Every finding on record at Bayada Home Health Care Inc

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure the administrator reported directly to the facility's Governing Body, for 1 of 1 home health agency administrator. Findings include: 1. A review of agency policy 0-523, "Ownership, Governance, and Administration: BAYADA Home Health Care," last revised 08/15/22, indicated "BAYADA'S governing body is the Board of Directors ... " Section 3.1.2.1, "Administrator," indicated the administrator must report to the governing body. 2. A review of the Administrator's job description, signed 02/02/22, failed to indicate to whom the administrator reported. 3. On 06/29/23 at 10:16 AM, the Administrator indicated the Board of Directors was the Governing Body. When asked for the names of the Board of Directors, the Administrator indicated he did not know the names of the members of the Board of Directors. When asked if he reported directly to the Board of Directors, the Administrator indicated there were several other people he reported to that were between the Administrator and the Board of Directors. When asked to whom he directly reported, the Administrator indicated he was unsure. On 06/29/23 at 2:40 PM, the Administrator stated, "I don't communicate directly with the Governing Body. I have several other leadership people." When asked for the names of the other leadership individuals the Administrator indicated he spoke with Corporate Staff 1 (Bayada Division Director). 410 IAC 17-12-1(b)(1)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Administrator was responsible for all day-to-day activities of the agency, for 1 of 1 home health agency. Findings include: 1. A review of agency policy 0-523, "Ownership, Governance, and Administration: BAYADA Home Health Care," last revised 08/15/23, failed to evidence the Administrator was responsible for the day-to-day activities of the agency. 2. A review of agency policy 0-9625, "Administrator Position Description Supplement - Indiana," dated 09/2018, failed to evidence the Administrator was responsible for the day-to-day activities of the agency. 3. On 06/29/23 at 10:16 AM, the Administrator indicated he did not know the names of the Board of Directors and was unsure to whom he directly reported. When asked if the agency was deemed, the Administrator indicated he did not know. On 06/29/23 at 9:28 AM, the Administrator was questioned concerning notification of the agency's relocation to the current address. When asked if he followed up concerning the agency's notification of relocation, the Administrator indicated he did not know the status of the notification at that time and stated, "We have a whole team that does that." On 06/29/23 at 11:39 AM, the agency's admission packet was reviewed. The admission packet evidenced instructions for Medicare, Personal Care Services, and Home Health Aide services and failed to include required admission information including, but not limited to, the Indiana Department of Health Toll Free Complaint Line phone number, and the OASIS (Outcome and Assessment Information Set) privacy notice. The admission packet also included Medicare information for pediatric patients referenced assessments done by therapists. The Administrator indicated he didn't know why Medicare was included in the pediatric admission information because Medicare isn't a pediatric payor source. The Administrator indicated he did not know the admission packet referenced therapy, the agency doesn't provide Medicare or therapy services, and doesn't provide Personal Care Services. The Administrator was also not aware of the missing Complaint Line phone number and OASIS privacy notice. The Administrator failed to ensure he was responsible for the day-to-day activities of the agency including, but not limited to, designated lines of authority, updated and correct agency admission information, updated services provided, reporting of complaints, and accepted payors. IAC 17-12-1(b)(3) IAC 17-12-1(c)(1)

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the written agreement for home health aide services under arrangement indicated BAYADA was the primary home health agency and maintained overall responsibility for the services provided, for 1 of 1 home health agency. Findings include: A review of agency policy 0-664, "Contract Management - Insurance and Supplemental, Facility, and Staffing Contracts," revised 06/15/22, indicated "Our Policy: BAYADA Home Health Care has procedures for the negotiation, management, and renewal of clinical service agreements." The policy failed to evidence the written agreement was required to indicate BAYADA was the primary agency and maintained overall responsibility for services provided. A review of the Home Health Aide Service Agreement with Entity B (a home health agency), signed by the Administrator on 11/01/22, indicated, but was not limited to, " ... Agency [Entity B] is willing to provide supplemental staffing services ... upon the request of BAYADA in the home of BAYADA clients." Article 1, section A indicated the nature and scope of services to be provided by Entity B were Home Health Aide services. The Home Health Aide Service Agreement with Entity B failed to indicate BAYADA Pediatrics was the primary agency and maintained overall responsibility for the services provided. A review of agency policy 0-965, "Subcontracted Services," last revised 08/21/17, indicated the following terms are addressed in the contract, including but not limited to: "a. Clients are accepted for care only by BAYADA as the primary home health agency ... " On 06/29/23 at 2:11 PM, Person A (Administrator for Entity B) indicated they started as Administrator for Entity B in May of 2023 and was unaware of a staffing contract with BAYADA, but if Entity B provided a home health aide to BAYADA, it would be considered a staffing only agreement and BAYADA would maintain responsibility for the care and services provided. On 06/29/23 at 5:01 PM, the "Home Health Aide Service Agreement," was reviewed with the Administrator. The Administrator indicated it did not evidence that BAYADA was the primary agency and maintained overall responsibility for care. 410 IAC 17-12-2(d)

This was a Federal complaint and State licensure complaint survey conducted at Bayada Pediatrics, a deemed home heath agency, by the Indiana Department of Health (IDOH). Complaint: #98595 - deficiencies cited Survey Dates: May 22, 23 (2023) Facility ID: 013748 Unduplicated Census for the past 12 months: 54 This deficiency report also reflects State Findings cited in accordance with 410 IAC 17. Based on the Condition-level deficiencies cited during the 5/23/2023 survey, at 42 CFR §484.100 Condition of Participation: Compliance with Federal, State, and Local Laws and Regulations Related to the Health and Safety of Patients, and 42 CFR §484.105 Condition of participation: Organization and Administration of Services, and pursuant to section 1891(c)(2)(D) of the Social Security Act on 5/23/2023, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning 5/23/2023 and continuing through 5/22/2025. Quality Review Completed 06/08/2023

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure its branch location was licensed as required by the State of Indiana (Please see tag G0860). This practice had the potential to affect all patients the agency served. The findings include: The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §484.100: Compliance with Federal, State, and Local Laws and Regulations Related to the Health and Safety of Patients.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure its branch location was licensed as required by the State of Indiana. The findings include: Review of an agency policy, revised date 4/19/2018, titled "0-6885 Office Licensure Application Process", stated "... Bayada ... is responsible for the completion, submission and follow-up of all initial and renewal license applications ... Applications are completed for ... branch ... [Bayada corporate level] will follow-up with the State licensing authority until the application has been processed to completion ...." Review of an agency policy, revised date 8/15/2022, titled "0-523 Ownership, Governance, and Administration: Bayada Home Health Care", stated, "... A copy of the state license, when required, is kept in the local office ... A structured relationship exists between parent and branch offices under the same Medicare certification number to ensure adequate oversight of the branch ... Parent offices provide supervision and administrative control of branch ... in order to meet the Medicare Conditions of Participation ...." During an observation on 5/22/2023, at 1:24 PM, the entrance doors were locked to the office located in Valparaiso, and no one was present to open the doors. A sign on the entrance doors was observed that stated, “For deliveries or any assistance, please call our Indianapolis office at 317-481-6800.” During an interview on 5/22/2023 at 1:37 PM, the Administrator indicated the red box affixed to the outside of the front of the building was used as a drop box/mailbox for submission of clinical record documents; at one point, the Valparaiso location was operating, but never became official, and was currently being managed by the Indianapolis home health agency. During an interview on 5/22/2023 at 1:56 PM, Administrative Registered Nurse (RN) #4 indicated the Valparaiso office was a branch of the Indianapolis home health agency. During an interview on 5/22/2023 at 2:31 PM, Administrative RN #4 indicated there wasn't an Emergency Preparedness Plan for the Valparaiso office, as everything was done out of Indianapolis; and all patients served at the Valparaiso location were billed through the Indianapolis agency. During an interview on 5/22/2023 at 2:39 PM, Administrative RN #4 indicated the Valparaiso location initially operated independently, but then corporate Bayada decided not to make the Valparaiso location an independent agency. Administrative RN #4 indicated the Valparaiso location operated "out of Indianapolis", and she was responsible to manage the Valparaiso patients. During an interview on 5/22/2023 at 4:05 PM, the Administrator indicated the Valparaiso location originally operated independently in 2018, was currently managed and controlled by the Indianapolis agency, and staff was assigned to the Valparaiso location. 410 IAC 17: 17-10-1(b)

