Bayada Home Health Care, Inc.

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on review of policies, personnel records and interview with the agency administrator the governing body failed to ensure personnel records contained performance reviews that had been conducted annually for two (2) of three (3) personnel requiring an annual review (PR#1 and PR#2), failed to ensure completed competencies for five (5) of eight (8) personnel (PR#1, PR#4, PR#5, PR#6, PR#8) and failed to maintain current Basic life support (BLS) certification for one (1) of eight (8) personnel (PR#8) Review of policies and procedures on 9/5/25 at approximately 1:00 PM revealed the following: Policy 0-117- Field employee Policies & Benefits states, “12.0 Performance evaluations. Every Bayaadaa fild employee receives aa performance evaluation annually (within 12 months from the date of hire or previous evaluation). Which is incorporated into the employee’s permanent employe file…” Policy 0-10356 Competency Assessments RN & LPN, states, “4.2 Initial Competency-Core Competency Assessment and Coding. 4.2.1 Core Competency Assessment. Core skills listed on 0-10343 Competency Checklist SNU-will be demonstrated to validate proficiency in the laab and the field/home (when applicable) before performing client care independently…4.2.1.1 All nurses will demonstrate the required core skills indicated on 0-10343-Competency checklist for their recent age group(s) experience.” Review of competency checklist form 0-10343 states, “purpose: This form is to be utilized to document a) initial competency and the assignment of skill code prior to independently caring for clients…Skills marked with (*) are required to be demonstrated in the lab during initial and annual skills competency.” Policy 0-10356 Competency Assessments RN & LPN, states, “3.3 Certifications. 3.3.1 CPR. All adult and pediatric care nurses will provide evidence of current CPR certification for Basic Life Support (BLS) skills from a Bayada approved accrediting source…Employees without CPR certification or expired CPR will obtain valid CPR certification before working with client…” Review of personnel records on 9/3/25 at 2:00 PM revealed the following: PR#1 Date of hire 8/9/24. There was no documentation of an annual performance review conducted until 9/4/25. All required skills marked with an (*) had not been demonstrated during initial skills competency training. PR#2 Date of hire 8/19/24. There was no documentation of an annual performance review conducted until 9/4/25 PR#4 Date of hire 5/27/25. All required skills marked with an (*) had not been demonstrated during initial skills competency training. PR#5 Date of hire 1/24/25. All required skills marked with an (*) had not been demonstrated during initial skills competency training. PR#6 Date of hire 6/16/25. All required skills marked with an (*) had not been demonstrated during initial skills competency training. PR#8 Date of hire 6/3/25. All required skills marked with an (*) had not been demonstrated during initial skills competency training. BLS certification expired 5/31/25 and was not renewed until 9/5/25. Documentation showed this employee worked with a skilled client on 6/18, 6/19, 7/2, 7/24, 8/27, 8/28/25. Interview with the agency administrator on 9/5/25 at approximately 2:00 PM confirmed the above findings”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on the review of agency policies, clinical records (CR), and interviews with the administrator, the agency failed to ensure services were provided in accordance with the plan of care for two (2) of nine (9) CR reviewed. (CR #5 and CR#7) Review of agency Policy #0-6277 Missed Visits/hours on 9/5/25 at 1:00 PM states, “Bayada Home Health Care has a process for communication and documentation related to missed visits/hours that are not provided at the frequency stated on the plan of care…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.” Review of Clinical records on 9/4/25 from approximately 9:30 AM to 11:00 AM and 9/5/25 from approximately 9:00 AM through 2:00 PM revealed the following: CR#5: Start of care 4/3/25 (certification period 8/1/25-9/29/25): The plan of care (POC) contains orders as follows: Skilled nursing (SN) to provide 3-8 hours a day, 5-7 day a week in the home for parents work schedule as well as care in the home while at least one parent is caring for needs of the other children in the home. And 8 hours a week for essential house hold duties (EHHD) for 60 days. For the week ending 8/9/25 only 2.25 EHHD hours had been provided. There was no documentation the physician was made aware For the week ending 8/16/25 only 6.75 EHHD hours had been provided. There was no documentation the physician was made aware For the week ending 8/30/25 only 4.75 EHHD hours had been provided. There was no documentation the physician was made aware CR#7: Start of care 6/25/24 (certification period 8/19/25-10/17/25): The plan of care (POC) contains orders as follows: Skilled nursing (SN) to provide 5-12 hours a day, 2-5 day a week for parents work and 8 hours a week for essential house hold duties (EHHD) for 60 days. For the week ending 8/23/25 only 4.25 EHHD hours had been provided. There was no documentation the physician was made aware Interview with the agency administrator on 9/5/25 at approximately 2:00 PM confirmed the above findings”

