Paragon Home Health Care Inc

The home health agency failed to send all necessary medical information pertaining to the patient’s current course of illness and treatment to the receiving health care practitioner to ensure a safe and effective transition of care (see tag G0564).

The agency failed to send all necessary medical information pertaining to the patient’s current course of illness and treatment to the receiving health care practitioner to ensure a safe and effective transition of care in 3 of 4 closed records reviewed.

The agency failed to ensure the patient had the right to participate in care in 1 of 1 closed record reviewed with care transferred to a urologist (a physician specializing in the care of the urinary tract).

The agency failed to ensure the patient and the physician responsible for the plan of care were notified that a discharge from the agency was being considered for cause in 1 of 1 closed clinical record reviewed for discharge for cause.

The agency failed to make efforts to resolve the problems presented by the patient’s behavior in 1 of 1 closed clinical record reviewed for discharge for cause.

The agency failed to provide the patient with contact information for other home care agencies who may be able to provide care in 1 of 1 closed clinical record reviewed for discharge for cause.

The skilled nurse failed to develop and evaluate the plan of care in 1 of 1 active clinical record reviewed with wounds.

The skilled nurse failed to provide the services as directed in the plan of care in 2 of 3 clinical records reviewed with wounds.

The home health agency failed to send all necessary medical information pertaining to the patient’s current course of illness and treatment to the receiving health care practitioner to ensure a safe and effective transition of care (see tag G0564).

The agency failed to send all necessary medical information pertaining to the patient’s current course of illness and treatment to the receiving health care practitioner to ensure a safe and effective transition of care in 3 of 4 closed records reviewed.

The home health agency failed to ensure all orders were recorded in the plan of care in 3 of 4 active clinical records reviewed with wounds.

The agency failed to ensure services were performed in conformance with physician orders in 1 of 2 clinical records reviewed with wounds.

The home health agency failed to ensure the plans of care were revised and reviewed in 3 of 5 active clinical records reviewed.

The agency failed to ensure the physician responsible for the plan of care was notified of a new wound in 1 of 2 active clinical records reviewed with wounds.

The agency failed to ensure the coordination of care with all disciplines and agencies providing services to the patient in 2 of 5 active clinical records reviewed.

The home health agency failed to ensure licensed practical nurses were supervised by registered nurses in 2 of 2 clinical records reviewed, which received services from licensed practical nurses.

The home health agency failed to ensure the Registered Nurse (RN) conducted a review of all medications, and/or major drug-drug interactions which were reported to the physician in 5 of 9 clinical records reviewed (Patient #3, 5, 6, 8, 9).

The home health agency failed to ensure services and treatments were administered only as ordered by the physician in 5 of 7 clinical records reviewed (Patient #1, 2, 3, 5, 6).

The home health agency failed to ensure the revised plans of care included information concerning the patients’ progress toward measurable outcomes and goals identified on the plan of care in 4 of 4 clinical records reviewed with patients who received services greater than 60 days (Patient #3, 5…

The home health agency failed to ensure registered nurses completed clinical notes in a timely and/or accurate manner in 9 of 9 clinical records reviewed (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9).

The Registered Nurse (RN) failed to conduct the initial evaluation within 48 hours of referral to determine eligibility for the Medicare home health benefit, including homebound status (Please see tag G0514); failed to complete a comprehensive assessment including the administration of the OASIS…

The Administrator failed to ensure: all patients' needs were met; all medical care/treatment provided by agency staff followed the written plan of care (Please see tag G0572); failed to ensure all patients' plans of care included all required elements (Please see tag G0574); failed to ensure the…

The Administrator failed to ensure agency personnel followed infection control precautions for the prevention/control of infection/communicable disease (Please see tag G0682); and failed to track and document the COVID-19 vaccination status of all agency personnel, and/or track and document if…

The home health agency failed to ensure the Administrator was responsible for all day-to-day operations of the home health agency (Please see tag G0948); the Clinical Manager provided oversight of all patient care services and personnel (Please see tag G0958); the Clinical Manager failed to provide…

The home health agency failed to ensure the patient's clinical record contained the current comprehensive reassessment and updated/revised plan of care (Please see tag G1012); failed to ensure the clinical record evidenced the name/contact information for the patient's primary care…

The home health agency failed to ensure all medical care/treatment provided by agency staff followed the written plan of care; and/or failed to ensure the plan of care was reviewed and signed by the certifying physician, for 8 of 8 clinical records reviewed (#1, 2, 3, 4, 5, 6, 7, 8).

The Administrator failed to ensure agency personnel followed infection control precautions for the prevention/control of infection/communicable disease for 3 of 3 home visits observed (Patient #2, 6, 9).

The home health agency failed to track and document the COVID-19 vaccination status of all agency personnel, and/or track and document if agency personnel received any COVID-19 booster doses, for 10 of 12 personnel records reviewed that did not have documented proof of exemption for COVID-19…

The Clinical Manager failed to provide oversight of all personnel, for 13 of 13 personnel records reviewed (Licensed Practical Nurse [LPN] #1, LPN #2, Certified Nursing Assistant [CNA] #1, CNA #2, Registered Nurse [RN] #1, RN #2, Clinical Manager, alternate Clinical Manager, Certified Occupational…

The home health agency failed to retain all patients' clinical records per State/Federal regulation, for 10 of 10 random patients sampled without clinical record review (#10, 11, 12, 13, 14, 15, 16, 17, 18, 19), and per the agency's own admission, 1 of 1 active patient records reviewed with missing…

The home health agency failed to ensure it safeguarded all patients' clinical record information against loss or unauthorized use.

