Golden Health Services Inc.

“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 review of Emergency Preparedness documentation and an interview with the administrator, the agency failed to maintain documentation for review/update of the emergency preparedness plan with all required elements every two (2) years since 2019. Findings include: A review of agency policy titled, “Emergency Management Policy” conducted on July 1, 2025, at approximately 11:00 AM states, “The agency will develop and maintain a written emergency management plan describing the process for disaster readiness and emergency management and implements it as appropriate...” Policy did not contain any documentation as to how often the policy will be reviewed/updated. A review of QAPI meeting minutes dated 9/26/2024; 12/16/2024; 3/31/2025; and 6/25/2025 conducted on July 2, 2025, at approximately 11:00 AM, did not contain any documentation regarding the annual review of the Emergency Preparedness program. A review of Governing Body meeting minutes dated 2/10/2025 conducted on June 1, 2025, at approximately 12:35 PM, did not contain any documentation regarding the annual review of the Emergency Preparedness program. A review of agency’s Emergency Preparedness Program conducted on July 1, 2025, at approximately 1:00 PM revealed no documentation that the facility reviewed or updated the emergency preparedness plan with all required elements every two (2) years since 2019. An interview with the administrator on July 2, 2025, at approximately 11:00 am confirmed the above findings.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on an interview with the administrator, review of agency policy, and the agency’s emergency preparedness plan, the agency failed to base the emergency preparedness plan on/or to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: A review of agency policy “Emergency Management Policy” was conducted on July 2, 2025, at approximately 10:30 AM. Policy states, “Golden Health Services conducts an analysis to identify potential emergencies and the direct and indirect effects these emergencies may have on agency operations and the demand for services...” Policy did not indicate a time frame for completion of the facility-based and community-based risk assessment, utilizing an all-hazards approach. A review of the agency emergency preparedness plan conducted on July 1, 2025, at approximately 1:30 PM revealed no documentation that the emergency preparedness plan based on/or included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach was updated/reviewed since 2019. Interview with the administrator conducted on July 2, 2025, at approximately 11:00 AM confirmed the above findings.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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 the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on a review of agency policy, emergency preparedness documentation, and interview with the administrator, the agency failed to develop an emergency plan that addressed patient population, including, but not limited to, persons at-risk; the types of services the agency had the ability to provide in an emergency; and continuity of operations, including delegation of authority and succession plans. Findings include: A review of agency policy titled “Emergency Management Policy” conducted on July 1, 2025, at approximately 10:10 AM states, “A classification system will be identified within the agency to determine client acuity and need for services during an emergency. This classification would be used to assure client with immediate needs are seen during this time or alternate arrangements are made...” A review of agency’s Emergency Preparedness Plan did not provide any documentation of an emergency plan that addressed patient/client population, including, but not limited to, persons at-risk; the types of services the facility had the ability to provide in an emergency; and continuity of operations, including delegation of authority and succession plans. An interview with the administrator conducted on July 2, 2025, at approximately 11:00 AM confirmed the above findings.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on a review of agency policy, and an interview with the administrator, the agency failed to demonstrate that the emergency preparedness communication plan included the Names and Contact Information for the following: Staff, Entities providing services under arrangement, Patients’ physicians and Volunteers. Findings include: A review of agency policy titled, “Emergency Management Policy” conducted on July 1, 2025, at approximately 10:20 AM states, “A listing of all staff members and telephone numbers will be included in the agency’s on-call book. If there were actual or impending disaster, the triage system would be initiated to ensure client needs are met...” A review agency’s Emergency Preparedness Plan did not provide any documentation that included the names and contact information for all agency staff and patients’ physicians. An interview conducted with the administrator conducted on July 2, 2025, at approximately 11:00 AM confirmed the above findings.”

“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, agency’s emergency preparedness plan, and an interview with the administrator, it was determined the agency failed to establish and maintain an emergency preparedness communication plan that included contact information for local/regional/state/federal emergency preparedness staff. Findings include: A review of the agency policy “Emergency Management Policy” conducted on July 1, 2025, at approximately 10:10 AM states, “Clients dependent on medical equipment that is necessary for maintaining life support will have battery pack backup available. Local authorities would be notified of these client’s high-risk status at the time of admission...The emergency plan will identify the links to local community organizations that may be needed to assist the agency in responding to client needs or who may need to utilize agency staff and resources to respond to community needs…” A review of agency’s Emergency Preparedness program did not contain any documentation of a printed copy of the communication plan that included contact information for local/regional/state/federal emergency preparedness staff. An interview with the administrator conducted on July 2, 2025, at approximately 11:00 AM confirmed the above findings.”

