at approximately 9:09 AM, review of “Governing Body Meeting” minutes dated 02/10/2025 revealed the following appointments were effective on 02/18/2025: Employee #9: Administrator On July 1, 2026 at approximately 9:13 AM, review of “Governing Body Meeting” minutes dated 08/01/2025revealed the following appointments were effective on 08/01/2025: Employee #1: Alternate Administrator/Alternate Director of Nursing On July 1, 2026 at approximately 9:14 AM, review of agency email documentation dated 05/09/2026 revealed employee #9 was served as the agency Administrator and DON. On July 1, 2026 at approximately 10:14 AM, review of “Governing Body Meeting” minutes dated 06/15/2026 revealed the following appointments were effective on 06/29/2026: Employee #1: Administrator/Director of Nursing Employee #9: Alternate Administrator On July 2, 2026 at approximately 3:25 PM, review of agency policy 1-004, titled “Categories/Qualifications of Personnel”, revealed the following: Policy: 2. All personnel are employed for an indefinite time. Therefore, either of the personnel or the organization may terminate the employment relationship at any time, with or without cause or notice. On July 2, 2026 at approximately 3:28 PM, review of the job description for the Executive Director/Administrator revealed the following: Job Description Summary: Responsible for planning, coordinating, managing and directing all activities and programs... Essential Job Functions/Responsibilities: 7. Establishing and maintaining effective channels of communication... On July 2, 2026 at approximately 1:19 PM, review of the job description for the Alternate Administrator revealed the following: Job Description Summary: Acts in the absence of the Administrator and directs and coordinates all administrative and financial activities of the professional home health agency. Review of personnel file documentation on 07/02/2026 between the approximate times of 11:40 AM and 3:05 PM revealed the following: Employee #7: Review of a type-written letter revealed the Community Ambassador submitted a letter of resignation dated 06/22/2026 and that the resignation was effective on 06/22/2026. Employee #8: Review of a type-written letter revealed the Human Resource Specialist submitted a letter of resignation dated 06/22/2026 and that the resignation was effective on 06/22/2026. On July 1, 2026 at approximately 8:00 AM, review of agency documentation revealed the following: Employees #7 and #8: Review of the Notice of Employment Separation letters dated 06/22/2026 revealed the Administrator signature entered on the letter was that of current Admin/former Alterante Admin (Employee #1) which was seven (7) days prior to the effective date that employee #1 assumed the position of Administrator (06/29/2026). There was no documentation on the Notice of Employment Separations letters which provided evidence that employee #1 was identified as being the Alternate Admin. There was no documentation which provided evidence that the former Admin (Employee #9-current Alternate Admin) authorized issuance of the Notice of Employment Separation letters dated 06/22/2026. During interviews conducted on July 2, 2026 between the approximate times of 1:22 PM and 3:40 PM, employee #9 reported that the resignation letters for employees #7 and #8 had been submitted to employee #9 and that employee #9 was not on leave on 06/22/2026 when employee #1 signed the separation letters as Administrator. Employee #9 reported employee #9 was unaware that employee #1 had forwarded the Notice of Employment Separation letters to employees #7 and #8. Employees #1 and #9 confirmed employee #1 failed to enter the Alternate Admin title on the Notice of Employment Separation letters forwarded to employees #7 and #8 and that there was no documentation that employee #9 authorized employee #1 to issue the aforementioned separation letters on 06/22/2026. PATIENT CONFIDENTIALITY FINDINGS: On July 2, 2026 at approximately 12:43 PM, review of agency policy 6-004, titled “Patient Privacy Rights” revealed the following: Policy...Golden Care of Northeast PA, Inc. will respect and safeguard all protected health information of the patient’s it serves... Definitions: Protected Health Information (PHI) is any information about...provision of health care that can be linked to a specific individual in any form...This is interpreted rather broadly and includes any...any geographical identification smaller than a state (except for the initial three digits of a zip code)... Patient #2: On July 1, 2026 at approximately 11:27 AM, review of “Patient Grievance” form documentation revealed that on 06/25/2026, the patient’s parent notified the agency that the parent of the registered nurse/Clinical Manager (RN/CM-Employee #2) accompanied the RN to the patient home for an unannounced skilled nursing (SN) visit. Review of “Patient Grievance” form investigation summary details revealed the RN/CM (Employee #2) reported that because the RN’s car had broken down before the SN visit, the RN had to utilize the RN’s parent’s car. The parent of the RN had to accompany the RN to the visit because of time constraints and because the parent of the RN had an appointment. There was no documentation on the “Patient Grievance” form which provided evidence that the parent of the RN was an employee of the agency. During interview conducted on July 2, 2026 at approximately 3:40 PM, employees #1 and #9 confirmed that the RN’s (Employee #2) decision to allow the RN’s parent to accompany the RN to the home of patient #2 would be considered a violation of PHI under the above referenced “Patient Privacy Rights” policy.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on review of agency documentation, policies/procedures, clinical records and personnel files, and based on interview with the current Administrator (Admin)-Director of Nursing (DON) (Employee #1-who previously served as the Alternate Admin-DON) and the current Alternate Admin-DON (Employee #9-who previously served as the Admin-DON), the current Alternate Admin (Employee #9-former Admin/DON) failed to ensure documentation was maintained in the personnel file which provided evidence skilled nursing (SN) skills checklists and/or background clearances had been completed in accordance with agency policies procedures or regulatory requirements for two (2) of six (6) agency staff members. (Employees #2 and #3) Findings include: On July 1, 2026 at approximately 9:14 AM, review of agency email documentation dated 05/09/2026 revealed employee #9 served as the agency Administrator and DON. On July 2, 2026 at approximately 3:23 PM, review of agency policy 3-001, titled “Competency Program” revealed the following under “Policy”: Personnel will demonstrate knowledge and proficiency of skills appropriate to their assigned responsibilities, including the ability to perform specified duties determined by the organization... Skills proficiency can be determined by...skills demonstration... On July 2, 2026 at approximately 3:25 PM, review of agency policy 1-004, titled “Categories/Qualifications of Personnel”, revealed the following: Policy: 1. The organization defines the qualifications, competencies, health status and type of staffing needed to fulfill its mission...3. The organization will employ or contract only those individuals who have valid credentials as stipulated by state and federal requirements. 4. Personnel qualifications include appropriate...absence of a criminal background for those positions designated by law and regulation. Qualifications of Organization Personnel-Competency: 1. Professional Personnel: Individuals must demonstrate their competency...according to the orientation checklists developed for each position... Patient #1 (Discharge): Review of the clinical record between 07/01/2026 at approximately 12:06 PM and July 2, 2026 at approximately 11:05 AM revealed the start of care date was 08/08/2022, that the patient is 20 years old, that the primary diagnosis was other seizures, and that SN services were to be provided 10.25 hours per day Monday through Friday for school, transportation accompaniment, extended school year (ESY), accompaniment to medical appointments as needed and home assistance for parent’s work schedule and 10 hours per night for five (5) days a week for parents’ sleep as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/20 through 07/18/2026. Review of SN visit documentation revealed a registered nurse (RN-Employee #3) provided SN services between 05/22 and 06/12/2026 and that an RN/Case Manager (RN/CM-Employee #2) completed SN recertification visits on 11/20/2025, 01/16/2026, 03/16/2026 and 05/19/2026. SN CHECKLIST FINDINGS: Review of personnel file documentation on 07/02/2026 between the approximate times of 11:40 AM and 3:05 PM revealed the following: “Skilled Nursing Skills Checklist”: The agency form included columns to determine if a SN’s ability to perform specific tasks are satisfactory, needed reinforcement or unsatisfactory as evidenced by the signature of an RN educator on the final page of the checklist. Employee #3: The date of hire of the RN was 05/11/2026. There was no documentation in the personnel file which provided evidence a “Skilled Nursing Skills Checklist” had been completed. BACKGROUND CLEARANCE FINDINGS: On July 2, 2026 at approximately 3:07 PM, review of the PA Older Adult Protective Services Act (OAPSA) background clearance requirements revealed the following: Three Acts Panel form--Process: All applicants must submit to a PA State Police (PSP) criminal history background check...If the applicant has not been a PA resident for the two consecutive years before application, they will need to have a PSP criminal history background check completed and an FBI Background Check. All requests for FBI background checks must be made directly through 3MCogent Systems, a 3rd party electronic background check processor contracted by the Department of Aging...The fingerprints will be forwarded to the FBI for processing by PDA. When the application has been processed by the FBI, the results will be returned to PDA. PDA will send letters to both the facility & applicant. Chapter 15.141. Prospective facility personnel. (a) General rule. A facility shall require applicants for employment to submit applications with a criminal history report, obtained within 1 year immediately preceding the date of application... Personnel file review findings revealed the following: Employee #2: The date of hire of the RN/CM was 09/02/2025. The employee’s address included on the RN nursing license was New York state. There was no documentation in the personnel file which provided evidence an FBI clearance issued by the PA Department of Aging had been requested/obtained by the agency. Employee #3: The PA State Police Response for Criminal Record Check report included in the personnel file was requested/completed on 05/10/2024 which was more than 2 years prior to the date of hire. There was no documentation in the personnel file which provided evidence a PA State Police Response for Criminal Record Check report had been requested upon application for employment. During interviews conducted on July 2, 2026 between the approximate times of 3:10 PM and 3:40 PM, employee #9 reported that due to the recent departure of a human resource staff member, complete personnel file contents may not be available for presentation/review. Employees #1 and #9 confirmed there was no documentation in the personnel file which provided evidence a “Skilled Nursing Skills Checklist” had been completed for employee #3 and that the above referenced background clearances had not been requested/obtained for employees #2 and #3.