Bay Nation Home Health Services Inc.

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on interviews and record reviews, the home health agency’s licensed staff failed to respect patient choices and did not maintain the privacy of 9 out of 13 sampled patients (Patients 1, 3, 4, 5, 6, 7, 8, 12, 13). Home Health Agency 1 (HHA 1) staff violated patient confidentiality by obtaining personal information without consent and providing care to patients who had not requested the Agency’s services. The cumulative effect of these systemic problems resulted in confusion, unauthorized disclosure of personal health information, and unnecessary distress for patients and their families. Condition of Participation not met for 42 CFR §484.50 – Patient Rights. - See Tag G438 See Tag G438”

“Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This Element is not met as evidenced by: 1.a. During a record review of the HHA 1’s policy and procedure (P & P) titled “Patient Privacy Rights” dated April 2020, the P & P indicated the Agency will “Respect and safeguard all protected health information of the patients it serves.” During a review of Patient 1’s document titled “Patient Profile” (PP), the PP indicated Patient 1’s Start of Care was 1/27/2026. During a review of Patient 1’s document titled “Skilled Nurse Visit Note” (SNVN) dated 1/29/2026, the SNVN indicated licensed nursing staff visited Patient 1 on 1/29/2026. During a review of Patient 1’s document titled “OASIS Discharge Assessment” ([Outcome and Assessment Information Set- a comprehensive questionnaire or evaluation tool that visiting nurse or physical therapist uses to build care plan, measure progress, and figure out how much Medicare or Medicaid will pay the home health agency] OASIS/DC) dated 2/6/2026, the OASIS/DC indicated HHA 1 discharged Patient 1 on 2/6/2026. During a review of Patient 1’s document titled “Patient Care Coordinator (PCC) Final Discharge Planning Note” dated 1/24/2026, the PCC indicated Patient 1 had elected to receive home health care services from another Home Health Agency (HHA 2) and not HHA 1. Patient 1 did not respond to attempts for telephone interviews and was unavailable for interview. 1.b. During a review of Patient 3’s PP, the PP indicated Patient 3’s Start of Care was 12/2/2025. During a review of Patient 3’s SNVN dated 12/4/2025, the SNVN indicated licensed nursing staff visited Patient 3 on 12/4/2025. During a review Patient 3’s OASIS/DC dated 12/5/2025, the document indicated the HHA 1 discharged Patient 3 on 12/5/2025. During a review Patient 3’s PCC dated 12/1/2025, the PCC indicated upon discharge from the hospital, Patient 3 elected to receive home health services from HHA 2 and not HHA1. Patient 3 did not respond to attempts for telephone interviews and was unavailable for interview. 1.c. During a review of Patient 4’s PP, the PP indicated Patient 4’s Start of Care was 3/11/2026. During a review of Patient 4’s SNVN, the SNVN indicated HHA 1’s licensed nursing staff visited Patient 4 on 3/14/2026. During a record review of Patient 4’s document “Missed Visit” (MV) dated 3/20/2026, the MV indicated Patient 4 refused care on 3/20/2026. There was no documentation in the clinical record which showed Patient 4 was discharged from HHA1. During a review of the document “Patient Census Report” (PCR) dated 4/15/2026, the PCR indicated Patient 4 was no longer receiving services from HHA1. During a record review of Patient 4’s document “PCC Final Discharge Planning Note,” (PCCFD) dated 3/9/2026, the PCCFD indicated Patient 4 had elected to receive services from HHA 2 and not HHA 1. Patient 4 did not respond to attempts for telephone interviews and was unavailable for interview. 1.d. During a record review of Patient 5’s PP, the PP indicated Patient 5’s Start of Care was 8/10/2025. During a record review of Patient 5’s OASIS/DC dated 8/22/2025, the OASIS/DC indicated the HHA 1 discharged Patient 5 on 8/22/2025. During a record review of Patient 5’s document “Discharge Planning Initial Assessment” (DPIA) dated 9/16/2025, the DPIA showed that Patient 5 planned to discharge home from the hospital and continue receiving care from HHA 2, not from HHA 1. During an interview on 4/21/2026 at 4:29 p.m. with Patient 5’s family member (FM 1), FM1 stated, upon discharge from the hospital, Patient 5 had chosen to receive home health services from HHA 2. FM 1 stated when Patient 5 arrived home, she was contacted by HHA 1. A nurse and a physical therapist arrived home from HHA1. FM 1 stated she did not know “What was going on at the time.” She stated she had assumed they were there to help. She stated she later realized she could not have two different agencies seeing Patient 5. FM 1 stated her daughter called HHA1 to discuss the fact that the family had already chosen HHA 2 and that FM 1 “Was 88 years old” and she did not need the added stress. FM1 stated her daughter never received a return call from HHA1. FM 1 stated she was very upset with the situation as she had only signed a consent for care with HHA 2 and HHA 1. FM 1 also stated Patient 5 knew what was going on but she chose not to share more information with Patient 5 as she did not want to upset him. FM1 stated even though her daughter had called the HHA 1 to tell them the family had not requested their services, an staff member from HHA 1 approached Patient 5’s home to provide care. FM 1 stated the situation was “Awful” and “Terrible.” She stated she was in tears but then also got mad. FM1 stated she asked the HHA 1staff “Who gave you my husband’s name?” and FM 1 stated she told the HHA 1 staff member to “Get off of my property.” 1.e. During a record review of Patient 6’s document titled, “OASIS Nursing Services SOC/ROC” (OASIS/SOC) dated 1/27/2026, the OASIS/SOC indicated Patient 6’s Start of Care was 1/27/2026. During a record review of Patient 6’s SNVN, dated 1/29/2026, the SNVN indicated Registered Nurse visited Patient 6 on 1/29/2026. During a review of Patient 6’s OASIS/DC dated 2/6/2026, the OASIS/DC indicated Patient 6 was discharged from services with HHA 1. During an interview on 4/15/2026 at 11:40 a.m. with Patient 6, Patient 6 stated he chose HHA 1 for his care. Patient 1 stated after returning home from the hospital, staff from HHA1 visited him. Patient 6 stated he then realized he was receiving services from “Two home health agencies” which he found “Confusing.” Patient 1 stated he called HHA 1 to report he did not need their services as he was already receiving services from HHA 2. During a record review of Patient 6’s document “Discharge Planning Progress Note” (DPPN) dated 1/24/2026, the DPPN indicated Patient 6 was discharged from the hospital and “Home Health is booked” with HHA 2. 1.f. During a record review of Patient 7 ’s document PP, the PP indicated Patient 7’s Start of Care was 1/12/2026. During a record review of Patient 7 ’s document SNVNs, the SNVNs dated 1/6/2026, 1/19/2026 and 2/20/2026, indicated HHA1’s licensed nursing staff visited Patient 7 on those dates. During a record review of Patient 7 ’s document “OASIS Transfer Non-Visit” (OASIST) dated 2/25/2026, the OASIS indicated Patient 7 was transferred to a “Nursing Home.” During a record review of Patient 7 ’s document PCC dated 1/9/2026, the PCC indicated upon discharge from the hospital, Patient 7 had elected to receive home health services from HHA 2 and not HHA 1. Patient 7 did not respond to attempts for telephone interviews and was unavailable for interview. 1.g. During a record review of Patient 8 ’s document PP dated 10/1/2025, the PP indicated Patient 8’s start of care was 10/1/2025. During a record review of Patient 8 ’s document SNVNs, the SNVN’s showed licensed nursing staff from HHA 1 visited Patient 8 on 10/8/2025 and 10/10/2025. During a record review of Patient 8 ’s document OASIS/DC dated 11/1/2025, the OASIS/DC indicated HHA 1 discharged Patient 8 on 11/1/2025. During a record review of Patient 8 ’s document PCC dated 9/29/2025, the PCC indicated Patient 8 had chosen HHA 2 and not HHA 1 upon discharge from the hospital. Patient 8 did not respond to attempts for telephone interviews and was unavailable for interview. During an interview on 4/29/2026 at 2:04 p.m. with Patient 8’s Family Member (FM 2), FM2 confirmed Patient 8 had chosen HHA 2 for care upon discharge from the hospital. FM 2 stated HHA 1 showed up at the home to provide care. FM 2 stated there had been confusion regarding who was providing the care and he called HHA 1 and asked them not to return. FM 2 stated his father (Patient 8) was older and with health issues and that the entire experience created a lot of anxiety for Patient 8 which elevated his blood pressure. FM2 stated Patient 8 was anxious and confused regarding the several phone calls he had been receiving regarding who was providing services. FM 2 stated it was time-consuming to deal with as his father would call him regarding the phone calls and FM 2 had to go and figure out what was going on. During an interview on 4/15/2026 at 11:59 a.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the way HHA 1 knows if a patient requests services from the Agency was through a “Welcome Call.” DPCSD stated that during this call HHA 1 confirms the patient will be expecting staff to visit. During an interview on 4/15/2026 at 1 p.m. with the HHA 1’s Marketer (MK), the MK stated the way she is made aware of the fact that a patient requests services with HHA 1 is through a discussion with the hospital case manager. The MK confirmed there was no documentation in the clinical record which showed a discussion had taken place with the hospital case managers regarding the HHA 1 providing services for Patients 1, 3, 4, 5, 6, 7 and 8. 