Golden Health Services Inc

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 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.

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.

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.

The agency failed to establish and maintain an emergency preparedness communication plan that included contact information for local/regional/state/federal emergency preparedness staff.

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).

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…

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).

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).

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).

The facility failed to ensure the emergency preparedness plan included the names and contact information for agency staff.

The agency failed to include sufficient documentation for an unannounced drill, tabletop exercise, emergency drills or participate in a full-scale community-based exercise.

The agency failed to follow its policy regarding transmitting OASIS (outcome and assessment information set) for one (1) of one (1) clinical records receiving skilled services over the age of eighteen.

The agency failed to ensure that a comprehensive assessment included a review of all medications that the patient was currently using in order to identify any potential adverse effects, drug reactions, significant side effects, significant drug interactions, ineffective drug therapy and…

The agency failed to follow the plan of treatment for visit frequency and failed to ensure the physican was notified about missed visits and/or failed to ensure the patient's files contained complete skilled nursing visit documentation for seven (7) of eight (8) clinical records reviewed (CR # 1…

The agency failed to ensure home health aide training of at least 75 hours of classroom instruction for two (2) of three (3) Home Health Aides Personnel Files (PF) . (PFs # 1 & 3) Findings include: Review of policy on 6/12/19 at approximately 12:00 P.M titled "Home Health Aide" stated "The Home…

The agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control guidelines for four (4) of ten (10) personnel files reviewed.

The agency failed to complete a comprehensive assessment within five (5) days of the end of the certification period for two (2) of three (3) CR reviewed.

The agency failed to ensure that the plan of care contained orders for care delivery that included the amount, frequency and duration of services for one (1) of three (3) clinical records reviewed.

The agency failed to provide a written summary to the physician at least every 60 days for two (2) of three (3) CR reviewed that contained more than one certification period.

The agency failed to follow its policy regarding alerting the physician to any changes in the patient's condition for two (2) of three (3) CR reviewed.

The agency failed to follow its policy regarding alerting the physician to any changes in the patient's condition for two (2) of three (3) CR reviewed.

The agency failed to follow its policy regarding Tuberculosis screening for one (1) of four (4) PF reviewed.