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure its administrative and supervisory functions were not delegated to another individual, agency, or organization; and all services not furnished directly were monitored and controlled by the parent agency. This practice had the potential to affect all patients the agency served. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §484.105: Organization and Administration of Services. A standard level deficiency was also cited at this level. The findings include: During an interview on 5/22/2023, at 12:52 PM, the clinical manager indicated clinical records were not on site at the Valparaiso office. The clinical manager indicated nurses servicing patients from the Valparaiso office were never required to come to the Indianapolis office and come into the Valparaiso office for training and clinical competency with the clinical manager assigned to the Valparaiso office. During an interview on 5/22/2023, at 1:27 PM, the administrator indicated to his knowledge, there were no clinical records at the Valparaiso location. The administrator was unsure of the exact date when he had last been to the Valparaiso location and indicated it would have been sometime last year. At 2:17 PM, the administrator indicated he was unsure if the clinical manager and alternate clinical manager had ever been to the Valparaiso location. During an observation at the Valparaiso location on 5/22/2023, at 1:56 PM, clinical records for Patient #1 and Patient #2 were observed on the desk unsecured in red binders. A stack of clinical documents was observed for Patient #3 with an agency discharge summary document on top of the stack on the desk unsecured. An agency assessment screening tool document was observed for Patient #4 in a bin unsecured on a desk. A room was observed containing medical supplies and equipment, which was identified by registered nurse #1, to be the simulator training lab for the nurses servicing the patients from the Valparaiso office. During an interview on 5/22/2023, at 2:28 PM, registered nurse (RN) #1 indicated she was responsible for the day-to-day operations of the Valparaiso location. Review of an undated agency document on 5/22/2023, identified to be the agency’s organization chart, indicated the administrator reported to Administrative Staff #1, who reported to Administrative Staff #2, who reported to Administrative Staff #3, who reported to Administrative Staff #4, who reported to Administrative Staff #5. Review of an undated agency document on 5/22/2023, identified to be the governing body members, failed to evidence Administrative Staff #1, Administrative Staff #2, Administrative Staff #3, Administrative Staff #4, and Administrative Staff #5 were members of the governing body. During an interview on 5/22/2023, at 2:50 PM, the administrator indicated he directly reported to Administrative Staff #1 and indicated Administrative Staff #1 was not a member of the governing body. The administrator indicated he was unsure why he reported to someone who was not a member of the governingn body and indicated corporate determined the orgainizational structure. During an interview on 5/23/2023, at 10:30 AM, the administrator indicated he was unaware the agency sign and the red drop box was in still in place on the front of the building because he had not been to the Valparaiso location. During an interview on 5/23/2023, at 1:54 PM, the clinical manager indicated RN #1 provided the clinical oversight of the patients serviced from the Valparaiso location and the client services manager provided oversight to the scheduling of the patients and staff. The clinical manager indicated she did not require the nurses from the Valparasio location to come to the Indianapolis location and indicated she has never been to the Valparasio location. The clinical manager indicated RN #1 provided the traning and competency validation for the nurses in Valparaiso and she did not do anything with the nurse training and competence for Valparaiso nurses. Review of an agency policy with revised date 9/01/2014, titled "0-3070 Medicare Service Provision - Enrollment Requirements", stated, "... Ongoing compliance with the Medicare Conditions of Participation, State Regulations ... are monitored through BAYADA's Quality Assurance Program [corporate level] ...." Review of an agency policy with revised date 8/15/2022, titled "0-523 Ownership, Governance, and Administration: Bayada Home Health Care", stated, "... Bayada ... has an ownership and governance structure, and meets administration requirements, in accordance with Delaware law ... The Governing Body ... is responsible for ... Appointing a qualified Administrator and designated back-up administrator ... and authorized in writing ... A structured relationship exists between parent and branch offices under the same Medicare certification number to ensure adequate oversight of the branch ... Parent offices provide supervision and administrative control of branch ... in order to meet the Medicare Conditions of Participation ...." Review of an agency policy dated 9/2018, titled "Administrator Position Description Supplement - Indiana", stated, "... direct the home health agency's ongoing functions ... Employ qualified personnel and ensure adequate staff education and evaluations ... Ensure the accuracy of public information materials ... Ensure that the home health agency meets all rules and regulations for licensure ...." Review of an agency policy dated 9/2018, titled "Supervising Nurse Position Description Supplement - Indiana", stated, "... Supervise and direct nursing and other therapeutic services ...." During an observation at the Valparaiso location on 5/22/2023 at 2:04 PM, a Bayada marketing pamphlet was observed on a table by the entrance, which indicated the agency provided hospice and therapy services (Physical, Occupational, and Speech Therapy) During an interview on 5/23/2023 at 10:52 AM, the Administrator indicated there wasn't hospice or therapy services provided by the Indianapolis or Valparaiso locations, Bayada agencies in other states provided those services, corporate Bayada provided marketing pamphlets, and the pamphlets weren't specific to the services Indianapolis or Valparaiso provided. 410 IAC 17: 17-12-1(a)(1); 17-12-1(a)(2); and 17-12-1(b)

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all clinical records/clinical record documents were safeguarded against loss or unauthorized use, for 8 of 8 random patients' unsecured clinical records/clinical documents observed (Patient #1, 2, 3, 4, 5, 6, 7, 8). The findings include: During an observation on 5/22/2023, at 1:24 PM, the entrance doors were locked to the office located in Valparaiso, and no one was present to open the doors. A sign on the entrance doors was observed that stated, “For deliveries or any assistance, please call our Indianapolis office at 317-481-6800.” Through the front window, red binders with the names of Patient #1 and Patient #2 on the outside of the binder. A red box affixed to the outside of the front of the building contained 3 envelopes addressed to the agency. Envelopes were visible from the outside of the box when the flap was opened and were retrieved through the slot. Upon entranced to the building at 1:56 PM, clinical records were observed unsecured on top of the desk in red binders for Patient #5 and Patient #6. A stack of clinical record documents with an agency discharge summary document on top were observed unsecured for Patient #3 on top of the desk. An agency assessment screening tool document for Patient #4 was observed in an open tray unsecured sitting on top of a table. During an observation at the Valparaiso office on 5/23/2023 at 10:30 AM, clinical records for Patient #1, Patient #2, Patient #5, and Patient #6 were observed unsecured on top of the desk in the same position from the previous day. During an interview on 5/22/2023, at 1:37 PM, the administrator indicated clinical records were to be stored in a locked filing cabinet. Review of an agency policy, revised date 2/27/2012, titled "37-2197 Confidentiality of PHI [protected health information] - Access and Disclosure", stated "Bayada Home Health Care maintains the confidentiality of all ... PHI of clients ...." Review of an agency policy dated 11/2021, titled "Standards of Honesty & Confidentiality ... Bayada's Compliance Program", stated, "... protection and confidential handling of protected health information ... Examples of ... violations ... Unprotected storage of private health information ...." Review of an agency policy, revised date 7/2021, titled "Client Bill of Rights ....", stated, Clients have the right to a confidential clinical record ...." During an interview on 5/22/2023 at 1:37 PM, Administrative Registered Nurse (RN) #4 indicated the red box affixed to the outside of the front of the building was used as a drop box/mailbox for submission of clinical record documents. During an observation on 5/22/2023 at 1:56 PM, Administrative RN #4 opened and removed documents from the 3 envelopes retrieved from the drop box. Observed clinical visit notes for Patients #7, dated 3/25/2023, 3/27/2023 - 4/01/2023, and 5/01/2023 - 5/06/2023; and a six page medication and treatment administration record, dated 4/01/2023 - 4/30/2023, for Patient #8. Administrative RN #4 confirmed the envelopes from the drop box contained clinical record documents for Patients #7 and #8.