2. During a review of Patient 12’s undated PP, the PP showed Patient 12’s address, phone number, date of birth, primary physician contact information, Medicare number and policy information. During a review of Patient 12’s “Claims Management Medicare Pro” dated 4/30/2026 showed Patient 12’s personal Medicare information. There were no other documents in the clinical record. During an interview on 5/19/2026 at 11:15 a.m. with Patient 12, Patient 12 stated she had not been receiving, nor did she sign up for home health services. Patient 12 stated the fact that someone had her personal information was “concerning.” During an interview on 5/19/2026 at 12:38 p.m. with MK, MK stated she had received Patient 12 and 13’s information from her Virtual Assistant (VA). MK stated the VA reports to the MK when she has a list of patients who need home health services. The MK stated the VA shares the name of the patient, their doctor’s contact information and eligibility (payment information) for services. The MK stated she was unsure how the VA acquired this information. During a record review there was no PP or clinical record for Patient 13. During an interview on 5/19/2026 at 12:50 p.m. with HHA 1’s’s President (AP), the AP stated he was not sure “What the VA does” since it was the MK’s assistant. The AP stated he did not know the source of the VA’s information which would be important information to have since he cannot “Ensure the confidentiality of the information coming from the VA.” During an interview on 5/19/2026 at 1:15 p.m. with the VA, the VA stated she receives the patient information from a shared electronic notepad. VA stated the notepad shows the lists of patients, personal patient information, Medicare numbers, the name of the doctor and phone/fax numbers. The VA stated she sends a fax to the doctor to request home health orders. The VA stated she has no training regarding confidentiality and there was no documentation on the notepad which showed the patient had chosen HHA1 to provide home health services. The VA stated she was not sure who else had access to the notepad, where the list came from, or who developed the list. During an interview on 5/19/2026 at 1:30 p.m. with MK, the MK stated she was the one who hired the VAs and does not provide them confidentiality training. The MK stated the personal information shared between herself and the VA was through a google document and not a secured system. During an interview at 11:46 a.m. on 5/20/2026 Medical Doctor 1 (MD 1) stated she had been receiving several faxes and telephone calls requesting she sign home health orders for Patients 9, 10, 11, 12 and 13. MD 1 stated HHA 1 continued to “bug” her office with these requests despite her telling them she had never referred these patients to HHA 1 for home health services.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure it admitted one of four sample‑selected patients (Patient 1) within 48 hours of the patient’s return home. This deficient practice placed Patient 1 at risk for delayed assessment, delayed interventions, and a lack of monitoring during a vulnerable period. This could also lead to deterioration in Patient 1’s condition, preventable complications, avoidable emergency department visits, or rehospitalization. A review of Patient 1’s “Referral Information” indicated Patient 1 was referred to the Home Health Agency on 1/24/26. A review of Patient 1’s “OASIS NURSING SERVICES SOC/ROC” indicated Patient 1 was admitted to the agency on 1/27/26. A review of Patient 1’s “Plan of Care” indicated Patient 1 was admitted to the agency with multiple diagnosis including Head laceration (wound) and Diastolic Heart Failure (when the heart’s lower chambers (usually the left ventricle) become stiff and cannot relax properly between beats, preventing them from filling with enough blood). During a concurrent interview and record review on 4/16/26 at 11:55 a.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1’s referral and start‑of‑care visit and did not find any documents showing why the agency delayed the start of care or whether it informed Patient 1’s physician or the case manager at the discharging facility. The DPCS stated the agency must visit patients within 48 hours after referral, and if there is any delay in starting care, the agency must inform the physician and referring case manager because delays can affect the patient’s care and treatment. A review of the agency’s policy and procedure “ADMISSION CRITERIA AND PROCESS” undated, indicated “…The Clinical Supervisor will assign clinical organization personnel to conduct initial assessments of eligibility for services within 48 hours of acceptance of referral information and/or discharge from referring facility….””

