Every finding on record at Bayada Home Health Care Inc

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 7/21/25 to 7/23/25 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 7/21/25 to 7/23/25 a recertification and complaint survey was conducted. This resulted in a standard survey at Bayada Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months:15 Total home visits conducted:2 all others were refused by clients List Parent Location visit. 3033 Campus Drive Suite E280, Plymouth, MN 55441 Hours of Operation: 8:30 a,m, to 5:00 p.m. Total number of records reviewed:7 The following complaints were reviewed without citations: H72099589C/MN116712 H72091142C/MN99403 H72091141C/MN99451

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide information on other community agencies who may be able to provide services to the patient for 1 of 2 patients (P7) reviewed for discharge. Findings include: P7's plan of care (POC) dated 2/10/25 - 2/10/25, identified start of care (SOC) date of 2/15/23. P7's transfer/discharge summary dated 4/10/25, indicated P7 was discharged from services on 4/8/25 due to schedule changes. The summary indicated P7 had no behaviors. P7's medical record lacked documentation information about outside resources that might be able to continue to meet patient needs was provided at time of discharge. During an interview on 7/23/25 at 9:07 a.m., clinical manager (CM)-A stated P7 was discharged from services because there was no nurse to provide P7 the care he needed. We tried for 5 months to find a nurse to provide him care but we could not find one. We provided him with his discharge instructions, discharge summary and medication list when we discharged him. We did not reach out to any other agency to see if they could provide the care he needed and did not provide a list of community resources to him at time of discharge. Facility policy Client Discharge and Transfer-Medicare Certified Home Health and SNU Offices last revised 5/4/20, indicated a client could be transferred for the following reasons: 1. necessary for client welfare, 2. Could no longer pay for services, 3. provider deemed patient no longer needed skilled services, 4. client refused services, 5. client became disruptive, abusive or uncooperative to extent ability to care for patient was seriously impaired, or 6. the patient died. The policy lacked documentation related to discharge to due staffing concerns. When a patient would be discharged for a cause, the patient would be given a list of other agencies or providers who could possibly be able to provide the cares.

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 interview and record review the home health agency failed to admit the patient within 48 hours of referral or obtain a provider order to delay admission for 6 of 6 patients (P1, P2, P3, P4, P7, P8) reviewed for admission. Findings include: P1: P1's plan of care (POC) for certification period of 722/25 to 9/19/25 indicated a start of care (SOC) date of 6/29/18. P1's referral form undated, indicated a referral to admit to services was received on 9/16/15 P1's medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. During an interview on 7/22/25 at 9:58 a.m. client services manager (CSM) stated P1's SOC date on the POC was incorrect and P1 started services on 11/3/15. P2: P2's plan of care (POC) for certification period of 5/28/25 to 7/26/25 indicated a start of care (SOC) date of 7/14/21. P2's referral form undated, indicated a referral to admit to services was received on 6/6/21. P2's medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. P3: P3's plan of care (POC) for certification period of 6/23/25 to 8/21/25 indicated a start of care (SOC) date of 7/14/21. P3's referral form undated, indicated a referral to admit to services was received on 6/6/21. P3's medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. P4: P4's plan of care (POC) for certification period of 6/26/25 to 8/26/25 indicated a start of care (SOC) date of 8/11/21. P4's referral form undated, indicated a referral to admit to services was received on 6/22/21 P4's medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. During an interview on 7/22/25 at 9:58 a.m. client services manager (CSM) stated P1's SOC date on the POC was incorrect and P1 started services on 11/3/15. P7: P7's plan of care (POC) for certification period of 2/10/25 to 4/10/25 indicated a start of care (SOC) date of 2/15/23. P7's referral form undated, indicated a referral to admit to services was received on 2/2/23. P7's medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. P8: P8's POC for certification period of 2/16/25 to 4/16/25 indicated a SOC date of 12/16/24. P8's referral form undated, indicated a referral to admit to services was received on 1/19/23 P8's medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. During an interview on 7/22/25 at 9:58 a.m. client services manager (CSM) stated all of the facility new patients take at least a month before they are admitted to services. They do not get orders to delay admissions from providers when it takes longer than two days to admit the patient. Agency policy Admission Criteria and Procedure-Medicare Certified Offices last revised 1/1/25, indicated all admissions would be completed within 4h hours of referral or return to client's home and admission outside of the 48-hour time period would be communicated to the provider.

