Jefferson Health at Home By Bayada

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on a review of agency policy, PFs, and an interview with the administrator, the agency failed to follow its policy for personnel file requirements for six (6) of twelve (12) PFs reviewed, (PF #5, 6, 9, 10, 11, and 12). Findings include: A review of agency policy titled “Field Employee Policies and Benefits” conducted on 4/15/26, at approximately 11:30 AM states, “Performance Evaluations, Every Bayada field employee receives a performance evaluation annually…” A review of agency policy titled “TB Risk Assessment and Exposure Plan” conducted on 4/15/26, at approximately 11:44 AM states, “Initial TB screening requirements for new employees: TB screening is required and performed at the time of hire before an employee enters a client’s home or other care setting…Initial TB screening procedure: The employee completes the employee screening tool…the employee then completes the requirements for TB testing…” A review of agency policy titled “Competency Assessments RN & LPN” conducted on 4/15/26, at approximately 11:49 AM states, “Certifications: CPR; All Home Health office and field employees who deliver direct client care will provide evidence of current CPR certification for BLS skills…Written exam(s) and skills observation are conducted at orientation and prior to case assignment…Annual Performance Evaluations: Annual performance evaluations completed for all nurses include at least one on-site observation during the year…The Home Health Field clinician supervision competency is used to document skills observed throughout the year…” A review of agency policy titled “Blood-Borne Pathogen Exposure Management Plan” conducted on 4/15/26, at approximately 11:54 AM states, “Hepatitis B Vaccination Program: At Bayada’s expense, the Hep B vaccination is made available to an employee who is at risk of occupational exposure…The employee must sign Hepatitis B vaccine consent/declination form…” A review of agency policy titled “Field Employee Orientation, Education, and Inservice Requirement” conducted on 4/15/26, at approximately 12:00 PM states, “Every field employee receives a complete orientation to Bayada and their position before providing care independently in the home…The new hire orientation is paid and includes d. Job description and performance evaluation procedures; y. Emergency Preparedness training…” A review of agency policy titled “Emergency Management Program and Plan” conducted on 4/15/26, at approximately 12:11 PM states, “A training program that provides education initially (at hire) and every two years to all employees…” A review of PFs was conducted on April 14, 2026, from approximately 9:30 AM to 12:00 PM; and on April 15, 2026, from approximately 9:15 AM to 10: 15 AM. PF #5, Date of Hire: 6/19/23, ST, did not contain any documentation of current CPR certification; an annual performance evaluation for 2025; and annual tuberculosis education for 2025. PF #6, Date of Hire: 1/17/22, OT, did not contain any documentation of current CPR certification. PF #9, Date of Hire: 1/12/26, LPN, did not contain any documentation of tuberculosis testing at hire. PF #10, Date of Hire: 5/10/22, RN, Alt. DON, did not contain any documentation of a Pennsylvania Criminal Background Check at hire or within one year of hire; annual competency for 2023; and tuberculosis testing at hire. PF #11, Date of Hire: 3/9/15, PT, Administrator, did not contain any documentation of Hepatitis B vaccination documentation; tuberculosis testing at hire; and a tuberculosis symptom screening and risk assessment at hire. PF #12, Date of Hire: 6/23/15, RN, DON, did not contain any documentation of a Pennsylvania Criminal Background Check; current CPR certification; annual competencies for 2023, 2024 and 2025; Emergency Preparedness training for 2023 and 2025; annual performance evaluations for 2023, 2024, and 2025; Hepatitis B vaccination documentation; tuberculosis testing at hire; and annual tuberculosis education for 2023, 2024, and 2025. An interview with the administrator conducted on April 15, 2026, at approximately 11:45 AM confirmed the above findings.”