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of agency policy, documentation and clinical records and based on interview with the Administrator (Employee #1), the agency failed to ensure the parent of three (3) of three (3) pediatric patients were involved in the care planning (coordination) process. (Patient #1, #2 and #3) Findings include: On January 8, 2026 at approximately 2:28 PM, review of agency policy 1-007, titled “Care Planning Process” revealed the following under “Policy”: The patient and family/caregiver will participate in the decisions regarding the plan of care whenever possible. The care planning process will be documented in the...clinical notes...care conference/summary forms... Patient #1: On January 8, 2026 at approximately 11:15 AM and January 13, 2026 at approximately 12:30 PM, review of the clinical record revealed the start of care (SOC) was 07/16/2024, the patient is 2 years old and that skilled nursing (SN) visit frequency orders are/were as follows as documented on the “Home Health Certification and Plan of Care”: -Recertification Periods 09/09 through 11/07/2025 and 11/08/2025 through 01/06/2026: Up to 16 hours per day Monday through Friday -Recertification Periods 05/12 through 07/10/2025 and 07/11 through 09/08/2025: Up to 9.5 hours per day Monday through Friday -The aforementioned SN visit frequencies were ordered to be provided to cover parent’s work schedule and to provide assistance in the home while parents are caring for four (4) other children in the home. Review of electronic medical record (EMR) schedule tab documentation revealed the SN visit schedule is/was as follows: -Time period of 09/02 through 03/07/2026: 9 hours per day Monday through Friday -Time period of 07/11 through 08/31/2025: 8.5 hours per day Monday through Friday -Time period of 06/20 through 06/27/2025: 8 hours per day Monday through Friday -Time period of 06/01 through 07/10/2025: 7.25 hours per day Monday through Friday Review of case conference/team communication note documentation dated 06/13/2025 revealed the patient was hospitalized due to suffering cardiac arrest (loss of heart function-heart stop) during a magnetic resonance imaging scan (MRI). Review of visit calendar and missed visit documentation revealed SN services were not scheduled/provided on 06/12, 06/13, 06/17, 06/18 and 06/19/2025 due to the patient’s hospitalization. Review of the resumption of care SN comprehensive assessment dated 06/20/2025 revealed a registered nurse (RN-Employee #3) documented the SN frequency and duration was eight (8) hours per day Monday through Friday for patient’s work schedule. Review of the agency “Social Letter” letter dated 06/18/2025 revealed the Private Duty Director/Licensed Practical Nurse (Employee #2-PPD/LPN) requested an increase in the SN visit frequency to up to 16 hours per day Monday through Friday. Review of a payor source letter revealed that the SN service authorization request was approved effective 07/10/2025. Review of EMR service authorization documentation revealed that for the time period of 09/01/2025 through 08/31/2026 revealed SN services are to be provided up to 16 hours per day. Review of case conference/team communication documentation revealed the following: -08/26/2025: Authorization was received for 16 hours of services (SN) per day and that an additional caregiver would be needed. -10/20/2025: Still advertising for a SN to fill hours. No concerns. Review of missed visit reports revealed that between 29.5 and 61.25 hours of SN service hours were not provided due to no nurse available, nurse scheduled off or “caregiver” unavailable for the time period of the week ending 08/09/2025 through the week ending 12/27/2025. Beginning with the missed visit report dated 08/15/2025, the agency documented the agency was seeking/recruiting for an additional and qualified SN to cover the remaining hours for the case. On January 13, 2026 at approximately 12:03 PM, review of the agency email dated 01/13/2026 revealed the following: -Text message documentation: An undated text message revealed the patient’s parent indicated that the parent would attempt to contact a SN friend to determine if the friend would be interested in part-time employment. -Human Resource (HR) Department statement: That prior to December 2025, the agency HR Department and Administrator had not discussed the 16-hour/day coverage need. After being contacted by the patient’s parent, the agency took immediate action to review staffing availability and begin recruitment efforts. The agency did not have any current nurses available who could fill the increased hours. As a result, the agency initiated recruitment efforts to support the increased authorized hours, including posting the case and contacting applicants/candidates already in process. Recruitment efforts began on 12/22/2025, including an advertisement posted on the agency’s social media page with the specific hours and location, as well as a listing on recruitment website. Despite these efforts, the agency received no qualified applicants for this case during the referenced period. The agency remained in communication with the patient’s parent. The first date the agency advertised for the SN position to seek coverage for the increased SN hours was 12/22/2025. There was no documentation in the clinical record which provided evidence the agency involved the parent in the care planning process as there was no documentation that the parent was notified of an in agreement with the SN visit schedule established under the EMR schedule tab nor was documentation present which provided evidence the agency coordinated the SN recruitment efforts with the parent between 07/10/2025 and prior to the patient’s parent contacting the HR Department in December 2025. Patient #2: On January 8, 2026 at approximately 12:35 PM, review of the clinical record revealed the SOC was 07/22/2024, the patient is 2 years old and that SN services are to be provided 9.5 hours per day Monday through Friday to cover parent’s work schedule and to accompany to medical appointments as ordered on the “Home Health Certification and Plan of Care” for the recertification period of 11/14/2025 through 01/12/2026. Review of electronic medical record (EMR) schedule tab documentation revealed the SN visit schedule was as follows: -Time period of 07/17/2025 through 12/31/2025: 8.5 hours per day Monday through Friday. Review of missed visit report documentation for the week ending 11/22/2025 revealed 16 hours of SN services were not provided, for the week ending 12/06/2025, 8 hours of SN services were not provided and for week ending 12/13/2025, 47.5 hours of SN services were not provided because the nurse was not available. There was no documentation in the clinical record which provided evidence the agency involved the parent in the care planning process as there was no documentation that the parent was notified and in agreement with the SN visit schedule established under the EMR schedule tab nor was documentation present which provided evidence the agency provided the parent with prior notification that a SN was unavailable to provide services per the ordered visit frequency for the weeks ending 11/22, 12/06 and 12/13/2025. Patient #3 (Discharge): On January 8, 2026 at approximately 2:17 PM, review of the clinical record revealed the SOC was 07/04/2024, the patient is 12 years old and that home health aide (HHA) services are to be provided up to 8 hours per day Monday through Friday for school, school transportation, extended school year, home and accompaniment to medical appointments as ordered on the “Home Health Certification and Plan of Care” for the recertification period of 10/26/2025 through 12/24/2025. Review of missed visit report documentation revealed for the week ending 10/11/2025 revealed 4.75 hours of HHA services were not provided, for the week ending 11/08/2025, 8.5 hours of HHA services were not provided and for week ending 12/20/2025, 32 hours of HHA services were not provided because the caregiver (HHA) was not available. There was no documentation in the clinical record which provided evidence the agency involved the parent in the care planning process as there was no documentation which provided evidence the agency provided the parent with prior notification that a HHA was unavailable to provide services per the ordered visit frequency for the weeks ending 10/11, 11/08 and 12/20/2025. During telephone interview conducted on January 13, 2026 at approximately 3:35 PM, the Administrator confirmed there was no documentation in the clinical record which provided evidence the parent of patients #1, #2 and #3 had been involved in the care planning process for the above referenced reasons and on/during the aforementioned dates/time periods.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on review of agency policy/procedure and documentation and based on interview with the Administrator (Employee #1), the Administrator failed to ensure two (2) of two (2) skilled nursing (SN) staff maintained patient confidentiality in accordance with agency policy/procedures. (Employees #2 and #3) Findings include: On January 8, 2026 at approximately 3:1`8 PM, review of agency policy 6-019, titled “Sanctions for Privacy and Security Violations” revealed the following under “Procedure”: A. Level 1 Carelessness...1. This level of violation occurs when an employee unintentionally or carelessly accesses...discloses to another person an individual’s PHI (Personal Health Information) and there is no legitimate reason for such...disclosure. Examples included are not limited to...A. Discussing an individua’s PHI in a public place... On January 13, 2026 at approximately 3:33 PM, review of agency privacy procedures revealed the following: Accordingly...you must maintain the confidentiality of clients’ (patients’)...treatment... Sharing a client’s protected health information with others, including family members, without...authorization, is prohibited. On January 8, 2026 at approximately 1:55 PM, review of agency personnel details included on the “Emergency Preparedness Call Tree” revealed the following: Employee #2: The SN is a licensed practical nurse for whom the job title is Private Duty Manager (PDM/LPN) Employee #3: The SN is a registered nurse for whom the job title is PDN Clinical Manager (PDN CM/RN) On January 8, 2026 at approximately 2:37 PM, review of agency documentation dated “October 31” revealed the PDM/LPN (Employee #2) added a HHA (Employee #5) to a chat for patient #4. The chat included patient #4’s name, details regarding hiring a parent to be the caregiver of patient #4, the proposed number of hours services would be provided. Chat documentation revealed the HHA left the chat on “December 2”. During interview con On January 8, 2026 at approximately 12:18 PM, review of agency documentation dated 12/08/2025 revealed the Administrator received a complaint from a home health aide (Employee #5) that a SN had spoken about a patient at another patient’s home. During interview conducted on January 8, 2026 at approximately 2:06 PM, the Administrator reported that the while performing a SN visit in the presence of the HHA (Employee #5), the PDN CM/RN (Employee #3) had reported that the PDN CM/RN did not wish to perform a scheduled SN visit for a patient for whom the HHA (Employee #5) was not assigned to provide care. During interview conducted on January 8, 2026 at approximately 3:25 PM, the Administrator confirmed Employee #2 and #3 failed to maintain patient confidentially in accordance with the above referenced policies procedures.”