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: Based on interview and document review, the agency failed to ensure visits were conducted in accordance with physician orders for 1of 7 patients (P7), failed to notify the physician when the visits were not conducted according to the plan of care (POC), and to educate the patient on the risks of missed visits or attempt to reschedule the missed visit. Findings include: P7's plan of care (POC) for certification period 12/12/24 through 2/9/25, indicated a start of care (SOC) date 2/15/23. Diagnoses included encounter for attention to tracheostomy. Ordered services included skilled nursing visits (SNV) 8-16 hours per day and 3-7 days per week not to exceed 60 hours a week for 60 days. P7's plan of care (POC) for certification period 2/10/25 through 4/10/25, indicated a start of care (SOC) date 2/15/23. Diagnoses included encounter for attention to tracheostomy. Ordered services included skilled nursing visits (SNV) 8-16 hours per day and 3-7 days per week not to exceed 60 hours a week for 60 days. P7's calendar from12/1/24 to 4/10/25 indicated a visit was performed on 12/9/24 but no other visit was scheduled or performed after that date, until discharge on 4/10/25. Review of P7's medical record indicated P7 did not receive an ordered visit the weeks of 7/14/24, 7/21/24, 7/28/24, 8/11/24, or 8/18/24. The medical record lacked evidence the physician had been notified of the missed visits until 5/13/25. The medical record lacked any documentation the appointments were rescheduled or educated on the risks related to missed visits. During an interview on 7/22/25 at 1:25 p.m., the scheduling manager (SM)-B stated if a nurse called off, we would notify the family or caregiver the nurse was not going to show up. Occasionally we would try to reschedule or get a different nurse to cover but not always. When there was no nurse to provide the care, it was up to the family to provide the specialized care the patient would need. We notify the provider on a weekly basis when missed visits occur for the prior week. Since the agency did not have a nurse for P7 we did not schedule appointments for a nurse to go out from the end of December 2024, to discharge in April 2024. We did not notify the provider about all of the missed visits until after P7 was discharged from the agency. Facility policy Missed Visits/Hours last reviewed 3/24/23, indicated the provider would be notified when the plan of care was altered related to fewer visits or hours of service were provided as ordered. At minimum, verbal or fax notification of the missed visit is made to the provider on a weekly basis.

On 7/31/24, 8/01/24,8/05/24, 8/06/24 and 8/07/24 a complaint survey was conducted. This resulted in a partial extended survey at Bayada Home Health Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. The following complaints were reviewed: H72096363C/108607. The Condition of Participation: Organization and Administration of Services at 42 CFR 484.105 at G940 was found not met.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interview and document review the home care agency failed to report an allegation of neglect for 2 of 2 patients (P1 and P2) reviewed when it was alleged registered nurse (RN)-A inverted a tracheostomy placement and failed to provide adequate emergency medical intervention during a respiratory failure event. Findings include: P1's plan of care (POC) with certification period from 7/10/24 to 9/07/24, indicated P1 was diagnosed with dependence with respirator, attention to tracheostomy, gastrostomy, and seizure disorder. The POC further indicated P1 was to receive skilled nursing (SNV) 8-24 hours a day, 5- 7 days per week, up to 168 hours. The POC also indicated P1 was Full Code and did not have an advanced directive. The POC further directed staff P1 was to receive 1.5 liters (L) of continous oxygen via trach/vent and 1-3 L as needed and titrate up to maintain saturations of 93% or greater. Place client on vent if requiring 3 L for two hours or more during the day. Oxygen (O2) can also be applied for comfort. Monitor signs or symptoms of respiratory distress or respiratory illness and/or seizure activity. P1's Abuse and Neglect Tool revised 8/03/24, indicated "client had a Hypoxic/decannulation event on 7-19-2024. Client hospitalized. Discharged home on 7-22-24. Re-hospitalized on 7-31-24 for uncontrolled seizures. Discharged home on 8-03-24." The report further indicated there was no indicators of abuse, yet the patient was susceptible to abuse by other individuals, including other vulnerable adults or children assessed. Patient was assessed and no abused noted. A Coordination of Services Note dated 7/19/24, completed by CM-B indicated CM-B received phone call from licensed practical nurse (LPN)-A on 7/19/24 at 3:30 a.m., and LPN-A reported P1's sisters just called her in a panic let her know that [P1] was being taken to the ER for a hypoxic event d/t (due to) saturations in "the 20’s" (normal level for oxygen level is 95 to 100%), "Family member (FM)-A stated the trach was all of the way out, per EMT (emergency medical technician) and FM-A stated she told the night nurse RN-A, and RN-A was surprised. On the call FM-A stated RN-A was not doing CPR correctly and she did not know anything!" During interview on 8/01/24 at 3:10 p.m. the agency administrator stated she thought P1's incident was more of a medical emergency versus abuse or neglect at the time. The administrator stated cooperate completed an investigation and there were discrepancies with what the patient’s family members were saying what happened compared to the nurse's report, so a report was not made. The administrator did state she was aware P1's case manager did file a report to the state agency. P2's POC with certification period from 6/17/24 to 8/15/24, indicated P2 was diagnosed with paralysis of vocal cords, epilepsy, and hydrocephalus (neurological disorder caused by an abnormal buildup of cerebrospinal fluid in the ventricles (cavities) deep within the brain). P2's POC further indicated P2 received skilled