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were accepted for treatment based on the reasonable expectation that the Home Health Agency (HHA) could meet the patients’ needs for two of four sample‑selected patients (Patient 2 and Patient 4).The agency did not ensure Patient 2 and Patient 4 received care as outlined in their care plans when staff did not complete the required visits. This deficient practice placed Patient 2 and Patient 4 at risk for worsened clinical conditions, including delayed healing, increased risk of complications (such as infections or pressure injuries), unmanaged symptoms such as pain, and overall preventable harm due to missed, delayed, or uncoordinated care. 1. A review of Patient 2’s “Plan of Care (POC)” indicated Patient 2 admitted to the agency in July 2025 with multiple diagnosis including multiple pressure ulcers (bed sore). A review of Patient 2‘s POC indicated nursing visits frequency was two times a week for nine weeks starting 10/30/25. A review of Patient 2’s “Patient chart, skilled nurse visit note” indicated Patient 2 was visited by the nurses one time for the week of 12/14/25. A review of Patient 2‘s POC, dated 10/30/25, indicated nursing visits frequency was two times a week for nine weeks starting 10/30/25, and wound care as follows: “Wound care to Center posterior sacrum (Triangular bone). “Dakin (Antibacterial)’s solution and pat dry with gauze. Apply Tetracyte (Antibiotic ointment) and medical grade honey (dressing with honey) collagen… Left lateral ankle: Dakin1s solution and pat dry with gauze, apply Tetracyte and medical grade honey… Left posterior heel…wound care will be carried out 2 times a week by home health…Keep surgical wounds on abdomen clean and dry…Wound care to Right posterior ischium (Lower pelvis): Dakin’s solution and pat dry with gauze. Apply Tetracyte and medical grade honey, followed by collagen, Pack wound…Wound care will be carried out 2 times a week by home health…Wound care to Lt (left) heel: Cleansed with NS (Normal Saline solution), hydrogel (hydrating and gel dressing) applied to base, covered with…Assess/Perform/instruct Pt/Peg (patient and patient care giver): Wound care to; RT (right) buttock (Gluteal region) :Cleanse with. NS, Packed with Hydrogel to wound bed…” During an interview on 4/15/26 at 11:25 a.m. with Patient 2’s Family Member (FM), FM stated the agency’s nurses did not show up for home visit during the week of 12/14/26 and family had to hire a nurse and pay them from out of pocket to do the wound care. 2. A review of Patient 4’ POC indicated Patient 4 was admitted to the agency in March 2026, with multiple diagnosis including Acute Respiratory Failure (a life-threatening, sudden-onset emergency where the lungs cannot get enough oxygen into the blood or fail to remove carbon dioxide). A review of Patient 4’s POC indicated Patient 4’s nursing visit frequency was two times a week for two weeks starting 3/11/26, and then once a week for six weeks starting 3/22/26. A review of Patient 4’s POC, dated 3/11/26, indicated the following goals for the home health service: “...stable vital sign (Essential body measurement), Patient has knowledge about her medications, not having respiratory distress, proper use of assistive devises...” A review of Patient 4’s “patient chart, skilled nurse visit note” indicated Patient 4 was not contacted by the nurses for coordination of visits from 3/26/26 to 4/15/26 (19 days). During a concurrent record review and phone interview on 4/16/26 at 12:30 p.m. with Registered Nurse (RN) 1, RN 1 reviewed Patient 4 and Patient 2’s patient chart and skilled nursing visit notes. RN 1 stated there was a missed visit for Patient 2 for the week of 12/14/25, and the nurses should have visited Patient 2 twice a week. RN 1 also confirmed Patient 4 had not been contacted by staff for the past 19 days and did not find any documentation showing any attempts to contact Patient 4 to coordinate visits. Furthermore, RN 1 stated missed visits should be documented, and staff should inform the physician and the agency team and attempt to see the patient within the same week. During an interview on 4/16/26 at 9:24 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated it is important to contact patients and document communication with the patient or family because the team needs to know what happened to the patient. The DPCS stated missed visits must be rescheduled within the same week and the physician and team must be informed. A review of the agency’s policy and procedure “MISSED VISITS” revised November 2017 indicated “…To ensure that missed visits are documented and does not affect the quality of patient care., Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled for the same week if possible. Missed visits will be documented in the clinical record, If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit…If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician…” A review of the agency’s policy and procedure “CARE PLANNING PROCESS” undated, indicated “...4. The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. 5. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs...The frequency of the review of the plan of care will be based on changes in the patient’s health status, needs, and the environmental factors affecting care. The clinicians will be responsible to revise the plan of care or update the plan at least every 60 days...” review and find the correct Home health federal citation for this tag. this is not a condition level deficiency”