Golden Heart Health Services LLC

The agency failed to transmit OASIS information for all skilled Medicaid patients utilizing federally funded health plans not meeting the transmittal requirements and failed to submit OASIS (Outcome Assessment Information Set) within 30 days of assessment completion (See tag G372) The cumulative…

The agency failed to have a signed plan of care (POC) or a verbal POC order from the primary physician before providing services and treatments (See tag G572): failed to document teaching and education provided to a patient (See tag G574); failed to follow physician orders for setting up a weekly…

The agency failed to ensure all Home Health Aides provided hands-on personal care as ordered per the plan of care (see Tag G802 ); the agency failed to ensure the Registered Nurse (RN) completed Home Health Aide Supervisory visits every 14 days (see tag G808 ), and failed to ensure the RN…

The agency failed to develop and implement policies and procedures that align with the hazards identified within its risk assessment for 1 of 1 Emergency Preparedness Program review.

The agency failed to maintain documentation of its training and testing program for emergency preparedness, as set forth in the emergency plan for 1 of 1 Emergency Preparedness Program review.

The agency failed to conduct and document the analysis of all tabletop drills, emergency events, and the agency response to the analysis for 1 of 1 Emergency Preparedness Programs.

The agency failed to submit OASIS (Outcome Assessment Information Set) within 30 days of assessment completion for 1 of 2 inactive records reviewed.

The agency failed to have a signed plan of care (POC) or a verbal POC order from the primary physician before providing services and treatments to patients for 3 of 7 active patient record reviews.

The agency failed to implement a performance improvement project for 2023 and 2024 for 1 of 1 quality performance improvement projects (QAPI) review.

The agency failed to ensure the clinical staff followed the agency’s policies for infection control practices with bag technique and hand hygiene in 4 of 5 home visit observations.

The agency failed to ensure all patients were provided with the correct and updated contact information for the administrator for 4 of 5 home visits conducted.

The agency failed to provide services as ordered on the plan of care (POC) for 4 of 7 active record reviews.

The agency failed to complete an initial assessment within 48 hours of a referral for 4 of 7 active record reviews.

The agency failed to ensure staff reviewed patient medications during a home visit for 1 of 1 recertification observations with a nurse.

The agency failed to document teaching and education provided to a patient for 1 of 1 record reviews with known cellulitis (infection).

The agency failed to follow physician orders for setting up weekly medication planner, affecting 1 of 1 observed medication set up.

The agency failed to ensure the agency coordinated care with another agency that was providing care for 3 of 7 active record reviews.

The agency failed to provide the patients and caregivers a visit schedule for the frequency of visits provided by the agency staff in 4 of 5 home visits conducted.

The agency failed to provide the patients with a medication schedule and instructions for 4 of 5 home visits.

The agency failed to ensure the patient received a current copy of medication and treatment instructions for 5 of 7 active record reviews.

The agency failed to ensure all patients were provided with a copy of written instructions outlining the name and contact information of the home health clinical manager/director of nursing for 2 of 5 home visits conducted.

The agency failed to ensure all Home Health Aides (HHA) provided assistance with Activities of Daily Living (ADLS), including bathing, showering assistance, assistance with dressings, hair care, oral care, skin care, and nail care (hands-on care), as ordered per the plan of care for 2 of 5 active…

The agency failed to ensure the Registered Nurse (RN) completed Home Health Aide Supervisory visits for patients who received skilled services every 14 days for 2 of 2 clinical records reviewed.

The agency failed to ensure the Registered Nurse (RN) documentation during supervisory visits accurately reflected the care that was being provided to the patient by the Home Health Aide (HHA) for 2 of 5 active records reviewed.

The agency failed to have a written agreement or contract with the primary Home Health agency for 2 of 2 patient records reviewed who received care from another entity.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's status at the time of the home visit for 1 of 1 home visit observations with a known wound.

The agency failed to ensure they provided information to the patients, in advance of receiving services, that included written notice of patient rights (See G412), the contact information for the administrator (See G414), and the OASIS (Outcome and Assessment Information Set) Privacy Notice (See…

The agency failed to ensure the comprehensive assessments were completed in-person to achieve accurate and complete information and were accurately and completely filled out; accurately reflected the patient's past medical history and current health, psychosocial, functional, and cognitive status…

The agency failed to ensure patients were accepted for services on the reasonable expectation the provider could meet their needs, failed to ensure the individualized plans of care specified the care and services necessary to meet the patient-specific needs as identified in the comprehensive…

The agency failed to use measurable indicators to improve outcomes, patient safety, and quality of care (G 642;) failed to use data derived from OASIS (Outcome and Assessment Information Set) assessments to monitor services and quality of care, and failed to obtain governing body approval for the…