nursing visits 8-24 hours per day, 3-7 days a week for 60 days. In addition, P2 had a tracheostomy tube and to maintain patency of Bivona (silicone tube construction allows the tube to remain flexible in the trachea) 6.0 cuffed trach inflated with one cubic centimeter (CC's) of water. P2's Abuse and Neglect Tool dated 7/12/24, indicated P2 felt safe at home, and there were no concerns with caregivers. In addition, the tool indicated there was no other concerns during the home visit. A Coordination of Services Note dated 7/07/24, completed by clinical manager (CM)-A indicated RN-A performed an unscheduled trach change for P2 as his high-pressure alarm was going off during the night shift on his ventilator machine. The CM-A stated he received a phone call from RN-B who noticed a vocalized sound from P2 that was different from normal and checked his trach and it was tied upside down, and the cuff was not inflated. The note indicated it was not sure how long the trach was upside down and the trach was placed with a new one and tied appropriately and inflated with a balloon with one milliliter (ml) sterile water and all vitals were within normal limits. The note further indicated the CM-A had RN-A came in 7/08/24 at 9:30 a.m. for retraining in the agencies lab to complete education and return demonstration for tracheostomy care and emergency protocols. RN-A completed all tasks successfully. During interview on 8/01/24 at 3:05 p.m., agency administrator stated a report was not made to the state agency in regard to P2 due to feeling it was an error, not abuse or neglect just an error on the nurse’s part. Agency Policy revised 2/08/23, indicated a field employee, who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained will, immediately report the information to the office Director, Clinical Manager, or Client Services Manager who will then report the information to the common entry point either by telephone and verbal report, or electronic reporting. In addition, the law protects anyone under the age of 18 who is the subject of physical and sexual abuse, neglect, and endangerment which a parent, guardian, or custodian has inflicted, may inflict, permitted another person, or had reason to know another person may inflict. These such incidents must be reported to the Minnesota Department of Human Services.

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 the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation: Organization and Administration of Services at 42 CFR 484.105. The agency failed to provide timely call to 911, emergency medical services. Findings include: Refer to G984: Based on interview and document review the agency failed to ensure emergency medical services (EMS) 911 were initiated timely for 1 of 1 patient (P1) when P1 had an acute respiratory event. In addition, the registered nurse (RN)-A did not follow the agency training for respiratory emergencies.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to ensure emergency medical services (EMS) 911 were initiated timely for 1 of 1 patient (P1) when P1 had an acute respiratory event. In addition, the registered nurse (RN)-A did not follow the agency training for respiratory emergencies. Findings include: P1's plan of care (POC) with certification period from 7/10/24 to 9/07/24, indicated P1 was diagnosed with dependence with respirator, tracheostomy, gastrostomy, and seizure disorder. The POC further indicated P1 was to receive skilled nursing visits (SNV) 8-24 hours a day, 5- 7 days per week, up to 168 hours. The POC further indicated P1 was Full Code and did not have an advanced directive. The POC directed staff P1 was to receive 1.5 liters (L) of continuous oxygen via trach/vent and 1-3 L as needed and titrate up to maintain saturations of 93% or greater. Place client on vent if requiring 3 L for two hours or more during the day. O2 can also be applied for comfort. Monitor signs or symptoms of respiratory distress or respiratory illness and/or seizure activity. The POC indicated in the event of emergency obstruction of the airway, Accidental decannulation, or malfunction of the trach tube, attempt to reinsert routine trach size, if unsuccessful, reposition the head and neck and try again. If still unsuccessful, insert the 5.0 x 44 downsized trach, if still unsuccessful, thread the #10 French suction catheter through the smaller sized trach and use as a guide to assist in placing the smaller sized trach, either leave the catheter in and use to supply oxygen or remove and provide support with the hand ventilator and mask to either the intact natural air supply or the tracheal stoma. Administer CPR and activate emergency medical services (EMS). Notify the case manager (CM), primary care giver and physician for all unplanned trach changes. P1’s Treatment Record (TAR) dated from 7/18/24 to 7/19/24, indicated the following treatments were not signed off while RN-A was working. RN-A started her shift on 7/18/24 at 4:30 p.m. and ended at 7/19/24 at 3:14 a.m. when the paramedics arrived. It could not be verified that treatments were completed while RN-A was working. -SN (Skilled nurse) to assess client Q shift for suspect of abuse by another individual, including caregivers, and self-abuse pm (evening shift). -SN to document verification of rotated pulse oxygen every 4 hours and as needed. -Pulse oximeter continuous high heart rate 170 beats per minute (BPM) low heart rate 50 BPM, low oxygen saturation rates (o2 sats) 90% high 100% continuous pulse oximetry to be on when leaving the client in care of primary care giver (PCG), check alarm settings and function prior to reporting. -Trach tie changes q shift and as needed when soiling. -change 2 x 2 dressing with trach tie dressing q shift. -trach care by SN and secretions for client every 8 hours evening shift. -safe suction depth via 10 FR suction Cath 14 CM or the thick red line in the hub. -Ambi Vest (coughs or huff coughs to clear the mucus. Sessions last about 20 to 30 minutes.) every evening. -cough and assist to be completed with three rounds breaths a cycle stetting with exhale and