Bayada Home Health Care, Inc.

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on clinical record review and staff interviews the Start of Care OASIS’ [Outcome and Assessment Information Set-collection of data elements that home health agencies use to assess and report on patient quality] were incorrect for 3 of 13 patients [#1, 8, and 4]. The findings included: 3. Patient #4 had a Start of Care date of 01/09/2025 with an admitting diagnosis of hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarct (stroke) affecting left, non-dominant side. Review of the Plan of Care for the certification period 01/09/2025-03/09/2025 included orders for PT (physical therapist) 1 time a week for 1 week, 2 times a week for 4 weeks, 1 time a week for 3 weeks. Review of the clinical record revealed PT #11completed the start of care OASIS (Outcome and Assessment Information Set- group of standard data elements used to measure home health patient outcomes) on 1/9/2025. NO415 (high risk medications) was answered incorrectly. The patient was taking Tramadol (an opioid pain medication used for moderate pain) 50mg 2 times daily and Plavix (anti-platelet drug used to prevent blood clots). NO415 indicated the patient was not taking any opioids or anti-coagulation (affects blood clotting) medication. Patient # 1 had a Start of Care [SOC] date of 12/5/24 and an admitting diagnosis of disrupt/dehisce closure wound [surgical wound reopens]. Review of the Plan of Care [POC] for the certification period 12/5/24-2/2/25 included orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 1 week, 1 time a week for 7 weeks. Review of the clinical record revealed RN # 9 completed the SOC OASIS [Outcome and Assessment Information Set-collection of data elements that home health agencies use to assess and report on patient quality] on 12/5/24. Review of the OASIS question NO415 [high risk medications] indicated the patient was taking an antibiotic and hypoglycemic only. Review of the POC revealed the patient was also using Oxycodone [opioid] 5 mg every 6 hours as needed for pain. NO415 did not capture the use of an opioid. During an interview with the agency director on 1/29/25 at approximately 10 am, the director confirmed the OASIS information was not accurate. Patient # 8 had a Start of Care [SOC] date of 12/4/24 with admitting diagnoses of disruption of wound [wound re-opens], infection following a procedure, and type 2 diabetes without complications. Review of the plan of care for the certification period 12/4/24-2/1/25 included orders for SN 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks. Review of the clinical record revealed RN # 1 completed the OASIS [Outcome and Assessment Information Set-collection of data elements that home health agencies use to assess and report on patient quality] on 12/4/24. Review of the OASIS question NO415 [high risk medications] indicated the patient was not taking an opioid. Review of the POC revealed the patient was ordered Oxycodone [pain medication] 5 mg every 6 hours as needed for pain. During an interview with the agency director on 1/29/25 at 9:45 am the director the OASIS was incorrect.”

“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 policy review, client record review, and staff interviews, the agency failed to update the plan of care for skilled nursing missed visits for 1 of 13 records reviewed (7); .and failed to update the care plan interventions for 2 of 13 patients [#4 and 8]. The findings included: The policy, Client Care Plan [1/1/93], was provided by the agency director on 1/27/25 at 2:07 pm. The policy stated, “...Actions and interventions are consistant with the plan of care and are documented...” 3. Patient # 8 had a Start of Care [SOC] date of 12/4/24 with admitting diagnoses of disruption of wound [wound re-opens], infection following a procedure, and type 2 diabetes without complications. Review of the plan of care for the certification period 12/4/24-2/1/25 included orders for SN 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks and “SN will assess and instruct...on diabetes management including...hypoglycemia/hyperglycemia, monitoring blood glucose...notify physician of blood glucose greater than 350 or less than 60.” Review of the clinical record revealed RN # conducted the SOC on 12/4/24 and documented, “Patient needs glucometer.” The patient received 9 SN visits from 12/4/24-1/23/25. No blood sugar readings were documented 9 out of 9 visits. During an interview with the agency director on 1/29/25 at approximately 11 am, the director stated, “The patient refused to check his blood sugars. We should have updated the POC to indicate that.” 2. Patient #4 had a Start of Care date of 01/09/2025 with admitting diagnoses of hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarct (stroke) affecting left, non-dominant side and heart