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 agency policy, clinical record review and staff interviews, the agency failed to ensure accuracy of the OASIS [Outcome and Assessment Information Set-a group of standard date elements included in comprehensive assessments] for 4 of 17 patients [ #1, 4, 7 and 17]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 8/17/23 with an admitting diagnosis of Marfan Syndrome [multi-systemic genetic disorder that affects the connective tissue]. Review of the Plan of Care for the certification period 8/17/23- 10/15/23 revealed the patient was ordered Aspirin 81 mg daily and Oxycodone 5 mg every 4 hours as needed for pain and Warfarin [blood thinner] 3 mg daily. Review of the clinical record revealed PT [physical therapy] # 4 completed the SOC OASIS [The Outcome and Assessment Information Set-patient specific, standardized assessment] on 8/17/23. Further review of the clinical record revealed the PT failed to capture the pain medication when answering N0415 [high risk medications] on the OASIS.]. During an interview with PT # 4 on 2/13/24 at approximately 3 pm, the PT confirmed N0415 was incorrect. 2. Patient # 4 had a Start of Care [SOC] date of 10/6/23 and an admitting diagnosis of sepsis [infection in the blood] due to methicillin susceptible staphylococcus aureus [type of bacteria]. Review of the Plan of Care [POC] for the certification period 10/6/23-2/4/23 revealed the patient was ordered Aspirin 81 mg each day and Zyvox [antibiotic] 2 times per day. Review of the clinical record revealed RN # 8 completed the SOC OASIS [The Outcome and Assessment Information Set-patient specific, standardized assessment] on 10/6/23. Further review of the clinical record revealed the RN failed to capture the antibiotic when answering N0415 [high risk medications] on the OASIS. RN # 8 was not available for an interview. During an interview with the agency director on 2/13/24 at approximately 3:15 pm, the director confirmed the OASIS was not accurate. 3. Patient # 7 had a Start of Care [SOC] date of 1/5/24 with an admitting diagnosis of hemiplegia [paralysis on one side of the body] following cerebral infarction [stroke] affecting the non-dominant side. Review of the Plan of Care for the certification period 1/5/24-3/4/24 revealed Aspirin 81 mg daily and Metformin [used for diabetes] 500 mg two times a day was ordered by the physician. Review of the clinical record revealed PT [physical therapy] # 4 completed the SOC OASIS [The Outcome and Assessment Information Set-patient specific, standardized assessment] on 1/5/24. Further review of the clinical record revealed PT # 4 failed to include aspirin as an antiplatelet [prevents blood from clotting] when answering the OASIS question N0415 [high risk medications]. During an interview with PT # 4 on 2/13/24 at approximately 3 pm, the PT confirmed N0415 was incorrect. 4. Patient # 17 had a Start of Care [SOC] date of 1/29/24 with an admitting diagnosis of respiratory syncytial virus [RSV] pneumonia [lung infection]. Review of the clinical record revealed RN # 5 completed the SOC OASIS [The Outcome and Assessment Information Set-patient specific, standardized assessment] on 1/29/24. Further review of the clinical record revealed RN # 5 did not capture Toujeo Max U-300 Solostar 300 units per ml insulin pen [medication used to treat diabetes] when she answered NO415 [question related to use of high-risk medication]. During an interview with RN # 5 on 2/13/24 at approximation 2:45 pm, the RN stated, “I guess I just missed that.””