inhale. -when ventilator on make sure whisper swivel/exhalation valve is in place with Flextend. -At 11:00 p.m. verify trach cuff is inflated when on vent and deflated when client is off the vent. -SN to consistently verify that the tubing circuit does not have too much water, drain the water away from the patient and into the sterile water bottle that is on the floor by the humidifier. The ambulance run sheet dated 7/19/24 indicated EMS received a call at 3:09 a.m. to dispatch to P1’s home for a breathing problem. EMS arrived on scene at 3:14 a.m., finding P1 lying in bed, P1 was connected to the turned off ventilator with no ventilations being provided. EMS departed P1’s home at 3:35 a.m., and P1 was transferred to the hospital at 4:15 a.m. The EMS ambulance run sheet indicated two attempts to intubate P1 and were successful at 3:28 a.m. P1 desaturated during the transfer and was suctioned with no improvement. P1’s vital signs varied when EMS arrived until the hospital transfer. The first reading at 3:18 a.m. indicated a pulse (heart rate) at 132 and oxygen saturations (o2 sats) at 43%, the last reading at 3:40 a.m. indicated a pulse (heart rate) at 130 and oxygen saturations (o2 sats) at 7%. Per P1’s TAR P1’s vital parameters were high heart rate 170 beats per minute (BPM) low heart rate 50 BPM, low oxygen saturation rates (o2 sats) 90% low, high 100%. A Coordination of Services Note dated 7/19/24, completed by case manager (CM)-B indicated CM-B received phone call from licensed practical nurse (LPN)-A on 7/19/24 at 3:30 a.m., and LPN-A reported P1's family member (FM)-A just called her in a panic letting her know that [P1] was being taken to the ER for a hypoxic event d/t (due to) saturations in "the 20"s" (normal level for oxygen level is 95 to 100%), "Family member (FM)-A stated the trach was all of the way out. Per EMT (emergency medical technician) FM-A stated she told the night nurse RN-A, and RN-A was surprised. On the call FM-A stated RN-A was not doing CPR correctly and she did not know anything!” P1's hospital discharge summary dated 7/19/24, indicated P1 was admitted with diagnoses of acute hypoxic respiratory failure due to trach dislodgement, emergency medical services were called, P1 was intubated through his tracheostomy site, however saturations did not come up to normal ranges with his intubations. His saturations were as low as 9%. P1 was a subsequent transfer to the hospital and in the ED (emergency department) P1 was successfully intubated and his saturations came up. The neurologist consultation report indicated it was unclear the amount of neurological insult P1 had due to this hypoxic event. P1 had one seizure, however he was at his neurological base line per family members. The report indicated P1 was transferred to another hospital. P1’s transferring discharge summary dated 7/22/24, indicated P1 was admitted on 7/19/24 for acute dislodgement of tracheostomy, prolonged hypoxic event with intractable epilepsy. The summary further indicated a follow up appointment with neurology on 7/31/24, which provided a new seizure action plan for the home health agency. P1's Abuse and Neglect Tool revised 8/03/24, indicated "client had a Hypoxic/decannulation event on 7-19-2024. Client hospitalized. Discharged home on 7-22-24. Re-hospitalized on 7-31-24 for uncontrolled seizures. Discharged home on 8-03-24." The report further indicated there was no indicators of abuse, yet the patient was susceptible to abuse by other individuals, including other vulnerable adults or children assessed. Patient was assessed and no abused noted. During an interview on 7/31/24 at 9:15 a.m., agency administrator stated P1 had a medical emergency and was aware the incident was reported to the Minnesota Department of Health from P1’s case manager. The administrator further stated P1’s trach came out. P1 received 24 hours skilled nursing services from the agency, had a ventilator at night, and had a tracheostomy. The administrator further stated it was unknow what happened due to the conflicting information they received, and their legal department completed an investigation. The administrator stated the registered nurse (RN)-A who was involved, started with the agency at the branch office in St. Paul in January 2024, and then transferred to our office in June 2024 and was not sure of the reason. On the night of the incident P1’s parents went on a vacation and needed a nurse the night of 7/19/24, so the client services manager (CSM) put out a message for staff if they wanted to pick up the shift. The administrator stated RN-A picked up the shift and received a home orientation from the day shift licensed practical nurse (LPN)-A at approximately 4:30 p.m. who was familiar with P1, and RN-A took over care around 5:00 p.m. The administrator further indicated about a month ago RN-A put a trach in a patient upside down and she was retrained on trach care and emergencies in the agency lab and completed return demonstration successfully. During an interview on 7/31/24 at 11:44 a.m., CM-B stated RN-A has not worked with any other patients since the incident occurred with P1. CM-B stated she was on-call 7/19/24 and spoke with FM-A. FM-A stated she had concerns with RN-A and called 911 during the incident. CM-B was notified of the incident around 3:30 a.m. by LPN-A. CM-B stated during the incident that occurred on 7/19/24, RN-A did not send P1’s emergency bag, which was required for P1 to have his supplies, and P1’s family members had to go back to his home to get the emergency bag for P1’s tracheostomy size and equipment. During an interview on 7/31/24 at 12:55 p.m., CM-A stated he took over P1’s case at the end of May 2024, and was informed by FM-A she was trying to change P1 when his oxygen levels were getting low and began to Ambu bag (resuscitation in emergency situations to provide respiratory support to patients who are unable to breathe on their own) P1, and she was changing from breaths to cath to suction him. RN-A connected P1’s oxygen to the Ambu bag, she connected the tubbing to the oxygen concentrator instead of the liquid