Bayada Home Health Care, Inc.

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on agency policy, clinical record review, incident report review, and staff interviews, the agency failed to track and analyze a patient fall with an injury for 1 of 1 patient experiencing a fall with an injury (patient #3). Findings included: A policy 0-933 Incident Reporting & Documentation (revised 06/02/2025) received on 01/22/2026 at 9:09 AM from the agency administrator #5 stated, “The following incidents must be reported regardless of their classification as defined in the Sentinel or Serious Adverse Events, Adverse Events, Cyber-Incidents, and Other Reportable Incidents sections below… Any client fall(s) that results in injury…” Patient #3 was admitted on 07/18/2025 with a diagnosis of Type 2 Diabetes Mellitus (condition where the boy doesn’t produce or use insulin effectively) with Diabetic Chronic Kidney Disease (reduced kidney function). The plan of care for 07/18/2025-09/15/2025 included orders for physical therapy (PT) 1 time a week for 6 weeks. During the PT visit on 08/28/2025 PT #17 documented, “Patient went to Urgent Care followed by emergency department and was diagnosed with UTI [urinary tract infection] as well as two fractured ribs from a fall a few weeks ago.” There was no documentation of the fall with rib fractures in the agency’s incident report log. During an interview on 01/22/2026 at 8:45 AM PT #17 stated, “I remember this client, I believe that there were other disciplines in there…. I did one [incident report] for the infection, I thought that another clinician would have done the other one [fall report].” During an interview conducted on 01/22/2026 at 8:51 AM agency administrator #1 stated, “The expectation would have been for an incident report to have been completed when we were made aware of the fall.””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on agency policy, observation, and staff interviews, the agency failed to perform hand hygiene and glove changes during wound care for 1 of 5 home visits conducted. Findings included: A policy, 0-1169 Hand Hygiene (revised 06/03/2024) received on 01/21/2026 at 4:55 PM from the agency administrator #1 stated, “Hands are decontaminated… Before applying and after removing gloves… Remove gloves and perform hand hygiene: … Before touching clean items; … When moving from client contact to the environment or the environment to client contact… During a single procedure when moving from dirty to clean, such as during wound care…” Patient #18 was admitted on 09/27/2025 with a diagnosis of laceration (wound) without foreign body, left lower leg. The plan of care for 11/26/2025-01/24/2026 included orders for skilled nurse visits 2 times a week for 2 weeks, 3 times a week for 1 week, 2 times a week for 1 week, 3 times a week for 1 week, 2 times a week for 2 weeks, and 3 times a week for 1 week, and “Wound change every other day or 3 times per week. Remove old dressing. Cleanse wound with normal saline or Vashe [name brand cleanser], apply Urgoclean [name brand dressing] … cover with ADB pad [absorbent dressing], wrap in place with kerlix [rolled gauze dressing], and then ace bandage…” During a home visit conducted on 01/21/2026 at approximately 2:00 PM registered nurse (RN) #12 failed to perform hand hygiene after removing soiled gloves and putting on clean gloves during wound care and failed to remove soiled gloves and perform hand hygiene after completing the wound care, putting patient #18’s shoe on, before cleaning up the unused supplies and returning them to the patient’s storage area. During an interview conducted on 01/22/2026 at 9:20 AM RN #12 stated, “I should have [performed hand hygiene] before putting on the second pair of gloves and I should have removed the gloves and performed hand hygiene after I put her shoe back on.” During an interview conducted on 01/22/2025 at 9:22 AM administrator #1 stated, ““The hand hygiene and infection control should have been per protocol [agency policy].””

