Bayada Home Health Care Inc.

“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 medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure all patients received an initial assessment within 48 hours of the prescriber’s referral in one of nine active medical records reviewed (Patients (P 7). Findings include: On 08/11/26 at 10:00 AM, a home visit for P1 was observed. After care was provided, P1 was interviewed. P1 expressed some concern over the delay with resuming care after being hospitalized and stated there was one time in particular it was “over a week.” A review of P1’s medical record revealed the following: An attachment in P1’s medical record, titled “Referral Document,” dated 04/27/26, stated “…On What date was the Face to Face Encounter?: 04/14/26…Requested SOC [Start of Care] Date: 4/27/2026…Disciplines Requested: Skilled Nursing…Special Instructions: Referral to continue once a week visiting nurse for nephrostomy tube [small tube placed directly into the kidney to drain urine into a bag outside the body] care and maintenance x 12 weeks…The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care. (List medical condition) Rectal cancer (C20) metastatic [spread from original site] to liver and lungs…” A “Client Coordination Note Report,” completed by S15 on 04/29/26, stated “CLIENT CALLED IN THIS MORNING TO CANCEL TODAY’S NURSING VISIT, AS [P1] IS CURRENTLY IN [facility name] FOR A BLOOD TRANFUSION. ADMITTED 04/28/26.” A “Client Coordination Note Report,” completed by S16 on 05/03/26, stated “SPOKE WITH CLIENT…AGREEABLE TO CALL BACK EARLY THIS WEEK FOR SOC DATE.” A “Client Coordination Note Report,” completed by S14 on 05/05/26, stated “CSM [Client Services Manager] PHONED CLIENT TO SCHEDULE SOC, NO ANSWER ON PHONE. CSM UNABLE TO LEAVE MESSAGE AS VOICEMAIL IS FULL.” A “Client Coordination Note Report,” completed by S12 on 05/06/26, stated “L/M [Left message] FOR CLIENT TO CB [Call Back] TO SETUP SOC”. A “Client Coordination Note Report,” completed by S12 on 05/06/26, stated “RECEIVED A CALL FROM CLIENT AND CONFIRMED RN SOC 5/8 ALL INFO CONFIRMED IN FILE”. A “Visit Note Report,” was completed by S13 on 05/08/26, stated “...Narrative...PT [patient] SEEN FOR SOC…” P1’s SOC was completed on 05/08/26 by S13, greater than 48 hours after the date of referral. On 08/13/26 at 11:56 AM, S1 stated staff likely did notify the provider, however confirmed P1’s medical record lacked evidence of communication to the provider regarding the changes made to P1’s SOC date. Facility policy titled, “0-672-Admission Criteria & Procedure-Medicare Certified Offices” dated 02/02/26, stated, “…Our Procedure:…9.0: A registered nurse [RN] or therapist (PT [Physical Therapist], SLP [Speech Language Pathologist]) must conduct an initial assessment visit to determine the immediate care and support needs of the client, and for Medicare clients, to determine eligibility for the Medicare home health benefit. Any delay or altered time from for the initiation of services beyond those stated, including those due to client preference, medically contraindicated, etc., are communicated to the physician and to the client, and documented in the client’s chart. 9.1: The initial assessment must be completed within: a. 48 hours of referral; b. 48 hours of the client’s return home; c. On the physician ordered SOC [start of care] date…” A review of P7’s medical record revealed the following: An attachment in P7’s medical record, titled “Referral Document,” dated 07/06/26, stated, “Ambulatory referral to Physical Therapy…Referral Information: # Visits: 12; Referral Type: Therapy...; Urgency: Routine; Referral Reason: Evaluation and Treat; Start date: July 6, 2026; End date: To be determined by Insurer; Diagnosis: Midline low back pain with right-sided sciatica, unspecified chronicity…” A “Client Coordination Note Report” completed by S12 on 07/08/26 stated, “…Note: Received a call from client and confirmed PT SOC 7/10. All info confirmed in file.” P7’s SOC was scheduled for 07/10/26, greater than 48 hours after the date of the referral. The medical record lacked evidence of communication of the delay in the SOC to the prescriber. On 08/14/26 at 12:06 PM, S1 explained that an initial visit should be completed within 48 hours of a referral. S1 stated that any changes to the SOC date should be communicated to the prescriber and to the patient and documented in the patient’s medical record. S1 and S2 confirmed that P7’s medical record lacked evidence of communication to the prescriber regarding the changes made to P7’s SOC date. Findings include: Facility policy titled, “0-672-Admission Criteria & Procedure-Medicare Certified Offices” dated 02/02/26, stated, “…Our Procedure:…9.0: A registered nurse [RN] or therapist (PT [Physical Therapist], SLP [Speech Language Pathologist]) must conduct an initial assessment visit to determine the immediate care and support needs of the client, and for Medicare clients, to determine eligibility for the Medicare home health benefit. Any delay or altered time from for the initiation of services beyond those stated, including those due to client preference, medically contraindicated, etc., are communicated to the physician and to the client, and documented in the client’s chart. 