The agency failed to ensure all home health aides had successfully completed a satisfactory training and evaluation program or a satisfactory competency evaluation program, and all aides were found to be in good standing in the state nurse aide registry (See tag G754); failed to ensure home health…

The Governing Body failed to ensure they periodically reviewed the written bylaws and assumed the full legal authority and responsibility for the operation of the home health agency by having failed to be aware of requirements of the Federal Regulations and State Rules, failed to ensure the…

The agency failed to ensure physician orders were correctly identified as faxed rather than verbal orders and failed to ensure clinicians documented the date and time with each entry authentication (See G 1024.) The cumulative effect of these systemic problems resulted in the agency's inability to…

The agency failed to ensure all patients were informed in writing of the agency's policies for transfer and discharge in 4 of 5 full active patients reviewed.

The agency failed to ensure a discharge or transfer summary that included the necessary medical information pertaining to the current course of illness and treatment, post-discharge goals of care, and treatment preferences was sent to the receiving facility or health care practitioner in 2 of 3…

The agency failed to ensure the plan of care was established with the physician/ or consulted to approve additions or modifications to the original plan of care, failed to ensure the plan of care was accurate, contained patient-specific and individualized interventions, measurable outcomes, and…

The agency failed to ensure staff implemented standard precautions, including hand hygiene, and bag technique in 2 of 3 home visits.

The agency failed to implement its own policies to ensure home health aides who had provided patient care, had successfully completed a competency evaluation program which addressed communication skills, observation/reporting/ documentation of patient status and care, reading/recording of basic…

The registered nurse failed to ensure a home health aide was provided instruction of the assigned patient to ensure all services are provided and failed to ensure the aide care plan was developed specifically to the patient needs and not "per patient request" for 3 of 6 record review of patients…

The Governing Body failed to ensure they periodically reviewed the written bylaws and assumed the full legal authority and responsibility for the operation of the home health agency by having failed to be aware of requirements of the Federal Regulations and State Rules, failed to ensure the…

The agency failed to ensure physician orders were correctly identified as faxed rather than verbal orders and failed to ensure clinicians documented the date and time with each entry authentication for 8 of 9 clinical records reviewed (1, 2, 3, 4, 6, 7, 8, 9.) Findings include: 1. Review of the…

The agency failed to ensure patients and/or patient representatives received a copy of patient rights and the agency's discharge and transfer policies in advance of furnishing care for 4 of 5 full active records reviewed.

The agency failed to ensure all patients were provided correct and updated contact information for the administrator for 4 of 5 full active patients reviewed.

The agency failed to ensure all patients received an OASIS (Outcome and Assessment Information Set) Privacy Notice in advance of services for 1 (Patient #4) of 3 patients who received skilled care of a total sample of 7 active patients whose clinical record was reviewed.

The agency failed to ensure they obtained the patient's signature confirming that he or she received a copy of the notice of rights and responsibilities for 2 of 5 active patients reviewed.

The agency failed to ensure all patients participated in and were informed about the care and services to be provided, including but not limited to disciplines, frequency, goals, and outcomes expected in 4 of 5 full active records reviewed.

The agency failed to ensure patients received all the services ordered in the plan of care for 4 of 5 full active records reviewed.

The agency failed to advise the patient and/or patient representative orally and in writing in advance of starting services of the extent to which planned services would be covered by Medicaid or any other federally funded program and the expected out-of-pocket cost to the patient in 4 of 5 full…

The agency failed to provide the patients with the toll-free home health telephone hotline information and purpose for 4 of 7 active patients reviewed.

The agency failed to document the existence and resolution of complaints made by the patient and/or patient representative in 3 of 3 records reviewed with complaints.

The agency failed to ensure that all patients received an in-person complete and accurate comprehensive assessment that included the patients' current health status, past/ current medical history, accurate psychosocial status and functional capacity, and accurate cognitive status in 8 of 9 patient…

The agency failed to ensure all patients received a detailed comprehensive assessment that included patient strengths, patient-specific care preferences, and goals that were patient-specific and measurable for 5 of 7 active patients reviewed.

The agency failed to ensure a complete and accurate assessment of the patient's medical, nursing, rehabilitative, social, and discharge planning needs in 4 of 5 active patients whose full clinical record was reviewed.

The agency failed to complete a review of all medications the patient was currently using to identify potential adverse effects, drug reactions, ineffective drug therapy, side effects, duplicate therapy, and non-compliance in 3 of 5 active patients reviewed.

The agency failed to complete the Resumption of Care assessment within 48 hours after a hospital stay, as required by agency policy, on 1 of 1 patient who required a resumption of care assessment, out of a total of 5 active patients whose clinical record was reviewed.