“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 clinical home visit observations, a review of agency policies, and an interview with the administrator, the agency failed to follow its policy pertaining to infection control for three (3) of three (3) clinical home visits conducted, (CR#1, 3, and 8). Findings Include: A review of agency policy titled “Nursing Bag Technique” was conducted on July 2, 2025 at approximately 12:30 PM. Policy states, “..Once in patient’s home, select the cleanest and most convenient work area away from children and pets, and spread the newspaper. Place bad on the newspaper….After providing care, clean all equipment with soap and water or a home health agency approved disinfectant before returning it to the bag..” On-site clinical home visits were conducted on July 1, 2025, from approximately 9:45 am- 11:30 am. CR #3 Start of Care 10/24/2022, arrived at the home at 9:45 AM. The nurse (PF#3) placed the clinical bag on the patient’s coffee table with no barrier beneath the bag. The nurse removed a blood pressure (BP) cuff and obtained patients’ blood pressure. Then put returned BP cuff to the bag without sanitizing the item. The observation revealed that there was no separation between clean equipment and equipment that was used and required sanitization. CR #1 Start of Care 11/07/2023, arrived at the home at 10:30 AM. The nurse (PF#3) placed the clinical bag on the patient’s couch with no barrier beneath the bag. The observation revealed that there was no separation between clean equipment and equipment that was used and required sanitization. CR #8 Start of Care 09/13/2021, arrived at the home at 11:00 AM. The nurse (PF#3) placed the clinical bag on the patient’s couch with no barrier beneath the bag. The nurse removed a blood pressure (BP) cuff and obtained patients’ blood pressure. Then put returned BP cuff to the bag without sanitizing the item. The observation revealed that there was no separation between clean equipment and equipment that was used and required sanitization. An interview with the agency administrator and staff conducted on July 3, 2025, at approximately 11:00 AM confirmed the above findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on a review of agency policy, clinical records (CR), and an interview with the agency Administrator, the agency failed to provide documentation showing staff completed evaluations of all patient medications per policy including but not limited to: any potential adverse effects, any drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for two (2) of seven (7) clinical records reviewed, (CR# 2 and #4). Findings include: A review of Agency policy titled “Medication Review & Reconciliation” conducted on July 2, 2025, at approximately 10:00 AM states, “Nurses preparing the plan of care and the Medication administration record must pay attention to detail, go over again, review and verify each medication for the correct patient, correct medication, correct dosage, correct route, and correct time against the physician orders, or medications listed. Nurses must compare this to the medication administration record (MAR)… Clarify and compare patient’s medication list on the plan of care (485) with the medication administration records. Reconcile the Medication and Treatment record with the current Home Health Certification and Plan of care/Physician Orders..” A review of CRs was conducted on June 30, 2025, at approximately 11:30 am and July 1, 2025, at approximately 11:00 am and completed on revealed the following: CR #2, Start of Care: 02/20/2025: Certification period reviewed 1/28/25 through 3/28/25; contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. CR #4, Start of Care: 03/20/2023: Certification period reviewed 12/22/24 through 2/19/25; contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. An interview with the agency administrator and staff conducted on July 3, 2025, at approximately 11:00 AM confirmed the above findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on a review of agency policy, clinical records (CR), and the agency administrator the agency failed to file clinical notes in accordance with its policy for two (2) of eight (8) CRs reviewed, (CR #1 and #4). Findings include: A review of agency policy titled “Contents of Clinical Record” conducted on July 1, 2025, at approximately 10:45 AM states, “Clinical notes must be written the day service is rendered and should be incorporated into the clinical record no less often then weekly. A review of CRs was conducted on June 30, 2025, at approximately 11:30 am and July 1, 2025, at approximately 11:00 am and completed on revealed the following: CR #1, Start of Care: 11/07/2023. Certification period reviewed: 04/30/2025- 06/28/2025. Orders included: SN 84 hours/week M-S overnight; 40 hours/week M-F days. File did not contain any skilled nursing (SN) notes dated 06/13/2025-06/28/2025. CR #4, Start of Care: 03/20/2023. Orders included: 63 hours/week days. Certification period reviewed: 06/14/25- 08/02/2025. File did not contain any skilled nursing (SN) notes dated 05/24/2025. An interview with the agency administrator and staff conducted on July 3, 2025, at approximately 11:00 AM confirmed the above findings.”

“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 a review of agency policy, personnel records (PF), and an interview the agency Administrator, the agency failed to be responsible for all day-to-day operations by not following its policies to provide documentation of tuberculosis testing at hire for two (2) of ten (10) PFs reviewed, (PF #2 and 7). Findings Include: A review of agency policy titled “Tuberculosis (TB) Screening Program” conducted on June 1, 2025, at approximately 12:10 PM states, “Screening will be provided upon hire to determine the baseline TB status of all health care workers and volunteers with potential exposure to aerosolized M. tb and will include two-step skin testing, as appropriate...” A review of PF’s conducted on June 30, 2025, from approximately 10:30 AM to 11:40 AM revealed the following: PF #2, RN, Date of Hire: 1/7/25, contained documentation of a negative QuantiFERON test dated 10/5/2023. PF #7, HHA, Date of Hire: 8/9/22, contained documentation of only one negative two-step tuberculosis skin test dated 4/3/2024. An interview with the Administrator on July 2, 2025, at approximately 11:00 AM confirmed the above findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on a review of agency policies, clinical records (CR), and interview with the administrator, it was determined that the agency failed to complete and/or submit to the physician a discharge summary for two (2) of two (2) discharged CRs, (CR #6 and 7). Findings include: A review of agency policy titled “Discharge Summary” conducted on July 1, 2025, at approximately 1:00 PM states, “A discharge summary will be completed for clients discharges from Golden Health Services to record a summary of care received by the client from the start of care through discharge; to document client status at the time of discharge, identify unmet needs, and referrals initiated; to document instructions given to the client/family regarding medications, treatments, referrals, and necessary follow-up…A copy of the discharge summary is mailed to the physician…” A review of CRs conducted on June 30, 2025, from approximately 11:30 AM to 2:30 PM and July 1, 2025, from approximately 9:30 AM to 11:00 AM revealed the following: CR #6, Start of Care: 10/7/24. Discharge Date: 5/15/25. Certification period reviewed: 5/5/25 through 6/9/25. File did not contain any documentation of a discharge summary and there is no documentation that a discharge summary was sent to the physician. CR #7, Start of Care: 1/29/24. Discharge Date: 3/10/25. Certification period reviewed: 1/23/25 through 3/10/25. File did not contain any documentation of a discharge summary and there is no documentation that a discharge summary was sent to the physician. An interview with the administrator conducted on July 2, 2025, at approximately 11:00 AM confirmed the above findings.”