Bayada at Inspira, Home Health and Hospice

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on observation, medical record review, staff interview, and review of facility policy, it was determined the facility failed to ensure individual emergency preparedness plans are developed in three of six medical records reviewed (Patients (P) 3, P4, and P5). Findings include: Facility policy titled, “0-9197 Emergency Management Program and Plan – Medicare-Certified Offices,” dated 02/06/25, stated, “… Our Procedure: … 4.0 Standards for Emergency Management Planning … 4.1.3 Client-Specific Emergency Plans. At admission, all clients will be educated on the risks of disasters and the importance of emergency planning. 4.1.3.1 As part of the comprehensive assessment, the admitting clinician will develop a Client- Specific Emergency Plan by entering the information into the electronic record and also using 0-9236 – Client -Specific Emergency Plan – Home Health and Hospice … The Client- Specific Emergency Plan will include specific instructions for the client …” On 05/04/26 at 1:45 PM, Staff (S) 9 was observed completing a home visit for P3. At 1:59 PM, a review of P3’s admission packet was conducted with S9. A blank “Client-Specific Emergency Plan – Home Health and Hospice Offices” form was observed in the admission packet. The admission packet lacked evidence of a completed individual emergency preparedness plan. At 2:31 PM, an interview was conducted with S9. S9 confirmed P3 did not have a completed individual emergency preparedness plan in his/her admission packet. S9 stated the individual emergency preparedness plan should be completed at the start of care and should be both on paper and electronic, in the patient’s medical record. On 05/06/26, a review of P3, P4, and P5’s medical record was conducted and revealed the following: For the start of care beginning on 02/09/26 and the recertification period beginning on 04/10/26, P3’s medical record lacked evidence of an individual emergency preparedness plan. For the start of care beginning 03/26/26, P4’s medical record lacked evidence of an individual emergency preparedness plan. For the start of care beginning 04/14/26, P5’s medical record lacked evidence of an individual emergency preparedness plan. On 05/06/26 at 1:16 PM, an interview was conducted with S1, S2, and S3. S1 stated an individualized emergency preparedness plan is completed for each patient during the start of care, resumption of care, recertification, and if there is a change in the plan. S3 stated all emergency preparedness plans should be uploaded to the patient’s electronic medical record. S1 stated that registered nurses, physical therapists, and speech-language pathologists are able to complete the patient’s emergency preparedness plan. At 2:27 PM, an interview was conducted with S3. S3 confirmed P3, P4, and P5 did not have a completed individual emergency preparedness plan in their electronic medical records. Cross reference: NJAC 8:42-6.1(a)(7)”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on observation, staff interview, facility document review, and review of medical records, it was determined the facility failed to ensure that all patients with Medicare coverage received a Notice of Medicare Non-Coverage (NOMNC) no later than two days prior to discharge, as per facility policy, for three of six discharged Medicare patients (Patients (P)4, P14, and P16). On 05/04/26 at 3:14 PM, Staff (S) 6 was observed, in the presence of S10, completing a discharge from agency home visit for P4. At 3:54 PM, P4 was observed signing a paper NOMNC form. At 4:06 PM, P4 was observed signing an electronic NOMNC form on a computer tablet. At 4:24 PM, an interview was conducted with S6. When asked about the NOMNC being signed the day of the discharge from the agency, S6 stated that it is usually filled out at least 48 hours prior to discharge, but this wasn’t possible since the patient is only seen once a week. S6 explained that P4 saw a Licensed Practical Nurse (LPN) during the previous week’s visit and that the NOMNC wasn’t completed at that time because only Registered Nurse’s (RN) can complete NOMNC’s. A review of P4’s medical record was conducted and revealed the following: On 05/04/26, P4 was discharged from Home Care services by S6. The NOMNC was completed on 05/04/26 and signed by P4, less than two days prior to discharge. Findings include: Facility Policy titled, “0-322 Home Health Change of Care Notice (HHCCN), Advanced Beneficiary Notice of Non-Coverage (ABN), Notice of Medicare Non-Coverage (NOMNC) and Fast Track Appeal Review Procedures” dated January 1, 2025, stated “… Our Procedure: …3.0: Notice of Medicare Noncoverage (NOMNC). 3.1: A standardized Review Notice, NOTICE OF MEDICARE NON-COVERAGE (NOMNC), #0-3195, is given on paper or electronically, to all beneficiaries when Medicare coverage is about to end based on the physician’s orders and all home healthcare is ending, (except those admitted to a facility or hospital) no later than two (2) days prior to discharge…3.2: The Initial Notice of Medicare Provider Non-Coverage is delivered as follows: a. Face to face and signed and dated by the client and representative, b. If the Initial Notice of Medicare Provider Non-Coverage cannot or will not be signed, a notation is made on the notice explaining why and dated… 5.0: Retention Requirements: The original notice(s) must be retained in the client’s chart…” On 05/05/26, a review of P14 and P16’s medical records was conducted and revealed the following: On 05/15/25, P14 was discharged from Home Care services by Staff (S)12. The NOMNC was completed on 05/15/25 and signed by P14, less than two days prior to discharge. On 11/13/25, P14 was discharged from Home Care services by S18. The NOMNC was completed on 11/13/25 and signed by P14, less than two days prior discharge. On 03/09/26, P16 was discharged from Home Care services by S5. P16’s electronic medical record (EMR) lacked evidence of a NOMNC. On 05/05/26 at 2:30 PM, an interview was conducted with S1, S2, and S3. When asked about the process for discharge, S1 stated that the NOMNC is provided to the client 48 hours prior to discharge. S1 stated, the signed NOMNC is then uploaded to the EMR by the clinician. At 3:23 PM, S3 confirmed that the NOMNC for P14’s discharges on 05/15/25 and 11/13/15 had both been completed on the same date as discharge and should have been completed at least two days prior to discharge. S3 confirmed that the NOMNC for P16 had not been uploaded to the EMR per facility policy.”

