Paramount Home Health

The agency failed to ensure a patient centered QAPI Program for future patients and all current employees.

The agency failed to ensure governing body oversite of a patient centered, data driven QAPI Program, and the program evaluation for calendar year 2022 and 2023 affecting all future patients and current staff.

The agency failed to ensure the retention of clinical records for (an unknown number) all previous patients.

The agency failed to ensure an emergency preparedness disaster tabletop exercises and drills were conducted for calendar years 2022 and 2023 for all patients and all current staff members.

The agency failed to ensure evidence of a patient centered QAPI Program for future patients and current employees.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all future patients and current employees.

The agency failed to ensure conduction of patient centered QAPI Program activities for all future patients and current employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for future patients and current employees.

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for future patients and all current employees.

The agency failed to ensure governing body oversite of a patient centered, data driven QAPI Program, and the program evaluation for calendar year 2022 and 2023 affecting all future patients and current staff.

The agency failed to ensure governing body oversite of an operating budget, capital expenditure plan, and allocation of resources activities for calendar year 2022 and 2023 for all future patients and agency staff.

The agency failed to ensure the retention of clinical records for all previous patients.

The agency failed to ensure the ability to retrieve patient records.

The agency failed to ensure the individualized POCs included patient interventions and goals for four (Pt's #1, 2, 3 and #4) of seven patients.

The agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees.

The agency failed to ensure: 1. a comprehensive infection control program for 81 patients and all employees; and 2. compliance with infection control surveillance activities after an incident of patient exposure to COVID-19 for eight (Pt's #8, 9, 10, 11, 12, 13, 14 and #15) of eight patients.

The agency failed to develop and implement an agency emergency preparedness program for 81 patients and all staff members.

The agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 81 patients and all employees.

The agency failed to ensure an Emergency Preparedness Communication Plan which included required information related to all patients, staff members and resources of the agency.

The agency failed to ensure an emergency preparedness disaster table top exercises and drills were conducted for fiscal years 2019 and 2020 for 81 patients and all staff members.

The agency failed to notify the physician of: 1. refused/missed SN vists for three (Pt's #1, 2 and #5); 2. delayed OT evaluation for one (Patient #3) and; 3. report an elevated blood pressure for one (Patient #7) of seven patients.

The agency failed to ensure evidence of a patient centered QAPI Program for 81 patients and employees.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for 81 patients and all employees.

The agency failed to ensure conduction of patient centered QAPI Program activities for 81 patients and all employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for 81 patients and all employees.

The agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for 81 patients and all employees.

The agency failed to ensure: 1. a comprehensive infection control program for 81 patients and all employees; and 2. compliance with infection control surveillance activities after an incident of patient exposure to COVID-19 for eight (Pt's #8, 9, 10, 11, 12, 13, 14 and #15) of eight patients.

The agency failed to show infection control education was: 1) included in QAPI activities; 2) showed interventions to reduce future infections; and 3) provided and/or maintained for all patients and employees.

The agency failed to ensure governing body oversite of: operating budget and allocation of resources for calendar years 2019 and 2020 for 81 patients and all staff.

The agency failed to: 1. educate the patient on potential health outcomes related to refusal of SN visits; and 2. notify the physician of the patient's continued refusal of SN visits for one (Patient #1) of seven patients.

The agency failed to ensure a SOC assessment was conducted within 48 hours of referral for one (Patient #2) of seven patients.

The agency failed to ensure medication embedded wound care supplies were included in the review of medications for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy for three (Pt's #5 and #7) of seven patients.

The agency failed to ensure a discharge oasis assessment was completed for two (Pt's #2 and #4) of seven patients.

The agency failed to ensure the individualized patient POCs included patient interventions and goals for four (Pt's #1, 2, 3 and #4) of seven patients.

The agency failed to notify the physician of patient refusal of care and imminent discharge from the HHA for two (Pt's #2 and #4) of seven patients.

The agency failed to ensure clinical records were complete for one (Patient #1) of seven patients.

The agency failed to ensure documentation of wound care interventions performed by the SN for two (Patient #5 and #7) of seven patients.

The agency failed to ensure the governing body provided oversight of agency operations and programs for 19 of 19 current patients.