oxygen. CM-A stated he teaches the nurses in class they should connect the Ambu bag directly to the portable oxygen tank to get immediate 100% oxygen and not use the concentrator during an emergency event. CM-A further stated he had concerns when RN-A was attempting to Ambu bag P1, the trach might not have been in place since his oxygen levels, according to the family members present in the room were going so low. CM-A stated he was concerned she was not checking for proper placement of the trach prior to using the Ambu bag. CM-A stated P1 was sent to the hospital and admitted with diagnosis of acute respiratory failure due to trach dislodgment and returned home on 7/22/24. During an interview on 7/31/24 at 2:22 p.m., RN-A stated she received 30 minutes of orientation from LPN-A prior to working on the night of the incident. RN-A stated P1 was more difficult than she had expected, she was not trained to the home, did not know where things were. It was reported P1 had increased secretions during the day. RN-A suctioned him and connected him to his ventilator around 11:00 p.m. Around 2:00 a.m. she turned P1 to change him, and his oxygen saturations went down to approximately 88% and the alarms on his machines started to go off. RN-A stated that was when she started to trouble shoot to try to figure out what to do to stop the alarms and yelled for P1’s family members. RN-A stated just prior to yelling for the family members she had started to Ambu bag P1, his oxygen saturations went up and then right back down, when the family member entered P1’s room things went crazy, and stated she didn’t know what the oxygen saturations were or if P1 had a heart rate due to the positioning of P1 and started chest compressions. RN-A stated she then told a family member to call 911. RN-A stated she did not know where the emergency supplies were at in P1’s home and did not send the emergency supply bag with P1 when P1 left with the paramedics. During an interview on 7/31/24 at 6:01 p.m., LPN-A stated she provided training to RN-A before she left her shift on 7/18/24, in the evening around 5:15 p.m. LPN-A stated she orientated RN-A for about 45 minutes and RN-A asked some questions about P1’s ventilator and trach. LPN-A stated she asked RN-A how comfortable she felt with trach/vents and RN-A told her she felt fine. LPN-A stated RN-A called her a couple of times during her shift asking questions about ventilator connections. On 7/19/24 when the paramedics arrived the family member put LPN-A on the phone as RN-A could not provide them the needed information. RN-A did not want to provide the paramedics with P1’s medical record at the home, which I told the paramedics to take. RN-A did not sign out any of the treatments during her shift for P1. During an interview on 7/31/24 at 7:34 p.m., family member (FM)-B stated RN-A woke her up at 2:45 a.m. on 7/19/24 yelling by knocking on the bedroom door and when FM-B walked into P1’s room, P1 was purple in color. FM-B had never seen P1 like that, and all the alarms of the ventilator, oxygen tank were going off. FM-B stated she saw the oxygen saturation rate on P1’s machine was at 20% and told RN-A she needed to Ambu bag P1 and after RN-A Ambu bagged P1, RN-A did chest compressions at 3:00 a.m. RN-A told me to call 911. FM-B stated at that point she thought his oxygen saturation rate was at 10%. During an interview on 8/06/24 at 9:15 a.m., the respiratory therapist (RT) from Pediatric Home Service (PHS) stated she was able to get readings from P1’s ventilator from 7/18/24 to 7/19/24. RT stated review of the readings indicated on 7/18/24 at 11:36 p.m., P1’s ventilator was turned on and problems started to appear at 2:42 a.m. on 7/19/24, and persist from 2:42 a.m. to 3:10 a.m., when the ventilator was turned off. The RT stated there was nine times the ventilator alarm was also placed on pause (silencing the alarm) and the RT stated they teach in their class to never silence the alarm during an emergency since it takes time away from a patient and the alarms are also to alert other family members in the home to assist for help. In addition, the RT stated RN-A should have called 911 or a family member immediately after using the Ambu-bag since that would be a sign the patient is losing oxygen to the brain. The RT stated from the readings noted an issue with low minute ventilation at 2:42 a.m. which means there was an airway leak either from the trach not being in place or the patients position and then the nurse needs to trouble shoot from repositioning and then check for trach placement. The low minute ventilation alarm continued to go on until the ventilator was shut off at 3:10 a.m. The RT further stated she was unable to retrieve the oxygen saturation readings since it was too late once the machine was picked up since the data can only be retrieved up to 96 hours after an incident. During an interview on 8/06/24 at 10:15 a.m., CM-A stated RN-A has been removed from providing care with patients with Vent/Trach patients after the incident occurred with P1. In addition, the agency also has made a list of nurses that are only qualified to provide care for P1 in the future if P1 would need a nurse. CM-A stated they should be documenting treatments at the time they are being completed. Facility policy revised 8/13/2021, indicated Preparing for Emergencies each client with a tracheostomy tube is required to have an Emergency Airway Bag and a Go Bag, which is to be used for the storage for emergency airway equipment. It contains all essential equipment for an emergency tracheostomy change and provides for a consistent setup for every client with a tracheostomy. The policy further indicated during Handling Client Emergency, if the client’s condition deteriorates, and they need immediate attention, the employee, client, or caregiver should proceed in the following manner: -Call emergency squad (911 in most areas) -Call the office and inform them of the situation; the office manage will them call the client’s health care provider and family members if applicable; and stay with the client until help arrives.