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based in interview with the Administrator (Employee #1) and the Operations Consultant (Employee #16), the agency failed to ensure discharge planning was conducted in accordance with agency policy/procedure for two (2) of three (3) patients/clients who were discharged from the agency. (Patients #4 and #5) Findings include: On August 8, 2025 at approximately 2:53 PM, review of agency policy 1-024, titled “Discharge Criteria and Process” revealed the following under “Policy”: When the patient’s plan of care changes and this change results in discharge..., the patient or his/her representative, as well as his/her primary physician...will be involved in discharge planning decisions. Patient #4 (Adult/Intermitted Skilled Services/Discharge): Between July 25, 2025 at approximately 2:14 PM and July 28, 2025 at approximately 11:28 AM, review of the clinical record revealed physical therapy (PT) services were to be provided three (3) times a week for two (2) weeks followed by two (2) times a week for two (2) weeks as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 05/05/2025 through 07/03/2025. Review of PT visit documentation revealed seven (7) PT visits were completed between 05/06/2025 and 05/20/2025. Review of the clinical record revealed a agency discharge assessment was completed on 05/27/2025. Review of the “Agency Discharge Ord” dated 06/02/2025 revealed the Administrator (registered nurse) obtained a physician order to discharge the patient from all services effective 06/02/2025. There was no documentation in the clinical record which provided evidence the patient, nor the patient’s physician, had been involved in the discharge planning process prior to completion of agency discharge comprehensive assessment on 05/27/2025. Patient #5 (Adult/Intermitted Skilled Services/Discharge): On July 28, 2025 at between the approximate times of 9:00 AM and 11:16 AM, review of the clinical record revealed skilled nursing (SN) services were to be provided one (1) time a week for nine (9) weeks as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 06/05/2025 through 08/03/2025. Review of SN documentation revealed one (1) skilled nursing visit was completed on 06/05/2025. Review of communication log documentation revealed the agency was unable to reach the patient by telephone on 06/09, 06/10, 06/11 and 06/16/2025. Review of the clinical record revealed a agency discharge assessment was completed on 06/26/2025. A physician order to discharge the patient was obtained on 06/26/2025. There was no documentation in the clinical record which provided evidence the patient had been involved in the discharge planning process (failure to receive notification of the agency’s intent to discharge) prior to completion of agency discharge comprehensive assessment which was completed on 06/26/20205. During Teams interview conducted on August 8, 2025 at approximately 3:02 PM, the Administrator and OC confirmed there was no documentation in the clinical record which provided evidence discharge planning had been completed in accordance with agency policy/procedure for the above identified patients.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based in interview with the Administrator (Employee #1) and the Operations Consultant (Employee #16), the agency failed to ensure home health services were provided in accordance with visit frequency orders included on the “Home Health Certification and Plan of Care” for four (4) of five (5) patients for whom intermittent skilled services were provided. (Patients #1, #2, #3 and #4) Findings include: On August 8, 2025 at approximately 2:51 PM, review of agency policy 1-007, titled “Care Planning Process” revealed the following: Purpose...To provide clinical direction to the clinicians providing direct patient care. Procedure...14. Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care or services provided against established patient goals and outcomes to determine if goals have been achieved. Patient #1 (Adult/Intermitted Skilled Services): Between July 25, 2025 at approximately 12:18 PM and July 28, 2025 at approximately 10:20 AM, review of the clinical record revealed skilled nursing (SN) services were to be provided two (2) times a week for one (1) week followed by one (1) time a week for eight (8) weeks as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/13/2025 through 07/11/2025. There was no documentation in the clinical record which provided evidence a SN visit had been completed during the treatment week of 05/25/2025 through 05/31/2025. There was no documentation in the clinical record which provided evidence the patient had refused a SN visit during the aforementioned treatment week. Patient #2 (Adult/Intermitted Skilled Services): Between July 25, 2025 at approximately 1:09 PM and July 28, 2025 at approximately 10:47 AM, review of the clinical record revealed SN services were to be provided one (1) time a week for nine (9) weeks as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/18/2025 through 07/16/2025. There was no documentation in the clinical record which provided evidence a SN visit had been completed during the treatment week of 06/29/2025 through 07/05/2025. There was no documentation in the clinical record which provided evidence the patient had refused a SN visit during the aforementioned treatment week. Patient #3 (Adult/Intermitted Skilled Services/Discharge): Between July 25, 2025 at approximately 1:38 PM and July 28, 2025 at approximately 11:03 AM, review of the clinical record revealed SN services were to be provided two (2) times a week for one (1) week followed by one (1) time a week for six (6) weeks as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/03/2025 through 07/01/2025. There was no documentation in the clinical record which provided evidence a SN visit had been completed during the treatment week of 06/08/2025 through 06/14/2025. There was no documentation in the clinical record which provided evidence the patient had refused a SN visit during the aforementioned treatment week. Patient #4 (Adult/Intermitted Skilled Services/Discharge): Between July 25, 2025 at approximately 2:14 PM and July 28, 2025 at approximately 11:28 AM, review of the clinical record revealed physical therapy (PT) services were to be provided three (3) times a week for two (2) weeks followed by two (2) times a week for two (2) weeks as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 05/05/2025 through 07/03/2025. Review of PT visit documentation revealed two (2) of three (3) PT visits were performed during the first week of the certification period 05/05/2025 through 05/10/2025. There was no documentation in the clinical record which provided evidence the patient had refused the third PT visit during the aforementioned treatment week. During Teams interview conducted on August 8, 2025 at approximately 3:02 PM, the Administrator and OC confirmed there was no documentation in the clinical record which provided evidence skilled services were provided in accordance with the aforementioned orders included on the “Home Health Certification and Plan of Care” for above identified patients.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on review of agency policy/procedure, clinical records and the Pennsylvania (PA) Health Care Facilities Act, and based on interview with the Administrator (Employee #1) and Operations Consultant (Employee #16), the agency failed to ensure verbal orders included on the “Home Health Certification and Plan of Care” were countersigned by the primary care physician within 30 days of the verbal order date for four (4) of eight (8) patients for whom skilled services were ordered on the plan of care. (Patients #1, #2, #3 and #5) Findings include: On August 8, 2025 at approximately 2:55 PM, review of agency policy 8-024, titled “Internal Control Systems/Accountabilities” revealed the following under “Procedure”: 3. Clinical Documentation Compliance...C. Physician Orders: Mechanisms are currently in place to assure timely signed physician orders prior to billing. On August 8, 2025 at approximately 3:25 PM, review PA state regulations included under the Health Care Facilities Act revealed the following under Section 806. Licensure...d) Home health care agency regulations: (4) Within 30 days of issuance, an order of home health care services must be signed and dated by a physician, nurse practitioner or physician assistant. Patient #1 (Adult/Intermitted Skilled Services): Between July 25, 2025 at approximately 12:18 PM and July 28, 2025 at approximately 10:20 AM, review of the clinical record revealed verbal orders for skilled nursing (SN) and home health aide (HHA) services were obtained by a registered nurse (RN) on 05/13/2025 as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/13/2025 through 07/11/2025. The physician countersignature for the verbal orders included on the above referenced “Home Health Certification and Plan of Care” was obtained on 06/23/2025 which was more than 30 days after the verbal order date. There was no documentation in the clinical record which provided evidence the physician countersignature had been obtained within 30 days of the verbal order date for the aforementioned verbal orders. Patient #2 (Adult/Intermitted Skilled Services): Between July 25, 2025 at approximately 1:09 PM and July 28, 2025 at approximately 10:47 AM, review of the clinical record revealed verbal orders for SN services were obtained by a RN on 05/16/2025 as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/18/2025 through 07/16/2025. There was no documentation in the clinical record which provided evidence the physician countersignature had been obtained for the aforementioned verbal orders. Patient #3 (Adult/Intermitted Skilled Services/Discharge): Between July 25, 2025 at approximately 1:38 PM and July 28, 2025 at approximately 11:03 AM, review of the clinical record revealed verbal orders for SN and HHA services were obtained by a RN on 04/30/3035 as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/03/2025 through 07/01/2025. The physician countersignature for the verbal orders included on the above referenced “Home Health Certification and Plan of Care” was obtained on 06/19/2025 which was more than 30 days after the verbal order date. There was no documentation in the clinical record which provided evidence the physician countersignature had been obtained within 30 days of the verbal order date for the aforementioned verbal orders. Patient #5 (Adult/Intermitted Skilled Services/Discharge): On July 28, 2025 at between the approximate times of 9:00 AM and 11:16 AM, review of the clinical record revealed verbal orders for SN services were 06/05/2025 as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 06/05/2025 through 08/03/2025. There was no documentation in the clinical record which provided evidence the physician countersignature had been obtained for the aforementioned verbal orders. During Teams interview conducted on August 8, 2025 at approximately 3:02 PM, the Administrator and OC confirmed there was no documentation in the clinical record which provided evidence a physician countersignature had been obtained within 30 days of the verbal order date included on the “Home Health Certification and Plan of Care” for the above identified patients.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based in interview with the Administrator (Employee #1) and the Operations Consultant (Employee #16), the agency failed involve the patient in the care planning process for two (2) of two (2) patients for whom an visit frequency reduction had occurred. (Patients #1 and #4) Findings include: On August 8, 2025 at approximately 2:51 PM, review of agency policy 1-007, titled “Care Planning Process” revealed the following: Purpose...To provide clinical direction to the clinicians providing direct patient care. Procedure...8...The patient/representative/caregiver will be involved in any change in care or services. Patient #1 (Adult/Intermitted Skilled Services): Between July 25, 2025 at approximately 12:18 PM and July 28, 2025 at approximately 10:20 AM, review of the clinical record revealed home health aide (HHA) services were to be provided two (2) times a week as documented on the skilled nursing recertification assessment dated 05/13/2025. Review of the “Home Health Certification and Plan of Care” for the recertification period of 05/13/2025 through 07/11/2025 revealed the HHA visit frequency had been reduced to one (1) time a week for nine (9) weeks. There was no documentation in the clinical record which provided evidence the patient was notified of or in agreement with the reduction in the HHA visit frequency. There was no documentation in the clinical record which provided evidence the patient was involved in the care planning process related to the reduction in the HHA visit frequency. Patient #4 (Adult/Intermitted Skilled Services/Discharge): Between July 25, 2025 at approximately 2:14 PM and July 28, 2025 at approximately 11:28 AM, review of the clinical record revealed skilled nursing (SN) services were to be provided two (2) times a week for one (1) week followed by one (1) time a week for eight weeks as documented on the “Client Agreement Form” which was signed by the patient on 05/05/2025. Review of the “Home Health Certification and Plan of Care” for the initial certification period of 05/05/2025 through 07/03/2025 revealed the SN visit frequency had been reduced to one (1) time a week for nine (9) weeks. There was no documentation in the clinical record which provided evidence the patient was notified of or in agreement with the reduction in the SN visit frequency for week one (1) of the certification period. There was no documentation in the clinical record which provided evidence the patient was involved in the care planning process related to the reduction in the SN visit frequency for week one (1) of the certification period. During Teams interview conducted on August 8, 2025 at approximately 3:02 PM, the Administrator and OC confirmed there was no documentation in the clinical record which provided evidence patients #1 and #4 had been involved the care planning related to the reduction in the aforementioned visit frequencies.