This visit was for a Focused Infection Control and Federal complaint survey of a Deemed Home Health provider. Complaint #: IN00344123; Substantiated. Federal deficiencies were cited Complaint #: IN00313840; Substantiated. No Federal deficiencies were cited. Date of survey: 01-11-2021 to 01-13-2021 Facility #: 013748 CCN #: 157685 Current Active Census: 58 patients During this complaint survey, Bayada Pediatrics was found to be out of compliance with 42 CFR 484.70 Infection Prevention and Control. Based on the Condition-level deficiencies identified during the 1/15/2021, survey, your home health agency was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being the site of a home health aide training and/or competency evaluation programs for two years beginning 1/15/2021, and continuing through 1/14/2023. Quality Review Completed on 02/10/2021 by Area 3

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure they followed their policy in regards to properly prevent and/ or contain COVID-19 in regards to failing to screen an employee prior to entering the agency, failed to remove staff from a home until they have completed a medical evaluation, fit testing, and educational process for N95 respirator use, and failed to ensure all visitors were screened for COVID - 19 (See G682); failed to properly prevent and/ or contain COVID-19 in regards to implementing a surveillance plan, to include early detection, tracking, monitoring, and management of potentially infectious diseases (See G684); and failed to ensure employees received education on the symptoms, transmission, screening criteria, and work exclusion in regards to the COVID -19 pandemic. (See G686). These deficient practices has the potential to affect all 58 patients who receive services from Bayada and all employees who provide those services. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 484.70 Infection Prevention and Control.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure they followed their policy in regards to properly prevent and/ or contain COVID-19 in regards to failing to screen an employee prior to entering the agency for 1 (Employee D) out of 4 employees known to be exposed to COVID-19, failed to remove staff from a home until they have completed a medical evaluation, fit testing, and educational process for N95 respirator use, and failed to ensure all visitors were screened for COVID - 19 for 3 out of 3 days for 1 of 1 agency. The findings include: 1. Review of the agency's policy titled "Bayada 0-1440 Contagious Disease Management," updated on November 23, 2020, indicated " ... 2.1.1 Employees who exhibit symptoms of a cold or an acute respiratory infection will not work with clients during the period of contagion ... 2.1.3 Employees with signs and symptoms of COVID - 19 should be advised to consult with their physician about their symptoms and testing to confirm COVID-19 ... 2.2 Notification by a Bayada supervisor will be made to: a. clients, their physicians when appropriate, and staff who have been in contact with an employee who has a physician-confirmed contagious disease .... " This policy indicated that a temperature and symptom screening log form in Director's tool was to be completed by the office for field employees who are asymptomatic post-exposure to COVID-19. 2. Review of the agency's policy titled "Bayada 0-3295 Respiratory Protection Plan" updated on April 21, 2020, indicated " ... 3.1.1 Existing Bayada client. All staff will be removed from the home and not re-enter until they have completed the medical evaluation, fit testing, and educational process for the N95 respirator use .... " 3. Upon observation when entering the agency on 01/11, 01/12, and 01/13/21 at 9:00 AM, the agency failed to evidence temperature monitoring to check for fevers of staff and surveyors. 4. Review of COVID-19 Case Entry Form dated 12/05/2020 at 1:45 P.M., revealed the agency was notified by patient's #4's family member that a household member was hospitalized with COVID-19 and all members in the household will be tested. The entry form revealed the household member symptoms started on 11/30/20 and tested positive on 12/05/2020. 5. The clinical record of Patient #4, start of care 07/26/2018, was reviewed on 1/12/2021. Review of the following skilled nurse visit notes failed to evidence any documentation of the household member having symptoms of COVID-19 nor any report to the agency of a household member having symptoms from 11/30/20 to 12/05/20; and failed to evidence any documentation of report between staff on/ after 12/5/20, when it was made known of the household exposure: Employee D, LPN - 11/30/2020 at 10:57 A.M. to 12/1/2020 at 07:05 A.M.; Employee G, RN - 12/1/2020 from 07:00 A.M. to 07:17 P.M.; Employee D - 12/1/2020 at 11:03 P.M. to 12/02/2020 at 07:07 A.M.; Employee G - 12/2/2020 from 07:00 A.M. to 07:17 P.M.; Employee F, RN - 12/2/2020 from 07:15 P.M. to 11:07 P.M.; Employee E, LPN - 12/2/2020 at 11:00 P.M. to 12/3/2020 at 07:12 A.M.; Employee G - 12/3/2020 at 07:15 P.M