On 11/30/22 - 12/2/22 a complaint survey was conducted. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Based on the severity of the deficiency citied the Condition of Participation: Skilled Professional Services 42 CFR 484.75 at G700 was found not met. H72096069C/94525 was substantiated deficiencies were issued at G710 as a result of the complaint investigation.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on severity of the deficiency cited, the home health agency (HHA) failed to meet the Condition of Participation: Skilled Professional Services at 42 CFR 484.75. The agency failed to provide skilled professional services according to the plan of care approved by the medical provider for 1 of 1 patients (P1) who required a gait belt with transfers. Refer to G710. The home health agency (HHA) failed to ensure staff adhered to the patients plan of care to maintain a safe environment by following fall precautions for 1 of 1 patient (P1) reviewed for skilled nursing services. P1 had multiple falls when nursing staff did not use a gait belt for transfers and failed to follow the agencies Fall Prevention Program resulting in a fractured arm.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and document review the home health agency failed to ensure staff adhered to the patients plan of care to maintain a safe environment by following fall precautions for 1 of 1 patient (P1) reviewed for skilled nursing services. P1 had multiple falls when nursing staff did not use a gait belt for transfers and failed to follow the agencies Fall Prevention Program resulting in a fractured arm. P1’s Home Health Certification and Plan of Care (485), dated 10/1/22 to 11/29/22, indicated P1 had diagnosis’s of congenital malform syndrome (deformities from birth), stenosis of the larynx (scarring in the throat limiting the larynx’s ability to open normally), spina bifida (a birth defect, in which the spinal cord fails to develop properly often leading to physical and intellectual disabilities depending on severity), P1 was ventilator dependent, required supplement oxygen and a feeding tube. P1 required the assistance of one staff member to transfer and a gait belt. P1 had function limitations of bowel and bladder incontinence, endurance, ambulation, speech, and dyspnea with minimal exertion. P1’s mental status indicated developmental delay. P1’s safety measures were oxygen precautions, seizure precautions, ambulation assistance, aspiration precautions, siderails up, 24-hour supervision, clear pathways, lock wheelchair with transfers, stand precautions, fall precautions and nursing following Covid protocols. P1’s goals were to maintain and optimal ease of respiration and saturation >90%, tolerate feedings, maintain intact skin, and remain free from injury during hours of service. Client summary indicated all her goals had been met. Upon interview on 11/30/22, at 11:07 a.m. LPN-B stated she was in training with LPN-A on 11/18/22, and P1 had a fall around 3:15 p.m. LPN-B stated she was sitting next to P1 on the side of her bed and P1 fell forward landing on the floor. LPN-B stated she attempted to break the fall, but she fell too. LPN-B stated P1 was not wearing a gait belt, and she has never seen a gait belt in the house. LPN-B stated P1 had shoes on, P1 often leans to the left and she needs to be watched closely. LPN-B stated, “I think her transfer technique is dangerous, her walker is never in her bedroom, we don’t use a belt. LPN-B stated the fall was not reported to the agency. LPN-B stated both she and LPN-A assisted P1 up off the floor and ambulated her to her walker in the dining room. Upon interview on 12/1/22, at 11:03 a.m. during an interview FM-A stated P1 was in pain after the agency nurses shift on 11/18/22. FM-A found bruising on P1’s arm, as P1 was crying and pointing to her arm. P1 was taken to the emergency department and diagnosed with a fractured arm. On 11/18/22, at approximately 8:00 p.m. FM-A sent a text message to registered nurse (RN-A) indicating P1 was in the emergency room with a fractured arm and FM-A asked if something happened during P1’s shift on 11/18/22. FM-A reported RN-A responded to the text message immediately and indicated she would investigate the matter. FM-A stated she attempted to call the nurses who worked on 11/19/22 as she hadn’t heard back from the agency. FM-A stated LPN-A had worked with P1 for about four months and LPN-B was in training with LPN-A. FM-A stated she asked P1 if she and fallen. P1 made her sign language response for “yes.” She then asked her where she fell and P1 pointed to her room. FM-A brought P1 into her bedroom and P1 pointed to the left side of her bed to the floor. FM-A stated this is the third fall P1 had under the care of LPN-A. FM-A could not recall the exact date but was certain it was the end of August when LPN-A reported P1 had fallen in the bathroom being transferred to the toilet. FM-A stated P1 would stand-up with the assistance of one assistant. P1 would place her left arm on a grab bar and her right hand on the windowsill. P1 slipped that day and fell into a seated position onto the floor. There were no injuries reported. LPN-A was in