The Registered Nurse (RN) failed to conduct the initial evaluation within 48 hours of referral to determine eligibility for the Medicare home health benefit, including homebound status, for 7 of 8 clinical records reviewed (#1, 2, 3, 4, 5, 6, 7), and 1 of 1 random patient selected who's initial…

The Registered Nurse (RN) failed to complete a comprehensive assessment including the administration of the OASIS (Outcome and Assessment Information Set) during the last 5 days of every 60 day certification period, for 2 of 2 home visits observed with an RN (#2, 6).

The Registered Nurse failed to ensure a comprehensive assessment was completed for 1 of 3 clinical records reviewed with patients who were hospitalized during the certification period (#1).

The Registered Nurse (RN) failed to complete a comprehensive assessment upon discharge, for 3 of 3 clinical records reviewed for patients who were discharged from the agency (#1, 5, 7).

The home health agency failed to ensure all patients' plans of care included one or more of the following: all services provided, all pertinent diagnoses, the patient's mental status, types of services and/or equipment required, frequency and duration of visits, nutritional requirements…

The home health agency failed to ensure the patient's plan of care was reviewed by the certifying physician, for 4 of 4 clinical records reviewed where a significant change in condition occurred that required an updated plan of care (#1, 3, 4, 5); and failed to ensure the patient's plan of care was…

The Registered Nurse (RN) failed to review the plan of care in partnership with the patient and/or caregiver for 2 of 2 home visits observed with an RN (#2, 6).

The Registered Nurse failed to provide patient and/or caregiver education as ordered on the patient's plan of care, for 2 of 2 home visits observed with an RN (#2, 6).

The Registered Nurse (RN) failed to ensure the Home Health Aide (HHA) provided care/services as ordered/included on the plan of care for 3 of 3 clinical records reviewed with patients who received HHA services (#1, 5, 8).

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

The home health agency failed to ensure the Clinical Manager was available during all operating hours.

The Clinical Manager failed to provide oversight of patient and personnel assignments.

The Clinical Manager failed to ensure coordination of care occurred with other agency personnel, physician(s), and other entities who provided care/treatment to meet the patient's needs, for 2 of 2 home visits observed (#2, 6).

The home health agency failed to ensure the Clinical Manager evaluated each patient referral to determine the appropriateness for home care.

The Clinical Manager failed to ensure the patients' needs were assessed, for 2 of 2 home visits observed with a Registered Nurse (RN) (#2, 6).

The Clinical Manager failed to ensure clinical services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice, for 2 of 2 home visits observed (#2, 6).

The home health agency failed to ensure the clinical record evidenced the name/contact information for the patient's primary care physician/practitioner, for 1 of 8 clinical records reviewed (#1).

The home health agency failed to ensure a transfer and/or discharge summary was completed and sent to the appropriate physician/practitioner and/or or receiving facility, for 4 of 4 records reviewed with patients who were transferred with inpatient admission and/or discharged from the agency (#1…

The agency failed to develop an emergency preparedness policy for the use of volunteers for 1 of 1 agency emergency preparedness plan.

The agency failed to evidence a community wide drill and a table top exercise was completed for 1 of 1 agency's emergency preparedness plan reviewed.

The home health agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system for 1 of 10 records reviewed within 30 days of completing the assessment (#1).

The agency failed to ensure treatment and services were provided per the physician ordered plan of care for 3 of 10 records reviewed (#4, #5, #7 ) The findings include: 1. An undated policy titled "Care Planning Process" stated, "Definitions 1. Plan of Care The clinical plan of care includes ...…

The agency failed to ensure 5 of 7 contract personnel files (#K, #L, #M, #W) reviewed were complete.

The agency failed to ensure clinical records reviewed included entries which were authentic and appropriately dated / timed for 3 of 10 records reviewed (#1, #2,#10).

The agency failed to ensure a written notice of the patient's rights were provided before the initiation of treatment in 2 of 3 clinical records reviewed (#6 and #9) of patients living in assisted living facilities and receiving home care services from this agency.

The agency failed to investigate the complaint made by a patient or patient family or legal representative about treatment or care that was not furnished for 1 of 4 closed records reviewed (#4).

The agency failed to update it's "Initial and Comprehensive" policy and follow it's "Admission Criteria and Process" policy to ensure a registered nurse performed an initial assessment within 48 hours of referral, hospital discharge, or physician ordered start of care date, to determine the…

The agency failed to ensure the registered nurse accurately assessed the patient's health status with the comprehensive assessment for 1 of 4 closed records reviewed (#1).

The agency failed to ensure the plan of care was updated to include a frequency, duration of visits and location of wound treatment to be provided in 2 out of 10 records reviewed.

The agency failed to follow their policy and ensure verbal orders were authenticated and dated by the physician within 30 days for 3 of 10 records reviewed (#1, 2, 10).

The agency failed to ensure a registered nurse assessed a patient's wound at least weekly, licensed practical nurse failed to provide an accurate ongoing assessment of a wound for 1 of 4 closed records reviewed (#4) and occupational therapy assistant failed to conduct an accurate pain assessment in…

Skilled nursing and physical therapy failed to ensure treatment and services were provided per the physician ordered plan of care for 3 of 10 records reviewed (#4, #5, #7 ) The findings include: 1. An undated policy titled "Care Planning Process" stated, "Definitions 1. Plan of Care The clinical…

The administrator failed to organize and direct the agency's ongoing functions for 1 of 1 agency.

The agency failed to ensure signed physician orders were filed in patients medical record within a timely manner for 1 of 10 records reviewed.

The agency failed to ensure the clinical record included a completed discharge summary for 1 of 4 closed records reviewed (#4).