Golden Plus Home Health Care

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status, past medical history, history of events leading to home care, baseline data for future assessments, and ascertained the patient's immediate care needs in 1 (P-7)…

The agency failed to provide skilled nursing (SN) and physical therapy (PT) services as ordered in the plan of care for 1 (P-6) of 7 records reviewed, out of a total sample of 7 records reviewed.

The agency failed to define abbreviations documented in the clinical record in 1 (P-1) of 7 records reviewed and failed to maintain required elements of the clinical record in 1 (P-7) of 7 records out of a total sample of 7 records reviewed, resulting in documentation that is missing and may be…

The agency failed to inform patients of the appropriate phone number for the State of Michigan's toll-free hotline for 7 of 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) records reviewed, resulting in a lack of required information to enable patients or caregivers to voice complaints or ask questions.

The agency failed to conduct the Start of Care (SOC) assessment within 48 hours of the referral in 3 (P-2, P-5, and P-7) of 7 records reviewed, resulting in the delay of patient care and the potential for poor clinical outcomes.

The agency failed to ensure the comprehensive assessment incorporated a review of all medications the patient is currently prescribed, and to determine interactions, adverse effects, or duplicate drug therapy in 2 (P-1, P-7) of 7 records reviewed, and failed to review for any potential medication…

The agency failed to ensure the goals on the Plan of Care (POC) were objectively measurable to determine the patient's progress towards meeting pre-established goals in 5 (P-1, P-2, P-3, P-4, P-6) of 7 records; and failed to include reportable parameters concerning abnormal blood sugar readings in…

The agency failed to provide services as ordered in the Plan of Care in 2 (P-2, P-6) of 7 records reviewed out of a total sample of 7 records, resulting in the patient not receiving interventions needed to evaluate the patient's current healthcare status.

The agency failed to ensure a discharge summary was sent to the physician after the patient was discharged from the agency in 3 (P-1, P-3, P-4) of 6 records reviewed in which the patient was discharged, and failed to produce evidence of a discharge summary in the patient's medical record in 1 (P-5)…