Bayada Home Health Care Inc.

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure clinical records containing current information for patient’s receiving skilled home health services for wound care is inclusive of information that is accurate and adheres to professional clinical record documentation standards, for 1 of 1 Patient reviewed for wounds. Findings are as follows: Review of the Lippincott Nursing Center, American Journal of Nursing Volume 113, Number 8 pages 60-61 state in part, “…Wounds must be assessed…to detect important changes…assessment covers a variety of variables and includes…the size of the wound…. PREDICTING WOUND OUTCOMES…merely assessing and documenting…doesn’t suffice...Only one of these variables-wound size…can be used to help predict wound outcome...” Review of an Agency policy titled, BAYADA 0-3230 Wound Care-Assessment and Treatment, dated 7/26/2023, states in part, “…6.0 Documentation…a. wound location, color, drainage, thickness, size and stage as appropriate…9.1.1 Home Health-RN role in wound care…the RN will complete the assessment of the wound by measuring, assessing, and documenting effective wound treatment…measurement (s) completed and documented weekly…” Review of the patient’s record revealed s/he was admitted to the Agency on 12/26/2024, with diagnoses including, but not limited to, stage III pressure ulcer to right buttocks, stage I pressure ulcer to left buttocks, and unspecified protein-calorie malnutrition. Review of the plan of care and comprehensive assessment that was completed upon admission states in part, “…skilled nurse will assess…management of skin integrity…perform wound care…skilled nursing need for wound care, pain management…assess wounds…” Further record review revealed a visit note report dated 1/30/2025, visit number 6, with visit type listed as [Registered Nurse Wound Management] RNWM-RN wound measurement due, which is electronically signed by Registered Nurse, Staff L, on 1/30/2025 at 7:07 PM, and states in part, “…Medical Treatment…were wound measurements taken? “Yes”. Review of another visit note report dated as above and authored by the same Registered Nurse states in part, “…wound to coccygeal region/buttocks…measurements are smaller…” Additional review of the note contained in the clinical record, states in part, “…measurements taken…no…reason measurements not taken…unable…” Further review of the clinical record including a wound record report and wound assessment tool report, revealed no measurements of the patient’s wounds were obtained during the visit conducted on 1/30/2025 by the above-mentioned nurse as evidenced by the documentation in the clinical record specifically, on the Wound Record Report is as follows: -1/30/2025 at 2:23 PM: Measurements Taken…”no” …Reason Measurements not taken…” unable” … During a surveyor interview on 2/17/2025 at approximately 3:00 PM with the Director of Nursing Services and Regional Director of Clinical Education, they were unable to provide explanation as to why the information in the patient’s clinical record related to wound measurements on 1/30/2025 is contradicting, and therefore, unable to provide evidence that the Agency ensures clinical records contain accurate information that conforms with the professional standards of clinical documentation. In addition, they were unable to provide evidence that the nurse obtained wound measurements during the visit conducted on 1/30/2025 and revealed she should have as per Agency policy.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to notify the ordering physician of missed skilled visits as indicated in the patient’s plan of care, for 1 of 1 patient reviewed for physician notification of missed visits. Review of the patient’s clinical record revealed s/he was admitted to the Agency on 10/27/2024 for skilled care to include nursing, physical and speech therapy for orthopedic aftercare. Further review of the record revealed the comprehensive assessment completed upon admission revealed a plan of care dated 10/27/2024 indicating the frequency and duration of skilled visits as ordered by the physician as follows: -SN (Skilled Nursing): 2WK1 (two visits during week one) and 1WK5 (once a week for 5 weeks) -PT (Physical Therapy): 2WK4 (two visits a week for 4 weeks) and 1WK4 (once a week for 4 weeks) -OT (Occupational Therapy): 1WK1 (one visit for week one) Additional review of the clinical record revealed the patient had two missed visits on the following dates: -1/12/2025 -1/19/2025 Further review of the record lacked there to be evidence that the physician was notified of the above missed visits. Review of coordination notes dated below revealed the following: - 1/12/2025 authored by Registered Nurse, Staff K, indicates method of physician notification as being left blank and without documentation related to evidence of physician notification of the missed visit. -1/19/2025 authored by Registered Nurse, Staff K, indicates method of physician notification as being left blank and without documentation related to evidence of physician notification of the missed visit. During a surveyor interview on 2/17/2025 at 3:15 PM with the Director of Nursing Services and Regional Director of Clinical Education, they acknowledged that the above lack of documentation and evidence of physician notification.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review, and staff and Patient interview, it has been determined that the agency failed to ensure that the Patient’s right to participate in, be informed about, and consent to or refuse care relative to the completion of the initial assessment for 1 of 1 patient reviewed for patient rights, Patient ID #3. Findings are as follows: Review of the Patient record revealed his/her start of care date was 1/14/2025. Further review of the record revealed the patient signed a consent for treatment and was involved in the development of the treatment plan. Review of e-mail documentation provided by the agency, dated 1/11/2025, revealed the office staff received a call from the Patient’s son indicating that, “…he wanted a call on Monday about scheduling for next week…” additionally, there was no evidence that the agency made effort to speak to the patient after speaking to the patient’s son regarding his request. During a surveyor visit to the Patient’s home on 2/11/2025 at 12:00 PM, s/he verbalized concerns relative to a delay with the agency sending staff to his/her home after returning home from the hospital on 1/11/2025. During a surveyor interview with the Director of Nursing Services on 2/17/2025 at approximately 2:00 PM, she was unable to explain why the Patient’s son but not the Patient, was consulted with regarding changes to services. Additionally, she acknowledged the patient does not require an alternate decision maker.