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on review of agency policy/procedure and documentation and interview with the Administrator (Admin-Employee #1) and the Operations Consultant (OC-Employee #16), the Governing Body failed to ensure one (1) of one (1) administrator completed an orientation for the duties of administrator upon employment. (Employee #1) Findings include: On August 8, 2025 at approximately 2:45 PM, review agency policy 8-002, titled “Governing Body” revealed the following under “Procedure”: 8. The Governing Body will appoint a qualified administrator... On August 8, 2025 at approximately 2:46 PM, review agency policy 1-02, titled “Orientation” revealed the following under “Policy”: All personnel will be required to attend an orientation program upon employment... On July 28, 2025 at approximately 1:54 PM and between August 4, 2025 at approximately 10:50 AM and August 8, 2025 at approximately 8:24 AM, review of personnel file documentation revealed the following: Employee #1: The date of hire of the administrator was 02/15/2025. Review of the administrator orientation form revealed the Administrator completed a self-evaluation for administrative qualifications but there was no documentation in the personnel file which provided evidence the Administrator completed an orientation program for the duties of an administrator upon employment. During interview conducted on August 8, 2025, the Administrator and OC confirmed there was no documentation in the personnel file which provided evidence the Administrator completed an orientation program for the duties of an administrator upon employment.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on review of agency policy/procedure and clinical record and interview with the Administrator (Employee #1) and Operations Consultant (Employee #16), the agency failed to ensure clinical record contents were maintained in accordance with agency policy/procedure for four (4) of eight (8) patients for whom skilled services were provided. (Patients #2, #3, #7 and #8) Findings include: On August 8, 2025 at approximately 3:26 PM, review of agency policy 6-022, titled “Clinical/Service Data Collection” revealed the following: Policy: Documentation in the clinical/service record will be...timely...accurate... Procedure: 1. A clinical/service record will be initiated and maintained for each patient receiving care or services...and will include at a minimum: I. Current patient status and progress towards goals... 6. Entries into the clinical/service record will be made the day care/service is provided to the patient. All documentation will be turned into the office at the end of the work day. 7. The clinical/service note will include...B. Treatment...performed... Patient #2 (Adult/Intermitted Skilled Services): Between July 25, 2025 at approximately 1:09 PM and July 28, 2025 at approximately 10:47 AM, review of the clinical record revealed a registered nurse (RN-Employee #18) provided skilled nursing services on 05/23/2025. The SN visit note dated 05/23/2025 was not available for review in the electronic medical record (EMR). Patient #3 (Adult/Intermitted Skilled Services/Discharge): Between July 25, 2025 at approximately 1:38 PM and July 28, 2025 at approximately 11:03 AM, review of the clinical record revealed a RN provided skilled nursing services on 05/14/2025. The SN visit note for 05/14/2025 was not available for review in the EMR. Patient #7 (Pediatric Client/Private Duty Nursing (PDN)): On July 28, 2025 at between the approximate times of 12:29 PM and 3:15 PM, review of the clinical record revealed the gastric tube (feeding tube) feeding is to be administered at 380 milliliters per hour (ml/hr) for a total feed volume of 190 ml as documented on the “Home Health Certification and Plan of Care” for the recertification period of 06/02/205 through 07/31/2025. Review of 22 of 22 SN visit notes between 06/03/2025 and 07/22/2025 revealed the LPN (Employee #4) documented the GT feeding rate was 155 ml/hr but the gastric tube feeding rate documented by the LPN on the Medication Administration Record was 380 ml/hr. The LPN failed to document the total volume administered during the GT feedings administered on 07/15 and 07/16/2025. Review of SN visit documentation revealed the LPN (Employee #4) provided SN services on 07/16/2025. The complete SN visit note dated 07/16/2025 was not available for review in the EMR as the SN assessment findings were not included on the visit note. During interview conducted on 07/28/2025 at approximately 3:15 PM, the Director of PDN (Employee #11) reported the LPN’s assessment findings did not capture on the EMR note but that the LPN had documented the assessment findings in a journal located in the client’s home. The Director of PDN confirmed the LPN’s assessment findings for 07/16/2025 SN visit were not maintained and available for review in the EMR. Patient #8 (Pediatric Client/PDN): On July 28, 2025 at approximately 1:12 PM, review of the clinical record revealed the gastric tube feeding is to be administered at 600 ml/hr for a total feed volume of 380 ml as documented on the “Home Health Certification and Plan of Care” for the recertification period of 05/17/205 through 07/15/2025. Review of 30 of 31 SN visit notes between 06/02/2025 and 07/18/2025 revealed the LPN (Employee #9) failed to document the GT feeding rate on the SN visit note nor the MAR. The LPN failed to document the total volume administered during the GT feedings administered on 06/02, 06/03 nor 06/04/2025. There was no documentation which provided evidence the contents included in the clinical records for patients #2, #3, #7 and #8 had been maintained in accordance with the above referenced policy/procedure. During Teams interview conducted on August 8, 2025 at approximately 3:02 PM, the Administrator and OC confirmed the contented of clinical/service records were not maintained in accordance with agency policy/procedure for the above identified patients.”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on review of agency policy/procedure, documentation, clinical records and personnel files and the Pennsylvania Department of Health database, and based on interview with the Private Duty (PDN) Director (Employee #5), the Administrator (Employee #2) and the Chief Executive Officer (CEO-Employee #13), the agency failed to ensure 75 hours of home health aide (HHA) training, including16 hours of classroom and 16 hours of supervised practical training had been completed by HHA’s whose date of hire was after October 10, 2023 (G0762), the agency failed to ensure the home health aide (HHA) competency evaluation program included all required subject matter (G0764), the agency failed to ensure HHA’s completed a HHA competency evaluation program prior to the assignment to provide HHA services (G0768), the agency failed to ensure 12 hours of in-service training had been completed by a HHA who provides HHA services to adults requiring intermittent visits (SNV) (G0774), and the agency failed to ensure documentation was maintained which provided evidence an eligible home health agency conducted the initial HHA training and competency evaluation program (G0782). Cross Reference Tags: §484.80(b) Standard (Non-Level 1): Content and duration of home health aide classroom and supervised practical training: Minimum hours of training (G0762) §484.80(b) Standard (Non-Level 1): Content and duration of home health aide classroom and supervised practical training: HHA training program topics (G0764) §484.80(c) Standard (Level 1): Competency evaluation (G0768) §484.80(d) Standard (Non-Level 1): In-service training: 12 hours In-service every 12 months (G0774) §484.80(f) Standard (Non-Level 1): Eligible training and competency evaluation organizations (G0782)”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on a review of agency policy/procedure, documentation, and clinical records and based on interview with the Private Duty Nursing (PDN) Director (Employee #5) and the Administrator (Employee #2), the agency failed to ensure the emergency preparedness plan included a risk assessment review of three (3) of seven (7) facility or community-based hazards. (Care-Related Emergencies, Cyber-Attacks and Loss All/Portion of Facility) Findings include: On February 11, 2025 at approximately 2:05 PM and February 13, 2025 at approximately 9:25 AM, review of “Emergency Preparedness Policy” revealed the following: The Incident Command Center will be located at the main office unless emergency results in unusable office space... After Receiving Notification of an Emergency-Direct Care Staff...1. All services will cease... Client (Patient) #1: On February 12, 2024 at approximately 9:05 AM, February 14, 2024 between the approximate times of 10:01 AM and 12:11 PM and February 19, 2025 at approximately 3:32 PM, review of the clinical record revealed the client is 12 years old, the client is a full code (CPR to be initiated) and that oxygen is to be administered for decreased oxygen saturation levels as documented on the “Home Health Certification and Plan of Care”/Addendum to Plan of Treatment for the recertification period of 01/01/2025 through 03/01/2025. On February 13, 2025 at approximately 1:03 PM, review of the February 13, 2025 letter signed by the agency’s CEO (Employee #13) revealed the agency’s access to the former electronic medical record (EMR) software system was removed by the previous CEO effective 09/29/2024 because the EMR software program was being terminated by the previous CEO. During interview conducted on February 13, 2025 at approximately 11:48 AM, the PDN Director confirmed access to the prior EMR software system was not available which resulted in the inability of agency staff to access clinical record documentation prior to 09/29/2024. On February 11, 2025 at approximately 2:05 PM and February 13, 2025 at approximately 9:25 AM, review of agency’s emergency preparedness plan/program failed to reveal that care-related emergencies, cyber-attacks and loss of all or portion of a facility had been included in the risk assessment review of facility and community-based hazards conducted in 2023 and 2024. During interviews conducted on February 14, 2025 at approximately 4:01 PM and February 21, 2025 at approximately 3:30 PM, the PDN Director and the Administrator confirmed that care-related emergencies, cyber-attacks and loss of all or portion of a facility had not been included in the risk assessment review of facility and community-based hazards conducted in 2023 and 2024.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on a review of agency policy/procedure and documentation and based on interview with the Private Duty Nursing (PDN) Director (Employee #5) and the Administrator (Employee #2), the agency failed to ensure the emergency preparedness plan included the contact information for two (2) of three (3) Federal or state agencies. (Federal Emergency Management Agency (FEMA) and Pennsylvania Department of Health-Division of Home Health (PA DOH/DHH licensing agency)). Findings include: On February 11, 2025 at approximately 2:05 PM and February 13, 2025 at approximately 9:25 AM, review of “Emergency Preparedness Policy” revealed the following: Planning....Administration: A current list of contact information will be maintained for...emergency services...and other community services. On February 11, 2025 at approximately 2:05 PM and February 13, 2025 at approximately 9:25 AM, review of agency’s emergency preparedness plan/program (EPP/P) failed to reveal the contact information for FEMA nor the PA DOH/DHH (licensing agency) had been included in the agency’s EPP/P. During interviews conducted on February 14, 2025 at approximately 4:01 PM and February 21, 2025 at approximately 3:30 PM, the PDN Director and the Administrator confirmed the contact information for FEMA and the PA DOH/DHH (licensing agency) had not been included in the agency’s EPP/P.