failure, unspecified (heart unable to pump sufficient amount of blood). Review of the Plan of Care for the certification period 01/09/2025-03/09/2025 included orders for PT (physical therapist) 1 time a week for 1 week, 2 times a week for 4 weeks, 1 time a week for 3 weeks and “physical therapist will assess and instruct on management of heart failure, early recognition of signs of exacerbation and client caregiver self-management including activity intolerance and client’s weight. Notify physician of weight gain of 3 pounds in one day or 5 pounds in one week.” Review of clinical record, on 1/15/2025, 1/16/2025, and 1/23/2025 visits, PTA #8 charted under interventions provided “…educated client on self-management of heart failure, breathing techniques, energy conservation, self-monitoring tools, oxygen management, and daily weights. On 1/15/2025, 1/16/2025, 1/23/2025, and 1/24/2025 visits under vital signs portion, PTA #8 charted “clinical exception-unable to weigh”. During phone interview on 01/29/2025 at approximately 10 am with PTA #8 with agency director present, it was confirmed that client can not weigh in home due to wheelchair bound and balance issues and client is not on oxygen. PTA #8 and Director stated that “interventions provided section automatically populates based on diagnosis and the plan of care interventions were not updated based on the patient’s inability to weigh and no supplemental oxygen in the home”. Review of a policy “0-945 Client Care Plan”, revised 7/5/21 was received from the agency director on 1/28/25 at 2:07 PM. The policy stated, …” changes in the client’s medical conditions and environment are reflected in ongoing revisions made to the original plan of care…” 1.Patient #7 was admitted on 12/7/24 with diagnoses of hemiplegia (weakness on one side of the body), essential hypertension (high blood pressure), and chronic pain. Orders were for skilled nursing 1 time a week for 5 weeks, 1 time every 2 weeks for 2 weeks, and 1 time a week for 1 week. Review of the clinical record on 1/28/25 revealed missed nursing visits for the weeks of 12/20/24 thru 1/24/25 for a total of 6 weeks. The plan of care was not updated to discontinue skilled nursing. Interview with the RN #1 on 1/29/25 at 9:19 AM revealed, “I never got to see Patient #7, she didn’t want a visit, always had to reschedule, or wouldn’t answer the phone”. “I kept on giving her the benefit of doubt, I didn’t want to discharge her without seeing her, I didn’t think about updating the plan of care”.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on agency policy, clinical record review, home visit observations, and staff interviews the Plan of Care failed to include all/current medications the patient was taking for 4 of 5 home visits [#1, 5, 2, and 4]. The findings included: The policy, Medication Managament and Administration [1/1/93], was presented by the agency director on 1/27/25 at 2:07 pm. The policy stated, “...medication reconcilation should be done on every assessment and reassessment...” 3. Patient #2 had a Start of Care date of 12/30/2024 with admitting diagnoses of Urinary tract infection, pneumonia, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarct (stroke) affecting right, dominant side. Review of the Plan of Care for the certification period 12/30/2024 - 02/27/2025 included orders for PT (physical therapist) 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks. “…physical therapist will develop physical therapy plan of care in consultation with the physician that includes…identification of new or changed medications…” A joint visit with PT #11 was conducted on 01/27/2025 at approximately 4 pm. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Melatonin (sleep aid) 3 mg as needed at bedtime, Docusate Sodium (stool softener)100 mg daily as needed, and Tylenol (for mild pain) 500mg 2 caplets as needed. The patient’s husband states that patient takes these medications when she needs them. During an interview with the agency director on 1/29/2025 at approximately 9:45 am, it was determined that the plan of care did not include all the correct medications the patient was using. 