9.1: The initial assessment must be completed within: a. 48 hours of referral; b. 48 hours of the client’s return home; c. On the physician ordered SOC [start of care] date…” On 08/11/26 at 10:00 AM, a home visit for P1 was observed. After care was provided, P1 was interviewed. P1 expressed some concern over the delay with resuming care after being hospitalized and stated there was one time in particular that resumption of care was “over a week.” A review of P1’s medical record revealed the following: An attachment in P1’s medical record, titled “Referral Document,” dated 04/27/26, stated “… On What date was the Face to Face Encounter?: 04/14/26 … Requested SOC [Start of Care] Date: 4/27/2026 …Disciplines Requested: Skilled Nursing … Special Instructions: Referral to continue once a week visiting nurse for nephrostomy tube [small tube placed directly into the kidney to drain urine into a bag outside the body] care and maintenance x 12 weeks … The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care. (List medical condition) Rectal cancer (C20) metastatic [spread from original site] to liver and lungs …” A “Client Coordination Note Report,” completed by S15 on 04/29/26, stated “CLIENT CALLED IN THIS MORNING TO CANCEL TODAY’S NURSING VISIT, AS [P1] IS CURRENTLY IN [facility name] FOR A BLOOD TRANFUSION. ADMITTED 04/28/26.” A “Client Coordination Note Report,” completed by S16 on 05/03/26, stated “SPOKE WITH CLIENT … AGREEABLE TO CALL BACK EARLY THIS WEEK FOR SOC DATE.” A “Client Coordination Note Report,” completed by S14 on 05/05/26, stated “CSM [Client Services Manager] PHONED CLIENT TO SCHEDULE SOC, NO ANSWER ON PHONE. CSM UNABLE TO LEAVE MESSAGE AS VOICEMAIL IS FULL.” A “Client Coordination Note Report,” completed by S12 on 05/06/26, stated “L/M [Left message] FOR CLIENT TO CB [Call Back] TO SETUP SOC”. A “Client Coordination Note Report,” completed by S12 on 05/06/26, stated “RECEIVED A CALL FROM CLIENT AND CONFIRMED RN SOC 5/8 ALL INFO CONFIRMED IN FILE”. A “Visit Note Report,” was completed by S13 on 05/08/26, stated “...Narrative ...PT [patient] SEEN FOR SOC …” P1’s SOC was completed on 05/08/26 by S13, greater than 48 hours after the date of referral. On 08/13/26 at 11:56 AM, S1 stated staff likely did notify the provider, however confirmed P1’s medical record lacked evidence of communication to the provider regarding the changes made to P1’s SOC date. A review of P7’s medical record revealed the following: An attachment in P7’s medical record, titled “Referral Document,” dated 07/06/26, stated, “Ambulatory referral to Physical Therapy…Referral Information: # Visits: 12; Referral Type: Therapy...; Urgency: Routine; Referral Reason: Evaluation and Treat; Start date: July 6, 2026; End date: To be determined by Insurer; Diagnosis: Midline low back pain with right-sided sciatica, unspecified chronicity…” A “Client Coordination Note Report” completed by S12 on 07/08/26 stated, “…Note: Received a call from client and confirmed PT SOC 7/10. All info confirmed in file.” P7’s SOC was scheduled for 07/10/26, greater than 48 hours after the date of the referral. The medical record lacked evidence of communication of the delay in the SOC to the prescriber. On 08/14/26 at 12:06 PM, S1 explained that an initial visit should be completed within 48 hours of a referral. S1 stated that any changes to the SOC date should be communicated to the prescriber and to the patient and documented in the patient’s medical record. S1 and S2 confirmed that P7’s medical record lacked evidence of communication to the prescriber regarding the changes made to P7’s SOC date.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, staff interview, and a review of facility policy and procedure, it was determined the facility failed to ensure staff complete medication reconciliation during reassessments in accordance with facility policy, in one of five home visits conducted (Patient (P)2). Findings include: Facility policy titled “Medication Management & Administration,” dated 08/03/2026, stated “…For Home Health…, medication reconciliation should be completed on assessment and reassessment; …” On 08/11/26 at 12:30 PM, Staff (S)6 was observed providing care to P2 during a home care visit. During the visit, S6 was not observed reviewing P2’s current medications with the patient. At 01:49 PM, an interview was conducted with S6. S6 confirmed he/she did not ask for P2’s list of medications during the visit. When asked about the process of medication reconciliation, S6 stated he/she checks medications at the start of care and they usually stay pretty much the same. S6 stated, it was rare to have new medications added. When asked how he/she knew if a medication change occurred, S6 stated he/she asks a family member if there was a change in medications. When asked how frequently he/she checks with a family member regarding medication changes, S6 stated “ideally, it should be every visit.” On 08/12/26 at 11:56 AM, during an interview with S1, he/she confirmed that medication reconciliation is expected to be completed at every visit. S1 stated that the clinician should review all of the patient’s medications and document any identified changes.