Every finding on record at Bayada Home Health Care, Inc

This facility is in substantial compliance with 42 CFR Part 484 Emergency Preparedness. A Standard level citation was identified.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on staff interview and review of the facility emergency preparedness plan, it was determined that the facility failed to ensure that at least one emergency preparedness drill or tabletop exercise was completed in the year 2020. Findings include: 1. Upon request to Staff #1, the facility provided a binder that contained the emergency preparedness plan, risk assessment, community resources, and drills and activations of the emergency preparedness plan for the years 2019, 2020, and 2021. 2. A review of the binder identified that there were no emergency preparedness drills or activations identified for the year 2020. 3. An interview with Staff #1 on 9/14/2021 at 11:27 AM identified that the facility office was potentially closing in 2020 and the emergency preparedness drill was not completed.

This was a Federal Recertification and State Relicensure survey that was conducted on September 13, 2021 to September 15th, 2021. The facility was found to be in substantial compliance with 42 CFR Part 484 Conditions of Participation for Home Health Agencies and also in substantial compliance with N.J.A.C. Title 8 Chapter 42- Licensing Standards for Home Health Agencies. Standard Level deficiencies were identified. Home Visits: 3 Total Medical Record Review: 7

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to document a complete set of vitals signs with each patient visit in three (3) out of four (4) medical records (#3, #6, #7) reviewed. Findings include: Reference: Facility policy, titled: “Client Assessment and Reassessment” states: “…2.0 Assessment Principles. A comprehensive assessment gives Registered Nurses and Therapists insight into a client’s status through: a. Observation b. measurement of vital signs c. the client’s self-reported symptoms… 6.3.2.1 Vital signs: Vital signs must be taken and recorded into HCHB (Home Care Home Base) during every skilled nurse and therapy visit. Vital Signs include blood pressure, temperature, pulse, respiratory rate with breath sounds, and pulse oximeter reading…..” 1. An interview with Staff #1 on 9/15/2021 at 1:41 PM confirmed that a complete set of vital signs should be assessed and documented for each clinician visit. A complete set of vital signs would include pulse, blood pressure, temperature, respiratory rate, and pain level. 2. The medical record of Patient #3 was reviewed. The following was identified: a. On 4/21/2021, the physical therapist did not document the respiratory rate, the pulse oximetry, and the temperature of the patient. b. On 4/27/2021, the physical therapist did not document the respiratory rate, the pulse oximetry, and the temperature of the patient. c. On 4/29/2021, the physical therapist did not document pulse, blood pressure, temperature, the pulse oximetry, and the respiratory rate. 3. The medical record of Patient #6 was reviewed. The physical therapist failed to document the patient’s respiratory rate on the following dates: 7/27/2021; 7/29/2021; and 8/18/2021. 4. The medical record of Patient #7 was reviewed. The physical therapist failed to document the patient’s respiratory rate and pulse oximetry on the following dates: 9/1/2021; 9/3/2021; 9/8/2021; and 9/14/2021. 5. The above findings were confirmed with Staff #1, Staff #2, Staff #4, and Staff #11 on 9/15/2021 at 2:30 PM. N.J.A.C. 8.3(a)(2)