The agency failed to ensure discharged patients received an updated comprehensive assessment that included a summary of the patient's progress in meeting the care plan goals for 2 of 2 discharged patients whose clinical record was reviewed.

The agency failed to ensure the plan of care was individualized and included all pertinent diagnoses with their date of onset, all supplies, and equipment in the home to meet the patients' needs, specific frequency, and duration of visits, nutritional requirements, accurate medications and…

The agency failed to ensure all services, treatments, and medications were ordered by the physician that established the plan of care prior to providing services in 5 of 6 active patients reviewed.

The agency failed to ensure clinical records included information about the services the patient received from other agencies and failed to ensure they coordinated care delivery to meet the patient’s needs for 1 of 1 active patient records reviewed (Patients #6) receiving outside services.

The agency failed to provide visit schedules including frequency of the visits of the home health aide according to the most updated plan of care in 1 of 3 home visits.

The agency failed to ensure a medication list was provided to the patient in 1 of 3 home visits completed.

The agency failed to ensure all patients were provided with a copy of written instructions outlining the name and contact information of the home health clinical manager/ director of nursing for 1 out of 3 home visits.

The agency failed to ensure home health aides successfully completed a home health aide training program and/or competency evaluation program for 3 of 7 home health aide records reviewed.

The agency failed to ensure home health aides successfully completed a home health aide training program and/or competency evaluation program for 2 of 7 home health aide records reviewed.

The agency failed to ensure 5 of 7 active home health aides reviewed met the minimum requirements of 16 hours of classroom training and 16 hours of supervised training as part of the 75 hours of training.

The agency failed to maintain documentation home health aides had received in-class training and supervised training for 5 of 7 home health aide records reviewed.

The agency failed to ensure home health aides (HHA) provided services per the plan of care for 3 of 3 active complete records reviewed of patients receiving home health aide services.

The agency failed to ensure home health aides provided hands on personal care as ordered per the plan of care for 1 of 7 active records reviewed.

The Administrator failed to ensure to be responsible for all of the day-to-day operations of the home health agency.

The agency failed to ensure it employed a qualified a alternate clinical manager for 1 of 1 alternate clinical manager of the home health agency.

The agency failed to sure the services were provided according to the written physician's plan of care, as required by agency policy, for 2 (Patients #3 and 10) of 10 patients whose clinical record was reviewed.

The agency failed to ensure the home health aide establishment of skills competency included the taking of temperature, pulse, and respiration, for 1 (employee R) of 1 home health aide whose establishment of skills competency was reviewed, of a total sample of 29 home health aides employed.

The registered nurse failed to ensure the home health aide completed contained adequate code status information to honor the patient's rights (resuscitate/do not resuscitate) for 1 (Patient #3) of 10 patients whose clinical record was reviewed for 1 (Patient #3) of 10 patients.

The agency failed to document the existence of 3 complaints, for 2017, 2018 and 2019, out of a total sample of 13 incident reports in 2017, 2018, and 2019, reviewed.

The agency failed to ensure the plan of care did not include a frequency order of zero (0) for 5 (Patients #4, 5, 6, 7, and 9) of 10 patients, failed to ensure the duration of visits was ordered on the plan of care, as required by agency policy, for 3 (Patients #1, 3, and 10) of 10 patients; and…

The agency failed to ensure a verbal order for disciplines, frequency of visits, duration of visits, and care orders was obtained prior to furnishing services for 7 ( Patients #1, 2, 4, 5, 6, 8, and 10) of 10 patients who were retained on service more than 60 days.

The registered nurse failed to ensure patient's needs were continually assessed and documented in the nurse visit in relation to reported fall for 1 (Patient #3) of 2 patients with reported fall during the certification period reviewed, of a total sample of 10 patients.

The agency failed to implement its clinical documentation policy, and the interdisciplinary participation of a home health aide (employee to ensure the home health aide documented a change in the patient's condition, and failed to ensure the the nurse responsible for managing the client's care…

The registered nurse failed to ensure the home health aide had complete information to honor the patient's rights in relation to code status (resuscitate/do not resuscitate) for 1 (Patient #3) of 10 patients whose clinical record was reviewed, and failed to identify the failure of the home health…

The administrator failed to ensure 3 (Home Health Aide Medication Administration, Home Health Aide Care Plan, and Plan of Care,) of 19 policies reviewed were updated in compliance with federal and state requirements for a home health agency.

The clinical manager failed to ensure patient's needs were continually assessed in relation to reported fall for 1 (Patient #3) of 2 patients with reported fall during the certification period reviewed, of a total sample of 10 patients.

The clinical manager failed to ensure the plan of care was implemented, as required by agency policy, for 2 (Patients #3 and 10) of 10 patients whose clinical record was reviewed.