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based in interview with the Private Duty (PDN) Director (Employee #5), Administrator (Employee #2) and the Chief Executive Officer (CEO-Employee #13), the agency failed to ensure home health Outcome and Assessment Information Set (OASIS) data was transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of the completion date for two (2) of five (5) adult patients for whom OASIS data was collected. (Patients #4 and #6) Findings include: On February 21, 2025 at approximately 3:48 PM, review of policy 1-028, titled “OASIS Data Collection” revealed the following: Procedure...Home Health Agency will submit the OASIS data...within 30 days of the completion of the OASIS. Patient #4 (Private Duty (PDN) Client): On February 12, 2025 at approximately 10:03 AM, February 14, 2025 between the approximate times of 11:25 AM and 2:10 PM and February 18, 2025 between the approximate times of 12:47 PM and 2:51 PM, review of the clinical record revealed the client is 22 years old and that SN services are to be provided 10.5 hours per day as ordered on the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the recertification period of 01/16/2025 through 03/16/2025. Review clinical record revealed the comprehensive reassessment visit was completed on 01/06/2025 and OASIS data collection was completed on 01/14/2025. There was no documentation in the clinical record which provided evidence the OASIS data collected on 01/14/2025 had been transmitted to the CMS system within 30 days of the completion of the assessment. Patient #6 (PDN Client): On February 14, 2025 at approximately 12:38 PM and February 18, 2025 at approximately 1:08 PM, review of the clinical record revealed the patient is 19 years old and that SN services are to be provided as documented on the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the recertification period of 01/17/2025 through 03/17/2025. Review clinical record revealed comprehensive reassessment and OASIS data collection was completed on 01/16/2025. There was no documentation in the clinical record which provided evidence the OASIS data collected on 01/16/2025 had been transmitted to the CMS) system within 30 days of completion of the assessment. During interview conducted on February 21, 2025 at approximately 3:30 PM, the PDN Director, Administrator and CEO confirmed there was no documentation in the clinical record which provided evidence OASIS data transmitted to the CMS system within 30 days of the assessment completion date for the above identified patients.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based in interview with the Private Duty (PDN) Director (Employee #5), Administrator (Employee #2) and the Chief Executive Officer (CEO-Employee #13), the agency failed to ensure home health Outcome and Assessment Information Set (OASIS) data was collected during the comprehensive re-assessment for two (2) of five (5) adult patients who received skilled nursing (SN) services. (Patients #4 and #6) Findings include: On February 21, 2025 at approximately 3:48 PM, review of policy 1-028, titled “OASIS Data Collection” revealed the following: Policy...OASIS data will be collected for all Medicare and Medicaid patients who are 18 years or older. RN (registered nurse) will collect OASIS data at...recertification... Procedure...14. Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care or services provided against established patient goals and outcomes to determine if goals have been achieved. Patient #4 (PDN Client): On February 12, 2025 at approximately 10:03 AM, February 14, 2025 between the approximate times of 11:25 AM and 2:10 PM and February 18, 2025 between the approximate times of 12:47 PM and 2:51 PM, review of the clinical record revealed the client is 22 years old and that SN services are to be provided 10.5 hours per day as ordered on the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the recertification period of 01/16/2025 through 03/16/2025. Review OASIS data collection documentation dated 01/14/2025 revealed the patient’s payer source is a Medicaid Managed Care Plan. There was no documentation which provided evidence OASIS data was collected with the comprehensive recertification assessments completed on 09/22/2024 and 11/17/2024. Patient #6 (PDN Client): On February 14, 2025 at approximately 12:38 PM and February 18, 2025 at approximately 1:08 PM, review of the clinical record revealed the patient is 19 years old and that SN services are to be provided as documented on the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the recertification period of 01/17/2025 through 03/17/2025. Review OASIS data collection documentation dated 01/16/2025 revealed the patient’s payer source was Medicaid There was no documentation which provided evidence OASIS data was collected with the comprehensive recertification assessments completed on 09/18/2024 and 11/15/2024. During interview conducted on February 21, 2025 at approximately 3:30 PM, the PDN Director, Administrator and CEO confirmed there was no documentation in the clinical record which provided evidence OASIS data was collected during the aforementioned comprehensive recertification assessments for the above identified patients.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based in interview with the Private Duty (PDN) Director (Employee #5), Administrator (Employee #2) and the Chief Executive Officer (CEO-Employee #13), the agency failed to ensure skilled nursing (SN) services were provided in accordance with orders included on the home plan of care for two (2) of eight (8) patients. (Patients #1 and #4) Findings include: On February 21, 2025 at approximately 3:47 PM, review of policy 1-007, titled “Care Planning Process” revealed the following: Purpose...To provide clinical direction to the clinicians providing direct patient care. Procedure...14. Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care or services provided against established patient goals and outcomes to determine if goals have been achieved. Patient #1 (Private Duty (PDN) Client): On February 12, 2025 at approximately 9:05 AM, February 14, 2025 between the approximate times of 10:01 AM and 12:11 PM and February 19, 2025 at approximately 3:32 PM, review of the clinical record revealed the client is 12 years old, the primary diagnosis is epilepsy (seizures), that SN services are to be provided eight (8) hours per day and that SN is to assess vital signs (temperature, pulse and respirations) every shift as ordered on the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the recertification period of 01/01/2025 through 03/01/2025. Review of “Web Pediatric Visit Assessment” documentation failed to reveal the registered nurse (RN-Employee #4) assessed the patient’s respiratory rate during 39 shifts between 01/01/2025 and 02/09/2025. Review of visit calendar documentation revealed less than eight (8) hours of SN services were provided on 01/02/2025 and 01/20/2025. There was no documentation in the clinical record which provided evidence the patient’s responsible party had requested a reduction in the SN visit hours on 01/02/2025 and 01/20/2025. Patient #4 (PDN Client): On February 12, 2025 at approximately 10:03 AM, February 14, 2025 between the approximate times of 11:25 AM and 2:10 PM and February 18, 2025 between the approximate times of 12:47 PM and 2:51 PM, review of the clinical record revealed the client is 22 years old, the primary diagnosis is type-1 diabetes mellitus and that SN services are to be provided 10.5 hours per day as ordered on the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the recertification period of 01/16/2025 through 03/16/2025. Review of visit calendar documentation revealed less than 10.5 hours of SN services were provided for 17 SN shifts completed between 01/16/2025 and 02/11/2025. There was no documentation in the clinical record which provided evidence the patient’s responsible party had requested a reduction in the SN visit hours between 01/16/2025 and 02/11/2025. During interview conducted on February 21, 2025 at approximately 3:30 PM, the PDN Director, Administrator and CEO confirmed there was no documentation in the clinical record which provided evidence the SN services were provided in accordance with the aforementioned orders included on the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for above identified patients.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on review of agency policy, documentation and Pennsylvania Department of Health (PA DOH) website reports and based on interview with the Private Duty (PDN) Director (Employee #5) and the Administrator (Employee #2), the agency failed to submit a report of four (4) of five (5) reports of Health Department Reportable Diseases to the PA DOH Event Reporting System (ERS) website which were received after October 10, 2023. (Influenza and Respiratory Syncytial Virus (RSV)) Findings include: On February 11, 2025 at approximately 2:02 PM, review of policy 7-001, titled “Infection Control Plan”, revealed the following under “Procedure”: 6. The Performance Improvement Coordinator will be responsible for...reporting infection control activities to...other appropriate authorities. On February 11, 2025 at approximately 1:25 PM, review of the PA DOH website (https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx) revealed influenza and RSV are Health Department Reportable Diseases. On February 11, 2025 between the approximate times of 1:20 PM and 1:47 PM, review of agency incident/adverse event report documentation revealed the following client-related contagious disease reports were received by the agency: 02/01/2025, 02/08/2025: Influenza 01/30/2025 and 01/24/2025: RSV. On February 11, 2025 at approximately 1:30 PM, review of the PA DOH database website failed to reveal that the agency had submitted a report of the above referenced Health Department Reportable Diseases to the PA DOH ERS website. During interviews conducted between February 14, 2025 at 4:01 PM and February 21, 2025 approximately 3:30 PM, the PDN Director and the Administrator confirmed the agency failed to submit a report of the above referenced Health Department Reportable Diseases to the PA DOH ERS website.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on review of agency policy/procedure, Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA DOH) tuberculosis screening recommendations and/or requirements, clinical records and personnel files, and based on interview with the Private Duty (PDN) Director (Employee #5) and the Administrator (Employee #2), the agency failed to ensure TB screening was completed in accordance with agency policy/procedure, CDC and PA DOH recommendations for four (4) of four (4) agency staff whose date of hire was after October 10, 2023. (Employees #7, #8, #9 and #10) Findings include: On February 11, 2025 at approximately 2:02 PM, review of policy 7-001, titled “Infection Control Plan”, revealed the following under “Purpose”: 5. Comply with all applicable local, state, and federal regulations including, but not limited to: A. State...mandates B. CDC recommendations and guidelines. On February 21, 2025 at approximately 1:34 PM, review of agency policy 2-051, titled Initial TB Screening for Employees” revealed the following under “Policy”: Golden Care shall ensure that each direct care worker...prior to consumer contact, provide documentation that the individual has been screened for and is free from active TB. On February 21, 2025 at approximately 1:35 PM, review of CDC recommendations for initial TB screening for health care personnel revealed the following as documented on the CDC website: https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/index.html The TB screening process for health care personnel includes: -A baseline individual TB risk assessment; -TB symptom evaluation; and -A TB test (TB blood test or a TB skin test (2-Step)). On February 21, 2025 at approximately 1:38 PM, review the PA DOH webpage ( https://www.pa.gov/agencies/health/diseases-conditions/infectious-disease/tuberculosis/tb-testing-health-care-workers.html ) revealed the following: Tuberculosis Testing Health Care Workers...On May 17, 2019 the Centers for Disease Control and Prevention (CDC) issued updated recommendations for TB testing of health care personnel. Key points include: The updated recommendations call for health care personnel to be screened for TB upon hire with an individual risk assessment(opens in a new tab), a symptom evaluation, and a TB test (either the interferon gamma-release assay, or IGRA, blood test or the tuberculin skin test-). On February 21, 2025 at approximately 1:45 PM, review of the PA DOH TB manual ( https://www.pa.gov/content/dam/copapwp-pagov/en/health/documents/topics/documents/diseases-and-conditions/tb/CMHD%20TB%20Manual%202023.pdf ) revealed the following: LAWS PERTAINING TO TB CONTROL...Pennsylvania laws on TB can be found in the Administrative Code of 1929 and the Disease Prevention and Control Law of 1955, 35 P.S. Sec. 521.1 . Under the provisions of the Pennsylvania Administrative Code of 1929 and the Disease Prevention and Control Law of 1955, DOH has the authority to “protect the health of the people of this Commonwealth, and to determine and employ the most efficient and practical means for the prevention and suppression of disease.” Patient #6 (PDN Client): On February 14, 2025 at approximately 