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of one (1) of three (3) medical records (#4, #5), staff interviews, and review of facility policy and procedure, it was determined that the agency failed to ensure that services ordered by the physician are provided, as indicated in the patient's plan of care. Findings include: Reference #1: Facility policy, "Client Care Plan" states, "... 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... c. The types of services, supplies and equipment needed... d. The frequency and duration of visits to be made... ." Reference #2: Facility policy, "Missed Visits/Hours" states, "... Physician Ordered Services... The physician must be notified when the plan of care is altered due to fewer visits or hours of service being provided as ordered. Notification of the missed visits/hours is timely, and as directed on a schedule determined in collaboration with the physician. ... Missed Visit Process Flow... Field clinician is responsible for documenting the missed visit in the "Missed Visit Coordination Note" found in the electronic record. The Missed Visit Coordination Note will include the following: a. Date missed visit occurred... b. Reason for missed visit... c. Method of notification to physician (verbal or fax)." 1. Review of Medical Record #4 on 9/15/21, revealed the following: a. The Home Health Certification and Plan of Care for start of care (SOC) date 8/18/21 states, "Frequency/Duration of Visits... HHA Effective 8/22/21 2WK3" (twice a week for three weeks). i. For week 8/22/21 to 8/28/21, one (1) HHA visit was made. The missed visit note dated 8/28/21 states, "Reason for Missed Visit: Add visit to following week. Method of Physician Notification: Notified RN and CM." There was no evidence that the physician was notified. ii. For week 9/5/21 to 9/11/21, one (1) HHA visit was made. There was no evidence of missed visit note indicating the reason for the missed visit. There was no evidence that the physician was notified. b. Upon interview at 1:43 PM, Staff #1 confirmed the HHA missed visits for Patient #4. c. Upon interview at 2:00 PM, Staff #1 confirmed that "Add visit to the following week" was not an acceptable justification for a missed visit. 2. Review of Medical Record #5 on 9/15/21, revealed the following: a. The Home Health Certification and Plan of Care for start of care (SOC) date 8/19/21 states, "Frequency/Duration of Visits... OT 1WK5 (Occupational Therapy once per week for five weeks)." b. Physician's order dated 9/9/2021 at 1:14 PM states, "Client would benefit from additional OT visits for shower transfer training." i. The updated Home Health Certification and Plan of Care, frequency of visits for OT states, "Effective 09/12/2021,1Q2WK2 (once every two weeks for two weeks), 1WK1 (once a week for one week)." The frequency of OT visits does not indicate an increase in the amount of OT visits as indicated by the physician's order. 3. Upon interview on 9/15/21 at 2:00pm, Staff #1 confirmed the OT visits were not increased for Patient #5.

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 of infection control practices during two (2) of three (3) home visits, staff interviews, and review of facility policies and procedures, it was determined that the facility failed to ensure that hand hygiene occurs in accordance with acceptable standards of practice, and failed to ensure that aseptic technique is maintained while performing patient care. Findings include: Reference: Facility policy, "Hand Hygiene" states, "... Indications for Hand Decontamination... b. Before applying and after removing gloves or other personal protective equipment. c. Between contact with the environment and the client (medical equipment, bedside tables, personal cell phone) in the immediate vicinity of the client before moving to another task." 1. During a home visit for Patient #1, on 9/13/21, the following was observed: a. At 1:16 PM, Staff #3 placed two barriers on a table, then placed his/her bag on one of the barriers. b. At 1:52 PM, while Staff #3 was taking Patient #1's blood pressure, a cat climbed onto the table and sat on the empty barrier. After approximately twenty (20) seconds, the cat jumped off the table. c. At 1:55 PM, Staff #3 used a Sani-wipe to clean his/her stethoscope, thermometer, pulse oximeter, and blood pressure cuff. Staff #3 placed the clean equipment on the barrier contaminated by the cat. 2. During a home visit for Patient #5, on 9/14/21, the following was observed: a. At 1:20 PM and 1:28 PM, Staff #5 failed to perform hand hygiene prior to donning gloves. 3. Staff #1 and Staff #2 confirmed the above findings on 9/15/21 at 12:30 PM. N.J.A.C. 8:42-12.2(b)3 N.J.A.C. 8:42-12.3(a)

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on observation, review of one (1) of three (3) medical records (#4), review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that Home Health Aides (HHAs) receive RN (Registered Nurse) supervisory visits a minimum of every fourteen (14) days. Findings include: Reference: Facility policy, "Frequency of Clinical Management Visits and Employee Supervision" states, "... Home Health Aide Services with skilled services... Clients receiving home health aide services along with another discipline are visited at least once every fourteen (14) days by an RN or Therapist to supervise the Home Health Aide... Supervisory visits are documented on the discipline-specific Clinical Note-Wound Care, or a corresponding field employee supervision note... ." 1. Review of Medical Record #4 on 9/15/21, indicated the following: a. The patient was admitted to the Home Health Agency on 8/18/21. On the "Home Health Certification and Plan of Care," the frequency of visits ordered for HHA services states, "HHA Effective 08/22/2021 2WK3" (home health aide visits twice a week for three weeks). i. Documentation in the medical record indicated that HHA visits were made on 8/27/21, 9/1/21, 9/3/21, and 9/8/21. b. There was no evidence in the medical record that supervisory visits were conducted. 2. Upon interview on 9/15/21 at 1:46 PM, Staff #1 confirmed that supervisory visits were not made for Patient #4. Staff #1 stated, "The visit should have been rescheduled with another RN. There was no supervisory visit completed."