Golden Home Healthcare

ADON #4 confirmed the assessments were not countersigned by a physician, and revealed the assessment was not the same as a plan of care.

The Condition of Participation 484.65, QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT, was out of compliance: G642 Program Scope - The agency failed to implement a quality assessment and performance improvement (QAPI) program which evaluated all agency services and showed measurable improvement in…

G948 - Standard: The Administrator failed to organize and direct the agency's day to day operations.

The agency failed to implement a quality assessment and performance improvement (QAPI) program which evaluated all agency services, showed measurable improvement in indicators for which there was evidence the improvements would show positive health outcomes and quality of care and complied with the…

The agency's governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained; home health agency (HHA) - wide quality assessment and performance improvement (QAPI) efforts addressed priorities for improved quality of care and…

The agency failed to ensure each patient's plan of care included all pertinent diagnoses and accurate wound care treatments for 1 of 5 patient records reviewed with an established plan of care (Patient #4).

The agency failed to ensure wound care services and treatments were administered by agency staff only as ordered by a physician for 2 of 7 patient records reviewed who received services for wound care (Patients #4 and #8).

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

The agency failed to ensure nursing staff promptly alerted the physician of changes in the patient's needs that suggested the plan of care may need to be altered for 1 of 10 patient records reviewed (Patient #4).

The agency failed to have their Quality Assessment Performance Improvement (QAPI) focus on high risk, high volume or problem prone areas in order to improve the safety of services and quality of care.

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

The clinical manager failed to provide oversight of all patient care services and personnel in accordance with requirements set forth in regulation.