“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 review of policies and procedures, clinical records (CR) and interview with the agency administrator, the agency failed to ensure that a comprehensive assessment included a review of all medications that the patient was currently using in order to ineffective drug therapy for nine (9) of nine (9) CR reviewed (CR#1 through CR#9). Review of Clinical records on 9/4/25 from approximately 9:30 AM to 11:00 AM and 9/5/25 from approximately 9:00 AM through 2:00 PM revealed the following: CR#1: Start of care 7/12/23 (certification period 5/24/25-7/22/25): The clinical record failed to contain documented evidence of a review of all medications the patient is currently taking to identify possible ineffective drug therapy. CR#2: Start of care 11/16/15 (certification period 4/30/25-5/18/25): The clinical record failed to contain documented evidence of a review of all medications the patient is currently taking to identify possible ineffective drug therapy CR#3: Start of care 6/5/23 (certification period 7/24/25-9/21/25): Start of care 11/16/15 (certification period 4/30/25-5/18/25): The clinical record failed to contain documented evidence of a review of all medications the patient is currently taking to identify possible ineffective drug therapy. CR#4: Start of care 5/6/25 (certification period 9/3/25-11/1/25): The clinical record failed to contain documented evidence of a review of all medications the patient is currently taking to identify possible ineffective drug therapy. CR#5: Start of care 4/3/25 (certification period 8/1/25-9/29/25): The clinical record failed to contain documented evidence of a review of all medications the patient is currently taking to identify possible ineffective drug therapy. CR#6: Start of care 7/16/25 (certification period 7/15/25-9/12/25): The clinical record failed to contain documented evidence of a review of all medications the patient is currently taking to identify possible ineffective drug therapy. Additionally, the verbal order for the plan of care was received by the nurse on 7/11/25. The physician’s signature was not obtained until 8/13/25 (33 days). The only documented attempt to obtain the physician’s signature was a fax on 8/2/25. CR#7: Start of care 6/25/24 (certification period 8/19/25-10/17/25): The clinical record failed to contain documented evidence of a review of all medications the patient is currently taking to identify possible ineffective drug therapy. Additionally, the verbal order for the plan of care was received by the nurse on 8/8/25. The physician’s signature was not obtained as of 9/5/25 (28 days). The only documented attempt to obtain the physician’s signature was a fax on 8/12/25 and 9/5/25. CR#8: Start of care 7/9/24 (certification period 9/2/25-10/31/25): The clinical record failed to contain documented evidence of a review of all medications the patient is currently taking to identify possible ineffective drug therapy. CR#9: Start of care 9/14/16 (certification period 7/29/25-9/26/25): The clinical record failed to contain documented evidence of a review of all medications the patient is currently taking to identify possible ineffective drug therapy. Interview with the agency administrator on 9/5/25 at approximately 2:00 PM confirmed the above findings”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on review of policies and procedures, clinical records (CR) and interview with the agency administrator, the agency failed to follow its own policy regarding verbal orders from a physician for two (2) of nine (9) clinical records reviewed (CR#6 and CR#7) Review of agency Policy #0-983 Physicians Orders on 9/5/25 at 1:00 PM states, “3.Signature updates and tracking. 3.1 Signature Timeframe. A physician/healthcare practitioner signature must be obtained within 28 days, unless a shorter timeframe is required by the state or program regulations. The 28-day requirement for obtaining a physician/healthcare practitioner’s signature begins when the verbal orders are obtained. The date the order is obtained is reflected in the verbal start of care date locator 23. 3.2 Signature tracking. A physician/health care practitioner’s signature is obtained and tracked according to the following procedure: a. If the orders are not returned with physician/health care practitioner’s signature after two weeks (or sooner if required by state regulations), a second copy is sent with an accompanying note requesting the signed orders be returned immediately. B. after one more week, if the orders are still unsigned, the client will be informed of the situation, and someone from the office will take a third copy to the physician/health care practitioner’s office and make one final attempt. c. if the final attempt proves unsuccessful, and signed orders are not received from the physician/health care practitioner by the end of four weeks, the client and physician/health care practitioner will be informed that client discharge and transfer procedures will be implemented immediately. Review of Clinical records on 9/4/25 from approximately 9:30 AM to 11:00 AM and 9/5/25 from approximately 9:00 AM through 2:00 PM revealed the following: CR#6: Start of care 7/16/25 (certification period 7/15/25-9/12/25): The verbal order for the plan of care was received by the nurse on 7/11/25. The physician’s signature was not obtained until 8/13/25 (33 days). The only documented attempt to obtain the physician’s signature was a fax on 8/2/25. CR#7: Start of care 6/25/24 (certification period 8/19/25-10/17/25): The verbal order for the plan of care was received by the nurse on 8/8/25. The physician’s signature was not obtained as of 9/5/25 (28 days). The only documented attempt to obtain the physician’s signature was a fax on 8/12/25 and 9/5/25. Interview with the agency administrator on 9/5/25 at approximately 2:00 PM confirmed the above findings”