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to ensure that the initial assessment visit to determine the immediate care and support needs of the Patient was conducted by a registered nurse, was held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the allowed practitioner ordered start of care date for 1 of 1 Patient reviewed with orders for skilled nursing and therapy disciplines, Patient ID #3. Findings are as follows: Review of the Patient record revealed his/her start of care date was 1/14/2025. S/he was referred to the agency on 1/9/2025 and discharged home from the hospital on 1/11/2025. Review of the hospital documentation revealed discharge orders for skilled nursing care (SN), physical therapy (PT), and occupational therapy (OT) services. Review of a document titled, “Visit Note Report” revealed a PT Oasis Admission Assessment was conducted by physical therapist, Staff J on 1/14/2025. During a surveyor interview with the Director of Nursing Services on 2/17/2025 at approximately 1:00 PM, she acknowledged that the initial assessment was not completed by the registered nurse as required.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure that drugs and treatments are administered in accordance with the orders of the physician, or allowed practitioner, for 1 of 2 patients reviewed relative to laxative medications, Patient ID #1, and 1 of 1 patient reviewed relative to a tracheostomy, Patient ID #3. Findings are as follows: Review of a community reported complaint, received at the Rhode Island Department of Health on 9/12/2024, revealed Patient ID# 1’s mother, alleged LPN, Staff A was administering laxative medications inappropriately. 1. Review of the record for Patient #1, revealed a start of care date 6/19/2013, admitted with diagnoses, including but not limited to, epilepsy (neurological disorder characterized by recurrent, unprovoked seizures) and dysphagia (difficulty with swallowing) requiring a feeding tube. Review of his/her plan of care, dated 8/20/2024, revealed the following physician laxative orders: - Started 9/21/2018, 1 Dulcolax suppository, via rectum, as needed (PRN) for no BM in 48 hours to be given only during the day. - Started 9/21/2018, 1 capful of Miralax via gastrostomy (G-tube, a flexible, hollow tube that is inserted into the stomach through the abdomen to provide long-term nutritional support) or jejunostomy tube (J-tube, soft plastic tube that is surgically inserted into the small intestine to provide nutrition and hydration when someone is unable to eat or drink enough by mouth) PRN for no bowel movement (BM) in 2 days to be given only during the day. - Started 9/21/2018, 2 capfuls of Miralax, via G-tube or J-tube, PRN for no BM on day 3 until patient has a BM to be given only during the day. - Started 12/24/2019, Diocto (stool softener) 50 mg/mL (milligrams/milliliter), administer 5 mL via G-tube or J-tube twice daily, 7 AM/7 PM. A Review of the Nurse’s notes authored by Staff A revealed the following: - 9/7/2024, “…day #3 no BM…PRN miralax given…” - 9/8/2024, “…day #4 no BM…PRN miralax given at 11:45pm…” - 9/9/2024, “…day#4 no BM…” Further review of this note lacked evidence that a laxative was administered. -On 9/9/2024 the patients’ mother reported she noted three Dulcolax tablets were missing from a blister pack which are not prescribed for Patient ID #1. According to the patients’ mother three laxatives were removed from the blister pack and were not verbally reported as administered. A review of the record for Patient ID #1 dated 9/9/2024, lacked documentation that any laxatives were administered. On 9/11/2024 Staff A was interviewed by Registered Nurse, Staff B and acknowledged she had administered 2 Dulcolax tablets to Patient #1 without a physician’s order. During a surveyor interview on 9/17/2024 at 3:45 PM with RN, Staff B, she stated her expectation would be that Staff A should not have administered the Dulcolax tablets without a physician’s order. 2. Review of the Agency’s grievance log revealed an entry, dated 7/31/2024, which states in part: “…Clients mother called this writer with concerns how the nurse [LPN, Staff C] handled an incident that occurred with her client overnight shift on 7/30/2024, this AM client has respiratory distress requiring an emergency trach change and nurse came knocking at their door early in the AM for help, the client was blue, mother did the emergency trach change and father had to ambu [artificially manual breathing unit] client and hook oxygen up. The mother called 911. EMS came but by the time they came client was stable after a successful trach change, the nurse failed to take those emergency steps and nurse reported she didn’t know [his/her] suction order had changed…” Review of the record for Patient #3, revealed his/her start of care date was 1/5/2024, and s/he was admitted with diagnoses, including but not limited to, pulmonary hypertension (a condition that occurs when blood pressure in the lungs is higher than normal), and chronic respiratory failure with hypoxia (condition that occurs when your blood oxygen levels are low), and hydrocephalus (condition that occurs when too much cerebrospinal fluid builds up in the brain). A review of his/her plan of care, dated 8/27/2024, revealed, in part, revealed an updated physician order for: - For respiratory distress/increased work of breathing or elevated end tidal CO2 readings not relieved by nebulizer treatments: suction, perform an emergency tracheostomy tube change and notify the clinical manager and physician after change for further direction. - Suction tracheostomy with #8 french Suction catheter to depth of 15 (solid yellow) Review of an 8/9/2024 document titled, “Counseling Report”, revealed in part, “…nurse did not report incident to the office or CM [clinical manager]. Nurse should’ve performed a trach change and starting ambuing/O2 when client was in distress. Also, nurse reported she wasn’t aware of a change to trach size and suction depth made to poc [plan of care] with an addendum on 6/25/2024…” During a surveyor interview on 9/17/2024 at 4:30 PM with the Director, he indicated that his expectation is that Staff C would have reviewed the plan of care for any changes at the beginning of her shift and that she would have followed the physician treatment orders.”