Every finding on record at Great Paragon Healthcare, Inc

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 11/27/24. The Agency was in compliance with the Condition 42 CFR 484.102, Establishment of the Emergency Program, for this survey. CFR = Code of Federal Regulations

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 11/27/24. Standard level deficiencies cited. Abbreviations: AM = morning PM = afternoon/evening Pt./Pts. = Patient/Patients PT = Physical Therapist SN = Skilled Nurse RN = Registered Nurse NS = Normal saline SOC = Start of Care POC = Plan of Care WK = Week X = times OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interviews, it was determined that in 4 of 4 reports submitted for the last 11 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 1/2024 to 11/2024, was reviewed on 11/25/24. The report included error # -3330 for 4 of 4 late submissions, which was 100 % of the OASIS reports submitted late, more than 30 days after the assessment was completed. 2. During an interview with the Administrator, and Administrative Assistant on 11/26/24 at 1:30 PM, the Administrative team confirmed that the error occurred.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on a review of clinical records, and staff interviews, it was determined in 2 of 7 (Pts. #7, and 5) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service or that the initial assessment visit was done within 48 hours of receipt of the referral. 2. Pt. #5 was referred to home health for SN and PT services, on 5/29/24 with a diagnosis of Essential (Primary) Hypertension per Physician orders on the Face-to-Face Encounter document. The clinical record was reviewed on 11/26/24. The record lacked a Physician ordered SOC date and lacked an RN initial comprehensive assessment within 48 hours of the referral. 3. During an interview with the Administrator, Administrative Assistant, Director of Nursing and Former Director of Nursing on 11/26/24 at 11:00 AM and at 1:00 PM, the above findings were confirmed. Findings include: 1. Pt. #7 was referred to home health services on 2/20/24 with diagnosis of Hemiplegia following Cerebral Infarction affecting right dominant side. The clinical record was reviewed on 11/26/24. The Face-to Face form signed by the PA (Physician Assistant) on 1/8/24 and received by the Agency on 1/29/24 that required: "Skilled Nursing Care and Physical Therapy”. The record lacked a physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 11/13/24, the record lacked documentation the Agency initiated service within the required time frame and initial comprehensive assessment was not completed.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interviews, it was determined that in 2 of 7 (Pts. #4 and 2) closed/discharged records reviewed, the Agency failed to ensure that a comprehensive assessment was updated at discharge. 2. Pt. #2 was admitted to home health services on 10/4/21 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 11/25/24. The record documented that the last visit by the SN was on 3/31/24. The record included a discharge summary dated 3/31/24 and indicated that Pt. #2 was discharged from home health services. As of 11/27/24, the clinical record lacked documentation of an updated comprehensive assessment upon discharge. 3. During an interview with the Administrator, Administrative Assistant, Director of Nursing, and Former Director of Nursing on 11/26/24 at 11:00 AM and 11/26/24 at 12:30 PM, the above findings were confirmed. Findings include: 1. Pt. #4 was admitted to home health services with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 11/25/24. The record included documentation the SN provided services from 11/8/21 through 1/3/22. The record also included an SN discharge summary dated 1/10/24 indicating that the Agency discharged the Pt. The record lacked documentation of an updated comprehensive assessment upon discharge.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews, it was determined for 1 of 1 (Pt. # 3) receiving wound treatment, the Agency failed to ensure care and services were provided as ordered by the Physician and as indicated in the POC. Findings include: 1.Pt. #3 was admitted to home health services with the diagnosis of Laceration with Foreign Body, Left Foot, Sequelae. The clinical record was reviewed on 11/25/24. The POC effective 1/7/22 to 3/7/22 required, “SN indicated for wound care management based on physician orders…and assess wound progression and decline...SN to perform wound care to left foot posterior aspect with 0.9 NS and 4 x 4 gauze, paint with (povidone-iodine), cover with 4 x 4 gauzes, secure with (bandage roll) and (elastic) bandage, using aseptic technique.” The clinical record had no documentation that the wound on the left foot had healed. The SN visit notes from 1/11/22 to 2/24/22 lacked wound treatments and assessments for the wound on the left foot as required on the POC. The POC for the same certification period required, “SN Frequency: 2 WK 9, X 2 PRN Visits Re: Wound.” The clinical record lacked a second SN visit for the weeks of 1/30/22 to 2/5/22 and 2/6/22 to 2/12/22, 2/13/22 to 2/19/22, 2/20/22 to 2/26/22 and 2/27/22 to 3/5/22. The clinical record also lacked a Physician order indicating a change in the visit frequency for the SN. 2. During an interview with the Administrator, Administrative Assistant, Director of Nursing and Former Director of Nursing on 11/26/24 at 11:00 AM, the above findings were confirmed.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interviews, it was determined that in 4 of 7 (Pts. #1, 2, 3, and 6) closed/discharged clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the patient discharge summary within the required time frame of the patient’s discharge. 4. Pt. #7 was admitted to home health services on 8/31/23 with diagnosis of Hypertension. The clinical record was reviewed on 11/26/24. The record included a discharge summary dated 12/27/23 when Pt. was discharged. The discharge summary was sent to the Physician on 1/17/24. 5. During interviews with the Administrator, Director of Nursing, Former Director of Nursing and Administrative Assistant on 11/26/24 from 11:00 AM to 1:30 PM, the above findings were confirmed. 3. Pt. #3 was admitted to home health services on 9/9/21 with a diagnosis of Laceration with Foreign Body of Left Foot, Sequelae. The clinical record was reviewed on 11/26/24. The record contained the Discharge comprehensive assessment dated 3/3/22, indicating that Pt. #3 was discharged from the Agency. The clinical record lacked documentation that the discharge summary was sent to the Physician as required. Findings include: 1. Pt. #1 was admitted to home health services on 7/25/23 with a diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 11/25/24. The record contained the discharge comprehensive assessment dated 12/31/23, indicating that Pt. #1 was discharged from the Agency. As of 11/27/24, the record lacked documentation that a copy of the Pt. #1’s discharge summary was sent to the Physician within five business days of the patient’s discharge. 2. Pt. #2 was admitted to home health services on 10/4/21 with a diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 11/25/24. The record contained the discharge summary dated 3/31/22, indicating that Pt. #2 was discharged from the Agency. As of 11/27/24, the record lacked documentation that a copy of the Pt. #2’s discharge summary was sent to the Physician within five business days of the patient’s discharge.