Bayada Home Health Care, Inc.

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to alert the physician to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved or the plan of care should be altered for three (3) of seven (7) records (CR1-CR3). Findings included: Review of agency policy on January 5, 2024, at 12:30 p.m. showed, “0-986 COMMUNICATING WITH PHYSICIANS ... 3.0 COMMUNICATING CHANGES IN STATUS. 3.1 Throughout the duration of service, whenever a change in client status occurs that requires the physician to be notified, the communication will be documented. This can be documented on the Clinical Notes, Nurses Notes, or on a Coordination of Services Form.” Review of agency policy on January 8, 2024, at 10:30 a.m. showed, “Percutaneous Endoscopic Gastrostomy, Gastrostomy, and Jejunostomy Tube Care (Home Health) ... 18. Elevate the head of the bed at least 30 degrees when feedings are infusing.” Review of CR1 on January 2, 2024, at 12 p.m. showed a physician ordered plan of care for an initial certification period from 11/27/2023 to 1/25/2024. Orders included skilled nursing (SN) to see the patient for care and assessment related to cerebral palsy diagnosis. The patient was to “wear AFOS [ ankle foot orthotic - supportive device for lower extremity] while awake [as] tolerated.” Further review of CR1 did not show patient was wearing their AFOs and on 12/5 the nurse documented, “Client was dressed for the day shoes put on, mom still hold AFOs at this time until she can work him back up to the length of time that he needs to wear them.” Review of treatment sheets showed the nurse documented an “H” for 11/28, 11/29, and 11/30/2023 to show that the patients AFOs were on hold and not being used. Further review of CR1 on January 5, at 9:30 a.m. did not show that agency notified the physician that the patient’s AFOs were on hold. Review of CR2 on January 4, 2024, at 9:30 a.m. showed a physician ordered plan of care with a recertification period from 11/17/2023 to 1/15/2024. The patient’s diagnosis included “encounter for attention to gastrostomy [tube inserted into stomach].” SN was to provide care 5-7 nights per week. Review of “Nurse’s Shift Note” from 12/18/2023 showed the patient’s mom did not elevate the patient’s head while the patient was receiving a feeding via their gastrostomy tube, “HOB [head of bed] flat - Mom previously educated on importance of elevating HOB with TF [tube feed] via GT [gastrostomy tube] to avoid aspiration [stomach contents getting into lungs] , verbalized understanding- requests client lay flat this shift.” Further review of CR2 on January 5, 2024, at 9:40 a.m. did not show that agency notified the physician concerning patient being fed via GT while lying flat which could increase the patient’s risk of aspiration. Review CR3 on January 4, 2023, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 6/28/2023 to 8/26/2023. SN was to see patient for care and assessment related to seizures. Orders included, “Apply bilateral AFO’s as per recommendation of PT/OT/physician. ... Maintain and encourage safe use of mobility aides and orthotics [AFOs] to decrease risk for falls; notify CM and/or physician regarding concerns.” On 6/29/2023, the SN documented, “1:15pm ... Unable to wear AFO’s due to improper fit with current shoes.” Further review of CR3 on January 5, 2024, at 10 a.m. did not show the physician was notified concerning the improper fir of AFOs. During an interview with EMP3 (manager of clinical operations) on January 5, 2023, from 9:30 a.m. to 11:30 a.m., he/she reviewed the above records and confirmed findings.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to integrate services to assure the coordination of care provided by all disciplines for one (1) of two (2) discharged records (CR3). Finding included: Review of policy on January 5, 2023, at 12:30 p.m. showed, “Client Care Coordination ... 