12:38 PM, February 18, 2025 at approximately 1:08 PM, review of the clinical record revealed the two (2) home health aides (HHA-Employees #9 and #10) provided HHA services in January and February 2025. Patient #7 (Discharge-PDN Client): On February 14, 2025 at approximately 1:32 PM, February 18, 2025 at approximately 1:04 PM and February 19, 2025 at approximately 3:27 PM, review of the clinical record revealed the registered nurse (RN-Employee #7) completed the pediatric start of care assessment on 10/11/2024. Patient #8 (PDN Client): On February 14, 2025 at approximately 2:55 PM, February 18, 2025 at approximately 12:49 PM and February 19, 2025 at approximately 3:30 PM, review of the clinical record revealed the RN (Employee #8) completed the pediatric start of care assessment on 01/27/2025. On February 12, 2025 at approximately 12:55 PM, February 13, 2025 at approximately 11:58 AM, February 14, 2025 between the approximate times of 9:47 AM and 3:15 PM, February 18, 2025 between the approximate times of 12:30 PM and 1:13 PM and February 20, 2025 at approximately 3:45 PM, review of personnel file documentation revealed the following: Employee #7: The date of hire of the RN was 03/05/2024. The first date of assignment to provide SN services was 04/15/2024. There was no documentation in the personnel file which provided evidence a TB individual risk assessment has been completed prior to the assignment to perform SN assessments. Employee #8: The date of hire of the RN was 01/15/2024. There was no documentation in the personnel file which provided evidence a TB individual risk assessment nor TB symptom screening had been completed prior to the assignment to perform SN assessments. Employee #9: The date of hire of the HHA was 02/05/2024. The first date of assignment (clock-in date) to provide HHA services was 02/09/2024. Review of the TST results revealed the first step TST was completed on 02/16/2024 and that on 02/14/2025, the TB individual risk assessment and TB symptom screening was completed by the HHA. There was no documentation in the personnel file which provided evidence the first step TST and TB individual risk assessment and TB symptom screening had been completed prior to the assignment to provide HHA services. Employee #10: The date of hire of the HHA was 01/15/2024. The first date of assignment (clock-in date) to provide HHA services was 01/18/2024. A chest x-ray was completed on 01/18/2024 for TB screening but there was no documentation in the personnel file which provided evidence the HHA had a past history of a positive TB screening result. TB blood screening was completed on 03/07/2024 which was after the first date of assignment. There was no documentation which provided evidence the TB individual risk assessment nor TB symptom screening had been completed prior to the assignment to provide HHA services. There was no documentation in the personnel files which provided evidence TB screening (TB individual risk assessment, TB symptom screening and TB skin or blood tests) had be completed in accordance with CDC and/or PA DOH recommendations and/or requirements prior to the assignment of Employees #7, #8, #9 and #10 to provide home health services. During interviews conducted on February 14, 2025 at approximately 4:02 PM and February 21, 2025 at approximately 3:30 PM, the PDN Director and the Administrator confirmed initial TB screening was not conducted in accordance with agency policy/procedure, CDC and PA DOH recommendations and/or requirements for the above referenced employees.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on review of agency policy/procedure, clinical records and personnel files, and based on interview with the Private Duty (PDN) Director (Employee #5), the Administrator (Employee #2) and the Chief Executive Officer (CEO-Employee #13), the agency failed to ensure two (2) of two (2) home health aides (HHA) completed a HHA competency evaluation program prior to the assignment to provide HHA services. (Employees #9 and #10) Findings include: On February 21, 2025 at approximately 1:50 PM, review of policy 2-952, titled “Home Health Aide Training/Competency Evaluation”, revealed the following: Policy...Home health aide employees’ skill training will be performed upon hire... Procedure...Pass competency test... Patient #6 (PDN Client): On February 14, 2025 at approximately 12:38 PM, February 18, 2025 at approximately 1:08 PM, review of the clinical record revealed the two (2) home health aides (HHA-Employees #9 and #10) provided HHA services in January and February 2025. On February 12, 2025 at approximately 12:55 PM, February 13, 2025 at approximately 11:58 AM, February 14, 2025 between the approximate times of 9:47 AM and 3:15 PM, February 18, 2025 between the approximate times of 12:30 PM and 1:13 PM and February 20, 2025 at approximately 3:45 PM, review of personnel file documentation revealed the following: Employee #9: The date of hire of the HHA was 02/05/2024. The first date of assignment (clock-in date) to provide HHA services was 02/09/2024 which was the four (4) days after the date of hire. Review of personnel file documentation revealed the “Home Health Aide Skills Check List-Golden Care of NEPA” and “HHA Training Quiz” were completed on 02/12/2024 which was after the first date of assignment. There was no documentation on the personnel file which provided evidence the HHA completed a competency evaluation program prior to the assignment to provide HHA services. Employee #10: The date of hire of the HHA was 01/15/2024. The first date of assignment (clock-in date) to provide HHA services was 01/18/2024 which was the three (3) days after the date of hire. Personnel file documentation revealed the “Home Health Aide Skills Check List-Golden Care of NEPA” was completed on 01/15/2024 but the personnel file did not include documentation that the “HHA Training Quiz” had been completed. Review of the “SwiftShift” Certificate of Completion revealed the HHA completed 75 hours of HHA training, which included 16 hours of in-person training, but the certificate was undated; therefore, there was no documentation on the personnel file which provided evidence the HHA completed a competency evaluation program prior to the assignment to provide HHA services. During interview conducted on February 21, 2025 at approximately 3:30 PM, the PDN Director, the Administrator and the CEO confirmed there was no documentation in the personnel file which provided evidence Employees #9 and #10 had completed a competency evaluation program prior to the assignment to provide HHA services.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on review of agency policy/procedure, clinical records and personnel files and based on interview with the Private Duty (PDN) Director (Employee #5) and the Administrator (Employee #2), the agency failed to ensure 12 hours of in-service training had been completed by one (1) of one (1) home health aides (HHA) who was employed for since 2017. (Employee #3) Findings include: On February 21, 2025 at approximately 1:50 PM, review of policy 2-952, titled “Home Health Aide Training/Competency Evaluation”, revealed the following under “Procedure”: 2. Attend scheduled training, and at least 12 hours of in-services per year. Patient #2 (Adult Skilled Nursing Visit): On February 12, 2025 at approximately 9:09 AM, review of the clinical record revealed the HHA (Employees #3) provided HHA services in January and February 2025. On February 12, 2025 at approximately 12:55 PM, February 13, 2025 at approximately 11:58 AM, February 14, 2025 between the approximate times of 9:47 AM and 3:15 PM, February 18, 2025 between the approximate times of 12:30 PM and 1:13 PM and February 20, 2025 at approximately 3:45 PM, review of personnel file documentation revealed the following: Employee #3: The date of hire of the HHA was 08/22/2017. In-service record documentation revealed the HHA completed six (6) hours of in-service training in 2024. There was no documentation in the personnel file which provided evidence the HHA completed 12 hours of in-service training in 2024. During interviews conducted on February 14, 2025 at approximately 4:02 PM and February 21, 2025 at approximately 3:30 PM, the PDN Director and the Administrator confirmed there was no documentation which provided evidence Employee #3 completed 12 hours of in-service training in 2024.”

“Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a “qualified home health aide” as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA’s patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA’s patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This Standard is not met as evidenced by: Based on review of agency policy/procedure, documentation, clinical records and personnel files, and Pennsylvania Department of Health (PA DOH) database documentation, and based on interview with the Private Duty (PDN) Director (Employee #5), the Administrator (Employee #2) and the Chief Executive Office (CEO-Employee #13), the agency failed to ensure documentation was maintained which provided evidence an eligible home health agency conducted the initial home health aide (HHA) training and competency evaluation program for two (2) of two (2) HHA’s whose date of hire was after October 10, 2023. (Employees #9 and #10) Findings include: On February 21, 2025 at approximately 1:50 PM, review of policy 2-952, titled “Home Health Aide Training/Competency Evaluation”, revealed the following: Policy...Home health aide employees’ skill training will be performed upon hire... Procedure...Pass competency test... On February 14, 2025 at 3:51 PM, review of PA DOH database documentation revealed a letter dated 08/08/2022 was forwarded to the Administrator (Employee #5). The letter provided notice to the agency that an extended survey was completed on 07/28/2022 and that the agency was advised a home health agency may not have had any Conditions of Participation identified as being out of compliance within the 24-month period of beginning a home health aide training and competency evaluation program. Patient #6 (PDN Client): On February 14, 2025 at approximately 12:38 PM, February 18, 2025 at approximately 1:08 PM, review of the clinical record revealed the two (2) home health aides (HHA-Employees #9 and #10) provided HHA services in January and February 2025. On February 12, 2025 at approximately 12:55 PM, February 13, 2025 at approximately 11:58 AM, February 14, 2025 between the approximate times of 9:47 AM and 3:15 PM, February 18, 2025 between the approximate times of 12:30 PM and 1:13 PM and February 20, 2025 at approximately 3:45 PM, review of personnel file documentation revealed the following: Employee #9: The date of hire of the HHA was 02/05/2024. The first date of assignment (clock-in date) to provide HHA services was 02/09/2024. Review of personnel file documentation revealed the “Home Health Aide Skills Check List-Golden Care of NEPA” and Golden Care Pediatrics “HHA Training Quiz” completed on 02/12/2024 were signed by a registered nurse (RN-Employee #14). The agency’s name was included on the top portion of the skills checklist and training quiz. Employee #10: The date of hire of the HHA was 01/15/2024. The first date of assignment (clock-in date) to provide HHA services was 01/18/2024. Personnel file documentation revealed the “Home Health Aide Skills Check List-Golden Care of NEPA” completed on 01/15/2024 and the undated “SwiftShift” Certificate of Completion were signed (hand-written or electronically) by an RN (Employee #14). The agency’s name was included on the top portion of the skills checklist. On February 11, 2024 at approximately 2:05 PM and February 13, 2025 at approximately 9:25 AM, review of the April 2023 “Emergency Preparedness Policy” revealed the above referenced RN (Employee #14) served as the agency’s alternate PDN clinical nurse manager. During interview conducted on February 14, 2025 at approximately 4:20 PM, the PDN Manager reported the RN (Employee #14) had been employed by both the agency and a second home health agency (Agency #2). The PDN Manager reported the RN conducted the HHA training and competency evaluation program as an employee of Agency #2. On February 18, 2025 at approximately 2:40 PM, review of documentation forwarded by the licensed practical nurse/PD specialist (LPN/PDS-Employee #6) revealed the RN (Employee #14) and the agency’s former CEO signed a contract in which the RN responsibilities under Agency #2 included home health aide and direct care worker training as documented in Appendix A. The effective date of the contract between the RN and Agency #2 was 11/10/2023. Review of compensation documentation under Appendix B and the 1099-NEC tax form revealed the RN was compensated for 8 hours of services in 2024 but the 1099-NEC form did not include the dates the RN provided HHA training and competency evaluation services under Agency #2. During interview conducted on February 21, 2025 at approximately 3:30 PM, the PDN Director, the Administrator and the CEO confirmed there was no documentation which provided evidence that the HHA competency training and evaluation programs for Employees #9 and #10 had been completed by Agency #2.”