the bathroom with P1. The family provided their own intervention of placing another grab bar on the windowsill FM-A stated in mid-September she witnessed LPN-A assisting P1 into her stander (a walker where she is strapped in to be able to stand or ambulate), LPN-A did not lock the stander and P1 fell, LPN-A grabbed P1’s arm and broke the fall with her own body. P1 was not injured. Upon interview on 12/2/22, at 8:41 a.m. LPN-A stated on 11/18/21 while she was training LPN-B, LPN-B was assisting P1 after her afternoon nap. P1 was on the edge of her bed and fell to the floor. LPN-A stated she was in the room but did not see the fall. LPN-A stated P1 did not appear in any pain. LPN-A stated she and LPN-B lifted P1 off the floor placing their hands under her arms and legs. She stated P1 was not wearing a gait belt and LPN-A was not aware that she was supposed to be using the belt. LPN-A stated LPN-B told her P1 did not hit her head, LPN-A assessed her skin and did not notice any redness or bruising. LPN-A denied taking vital signs or reporting the fall to the agency. LPN-A stated she thought the agency policy was to call the agency if there was a fall with injury but stated she could not really remember her training. LPN-A confirmed P1 had two other falls when she was working with her. She stated in August she was transferring P1 to the toilet and P1 slipped and fell backwards onto LPN and they both fell to the floor. She stated she did report the fall to the P1’s family, but not the agency since there was not an injury. LPN-A stated P1 was not wearing a gait belt during that fall. LPN-A stated the other fall happened a few weeks after the fall in the bathroom. LPN-A stated P1’s walker is usually pushed up against the dining room table where P1 likes to color, so the stander does roll, however this time it was pushed back from the table and the walker slide forward, P1 lost her balance and LPN-A lowered P1 to the floor. P1 was lifted back up to the stander with LPN-A placing her arms under P1’s arms without a gait belt. Upon interview on 12/2/22, at 10:29 a.m. RN-A stated she received three text messages on the evening of 11/18/22, from FM-A and was aware that P1 had a fracture. RN-A stated she notified the Director on 11/19/22. The agency was attempting to contact the LPN’s who were in the home on 11/18/22. RN-A stated that she goes to the home every 60 days for the re-certification assessment and there is a question on the Oasis assessment that asks about prior falls. RN-A stated it is not her practice to specifically ask for falls, since those should have been reported prior to the assessment. She stated she asks in the summary if there had been any concerns and there were none reported by FM-A. RN-A denied knowledge that P1 was to use a gait belt with transfers. RN-A verified that the care plan she had written did indicated a transfer of one with a gait belt. RN-A stated when she had been to the house, she had not observed the family using a gait belt with P1. Upon interview on 12/2/22, at 10:55 a.m. the agency Director stated she received a text from RN-A on 11/19/22, at 10:39 a.m. indicating RN-A had received a text the following evening from FM-A indicating P1 had a broken arm and bruising on her legs. The Director stated she started to investigate the incident 11/19/22 through 11/20/22. She stated if for some reason the care plan changes or they cannot follow it, they need to notify the agency and see if a new order is warranted. The agency’s policy titled Fall Prevention Program dated 12/19/22, [sic] indicated the agency has a comprehensive fall prevention program that is designed to reduce occurs of falls. It is proactive, risk-based that identified clients who are at risk for falls by providing ongoing monitoring and evaluation of current strategies. This includes assessment of risk and establishing interventions aimed at reducing injuries. 1. An initial screening is performed to evaluate a baseline. A set of tasks known as fall assessment tools including to test client’s strength, balance, and gait. 2. Interventions, risk specific, include possible use of therapy, and the need to address the need for special equipment or training to improve safety. 3. Documentation, all client specific fall precautions and interventions are identified in the treatment plan. 4. Reporting of falls, all falls are to be reported via an incident report. A client follow-up visit is completed for client’s who have falls occurring when agency staff are present. Falls resulting in injury that alters the client’s previous status/function and clients who have had previous falls with in the prior three months. 5. Coordination of a client’s fall prevention plan with all team members if the responsibility of the clinical manager, clinical associate or case managing clinician to ensure follow through occurs on the safety plan of the client. The client’s record will reflect communication among all team members and clear directions related to client safety. Any special training required to maintain the safety of the client and employee must be completed before the employee is permitted to work independently with that client.