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that 1.) physicians are notified when a plan of care is altered due to fewer visits or hours of service being provided in one of three active medical records reviewed (Patient (P) 5); and 2.) physicians are notified when services requested in referral are not provided in one of three active medical records reviewed (P5), and 3.) physicians are notified when there is a delay in the start of care in one of three active medical records reviewed (P1). 1. Facility policy titled, “06277 Missed Visits/Hours” dated 03/24/23, stated, “… Our Procedure: 1.0: Communicating Missed Visits/Hours. 1.1: Physician Ordered Services. The physician must be notified when the plan of care is altered due to fewer visits or hours of service being provided as ordered. Notification of the missed visits/hours is timely, and as directed on a schedule determined in collaboration with the physician. 1.1.1. Documentation – Home Health and Hospice Offices. … 1.1.1.2 Missed Visit Process Flow. The field clinician is responsible for documenting the missed visit in the “Missed Visit Coordination Note” found in the electronic record. 1.1.1.2.1 The Missed Visit Coordination Note will include the following: a. Date missed visit occurred; b. Reason for missed visit; and c. Method of notification to physician (verbal or fax) … ” A review of P5’s medical record was conducted and revealed the following: P5’s “Home Health Certification and Plan of Care” for the certification period 07/08/26 to 09/05/26, stated, “…Frequency/Duration of Visits: PT [physical therapy] 1WK2 [1 visit a week for 2 weeks], 2WK3 [2 visits a week for 3 weeks], 1WK3 [1visit a week for 3 weeks]...” P5’s “Patient Calendar” for the week of 07/19/26 revealed that he/she received one of two PT visits. P5’s medical record lacked evidence of physician communication regarding the missed visit. On 08/13/26 at 2:34 PM, Staff (S) 2 confirmed that P5’s medical record lacked evidence of communication with the physician regarding the missed visit. 2. Facility policy titled, “0-4172 Referral Process & Admission Criteria & Procedure – Home Health – NJ” dated 11/12/20, stated, “…Our Procedure: 2.0. Admission Criteria…2.2 Clients shall be accepted for treatment on the basis of a reasonable expectation that the clients needs can be met by [Home Health Agency] in the client’s place of residence or the community. Such reasonable expectation shall be based on an assessment of at least the following factors: a. Adequacy and suitability of [Home Health Agency] personnel and resources to safety [sic] and adequately provide services to the client…3.0. Admission/Readmission Procedure…3.9. When multiple disciplines are ordered and/or evaluation for services are ordered at the time of referral or added on the course of treatment, initiate of each initial discipline specific assessment/evaluation will be completed as soon as is necessary to meet the client’s care needs in coordination with the physician and client. Any delay or altered time frame for the initiation of services beyond those stated, including those due to client preference, contraindicated, etc., are communicated to the physician and to the client, and documented in the client chart…” An attachment in P5’s medical record, titled “Referral Document,” dated 07/07/26, stated, “Patient Demographic/Referral Form…Orders: 1. PT, OT [Occupational Therapy], HHA [Home Health Aide] 2. Lymphedema for bilateral lower extremities…” P5’s “Home Health Certification and Plan of Care” for the certification period 07/08/26 to 09/05/26 lacked evidence of an order for OT and HHA. A “Visit Note Report” completed by S3 on 07/08/26 lacked evidence of P5’s declination of HHA and OT services or a note from S3 indicating P5 did not require these services per clinician assessment. P5’s medical record lacked evidence of communication with the physician notifying him/her that P5 was not receiving HHA and OT services. On 08/11/26 at 11:07 AM, an interview was conducted with P5. P5 stated that he/she only receives PT services from the Home Health Agency. When asked if he/she required a HHA, P5 explained that his/her spouse is paid to provide HHA services from an outside company. On 08/13/26 at 11:01 AM, S2 confirmed that P5’s medical record lacked evidence of a note from the clinician explaining that the patient did not require OT or HHA services or that P5 declined OT or HHA services. S2 confirmed that P5’s medical record also lacked evidence of communication with the physician notifying him/her that P5 was not receiving HHA and OT services. S2 explained that the physician should have been notified that these services were not being provided. Findings include: Facility policy titled, “0-672-Admission Criteria & Procedure-Medicare Certified Offices” dated 02/02/26, stated, “…Our Procedure:…9.0: A registered nurse [RN] or therapist (PT [Physical Therapist], SLP [Speech Language Pathologist]) must conduct