4. Patient #4 had a Start of Care date of 01/09/2025 with an admitting diagnosis of hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarct (stroke) affecting left, non-dominant side. Review of the Plan of Care for the certification period 01/09/2025-03/09/2025 included orders for 1 time a week for 1 week OT (occupational therapist) evaluation. Supplemental order was dated 1/12/2025 for 1 time every other week for 2 weeks, 1 time a week for 2 weeks. During a joint visit with OT #10 on 01/28/2025 at approximately 1pm, a medication review was conducted using a medication profile provided by the agency. The patient’s caregiver presented all the patient’s medication bottles for review. The patient confirmed that he takes all the medications presented by the paid caregiver. The following discrepancies were noted: The medication profile listed Amiodarone (used to treat an irregular heartbeat) 200mg daily. This medication was not found in the patient’s home with his other medications and the patient denies taking it. The patient reported using the following medications that were not listed on the agency provided medication list: Atorvastatin (used to treat high cholesterol) 80mg 1 tablet at bedtime, Tamsulosin (used to treat symptoms such as decreased urine flow in men with an enlarged prostate) 0.4 mg 1 tablet daily, Lisinopril (used to treat high blood pressure and heart failure) 10 mg 1 tablet daily, Senna (laxative for constipation) over the counter, 8.6 mg as needed, Aspirin (low dose preventative daily dose for treating risk of heart attack and stroke) 81mg 1 tablet daily, and a generic Men’s 50+ multivitamins over the counter. During an interview with the agency director on 1/29/2025 at approximately 9:30 am, it was determined that the plan of care did not include the correct medications. Patient # 1 had a Start of Care date of 12/5/24 and an admitting diagnosis of disrupt/dehisce closure wound [surgical wound reopens]. Review of the Plan of Care for the certification period 12/5/24-2/2/25 included orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 1 week, 1 time a week for 7 weeks. There was a supplemental order written on 12/15/24 for SN 2 times a week for 1 week and 3 times a week for 6 weeks. On 1/17/25 at approximately 4:30 pm, a joint visit was conducted with RN # 9. During the visit a medication review was conducted using the medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Methocarbamol [muscle relaxant] 500 mg 3 times per day, Sulfamethoxazole 800 mg/Trimethoprim 160 mg [antibiotic]. Take 1 tablet 2 times per day, and Famotidine 40 mg [used for reflux]. Take 1 tablet every evening. During an interview with the patient on 1/27/25 at approximately 5:30 pm, the patient stated, “I don’t use those medicines.” During an interview with the agency director on 1/29/25 at approximately 9:30 am, the director confirmed the plan of care did not include the correct medications the patient was taking. Patient # 5 had a Start of Care date of 11/5/24 and admitting diagnoses of type 2 diabetes mellitus with foot ulcer, and non-pressure chronic ulcer other part left foot limited to breakdown of skin. Review of the plan of care for the certification period 1/4/25-3/4/25 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks and “...continuous review of medication regimen...” On 1/28/25 at approximately 9:30 am a joint visit was made with RN # 7. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed oxycodone [pain medication] 5 mg. Take 1 capsule every 6 hours as needed for pain. [There was a 5-day supply ordered with a start day of 11/13/24]. During an interview with the patient, he reported “I haven’t had any of those pills in a long time.” The patient reported using Tylenol 325 mg 2 tablets every 4 hours as needed for pain. The Tylenol was not on the medication profile. During an interview with the agency director on 1/29/25 at approximately 9:45 am, the director confirmed the plan of care did not include all/correction medications the patient was using.”

“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 policy review, client record review, and staff interviews, the agency failed to follow the physicians order for physical therapy evaluations for 2 of 9 records reviewed with physical therapy (1 and 12). Findings included: Review of a policy “0-945 Client Care Plan”, revised 7/5/21 was received from the agency director on 1/28/25 at 2:07 PM. The policy stated, …” changes in the client’s medical conditions and environment are reflected in ongoing revisions made to the original plan of care…” 2. Patient #12 was admitted on 3/13/24 with diagnoses of pressure ulcer stage 2, right buttock; osteoarthritis, kidney disease, and heart failure. Orders were for physical therapy 1 time a week for 1 week effective the week of 3/17/24. Review of the clinical record on 1/27/25 revealed the physical therapy evaluation was completed on 3/27/24 not as ordered the week of 3/17/24. Interview with the agency director on 1/29/25 at 10:00 AM revealed, “I didn’t see any documentation on the reason the physical therapy evaluation was delayed”. 1. Patient # 1 had a Start of Care date of 12/5/24 and an admitting diagnosis of disrupt/dehisce closure wound [surgical wound reopens]. Review of the clinical record revealed a supplemental order dated 12/23/24 to for PT [physical therapy] to eval. Further review of the clinical record revealed no PT evaluation as of 1/27/25. During an interview with the agency director on 1/29/25 at approximately 10 am, the director confirmed the patient did not receive a PT evaluation.”