An abbreviated survey was conducted at your agency on 2/24/21 to 2/25/21 to conduct a complaint investigation. Bayada Home Health Care Inc. was found NOT to be in compliance with requirements at 42 CFR Part 484, requirements for Home Health Agencies. The following complaint was found to be SUBSTANTIATED: H7029006C (MN47471) with deficiencies issued at G574 The following complaints were found to be UNSUBSTANTIATED: H7209005C (MN70169) H7209007C (MN63441) The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure the plan of care (POC) included pertinent information to include wheelchair safety belt for 1 of 3 patients (P3) reviewed. Findings include: P3's Coordination of service note dated 5/30/19, at 2:03 p.m. identified RN-A had called to report she transferred P3 to the wheelchair and pushed chair forward and it jumped up and she slipped off. RN-A identified she was moving the chair to better fit P3's shoulder straps. P3 fell on her face and the school recommended she be seen at the hospital. The note further identified that her front teeth were loose. P3's Clinical note dated 6/2/19, included registered nurse (RN)-A identified P3 was being pushed in wheelchair to an area to allow RN-A to adjust straps and the wheelchair tilted up suddenly and P3 fell on her face from the chair. P3 was assisted back into the wheelchair. P3 was sent to the hospital were the loose teeth were splinted and sent home to see the dentist in regards to P3's three front teeth. P'3 Coordination of care note dated 6/4/19, RN-B identified RN-A had reported P3 fell out of the wheelchair when RN-A was pushing her forward to adjust her shoulder straps when her chair jumped and she slid forward falling on her face. RN-B stressed the importance of P3's seat belt to be fastened before moving the chair. RN-A verbalized understanding. P3's 485 certification period 4-1-19 to 5-30-19 identified diagnosis as Cerebral palsy (disorder of movement, muscle tone, or posture), neuromuscular dysfunction of bladder (urinary bladder problems), incontinence without sensory awareness, gastrostomy tube (Tube surgically placed into the stomach for nutrition), and tracheostomy (tube surgically placed in trachea for breathing). Safety measures include oxygen precautions, seizures, aspiration precautions, elevate head of bed. 24 hour supervision. clear pathways, lock wheelchair with transfers, standard precautions, fall precautions, and siderails on bed up. (Did not identify use of a wheelchair safety belt). Activities permitted: up as tolerated, transfer bed/chair, exercises prescribed, and wheelchair. Client is non ambulatory. P3's current 485 certification period 1-20-21 to 3-20-21 lacked any evidence of wheelchair safety belt. During interview on 2/24/21, at 12:35 p.m. the designated coordinator stated P3 fell out of her wheelchair when RN-A was wheeling her without having her safety belt strapped. Designated coordinator further stated clients should never be moved without being fastened During interview on 3/24/21, at 3:14 p.m. the Director stated they received a call from the day program about P3 having a fall and was not buckled in her wheelchair. During interview on 2/24/21, at 3:27 RN-A stated she cannot recall all of the details of the incident as it was a long time ago, but remembers she was retrained on P3's cares including using her wheelchair belt. P3 should have her seat belt on at all times when in the wheelchair. Uses care plan to care for clients. During interview on 2/25/21, at 10:18 a.m. RN-B stated P3 had fallen out of her wheelchair due to not being buckled in. RN-A stated P3 uses a seat belt to prevent her from falling out of her chair. RN-A was educated on importance of wearing the safety straps when in the wheelchair. During interview on 2/25/21, at 12:58 p.m. RN-B stated the 485 does not identify P3 was to wear the safety belt, however he will get that fixed. RN-B further stated the nursing staff uses the 485 to assist with caring for the clients. During interview on 2/25/21, at 1:05 p.m. RN-C stated if a client has a safety seat belt they are supposed to be wearing and it should be identified on the 485. RN-C stated that nurses uses the 485 to care for the client. RN-C further stated potential risk for not identifying safety precautions on a care plan could result in a fall and they want to prevent all falls in clients. During interview on 2/25/21, at 1:11 p.m. the Associate Director stated she did not see any safety belts or buckles listed on P3's 485. The Associate director recommended speaking with clinical management in regards to what is on the 485. The Associate Director further stated nurses look to the 485 to care for the clients. Client Care Plan policy revised 1/4/20 identified "BAYADA Home Health Care develops and implements an individualized plan of care for/with each client. The individualized plan of care based on the client's medical diagnosis, physician's order, comprehensive assessment and client input must include the following elements: a)all pertinent diagnosis, b) the client's medical psychosocial and cognitive status, c)the types of services, supplies and equipment needed, d) the frequency and duration of visits to be made, e) prognosis and rehabilitation potential, f) functional limitations, g) activities permitted, h)nutritional requirements, i) all medications and treatments, j)safety measures to protect against injury, k) description of the client's risk for emergency department visits and hospital readmission, and all necessary interventions to address underlying risk factors. l) client and caregiver education and training to facilitate timely discharge, m) client specific interventions and education, n)measurable outcomes and goals identified by BAYADA and the client, o) information related to any advance directives; p) any additional items BAYADA or physician may choose to include; and q) pan for the client during a natural or man made disaster".