to 12/3/2020 at 07:01 P.M.; Employee D - 12/3/2020 at 11:00 P.M. to 12/04/2020 07:12 A.M.; Employee E - 12/4/2020 from 07:00 A.M. to 07:01 P.M.; Employee D - 12/4/2020 at 10:59 P.M. to 12/05/2020 at 07:25 A.M.; Employee F, RN - 12/5/2020 at 07:15 A.M. to 12/5/2021 at 11:07 P.M. Review of the skill nursing note revealed employee F was notified by Employee BB, Case Manager, of the COVID-19 exposure. The SN note document failed to evidence if Employee E was informed of the household COVID-19 exposure. Employee E, LPN - 12/5/2020 at 11:00 P.M. to 12/05/2020 07:07 P.M. Employee F- 12/6/2020 at 07:00 A.M. to 12/6/2020 11:00 P.M. Review of a skilled nursing note by Employee F, dated 12/6/2020 at 07:00 A.M TO 11:00 P.M. The SN note document failed to evidence if Employee D was informed of the household COVID-19 exposure. Employee D, LPN - 12/6/2020 at 11:03 P.M to 12/7/2020 07:09 A.M. Employee E - 12/7/2020 at 07:00 A.M. to 12/7/2020 07:02 P.M. Employee F - 12/7/2020 at 07:00 P.M. to 12/7/2020 11:00 P.M. 6. Review of the COVID-19 tracking log revealed Employee D symptoms for COVID-19 began 12/1/2020, and tested positive on 12/08/2020. 7. During an interview on 01/11/2021 at 11:22 A.M., Person A stated Employee D was not informed about the positive COVID-19 household member in patient #4's home. Person A stated Employee D worked in the home 2 days (Friday and Sunday) before the agency notified Employee D that a household member tested positive for COVID-19. Person A stated Employee D was hospitalized for two weeks. 8. During an interview on 01/12/20 at 10:07 AM., Employee BB, Clinical Manager of patient #4, stated when she was on-call on 12/5/20 at 1:45 P.M., she was notified by patient #4's family member, who indicated a household member had tested positive for COVID-19 and was putting themselves in self-quarantine pending COVID-19 test results. The Clinical Manager indicated she took PPE (personal protective equipment) to patient #4's home on 12/06/20 during the day. The Clinical Manager was unable to give the exact time. Clinical Manager stated she did call all the staff that work with the client but was not able to reach Employee D before she started working on the evening of the 5th. The Administrator stated Employee D was informed about the COVID-19 exposure before coming into the office on 12/7/20. Employee BB stated Employee D came into the office on 12/07/20 to complete medical release for N95 mask and had close contact with Employee CC. The Administrator stated Employee D reported on 12/08/20, Employee D had a symptom of COVID-19 (a loss of taste) and tested positive. Employee BB stated due to Employee CC being in close contact with Employee D, Employee CC was required to quarantine for 10 days. When asked if the employee was screened prior to her entry into the agency and before coming into contact with Employee CC on 12/07/20, the administrator and Employee BB stated Employee D was not screened. When asked if the agency tracked, logged temperatures, or symptoms of COVID-19 exposure with all employees, the Administrator indicated they do not. The agency failed to follow their policy to ensure preventive measures were put into place to prevent the spread of COVID-19. 9. During an interview on 01/13/21 at 9:45 AM, the Administrator stated no changes were made to the agency's COVID screening processes since the COVID-19 positive exposure by Employee D and no temperatures are being monitored or tracked for any employees or visitors.

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 observation, record review, and interview, the agency failed to properly prevent and/ or contain COVID-19 in regards to implementing a surveillance plan, to include early detection, tracking, monitoring, and management of potentially infectious diseases for 1 of 1 agency. The findings include: Review of the agency's policy titled, "Bayada 0-403 Quality Assurance and Performance Improvement [QAPI] Program," updated on 1/1/2021, indicated " ... 4.1.5 Monitoring of other data and other reportable events is gathered, reviewed and analyzed to assess performance and to identify any trends requiring further study and intervention. Data includes, but not limited to: a. ... Adverse events ... d. Infections .... " Review of COVID-19 Case Entry Form dated 12/05/2020 at 1:45 P.M., revealed the agency was notified by patient's #4's family member that a household member was hospitalized with COVID-19 and all members in the household will be tested. The entry form revealed that the household member symptoms started on 11/30/20 and tested positive on 12/05/2020. The clinical record of Patient #4, start of care 07/26/2018, was reviewed on 1/12/2021. The record contained a plan of care for certification 11/12/2020 to 01/10/2021, with orders for 12-24 hours of skilled nursing (SN) care 4-7 days a week for vent management, gastrostomy feedings, medication administering, dressing, bathing, changing diaper during incontinence, suctioning and tracheostomy care. The patient's diagnosis included Chronic