Golden Harmony Inc

The agency failed to ensure services were provided in accordance with physician's orders for 1 of 3 active patients reviewed who received blood glucose monitoring and insulin administration (Patient #4).

The agency failed to ensure the director of nursing (DON), who was also the administrator, followed accepted standard infection control practices to prevent the transmission of infections and communicable diseases for 1 of 1 patients observed receiving administration of insulin during a home visit…

The agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician for 3 of 6 active patients reviewed (Patients #3, #4 and #7).

The agency failed to ensure skilled professionals assumed responsibility for preparing and maintaining accurate and complete clinical notes for 3 of 7 patients who received skilled nursing (SN) services (Patients #3, #4 and #7).

The agency failed to ensure skilled professional services communicated with the physician involved in the plan of care and other health care practitioners related to the current plan of care for 2 of 6 active patients reviewed (Patients #2 and #4).

The agency failed to ensure certified nurse aides (CNA) received the required observed competency evaluation in accordance with regulation prior to assignment of CNA services for 1 of 2 CNA personnel records reviewed who were hired after 1/1/18 (CNA #3).

The agency failed to ensure drugs and treatments were administered by agency staff only as ordered by a physician for 2 of 3 patients reviewed who had wound care ordered (Patients #4 and #5).

The agency failed to have evidence of communication with the physician for laboratory results in 1 of 5 active patients reviewed (Patient #5).

The agency failed to ensure all nursing interventions, treatments and services provided to patients were accurately documented and included within the clinical record for 1 of 1 active patient records reviewed receiving oxygen therapy (Patient #4).

The agency failed to ensure a discharge summary was sent to the primary care practitioner within five business days of discharge and a transfer summary within two business days of becoming aware of a patient's transfer for 2 of 2 patients records reviewed requiring a transfer or discharge summary…

The agency failed to ensure clinical record entries contained clear, complete and appropriately authenticated, dated, and timed records for 5 of 7 patient records reviewed (Patient #1, #2, #3, #5 and #6).

The agency failed to ensure drugs, services and treatments were administered as ordered by a physician in 1 of 6 patients reviewed (Patient #3).

The agency failed to ensure each patient's total Plan of Care was reviewed by the physician at least every 60 days.

The agency failed to coordinate care delivery to meet the patient's needs for 1 of 2 patients reviewed who received home health and home care services (Patient #5).

The Administrator failed to organize and direct the agency's day to day operations.