4.0 When more than one service is provided, whether directly or through contact, the Client Service Manager and Clinical Manager work together to assure that the actions and goals of the individual services are complementary. ... When service is provided through liaison with other organizations or individuals, coordination of services is maintained by the team effort of the Client Services Manager and Clinical Manager, and the information is documented in the client chart.” Review CR3 on January 4, 2023, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 6/28/2023 to 8/26/2023. SN was to see patient for care and assessment related to seizures. Orders included, “Apply bilateral AFO’s as per recommendation of PT/OT/physician.” CR3 was receiving PT/OT services from another organization. On 6/29/2023, the SN documented, “1:15pm ... Unable to wear AFO’s due to improper fit with current shoes.” Further review of CR3 on January 5, 2024, at 10 a.m. to include treatment records, did not show patient had worn their AFOs until 8/10/2023 and just prior to the end of episode. There was nothing in the record to show what PT/OT recommended concerning the patient’s AFOs. During a staff interview on January 5, 2023, at 10:30 a.m., EMP3 (manager of clinical operations) reviewed the above records and confirmed findings. EMP3 noted he/she could not view or see what the PT/OT recommendations were because they were kept in the patient’s home.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the licensed practical nurse failed to report changes in the patient’s condition to the physician for three (3) of seven (7) clinical records (CR1-CR3). Findings included: Review of agency policy on January 5, 2023, at 12:30 p.m. showed, “JOB DESCRIPTION AND PERFORMANCE EVALUATION LICENSED PRACTICAL NURSE [LPN] ... CLINICAL RESPONSIBILITIES ... 3. Reports any changes in the client’s condition to the physician; executes and properly documents any new doctor’s orders.” Review of CR1 on January 2, 2024, at 12 p.m. showed a physician ordered plan of care for an initial certification period from 11/27/2023 to 1/25/2024. Orders included skilled nursing (SN) to see the patient for care and assessment related to cerebral palsy diagnosis. The patient was to “wear AFOS [ ankle foot orthotic - supportive device for lower extremity] while awake [as] tolerated.” Further review of CR1 did not show patient was wearing their AFOs and on 12/5 the LPN documented, “Client was dressed for the day shoes put on, mom still hold AFOs at this time until she can work him back up to the length of time that he needs to wear them.” Review of treatment sheets showed the LPN documented an “H” for 11/28, 11/29, and 11/30/2023 to show that the patients AFOs were on hold and not being used. Further review of CR1 on January 5, at 9:30 a.m. did not show that agency notified the physician that the patient’s AFOs were on hold. Review of CR2 on January 4, 2024, at 9:30 a.m. showed a physician ordered plan of care with a recertification period from 11/17/2023 to 1/15/2024. The patient’s diagnosis included “encounter for attention to gastrostomy [tube inserted into stomach].” SN was to provide care 5-7 nights per week. Review of “Nurse’s Shift Note” by the LPN from 12/18/2023 showed the patient’s mom did not elevate the patient’s head while the patient was receiving a feeding via their gastrostomy tube, “HOB [head of bed] flat - Mom previously educated on importance of elevating HOB with TF [tube feed] via GT [gastrostomy tube] to avoid aspiration [stomach contents getting into lungs] , verbalized understanding- requests client lay flat this shift.” Further review of CR2 on January 5, 2024, at 9:40 a.m. did not show that agency notified the physician concerning patient being fed via GT while lying flat which could increase the patient’s risk of aspiration. Review CR3 on January 4, 2023, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 6/28/2023 to 8/26/2023. SN was to see patient for care and assessment related to seizures. Orders included, “Apply bilateral AFO’s as per recommendation of PT/OT/physician. ... Maintain and encourage safe use of mobility aides and orthotics [AFOs] to decrease risk for falls; notify CM and/or physician regarding concerns.” On 6/29/2023, the LPN documented, “1:15pm ... Unable to wear AFO’s due to improper fit with current shoes.” Further review of CR3 on January 5, 2024, at 10 a.m. did not show the physician was notified concerning the improper fir of AFOs. During an interview with EMP3 (manager of clinical operations) on January 5, 2023, from 9:30 a.m. to 11:30 a.m., he/she reviewed the above records and confirmed findings.”