an initial assessment visit to determine the immediate care and support needs of the client, and for Medicare clients, to determine eligibility for the Medicare home health benefit. Any delay or altered time from for the initiation of services beyond those stated, including those due to client preference, medically contraindicated, etc., are communicated to the physician and to the client, and documented in the client’s chart...” On 08/11/26 at 10:00 AM, a home visit for P1 was observed. After care was provided, P1 was interviewed. P1 expressed some concern over the delay with resuming care after being hospitalized and stated there was one time in particular that resumption of care took “over a week.” A review of P1’s medical record revealed the following: An attachment in P1’s medical record, titled “Referral Document,” dated 04/27/26, stated “… On What date was the Face to Face Encounter?: 04/14/26 … Requested SOC [Start of Care] Date: 4/27/2026 …Disciplines Requested: Skilled Nursing … Special Instructions: Referral to continue once a week visiting nurse for nephrostomy tube [small tube placed directly into the kidney to drain urine into a bag outside the body] care and maintenance x 12 weeks … The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care. (List medical condition) Rectal cancer (C20) metastatic [spread from original site] to liver and lungs …” A “Client Coordination Note Report,” completed by S15 on 04/29/26, stated “CLIENT CALLED IN THIS MORNING TO CANCEL TODAY’S NURSING VISIT, AS [P1] IS CURRENTLY IN [facility name] FOR A BLOOD TRANFUSION. ADMITTED 04/28/26.” A “Visit Note Report,” completed by S13 on 05/08/26, stated “...Date of Referral: 05/01/26...” A “Client Coordination Note Report,” completed by S16 on 05/03/26, stated “SPOKE WITH CLIENT … AGREEABLE TO CALL BACK EARLY THIS WEEK FOR SOC DATE.” A “Client Coordination Note Report,” completed by S14 on 05/05/26, stated “CSM [Client Services Manager] PHONED CLIENT TO SCHEDULE SOC, NO ANSWER ON PHONE. CSM UNABLE TO LEAVE MESSAGE AS VOICEMAIL IS FULL.” A “Client Coordination Note Report,” completed by S12 on 05/06/26, stated “L/M [Left message] FOR CLIENT TO CB [Call Back] TO SETUP SOC”. A “Client Coordination Note Report,” completed by S12 on 05/06/26, stated “RECEIVED A CALL FROM CLIENT AND CONFIRMED RN SOC 5/8 ALL INFO CONFIRMED IN FILE”. A “Visit Note Report,” completed by S13 on 05/08/26, stated “... Narrative ... PT [patient] SEEN FOR SOC …” P1’s SOC was completed on 05/08/26 by S13, greater than 48 hours after the date of referral. The above documentation reviewed lacked evidence that a provider was notified of the delay in start of care. On 08/13/26 at 11:56 AM, S1 stated staff likely did notify the provider, however confirmed P1’s medical record lacked evidence of communication to the provider regarding the changes made to P1’s SOC date.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on interview and review of facility documents, it was determined the facility failed to ensure the Administrator was appointed by the governing body. Findings include: During entrance conference on 08/10/26 at 9:50 AM, Staff (S)1 stated the current acting Administrator had previously served as the Alternate Administrator. S1 further stated the change in roles had been in affect since February 2026. Upon review of governing body meeting minutes documentation, from 05/2025-04/2026, there was no documented evidence the Governing Body appointed the current Administrator in writing. During interview on 08/12/26 at 11:27 AM, S1 confirmed the agency was unable to provide documentation demonstrating the Governing Body’s written appointment of the current Administrator. S1 stated the formal appointment of the Administrator was scheduled to be addressed at the governing body meeting scheduled for 09/03/26.”

“Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA’s patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This Element is not met as evidenced by: Based on interview and review of facility documents, it was determined the facility failed to ensure clinical services provided by personnel, from a separately licensed home health agency, are furnished under a written agreement or contractual arrangement. Findings include: During an interview on 08/10/26 at 1:46 PM, Staff (S)1 stated this agency routinely utilizes a Registered Nurse (RN) from a separate agency to provide weekend nursing coverage and to precept newly hired staff. S1 further stated that the agency utilizes a Physical Therapist (PT) on a per diem basis to provide PT services as needed due to staffing limitations. Upon review of the agency’s staff roster on 08/12/26 at 12:17 PM, S1 confirmed the clinicians, routinely used from another agency, were not employed at this agency and were associated with another home health agency operating under a separate license number. S1 stated he/she supervises the non-employee staff’s documentation when these clinicians provide RN or PT home care services. S1 confirmed that was no written agreement or contractual arrangement governing the use of RN and PT between the two separately licensed agencies.”