“Disclosure of ownership and management info. CFR(s): 484.100(a) The HHA must comply with the requirements of part 420 subpart C, of this chapter. The HHA also must disclose the following information to the state survey agency at the time of the HHA’s initial request for certification, for each survey, and at the time of any change in ownership or management: (1) The names and addresses of all persons with an ownership or controlling interest in the HHA as defined in §420.201, §420.202, and §420.206 of this chapter. (2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. (3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This Standard is not met as evidenced by: Based on a review of agency policy/procedures, documentation and the Pennsylvania Department of Health (PA DOH) database and based on interview with the Private Duty (PDN) Director , Administrator (Employee #2), Consultant (Employee #12)) and the Chief Executive Officer (CEO-Employee #13), the Governing Body (Board of Directors) failed to submit written notice to the PA DOH/Division of Home Health for three (3) of three (3) organizational changes which occurred in 2024. (Change in the Chief Executive Officer, Board of Directors (Governing Body) and Administrator) Findings Included: On February 13, 2025 at approximately 11:32 AM,, review of the policy 8-002, titled “Governing Body”, revealed the following: Policy: The Governing Body will assume full legal authority, responsibility and accountability for the overall management and operations... On February 13, 2025 at approximately 1:16 PM, review of the “Governing Body Approval of New Administrator Meeting” minutes dated 07/19/2024 revealed a registered nurse (Employee #2) was appointed as administrator effective 07/23/2024. On February 13, 2025 at approximately 3:01 PM, review of agency documentation revealed the following organizational changes occurred in October 2024: “Golden Care Resignation” letter: The former Chief Executive Officer resigned as sole director of the Board of Directors effective 10/09/2024. “Action by Unanimous Written Consent of the Sole Director of Golden Care of Northeast Pennsylvania, Inc.”: A new Chief Executive Officer and President (Employee #13), Secretary (Employee #5) and Treasurer (Employee #12) were appointed to the Board of Directors (Governing Body) effective 10/01/2024. On February 13, 2025 at approximately 3:12 PM, review of the PA DOH database failed to reveal that written notice of the above referenced organizational changes had been submitted to the PA DOH/Division of Home Health prior to 02/11/2025. During interview conducted on February 14, 2025 at approximately 4:01 PM, the Administrator, PDN Director and Consultant confirmed there was no documentation which provided evidence that written notice of the above referenced organizational changes had been submitted to the PA DOH/Division of Home Health prior to 02/11/2025. During interview conducted on February 21, 2025 at approximately 3:30 PM, the CEO confirmed there was no documentation which provided evidence that written notice of the above referenced organizational changes had been submitted to the PA DOH/Division of Home Health prior to 02/11/2025.”

“Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient’s equipment when assisting with self-administered tests. This Standard is not met as evidenced by: Based on review of agency policy, Federal regulations under the Clinical Laboratory Improvement Amendment of 1988 (CLIA) and clinical records and based on interview with a licensed practical nurse (LPN-Employee #1) and the Private Duty (PDN) Director (Employee #5) and the Administrator (Employee #2), the agency failed to maintain a CLIA Certification of Waiver for 6 of 6 months after expiration of the CLIA Certification of Waiver. (September 2024 through February 2025) Findings include: On February 13, 2025 at approximately 11:42 AM, review of agency policy 2-022, titled “Waived Testing” revealed the following under “Procedure”: Golden Care will apply for and maintain a CLIA Waiver on file. On February 21, 2025 at 1:15 PM, review of the Centers for Disease Control website ( https://www.cms.gov/medicare/quality/clinical-laboratory-improvement-amendments/apply ) revealed the following as included under the CLIA regulatory requirements: Under CLIA, a facility is a laboratory if it performs even one test on “materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings.” Patient #4: On February 14, 2025 at approximately 10:23 AM, February 14, 2025 at approximately 11:25 AM and February 18, 2025 between the approximate times of 12:47 PM and 2:51 PM, review of the clinical record revealed diagnoses include Type-1 diabetes mellitus and spastic cerebral palsy and that skilled nursing (SN) is to perform blood glucose monitoring via a glucometer every shift and as needed as documented on the Addendum to the Plan of Treatment for the recertification period of 01/16/2025 through 03/16/2025. An interview was conducted with the LPN (Employee #1) during the home visit conducted on February 12, 2025 at approximately 10:25 AM. The LPN confirmed the LPN performs blood glucose monitoring via a glucometer at least one (1) time per SN shift. On February 11, 2025 at approximately 11:50 AM, review of the CLIA Certificate of Waiver revealed the CLIA waiver was issued on 09/01/2022 and expired on 08/31/2024. There was no documentation which provided evidence that the agency obtained a CLIA Certificate of Waiver after 08/31/2024. During interview conducted on February 14, 2025 at approximately 4:01 PM and February 21, 2025 at approximately 3:30 PM, the PDN Director and the Administrator confirmed the agency failed to obtain a CLIA Certification of Waiver after 08/31/2024.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the Private Duty (PDN) Director (Employee #5) and the Administrator (Employee #2), the agency failed to ensure the patient rights forms included notification of the right to be notified of expected outcomes of care, including patient-identified goals, and anticipated benefits for two (2) of two (2) active patients/clients whose start of care date was after September 29, 2024. (Patients #3 and #8) Findings include: On February 13, 2025 at approximately 11:40 AM, review of agency policy titled “Bill of Rights” revealed the following: Purpose...To encourage awareness of patient rights and provide guidelines to assist patients in making decisions regarding care and for active participation in care planning... Procedure...1. The patient will be informed verbally and in writing during the initial evaluation visit and in advance of furnishing care of their rights. On February 11, 2025 at approximately 10:35 AM, review of the skilled nursing visit (SNV-skilled intermittent visits) service line admission packet failed to reveal the patient rights forms included notification of the right to be informed of the expected outcomes of care, including patient-identified goals, and anticipated benefits. On February 11, 2025 at approximately 11:11 AM, review of the PDN (pediatric/adult shift care) service line admission packet failed to reveal the patient rights forms included notification of the right to be informed of the expected outcomes of care, including patient-identified goals, and anticipated benefits. Patient #3 (SNV): On February 12, 2025 at approximately 9:45 AM, review of the clinical record revealed the start of care date was 11/11/2024 and that goals included for the patient to “walk better” and to experience “less pain” as documented on the “Home Health Plan of Care & Certification” for the recertification period of 01/10/2025 through 03/10/2025. Patient (Client) #8 (PDN): On February 14, 2025 at approximately 2:55 PM, February 18, 2025 at approximately 12:49 PM and February 19, 2025 at approximately 3:30 PM, review of the clinical record revealed the start of care date was 01/29/2025 and that goals included for the client to maintain adequate hydration and nutrition status as documented on the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the initial certification period of 01/29/2025 through 03/29/2025. There was no documentation in the clinical record which provided evidence patients #3 and #8 received written notification of the right to be informed of the expected outcomes of care, including patient-identified goals, and anticipated benefits. During interviews conducted on February 14, 2025 at approximately 4:01 PM and February 21, 2025 at approximately 3:30 PM, the PDN Director and the Administrator confirmed there was no documentation in the clinical record which provided evidence the above referenced patients received written notification of the right to be informed of the expected outcomes of care, including patient-identified goals, and anticipated benefits.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the Private Duty (PDN) Director (Employee #5) and the Administrator (Employee #2), the agency failed to ensure the patient rights forms included notification of the right to be notified of the right to receive all services outlined in the plan of care for two (2) of two (2) active patients/clients whose start of care date was after September 29, 2024. (Patients #3 and #8) Findings include: On February 13, 2025 at approximately 11:40 AM, review of agency policy titled “Bill of Rights” revealed the following: Purpose...To encourage awareness of patient rights and provide guidelines to assist patients in making decisions regarding care and for active participation in care planning... Procedure...1. The patient will be informed verbally and in writing during the initial evaluation visit and in advance of furnishing care of their rights. On February 11, 2025 at approximately 10:35 AM, review of the skilled nursing visit (SNV-skilled intermittent visits) service line admission packet failed to reveal the patient rights forms included notification of the right to receive all services outlined in the plan of care. On February 11, 2025 at approximately 11:11 AM, review of the PDN (pediatric/adult shift care) service line admission packet failed to reveal the patient rights forms included notification of the right to receive all services outlined in the plan of care Patient #3 (SNV): On February 12, 2025 at approximately 9:45 AM, review of the clinical record revealed the start of care date was 11/11/2024 and that skilled nursing services are to be provided two (2) times a week for one (1) week followed by one (1) time a week for eight weeks as documented on the “Home Health Plan of Care & Certification” for the recertification period of 01/10/2025 through 03/10/2025. Patient (Client) #8 (PDN): On February 14, 2025 at approximately 2:55 PM, February 18, 2025 at approximately 12:49 PM and February 19, 2025 at approximately 3:30 PM, review of the clinical record revealed the start of care date was 01/29/2025 and that home health aide services ate to be provided eight (8) hours per day for a total of 40 hours per week as documented on the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the initial certification period of 01/29/2025 through 03/29/2025. There was no documentation in the clinical record which provided evidence patients #3 and #8 received written notification of the right to receive all services outlined in the plan of care. During interviews conducted on February 14, 2025 at approximately 4:01 PM and February 21, 2025 at approximately 3:30 PM, the PDN Director and the Administrator confirmed there was no documentation in the clinical record which provided evidence the above referenced patients received written notification of the right to receive all services outlined in the plan of care”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based in interview with the Private Duty (PDN) Director (Employee #5), Administrator (Employee #2) and the Chief Executive Officer (CEO-Employee #13), the agency failed to ensure a comprehensive assessment was completed by a registered nurse (RN) within five (5) days of the start of care date (SOC) for two (2) of three (3) patients for whom the initial certification period was reviewed. (Patients #7 and #8) Findings include: On February 21, 2025 at approximately 3:46 PM, review of policy 1-016, titled “Initial and Comprehensive Assessment” revealed the following under “Policy”: A comprehensive patient assessment will be completed by the registered nurse within five (5) calendar days of the patient’s start of care... Patient #7 (Private Duty (PDN) Client-Discharge): On February 14, 2025 at approximately 1:32 PM, February 18, 2025 between the approximate times of 1:04 PM and 2:55 PM and February 19, 2025 at approximately 3:27 PM, review of the clinical record revealed the SOC date was 10/15/2024 and that home health aide (HHA) services were to be provided as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 10/15/2024 through 12/13/2024. Review of the “Web Pediatric Assessment”, for which a handwritten note of “RN Admission Assessment” was documented on the top of page 1 of the form, revealed an initial nursing assessment was completed by the PDN Assistant Clinical Nurse Manager/RN (Employee #7) on 10/11/2024 which was four (4) days prior to the start of SOC date. There was no documentation which provided evidence a comprehensive nursing assessment had been completed by an RN within five (5) days of the SOC. Patient #8 (PDN) Client): On February 14, 2025 at approximately 2:55 PM, February 18, 2025 between at approximately 12:49 PM and February 19, 2025 at approximately 3:30 PM, review of the clinical record revealed the SOC date was 01/29/2025 and that HHA services are to be provided as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 01/29/2025 through 03/29/2025. Review of the “Web Pediatric Assessment”, for which a handwritten note of “RN Comp Assessment” was documented on the top of page 1 of the form, revealed an initial comprehensive assessment was completed by the PDN Clinical Manager/RN (Employee #8) on 01/27/2025 which was two (2) days prior to the start of SOC date. There was no documentation which provided evidence a comprehensive nursing assessment had been completed by an RN within five (5) days of the SOC. During interview conducted on February 21, 2025 at approximately 3:30 PM, the PDN Director, Administrator and CEO confirmed there was no documentation in the clinical record which provided evidence a comprehensive assessment had been completed by an RN within five (5) days of the SOC for the above referenced patients.”