Respiratory Failure, Epilepsy, and Constipation. Review of the following skilled nursing visits revealed 4 employees who provided services at patient #4's home and who was in contact with one another: Review of the following skilled nurse visit notes revealed the following employees who were in the patient's home providing services while being exposed to COVID-19: Employee D, LPN - 11/30/2020 at 10:57 A.M. to 12/1/2020 at 07:05 A.M.; Employee G, RN - 12/1/2020 from 07:00 A.M. to 07:17 P.M.; Employee D - 12/1/2020 at 11:03 P.M. to 12/02/2020 at 07:07 A.M.; Employee G - 12/2/2020 from 07:00 A.M. to 07:17 P.M.; Employee F, RN - 12/2/2020 from 07:15 P.M. to 11:07 P.M.; Employee E, LPN - 12/2/2020 at 11:00 P.M. to 12/3/2020 at 07:12 A.M.; Employee G - 12/3/2020 at 07:15 P.M to 12/3/2020 at 07:01 P.M.; Employee D - 12/3/2020 at 11:00 P.M. to 12/04/2020 07:12 A.M.; Employee E - 12/4/2020 from 07:00 A.M. to 07:01 P.M.; Employee D - 12/4/2020 at 10:59 P.M. to 12/05/2020 at 07:25 A.M.; Employee F - 12/5/2020 from 07:15 A.M. to 11:07 P.M.; Employee E - 12/5/2020 at 11:00 P.M. to 12/05/2020 at 07:07 P.M.; Employee F- 12/6/2020 from 07:00 A.M. to 11:00 P.M.; Employee D- 12/6/2020 at 11:03 P.M to 12/7/2020 at 07:09 A.M.; Employee E - 12/7/2020 from 7:00 A.M. to 07:02 P.M.; and Employee F - 12/7/2020 at 07:00 P.M. to 12/7/2020 11:00 P.M. Review of the agency's complaint and incident reports, failed to evidence documentation of exposure to infection or communicable disease on complaint and incident report, for the incidences that occurred on 12/5/2021 and 12/8/2021. The incident reports failed to evidence documentation and follow up with patient #4's family member and all staff caring for patient #4 after COVID-19 notification. Review of the COVID-19 tracking log revealed Employee D symptoms for COVID-19 began 12/1/2020, and on 12/08/2020 tested positive. Review of agency's QAPI binder on 1/12/2021, failed to evidence COVID-19 exposure surveillance log to assess performance and to identify trends requiring further study or investigation. The agency failed to follow up with COVID-19 positive household members and all staff providing services to patient #4 to assess for symptoms post COVID-19 diagnosis exposure. During an interview on 01/11/2021 at 11:22 A.M., Person A stated Employee D was not informed about the positive COVID-19 household member in patient #4's home. Person A stated Employee D worked in the home 2 days (Friday and Sunday) before the agency notified Employee D that a household member tested positive for COVID-19. Person A stated Employee D was hospitalized for two weeks. During an interview on 01/12/20 at 10:07 AM., the Administrator stated Employee D was informed about the COVID-19 exposure before coming into the office on 12/7/20, but Employee BB stated Employee D came into the office on 12/07/20 to complete medical release for N95 mask and had close contact with Employee CC. Employee BB stated due to Employee CC being in close contact with Employee D, Employee CC was required to quarantine for 10 days. When asked if Employee D was screened upon arrival to the agency, Employee BB stated she did not complete a temperature and screen. The Administrator stated Employee D reported on 12/08/20 that she had a symptom of COVID-19 (a loss of taste). When asked if the agency tracked, logged temperatures, or symptoms of COVID-19 exposure with employees, the Administrator indicated he did not. The agency failed to follow their agency policy by failing to ensure Employee D, and all visitors, were screened prior to entering the office. During an interview on 01/13/21 at 9:45 AM, the Administrator stated no changes were made to the agency's COVID screening processes since the COVID-19 positive exposure by Employee D and no temperatures are being monitored or tracked for any employees or visitors.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure employees received education on the symptoms, transmission, screening criteria, and work exclusion in regards to the COVID -19 pandemic for 5 of 5 personnel records reviewed. ( A, B, C, D, E). The finding include: Review of personnel records for Employee A, B, C, D, E, failed to evidence documentation that the agency has educated staff on COVID-19 (e.g., symptoms, how it is transmitted, screening criteria, work exclusions ) Record review of agency's policy titled, "Bayada 0-633 Annual Infection Prevention Education Requirements," updated January 1, 2021, failed to include educational content related to COVID-19 as evidenced in 1.0 education content and 1.1 infection prevention. During interview 1/12/21 at 10:30 AM., Administrator and Employee BB stated the employees receive updates regarding COVID-19 and infection control emails on their tablets. When surveyor asked evidence of documentation for the in-services pre, posttest, or check off for understanding, the Administrator stated this was not completed. No further documents were provided by agency of competency, understanding of infection control policies, and updates on COVID-19.