“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: G574 Based on agency policy review, clinical record review and patient/staff interviews the Plan of Care [POC] failed to include all current medications the patient was using for 4 of 7 home visits observed (#12,11,13 & 17) The findings included: 2. Patient # 11 had a Start of Care [SOC] date of 1/22/24 with an admitting diagnosis of essential hypertension. Review of the Plan of Care [POC] for the certification period 1/22/24-3/21/24 included orders for OT [occupational therapy] 1 time a week for 4 weeks. On 2/12/24 at approximately 11 am a joint visit was conducted with OT # 7. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed NicoDerm [patch used to help stop smoking] CQ 21 mg/24 hr. Apply 1 patch daily. During an interview with the patient during the visit, she stated, “I have never used that. I told them when they asked me at the hospital.” During an interview with OT # 7, he confirmed the POC was inaccurate for medications. 3. Patient # 13 had a Start of Care [SOC] date of 1/17/24 with an admitting diagnosis of unspecified dementia with other behavioral disturbances. Review of the Plan of Care [POC] for the certification period 1/17/24-3/16/24 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “…continuous review of medication regimen…” On 2/13/24 at approximately 10 am a joint home visit was made with RN # 5. 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 Omeprazole [reflux medication] 40 mg each day. During an interview with the caregiver, the caregiver reported the patient only takes 20 mg of Omeprazole. The daughter stated, “She has only taken 20 mg for several months now.” The caregiver presented a bottle of Fish Oil [supplement] 1000 mg and stated the patient was taking this “for several years now”. The Fish Oil was not included on the POC. The caregiver also reported the patient was taking Iron [supplement] 324 mg every other day. During the interview, the caregiver stated the patient had been on Iron since her last hospitalization which was prior to the admission to home health. During an interview with RN # 5 on 2/13/24 at approximately 3 pm, the RN confirmed the POC did not include all the correct medications the patient was taking. 4. Patient # 17 had a Start of Care [SOC] date of 1/29/24 with an admitting diagnosis of respiratory syncytial virus [RSV] pneumonia [lung infection]. Review of the Plan of Care [POC] for the certification period 1/29/24 to 3/28/24 included orders for SN [skilled nursing] 1 time a week for 5 weeks and “continuous review of medication regimen…”. On 2/13/24 at approximately 1:30 pm a joint visit was conducted with LPN # 6. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Vitamin D2 [supplement] 1250 mcg 1 tablet weekly. During an interview with the patient on 2/13/24, the patient stated, “I have never taken any Vitamin D.” During an interview with LPN # 6 the LPN confirmed the POC was not accurate. The policy, “Client Plan of Care”, revised 07/05/21 was provided by the agency director on 02/13/24 at 3:58 p.m. The policy stated, “...the client plan of care includes all medications and treatments…activities permitted”. 1.Patient #12 was admitted on 01/30/24 with diagnoses of encounter for surgical aftercare following circulatory surgery, other ventricular tachycardia (fast heart rate), and essential hypertension. The Plan of Care (POC) for 01/30/24-03/29/24 included orders for physical therapy 1 time a week for 4 weeks, and occupational therapy 1 time a week for 1 week. A home visit was conducted with the physical therapist on 02/12/24 at 2:45 p.m. A medication review was conducted and revealed the following discrepancy: -sodium chloride (saline nasal spray) 1 spray into both nostrils as needed for nasal congestion was not included on the plan of care. Interview with the patient on 02/12/24 at 3:00 p.m. revealed the patient has been using the nose spray since 01/23/24.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record review and staff interviews the Registered Nurse failed to document a wound assessment in the clinical record for 1 of 5 patients with a wound [#17]. The findings included: Patient # 17 had a Start of Care [SOC] date of 1/29/24 with an admitting diagnosis of respiratory syncytial virus [RSV] pneumonia [lung infection] and other mechanical complication of internal fixation of bones of foot and toes. Review of the Plan of Care [POC] for the certification period 1/29/24 to 3/28/24 included orders for SN [skilled nursing] 1 time a week for 5 weeks. Review of the clinical record revealed RN # 5 completed the SOC comprehensive assessment on 1/29/24. RN # 5 documented the following, “…The patient has a device in his R [right] toe. The device is protruding through the skin. The patient will have surgical repair in February…” Further review of RN # 5’s documentation revealed no wound assessment related to the right great toe. LPN # 6 conducted a routine visit on 2/6/24. Review of the clinical record revealed no documentation related to the right great toe for the visit conducted on 2/6/24. During an interview with the agency director on 2/13/24 at approximately 3 pm, the director confirmed a wound assessment should have been documented the patient’s chart.”