Bayada Home Health Care, Inc.

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on a review of the agency policy/procedure and documentation and based on interview with the administrator (Employee #10), the agency failed to ensure the contact information for the state survey agency (Pennsylvania Department of Health/Division of Home Health) had been included in the emergency management plan (EPP). Findings Include: On October 16, 2024 at approximately 11:40 AM, review of the August 2024 “Emergency Management Agency Contact Information by Federal/State/County/City/Town” revealed the following: Directions: Office are required to include in the communication plan a process for communicating with state...emergency preparedness officials... On October 15, 2024 at approximately 12:50 PM and October 16, 2024 at approximately 11:40 AM, review of the “01/02/2024 Emergency Management Plan Office Specific Clarks Summit Pediatrics” and the August 2024 “Emergency Management Agency Contact Information by Federal/State/County/City/Town” failed to reveal that the contact information for the state survey agency (717-783-1379)) had been included in the EPP. During interview conducted on October 17, 2024 at approximately 10:20 AM, the administrator confirmed the contact information for state survey agency was not included in the EPP prior to 10/15/2024.”

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based on interview with the clinical manager/registered nurse (CM/RN-Employee #4), the clinical educator/registered nurse (CE/RN-Employee #8) and the administrator (Employee #10), the agency failed to ensure documentation of discharge planning was completed in accordance with agency policy procedure for two (2) of two (2) clients (patients) who were discharged from services. (Clients #6 and #7) Findings include: On October 17, 2024 at approximately 5:06 PM, review of agency policy 0-9307, titled “Client Discharge and Transfer-Medicare Certified Home Care and Home Health Offices” revealed the following: Our Procedure... 1.1 A client is...discharged from service...for any of the following reasons...a...discharge is necessary for he client’s welfare because Bayada and the client’s physician agree that Bayada can no longer meet the client’s needs based on the client’s acuity... 3.1 Discharge...Any revisions to the client’s discharge plan will be communicated to the client, the client’s representative, all physician’s issuing orders for the client’s plan of care and the client’s primary care practitioner or other health care professional who will be responsible for providing care and services to the client after discharge from the organization...Communication with the client/representative and physician is documented on the coordination of services (COS) note or on a comparable form. Client #6: On October 17, 2024 at approximately 3:54 PM, review of the clinical record revealed the start of care date was 08/29/2023, the client is 5 years old, the primary diagnosis was cerebral palsy and that home health aide (HHA) services were to be provided three (3) to seven (7) hours per day for five (5) days per week as documented on the “Home Health Certification and Plan of Care” for recertification period of 02/25/2024 through 04/24/2024. Review of missed visit report (MVR) documentation for April, May, June and July 2024 revealed client services were on hold. Review of “Addendum to Plan of Care” order documentation dated 09/11/2024 revealed the CM/RN (Employee #4) documented the client was being discharged due to lack of available staff and that the client’s last day of services was 04/19/2024. Additional type-written documentation entered below the discharge order revealed the following: Do not agree with plan to discharge and would not sign order to discontinue services. Family aware to look at alternative options if no services currently available through Bayada. The type-written name of the client’s physician was entered below the above referenced type-written statement. Review of COS note documentation revealed the discharge order was faxed to the physician on 09/19/2024 and that the order returned by the physician included the above referenced type-written statement. The CM/RN documented that the physician refused to sign the discharge order because the physician “felt the client needed care”. There was no documentation in the clinical record which provided evidence the client’s responsible party and physician had been involved in the discharge planning process between 04/19/2024 and 09/11/2024. Client #7: On October 17, 2024 at approximately 4:32 PM, review of the clinical record revealed the start of care date was 04/06/2016, the client is 33 years, the primary diagnosis was type-1 diabetes mellitus (diabetes) and that skilled nursing (SN) services were to be provided 26 to 45 hours for one (1) week then 36 to 53 hours on the alternate week for 60 days as documented on the “Home Health Certification and Plan of Care” for recertification period of 02/24/2024 through 04/23/2024. Review of SN visit documentation revealed SN services were provided through 03/14/2024. Review of the discharge comprehensive assessment revealed the CE/RN performed an off-site discharge assessment on 04/23/2024. Review of “Addendum to Plan of Care” order documentation dated 04/25/2024 revealed the CE/RN (Employee #8) documented the client was being discharged from the agency. There was no documentation in the clinical record which provided evidence the client and physician had been involved in the discharge planning process prior to the completion of the discharge assessment. During interview conducted on October 17, 2024 at approximately 5:30 PM, the CM/RN, CE/RN and the administrator confirmed documentation of discharge planning was not completed in accordance with agency policy/procedure for the above referenced clients.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on review of agency policies/procedures, documentation and Pennsylvania Department of Health (PA DOH) website reports and based on interview with the administrator (Employee #10), the agency failed to submit a report of five (5) of eight (8) reports of Health Department Reportable Diseases to the PA DOH Event Reporting System (ERS) website which were received after 06/01/2023. Findings included: On October 17, 2024 at approximately 5:00 PM, review of agency policy 0-933, titled “Incident Reporting and Documentation”, revealed the following: Our Policy...Bayada Home Health Care report, investigate, document employee and client accidents, injuries, and safety hazards related to the care and services provided... Our Procedures...2.0 Definitions of Incidents... 2.2...Incidents defined as Adverse Events include, but are not limited to... f. Safety risks or endangerment of employees or clients may include... j. Exposure to infection or communicable disease... On October 16, 2024 at approximately 11:51 AM, review of agency policy 9-582, titled “Infection Prevention Program” revealed the following: Our Procedure...4.0 Strategies for Infection Prevention... 4.4 Reporting and Tracking of Infections...4.4.2 Each individual service office’s clinical staff are responsible for reporting client infections... On October 16, 2024 at approximately 9:34 AM, review of agency policy 0-403, titled “Quality Assurance & Performance Improvement (QAPI) Program revealed the following: 4.0 Measures, Outcomes and Goals...4.1 Data Collection and Measurement...4.1.5 Monitoring of other data and reportable events is gathered, reviewed and analyzed to assess performance and to identify trends requiring further...intervention. Data includes, but is not limited to...d. Infections... On October 17, 2024 at approximately 7:45 AM, review of the PA DOH website (https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx) revealed influenza and respiratory syncytial virus are Health Department Reportable Diseases. On 10/17/2024 at approximately 8:04 AM, review of agency incident/adverse event report documentation revealed the following client-related contagious disease reports were received by the agency: 06/15/2023, 12/08/2023 and 05/17/2024: Influenza 11/15/2023 and 11/20/2023: RSV. On October 17, 2024 at approximately 10:45 AM, review of the PA DOH ERS website failed to reveal that the agency had submitted a report of the above referenced Health Department Reportable Diseases. During interview conducted on October 17, 2024 at approximately 5:30 PM, the administrator confirmed the agency failed to submit a report of the above referenced Health Department Reportable Diseases to the PA DOH ERS website.”