Bayada Home Health Care, Inc.

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on review of agency policy/procedure and documentation and based on interview with the Administrator (Employee #10), the agency failed to ensure documentation was maintained which provided evidence that patient complaints were tracked and analyzed during three (3) of three (3) Quality Assessment/Performance Improvement Meetings (QAPI). (September 2025, November 2025 and March 2026) Findings include: On May 21, 2026 at approximately 2:07 PM, review of agency policy 0-403, titled “Quality Assurance & Performance Improvement (QAPI) Program” revealed the following: 3.0 Governance and Leadership...3.1 The governing body ensures that the QAPI program reflects the complexity and scope of services of Bayada... 4.0 Measures, Outcomes and Goals...4.1 Data Collection and Measurement... 4.1.5 Monitoring other data and other reportable events is gathered, reviewed, and analyzed to assess performance and identify trends requiring further study and intervention. Data includes, but is not limited to...a. Incidents, complaints and adverse events... Between May 18, 2026 at approximately 3:20 PM and May 21, 2026 at approximately 9:15 AM, review of patient complaint log documentation revealed the following as documented on the “QI Event Summary” form: -One (1) complaint was received in July 2025, September 2025 and February 2026 -Two (2) complaints were received in August, October, November and December 2025. Between May 19, 2026 at approximately 1:30 PM and May 21, 2026 at approximately 9:18 AM, review of QAPI meeting minutes revealed QAPI meetings were conducted on 09/21/2025 and during the months of November 2025 and March 2026. There was no documentation on the “QAPI Monthly Meeting” forms which provided evidence the above listed complaints were tracked and analyzed during the QAPI meetings conducted in September and November 2025 nor March 2026. During interview conducted on May 21, 2026 at approximately 4:10 PM, the Administrator confirmed there was no documentation which provided evidence the above listed complaints were tracked and analyzed during the QAPI meetings conducted in September and November 2025 nor March 2026.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on review of agency policy/procedure, clinical records, personnel files and COVID-19 bulletins issued by the Pennsylvania Department of Health (PA DOH) and based on interview with the Administrator (Employee #10), the agency failed to ensure tuberculosis (TB) screening was conducted in accordance with agency policy/procedure and post COVID-19 pandemic guidance from the PA DOH for three (3) of three (3) staff members who were hired during the COVID-19 pandemic disaster declaration. (Employees #1, #6 and #9) Findings include: On May 21, 2026 at approximately 3:52 PM, review of agency policy 0-1999, titled “TB Risk Assessment & Exposure Plan” revealed the following: Definitions...a. TST-Two (2)-step Mantoux TB skin test...b. IGRA-Interferon-gamma release assay a type of TB blood test...c. TB Screening-a term that encompasses the following...TB testing... 3.0 Initial TB Screening Requirements for New Employees... 3.1 Initial TB Screening Procedure. The following steps meet the requirements for initial TB screening...c. The employee then completes the requirements for TB testing... 3.2 Options for TB Testing During TB Screening...a. TST...b. IGRA... 9.0 State and Program-Specific Amendments...9.6 Pennsylvania: All employees...will receive the baseline two(2)-step TST (or one time IGRA), if the baseline two(2)-step TST is utilized... On May 21, 2026 at approximately 8:05 AM, review of the memorandum titled “REVISED Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic”, which was issued by the PA DOH on 05/20/2020, revealed the following under “9. Pre-Employment Health Screening”: Any new employee who does not provide evidence of a Mantoux skin test within the previous 12 months must, as a condition of employment, receive the tuberculin skin test as soon as possible following termination of the Governor’s COVID-19 Disaster Declaration. On May 21, 2026 at approximately 8:19 AM, review of the May 11, 2023 PA DOH bulletin titled “UPDATE: Interim Infection Prevention and Control Recommendations for COVID-19 in Healthcare Settings” revealed the COVID-19 Public Health Emergency (PHE) ended on 05/11/2023. Patient #2: On May 19, 2026 at approximately 9:06 AM, review of the clinical record revealed the registered nurse (RN-Employee #1) provided skilled nursing services in May 2026. Patient #7: On May 21, 2026 at approximately 11:08 AM, review of the clinical record revealed the physical therapist (PT-Employee #6) provided PT services in May 2026. Patient #11: On May 21, 2026 at approximately 1:36 PM, review of the clinical record revealed the PT (Employee #9) provided PT services in May 2026. Between May 20, 2026 at approximately 2:10 PM and May 21, 2026 at approximately 3:51 PM, review of personnel file documentation revealed the following: Employee #1: The date of hire of the RN was 11/29/2021. There was no documentation in the personnel file which provided evidence a two (2)-step TST nor a single-step IGRA screening had been performed. Employee #6: The date of hire of the PT was 06/06/2022. There was no documentation in the personnel file which provided evidence a two (2)-step TST nor a single-step IGRA screening had been performed. Employee #9: The date of hire of the PT was 02/28/2022. There was no documentation in the personnel file which provided evidence that the second step of the two(2)-step TST had been performed. During interview conducted on May 21, 2026 at approximately 4:10 PM, the Administrator confirmed TB screening had not been conducted in accordance with agency policy/procedure, nor the PA DOH post-pandemic screening guidance, for the above identified employees.”