“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 observations, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure 1.) hand hygiene is performed before having contact with a patient’s intact skin and re-usable equipment; 2.) re-useable equipment is cleaned in accordance with manufacturer’s instructions and facility policy, during two of three home visits for Patient 4 (P4) and P5. Findings include: Facility policy titled, “Hand Hygiene” states, “....1.0 Indications for Hand Decontamination. …a. Before and after having and direct client contact with intact skin (bathing, dressing, performing physical examinations, taking a blood pressure or pulse, transferring/lifting, etc.). b. Before applying and after removing gloves... “ Facility policy titled, “Infection Prevention Procedures for Point of Care Devices” states, “... 3.0 Bayada Issued Tablet or Phone Transported from Home to Home … 3.3 Decontaminate hands when moving from direct client care to tablet. …” 1.) On 11/29/23 at 10:21 AM, during a home visit for P5, Staff 11 (S11), a Physical therapist, was observed applying gloves without first performing hand hygiene. While wearing gloves, S11 proceeded to take the patient’s blood pressure, pulse, and temperature and was observed entering information on his/her tablet wearing the same gloves and without decontaminating hands. S11 then brought P5 his/her walker, and followed the patient into the hallway and into the Wellness Center, wearing the same gloves, and holding the tablet in one hand. At 10:30 AM, P5 ambulated out of the Wellness Center, and S11 was observed holding the door open with his/her gloved hand. P5 ambulated back to the room with S11, and S11 was then observed removing a paper from a folder in the patient’s room, placing the paper near the patient on the counter, touching the patient’s walker, and utilizing his/her tablet, while wearing the same gloves. At 10:35 AM, P5 ambulated back to his/her chair and sat down. S11 was observed holding the patient’s wrist to check a pulse, still wearing the same gloves, without performing hand hygiene before contact with P5’s skin. P5 removed his/her socks and shoes, and S11 physically examined each of the patient’s feet, using his/her gloved hand, without first performing hand hygiene. At 10:41 AM, S11 removed his/her gloves, performed hand hygiene, applied new gloves, and began using his/her tablet. S11 provided P5 the paper from the counter, and then rechecked P5’s blood pressure and pulse oximeter, wearing the same gloves, without performing hand hygiene before contact with P5’s skin. S11 picked up the tablet, wearing the same gloves. 2.) Review of the facility policy titled, “Infection Prevention Procedures for Point of Care Devices” states, “... 3.4 Bayada Issued Tablet or Phone Transported from Home to Home … 3.4 “Disinfect tablet or phone using an approved EPA registered disinfectant wipe, and stylus using a 70% isopropyl alcohol wipe or EPA registered disinfectant wipe with gloved hands, at the following time: 3.4.1 Beginning of visit … 3.4.2 Before and after client visit verification signature 3.4.2.1 Client finger - Disinfect tablet screen before and after client touches screen to sign for visit verification with a manufacturer’s approved EPA registered disinfectant wipe following the manufacturer’s recommended contact time. Note: The manufacturer’s approved wipe for the Galaxy device is the PDI brand. …” On 11/28/23 at 12:45 PM, during a home visit for P4, S8 (Physical Therapist) was observed using a tablet asking P4 questions. S8 was not observed disinfecting the tablet at the beginning of the visit. At 1:19 PM, S8 was observed placing the tablet on the table in front of P4 without disinfecting the tablet. P4 used his/her finger to sign the tablet. On 11/29/23 at 10:21 AM, during a home visit for P5, S11 (Physical Therapist) was observed using a tablet while checking P5’s vital signs. S11 was not observed disinfecting the tablet at the beginning of the visit.. At 10:54 AM, S11 was observed disinfecting a tablet with a wipe. Five seconds later, S11 handed the tablet to P5 to hold and provide signature. S11 did not allow the tablet to remain wet for a full two minutes. At 11:02 AM, upon interview, S11 confirmed that he/she used a PDI Super Sani Cloth to clean the tablet. PDI Super Sani-Cloth Large Wipe Directions for use state, “...To disinfect and Deodorize: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two minutes. …” N.J.A.C. 8:42-12.2(b)(6)”