Golden Care of Northeast PA, Inc

The agency failed to ensure clinical notes retrievable two (2) of five (5) patients.

The agency failed to ensure discharge planning was conducted in accordance with agency policy/procedures for two (2) of two (2) planned discharges.

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.

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.

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.

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.

The agency failed to ensure the parents of three (3) of three (3) patients were involved in the care planning (coordination) process.

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…

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…

The agency failed to ensure the parent of three (3) of three (3) pediatric patients were involved in the care planning (coordination) process.

The Administrator failed to ensure two (2) of two (2) skilled nursing (SN) staff maintained patient confidentiality in accordance with agency policy/procedures.

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.

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.

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.

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.

The Governing Body failed to ensure one (1) of one (1) administrator completed an orientation for the duties of administrator upon employment.

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.

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…

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.

The agency failed to ensure the emergency preparedness plan included the contact information for two (2) of three (3) Federal or state agencies.

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.

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.

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.

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…

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…

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.

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…

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)…

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…

The agency failed to maintain a CLIA Certification of Waiver for 6 of 6 months after expiration of the CLIA Certification of Waiver.

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.…

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)…

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.

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.

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…

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.

The Governing Body (Board of Directors) and the Administrator failed to appoint one (1) of one (1) qualified alternate to the administrator.

The agency failed to ensure tuberculosis (TB) screening was completed for one (1) of two (2) health care staff members who began employment in 2023. (Employee #1) Finding include: On June 7, 2023 at approximately 3:42 PM, review of the CDC TB screening guidance for health care personnel revealed…

The agency failed to ensure a comprehensive nursing assessment was completed upon agency discharge for one (1) of two (2) private duty nursing (PDN-adult/pediatric shift care) clients (patients).

The agency failed to ensure a discharge summary was forwarded to the physician within 5 business days of the agency discharge date for two (2) of two (2) private duty nursing (PDN-shift care of adult/pediatric patients).

The agency failed to ensure the primary home health service was initiated on the physician ordered start of care date for two (2) of three (3) PDN (pediatric shift care) clients (patients) for whom home health services were initiated after March 6, 2023. (Clients #6 and #7) Findings include: On…

The agency failed to ensure the home health aide (HHA) plan of care was developed in accordance with agency policies/procedures for two (2) of two (2) PDN (pediatric shift care) clients (patients) for whom HHA services were provided . (Clients #6 and #7) Findings include: On April 28, 2023 at…

The agency failed to ensure clinical record entries were completed as per agency policy and procedure for two (2) of five (5) PDN (pediatric shift care) clients (patients).

The agency failed to ensure the initial nursing assessment was completed by the registered nurse (RN) on the physician ordered start of care date for three (3) of three (3) PDN (pediatric shift care) clients (patients) who were admitted to services after March 6, 2023. (Clients #3, #6 and #7)…

The agency failed to ensure skilled nursing (SN) services were provided per the frequency ordered on the "Home Health Certification and Plan of Care" for two (2) of three (3) active PDN (pediatric shift care) clients (patients).

The governing body failed to ensure lines of authority included on organizational charts were approved by the governing body (G0942), the administrator failed to maintain documentation which provided evidence that the supervising RN (clinical manager) or similarly qualified alternate was available…

The facility failed to complete a facility and community based all-hazard risk analysis review ("Hazard and Vulnerability Assessment Tool") after February 17, 2020. Findings include: On July 27, 2022 at approximately 9:59 AM, review of agency emergency preparedness plan/program (EP/P) revealed the…

The agency failed to ensure initial emergency preparedness training was completed by four (4) of eight (8) staff members who were hired after February 12, 2020. (Employees #4, #8, #11 and #12) Findings include: On July 27, 2022 at approximately 9:59 AM, review of "Emergency Preparedness Plan"…

The agency failed to ensure infection control education was provided to/completed by four (4) of eight (8) nursing staff members who were hired after February 12, 2020. (Employees #4, #8, #11 and #12) Findings include: On July 28, 2022 at approximately 9:55 AM, review of the agency policy titled…

The agency failed to ensure COVID-19 mitigation precautions were implemented for two (2) of two (2) unvaccinated staff members who were observed during the survey.

The governing body failed to ensure lines of authority included on two (2) of two (2) organizational charts were approved by the governing body.

The agency failed to ensure the name of the administrator, in order to receive complaints, was included on the patient rights forms provided to three (3) of three (3) patients whose admission folder/binder was available for review during the onsite home visit.

The agency failed to ensure a comprehensive nursing assessment was completed aa RN at the start of care for three (3) of three (3) active PDN patients, (Patients #2, #5 and #6) Findings include: On July 27, 2022 at approximately 11:35 AM, review of the agency document titled "Home Health Regulatory…

The agency failed to ensure OASIS data collection was completed for one (1) of one (1) patient who was 18 years old at the time of admission to the agency.

The agency failed to ensure three (3) of three (3) licensed practical nursing (LPN) staff notified the PDN Clinical Manager (Employee #2) of the need to alter patient/client treatments or documentation procedures.

The agency failed to ensure a written visit frequency was provided to three (3) of three (3) patients whose admission folder was available for review during the onsite home visit.

The agency failed to ensure a written treatment instructions were provided to two (2) of two (2) patients whose admission folder was available for review during the onsite home visit.

The agency failed to ensure the name of the SNV clinical manager (Employee #1) was provided to two (2) of two (2) SNV patients whose admission folder was available for review during the onsite home visit.

Chapter 601, and based on interview with the Administrator/Skilled Nursing Division (SNV) Clinical Manager/Registered Nurse (RN-Employee #1), the Director of Clinical Excellence/Alternate Administrator/Private Duty Nursing (PDN) Clinical Manager/RN (Employee #2) and the Chief Executive Officer…

The administrator/alternate administrator (Employees #1 and #2) failed to ensure a competency evaluation/hands-on skills demonstration was completed prior to the assignment of six (6) of six (6) nursing staff to provide skilled nursing (SN) care to or oversight of tracheostomy (artificial airway…

The agency failed to ensure the contact information for the Centers of Independent Living, Protection and Advocacy Agency and/or Aging and Disability Resource Center were included on patient rights notification forms provided to two (2) of two (2) patients whose admission folder was available for…

The agency failed to ensure written information/instructions regarding the means to access auxiliary aids (accessible web sites, assistive aids identified in the American's with Disabilities Act) and language services were included on the patient rights notification forms for two (2) of two (2)…

The agency failed to ensure the "Home Health Certification and Plan of Care" included advance directive information for five (5) of five (5) active patients.

The agency failed to ensure the name and contact information for the clinical manager was provided in writing to two (2) of two (2) patients whose admission folder was available for review during the onsite home visit.