Golden Home Health Care

The agency failed to ensure staff provided quality care through the establishment of a written plans of care, conformance with physicians orders and adherence to written policies.

The agency failed to ensure competency of skilled nursing staff through documentation of competency skill assessments.

The agency failed to ensure organization, management, and administration of its resources to attain and maintain the highest practicable functional capacity including providing optimal care to achieve the goals and outcomes identified in the patients’ plans of care.

The agency failed to ensure medical records that are accurate, complete, and adherent to current clinical record documentation standards of practice.

The agency failed to ensure that the emergency preparedness plan was updated with change of ownership and location of agency for one (1) of one (1) plan reviewed.

Agency Administrator the agency failed ensure the emergency plan was specific for the current location for one (1) of one (1) plan reviewed.

The agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for five (5) of fourteen (14) records reviewed.

The agency failed to ensure that the clients had individualized plans of care in nine (9) of nine (9) medical records reviewed.

The agency failed to ensure conformance with physician orders for six (6) out of nine (9) medical records (MR # 1-3, # 6, and #8-9) Review of medical records completed January 24, 2023, between approximately 1:30 PM to 2:00 PM and January 26, 2023, between approximately 2:30 PM to 3:30PM revealed…

The agency failed to ensure staff had health screenings for Mycobacterium tuberculosis upon hire for nine (9) out of nine (9) files (PF # 1- # 9) and on an annual basis for five (5) out of nine (9) files (PF #1-2, # 6-7 and PF # 9) Findings include: The CDC guidelines state that all Health Care…

The agency failed to ensure that skilled nursing staff had pediatric competencies completed upon hire for four (4) out of four (4) files (PF # 1- # 4) Findings include: Review of Golden Home Healthcare Registered Nurse (RN) job description on February 14, 2023 at 12:25 PM revealed: “Organizational…

The governing body failed to ensure the overall operation of the agency to ensure the agency provided services in a compliant manner through appropriate plans of care and adherence to written policies and procedures.

The Agency administrator failed to ensure the agency adhered to written policies and procedures, was compliant in adhering to all federal, state, and local regulations and provided services in a compliant manner through appropriate plans of care.

The agency director of nursing (DON) failed to ensure that staff had pediatric competencies completed upon hire for nine (9) out of nine (9) files (PF # 1- # 9); failed to ensure that staff had pediatric competencies and performance evaluations completed on an annual basis for five (5) out of nine…

The agency failed to ensure medical records contained adequate and complete documentation.

Agency administrator the agency failed to ensure that treatment or care was furnished appropriately for six (6) of nine (9) records reviewed.

Agency Administrator the agency failed to ensure an update of the comprehensive assessment was completed within the last five (5) days of every sixty (60) days for one (1) of one (1) skilled record reviewed.

Agency administrator the agency failed to ensure that home health aide care plans contained visit frequency for eight (8) out of eight (8) files (MR # 2-9).

The agency administrator failed to ensure that the agency employed qualified personnel in four (4) out of four (4) files.

The agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for five (5) of fourteen (14) records reviewed.

The agency failed to ensure physicians' orders were signed within established timeframe for one (1) of seven (7) records reviewed.

The agency failed to coordinate patient services for one (1) out of seven (7) medical records reviewed.

The agency failed to ensure that the client received all services as ordered by the physician for one (1) out of seven (7) records reviewed.

The agency failed to ensure staff provided quality care through the establishment of a written plans of care, conformance with physicians orders and adherence to written policies.

The agency failed to ensure a qualified administrator or clinical manager was available at all times to direct agency ongoing functions for staff, provide services in a compliant manner through implemented plans of care, and adherence to written policies and procedures.

The agency failed to ensure a plan of care was established for five (5) of ten (10) records reviewed.

The agency failed to ensure conformance with physician's orders for six (6) out of ten (10) records reviewed.

The agency failed to coordinate patient services for three (3) out of ten (10) medical records reviewed.

The agency failed to ensure employment of a qualified individual to act as Director of Nursing for one (1) of one (1) files reviewed.

The agency failed to ensure that the client received all services as ordered by the physician for two (2) out of ten (10) records reviewed.

The agency failed to conduct the initial visit, made by the RN, within forty eight (48) hours of the referral for one (1) of ten (10) medical records (MR) reviewed.

The agency failed to ensure physicians' orders were signed within established timeframe for seven (7) of ten (10) records reviewed.

The agency failed to ensure that there was a Clinical Manager/ Alternate Administrator available during all business hours for one (1) of one (1) agency surveyed.

The agency failed to ensure that the plan of care was implemented in five (5) of ten (10) records reviewed.

Staff (EMP) the agency failed to ensure that the physician was notified of a patient's discharge/transfer from the agency (H 1022); failed to ensure the medical record contained a discharge/transfer summary ( H1010).

Personnel files (PF) and interviews with staff (EMP) the agency failed to ensure annual performance evaluations were completed for staff for seven (7) of eleven (11) files reviewed; failed to ensure staff maintained current Cardiopulmonary Resuscitation (CPR) certifications for two (2) of eleven…

The agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for one (1) of thirteen (13) records reviewed.

The agency failed to ensure that the medical record contained discharge/transfer summaries for (1) of thirteen (13) records reviewed.

The agency failed to ensure that personnel met all essential training requirements of employment for one (1) of eleven (11) files reviewed.

The agency failed to ensure that personnel met all essential training requirements of employment for one (1) of eleven (11) files reviewed.

The agency failed to conduct the initial visit in forty eight (48) hours of the referral for five (5) of thirteen (13) medical records (MR) reviewed.

The agency failed to ensure staff completed required home health aide supervisory visits by a skilled licensed professional stated in the agency policy, every two weeks for the patients receiving home health aide care for one (1) of thirteen (13) clinical records.

The agency failed to ensure that discharge summaries and/or transfer summaries were maintained in the medical record for one (1) of thirteen (13) records reviewed.