“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 review of agency policy/procedure and clinical records and based in interview with the Private Duty (PDN) Director (Employee #5), Administrator (Employee #2) and the Chief Executive Officer (CEO-Employee #13), the agency failed to ensure a home health certification and plan of care included 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, for four (4) of six (6) active patients. (Patients #1, #4, #6 and #8) Findings include: On February 21, 2025 at approximately 3:47 PM, review of policy 1-007, titled “Care Planning Process” revealed the following under “Policy”: Definitions...1. Individualized Plan of Care: The patient-specific plan of care includes... V. 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. Patient #1 (Private Duty (PDN) Client): On February 12, 2025 at approximately 9:05 AM, February 14, 2025 between the approximate times of 10:01 AM and 12:11 PM and February 19, 2025 at approximately 3:32 PM, review of the clinical record revealed there was no documentation which provided evidence the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the recertification period of 01/05/2025 through 03/01/2025 included 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. Patient #4 (PDN Client): On February 12, 2025 at approximately 10:03 AM, February 14, 2025 between the approximate times of 11:25 AM and 2:10 PM and February 18, 2025 between the approximate times of 12:47 PM and 2:51 PM, review of the clinical record revealed there was no documentation which provided evidence the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the recertification period of 01/16/2025 through 03/16/2025 included 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. Patient #6 (PDN Client): On February 14, 2025 at approximately 12:38 PM and February 18, 2025 at approximately 1:08 PM, review of the clinical record there was no documentation which provided evidence the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the recertification period of 01/17/2025 through 03/17/2025 included 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. Patient #8 (PDN Client): On February 14, 2025 at approximately 2:55 PM, February 18, 2025 between at approximately 12:49 PM and February 19, 2025 at approximately 3:30 PM, review of the clinical record revealed there was no documentation which provided evidence the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment for the initial certification period of 01/29/2025 through 03/29/2025 included 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. During interview conducted on February 21, 2025 at approximately 3:30 PM, the PDN Director, Administrator and CEO confirmed there was no documentation in the clinical record which provided evidence the “Home Health Certification and Plan of Care”/Addendum to the Plan of Treatment included 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 for the above identified patients.”

“Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This Element is not met as evidenced by: Based on review of agency policy/procedure, clinical records and personnel files, and based on interview with the Private Duty (PDN) Director (CEO-Employee #5), the Administrator (Employee #2) and the Chief Executive Officer (Employee #13), the agency failed to ensure 75 hours of home health aide (HHA) training, including 16 hours of classroom and 16 hours of supervised practical training had been completed by two (2) of two (2) HHA’s whose date of hire was after August 21, 2023. (Employees #9 and #10) Findings include: On February 21, 2025 at approximately 1:50 PM, review of policy 2-952, titled “Home Health Aide Training/Competency Evaluation”, revealed the following: Policy...Home health aide employees’ skill training will be performed upon hire... Procedure...Pass competency test... Patient #6 (PDN Client): On February 14, 2025 at approximately 12:38 PM, February 18, 2025 at approximately 1:08 PM, review of the clinical record revealed the two (2) home health aides (HHA-Employees #9 and #10) provided HHA services in January and February 2025. On February 12, 2025 at approximately 12:55 PM, February 13, 2025 at approximately 11:58 AM, February 14, 2025 between the approximate times of 9:47 AM and 3:15 PM, February 18, 2025 between the approximate times of 12:30 PM and 1:13 PM and February 20, 2025 at approximately 3:45 PM, review of personnel file documentation revealed the following: Employee #9: The date of hire of the HHA was 02/05/2024. The first date of assignment (clock-in date) to provide HHA services was 02/09/2024 which was the four (4) days after the date of hire. Review of personnel file documentation revealed the “Home Health Aide Skills Check List-Golden Care of NEPA” and “HHA Training Quiz” were completed on 02/12/2024 which was after the first date of assignment. There was no documentation on the personnel file which provided evidence the HHA completed a total of 75 hours of HHA training, including 16 hours of classroom and 16 hours of supervised practical training. Employee #10: The date of hire of the HHA was 01/15/2024. The first date of assignment (clock-in date) to provide HHA services was 01/18/2024 which was the three (3) days after the date of hire. Personnel file documentation revealed the “Home Health Aide Skills Check List-Golden Care of NEPA” was completed on 01/15/2024 but the personnel file did not include documentation the “HHA Training Quiz” had been completed. Review of the “SwiftShift” Certificate of Completion revealed the HHA completed 75 hours of HHA training, which included 16 hours of in-person training but there was no documentation on the personnel file which provided evidence the HHA completed a total of 16 hours of classroom and 16 hours of supervised practical training. During interview conducted on February 21, 2025 at approximately 3:30 PM, the PDN Director, the Administrator and the CEO confirmed there was no documentation in the personnel file which provided evidence Employees #9 and #10 had completed a total of 75 hours of HHA training and/or 16 hours of classroom and 16 hours of supervised practical training.”

“HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This Element is not met as evidenced by: Based on review of agency policy/procedure, clinical records and personnel files and based on interview with the Private Duty (PDN) Director (Employee #5), the Administrator (Employee #2) and the Chief Executive Office (CEO-Employee #13), the agency failed to ensure the home health aide (HHA) competency evaluation program completed by one (1) of two (2) HHA’s included all required subject matter. (Employee #10) Findings include: On February 21, 2025 at approximately 1:50 PM, review of policy 2-952, titled “Home Health Aide Training/Competency Evaluation”, revealed the following: Policy...Home health aide employees’ skill training will be performed upon hire... Procedure...Pass competency test... Patient #6 (PDN Client): On February 14, 2025 at approximately 12:38 PM, February 18, 2025 at approximately 1:08 PM, review of the clinical record revealed the two (2) home health aides (HHA-Employees #9 and #10) provided HHA services in January and February 2025. Tasks included on the HHA Plan of Care included, but were not limited to, the following: -Check skin condition; check pressure areas -Fall precautions; -Bath-assist patient; shower with assistance; and -Encourage fluids. On February 12, 2025 at approximately 12:55 PM, February 13, 2025 at approximately 11:58 AM, February 14, 2025 between the approximate times of 9:47 AM and 3:15 PM, February 18, 2025 between the approximate times of 12:30 PM and 1:13 PM and February 20, 2025 at approximately 3:45 PM, review of personnel file documentation revealed the following: Employee #10: The date of hire of the HHA was 01/15/2024. The first date of assignment (clock-in date) to provide HHA services was 01/18/2024. Review of the “Home Health Aide Skills Check List-Golden Care of NEPA” and the undated “SwiftShift” Certificate of Completion failed to provide evidence the following subject matter was included in the HHA’s training/competency evaluation program: v) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor. (vi) Maintenance of a clean, safe, and healthy environment (ix) Tub bath and shower (xii) Adequate fluid intake. During interview conducted on February 21, 2025 at approximately 3:30 PM, the PDN Director, the Administrator and the CEO confirmed there was no documentation which provided evidence the HHA competency training/evaluation program completed by Employee #10 included the above referenced subject matter.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on a review of agency policy/procedures and documentation and based on interview with the Private Duty (PDN) Director, Administrator (Employee #2), Consultant (Employee #12)) and the Chief Executive Officer (CEO-Employee #13), the Governing Body (Board of Directors) and the Administrator failed to appoint one (1) of one (1) qualified alternate to the administrator. (Assistant Administrator) Findings Included: On February 13, 2025 at approximately 11:34 AM, review of policy 8-008, titled “Designation of Individual in Absence of Executive Director/Administrator” revealed the following under “Policy”...will have an Executive Director/Administrator or designee available at all times. On February 13, 2025 at approximately 11:32 AM,, review of the policy 8-002, titled “Governing Body”, revealed the following: Policy: The Governing Body will assume full legal authority, responsibility and accountability for the overall management and operations... On February 13, 2025 at approximately 1:34 PM, review of the “Administrator” job description revealed the following: The Administrator is responsible for the overall leadership, management and operational oversight of the agency. This includes compliance with Federal, state and local regulations. On February 11, 2025 at approximately 11:38 AM, review of the “Organizational Chart” revealed the Assistant (Alternate) Administrator position was “vacant at present time”. On February 11, 2025 at approximately 1:38 PM, review of Governing Body meeting minutes documentation dated 10/15/2024 and 01/16/2025 failed to reveal the Governing Body appointed a qualified designated alternate to the administrator (Assistant Administrator). During interview conducted on February 14, 2025 at approximately 4:01 PM, the Administrator, PDN Director and Consultant confirmed there was no documentation which provided evidence that a qualified alternate to the administrator had been appointed by the Governing Body nor the Administrator. During interview conducted on February 21, 2025 at approximately 3:30 PM, the CEO confirmed there was no documentation which provided evidence a qualified alternate to the administrator had been appointed by the Governing Body nor the Administrator.”