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the home health aide (HHA) failed to follow the plan of care for 1 of 3 patients receiving HHA services (patient #9). Findings included: A policy, 0-998 Understanding & Following the Home Health Aide Care Plan (reviewed 04/27/2023) received on 01/22/2026 at 9:10 AM from agency director #5 stated, “Employees are instructed to read the Home Health Aide Care Plan at each visit before providing care, and to provide only the care indicated.” Patient #9 was admitted on 12/14/2025 with a diagnosis of unspecified open wound, right lower leg. The plan of care for 12/14/2025-02/11/2026 included orders for home health aide (HHA) visits 1 time a week for 3 weeks and “assist with shower every visit min [minimum] to mod [moderate] assist.” Review of the clinical record revealed that during the HHA visit on 12/26/2025 HHA #4 documented, “Client is bed bound. Gave full bed bath.” During the HHA visit of 12/31/2025 HHA #4 documented, “Gave client a total bed bath because he is primarily bed bound.” During the HHA visit on 01/14/2025 HHA #4 documented, “Not required this visit. Client is bed bound. Gave client a full bed bath.” An interview conducted on 01/22/2026 at 9:00 AM with HHA #4 revealed that the plan of care should be followed or the plan of care should be updated by the registered nurse. An interview conducted on 01/22/2026 at 9:13 AM with administrator #1 revealed that the plan of care should be reviewed prior to the visit.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record review and staff interviews, the agency inaccurately documented home health aide (HHA) supervisory visits for 1 of 3 patients receiving HHA visits (patient #9) Findings included: Patient #9 was admitted on 12/14/2025 with a diagnosis of unspecified open wound, right lower leg. The plan of care for 12/14/2025-02/11/2026 included orders for skilled nurse visits 2 times a week for 3 weeks, 1 time a week for 6 weeks, occupation therapy (OT) 1 time a week for 1 week, 1 time every other week for 2 weeks, 1 time a week for 1 week, 1 time every other week for 2 weeks, and home health aide (HHA) visits 1 time a week for 3 weeks. Review of the clinical record revealed that on 12/26/2025 registered nurse (RN) #13 documented an HHA supervisory visit prior to the HHA conducting any visits and on 01/09/2026 OT #14 conducted a supervisory visit for HHA #4 and documented, “Does the supervised homecare aide follow care plan orders… Yes” Further review revealed that HHA #4 was not following the orders in the plan of care. During an interview conducted on 01/22/2026 at 9:27 AM RN #13 stated, “I do not know why I would have documented that.” An interview conducted on 01/22/2026 at 9:29 AM with administrator #1 revealed that supervisory visits cannot be completed before the HHA completes a visit. During an interview conducted on 01/22/2026 at 9:10 AM OT #13 stated, supervisory visits are completed by, “I communicate with the patient and caregiver about the established aide care plan, also communicating with her [HHA name], I should have a copy of that [the HHA care plan] when completing the supervisory visit.” An interview conducted on 01/22/2026 at 9:13 AM with administrator #1 revealed that the HHA care plan should be looked at to make sure it matches.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on agency policy review, clinical record review, complaint log review, on-call log review, and employee interview, the agency failed to document follow-up of a complaint and failed to document a formal client complaint for 1 of 1 record reviewed with a complaint documented in the clinical record (Patient #1). Findings included: Policy 11-368, titled “Client Complaints”, and last revised 01/01/21 was received from the agency director on 11/06/23 at 12:13 PM. This policy revealed, “The Client Services Manager, Clinical Manager and/or Director investigate and respond to complaints from clients or their representatives promptly and in accordance with applicable state requirements…All complaints, verbal and written, are documented in the applicable electronic system…In the event that the online complaint system cannot be accessed, the CLIENT COMPLAINT REPORT…remain published as paper back-up documentation. If the paper back-up must be used, it will be scanned and attached to the online incident system when available.” Patient #1 was admitted to the agency 08/30/23 with diagnoses including partial intestinal obstruction, chronic kidney failure, and history of prostate cancer. Plan of Care from 08/30/823 to 10/28/23 revealed orders for skilled nursing three times per week for one week and one time per week for eight weeks. The Plan of Care included orders for skilled nursing to collect labs weekly on Monday and to change the PICC dressing weekly. Review of the agency’s on-call log revealed that Patient #1’s caregiver contacted the agency after hours to inquire about the schedule for nursing visits on 10/09/23, 10/15/23, and 10/29/23. There was no evidence in the clinical record that the calls on 10/15/23 or 10/29/23 were returned. Employee #4, clinical manager, documented a coordination note dated 10/09/23. The coordination note revealed that Patient #1’s caregiver had called the agency because she had not heard from the skilled nurse to schedule the Monday nursing visit and she was “worried about the lab [sic] being drawn”. Additional documentation from this call revealed, “…client and spouse are in agreement that they will go to [name of independent lab company] today…but starting next week he [Patient #1] will need RN [registered nurse] or [name of agency contracted mobile lab company] to draw the labs and continue to change the PICC line dressing”. There was no evidence that a formal complaint process was initiated to address this concern. There was no documentation in the clinical record regarding any additional follow-up related to this concern after Employee #4’s coordination note dated 10/09/23. In an interview on 11/07/23 at 9:38 AM, Employee #1, agency director, stated that she had spoken to Patient #1’s caregiver on more than one occasion and stated, “I spoke with her [Patient #1’s caregiver] …about our staffing…and felt like it [the complaint] was resolved…looking back, it probably would have been better to have put in a formal complaint...””

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on agency document review, clinical record review, and employee interview, the agency failed to document investigation of variances in the peripherally inserted central catheter (PICC) measurements for 1 of 2 records reviewed of patients with a PICC. Findings included: A document titled, “Skills: Peripherally Inserted Central Cather: Maintenance and Dressing Change [Home Health Care]” and published 05/2023, was received from the agency director on 11/06/23 at 3:15 PM. This policy revealed, “…Assess for catheter migration [movement of the catheter that could place the patient at risk for complication]. Observe the external catheter length and compare it to the insertion record...” Patient #1 was admitted to the agency 08/30/23 with diagnoses including partial intestinal obstruction, chronic kidney failure, and history of prostate cancer. Plan of Care from 08/30/823 to 10/28/23 revealed orders for skilled nursing three times per week for one week and one time per week for eight weeks. This Plan of Care included orders for skilled nursing to change the PICC dressing weekly. Employee #5, registered nurse, conducted a skilled nursing visit on 09/05/23 and documented the PICC measurements as 5.5 centimeters from the insertion site (the point where the catheter exits the skin) to the hub (the end cap on the PICC). Employee #3, registered nurse, conducted a skilled nursing visit on 10/23/23 and documented the PICC measurements as 0.0 centimeters from the insertion site to the hub. There was no documented explanation for the variance in measurements between the 09/05/23 and 10/23/23 visits. There was no evidence that the potential that the PICC had moved was investigated. In an interview on 11/07/23 at 9:15 AM, Employee #3 stated, “Normally, I just follow the procedure in the policy and I just measure [the length from the insertion site to the hub] …a lot of times…they normally send documentation about if it is exposed [the external catheter]” and “I normally look at the referral information…” In an interview on 11/07/23 at 9:24 AM, Employee #1, agency director, stated “I do think it is best practice to see what other notes have been documented so that you can get a feel of what has occurred, if there is migration [movement], etc.””