Every finding on record at Bayada Home Health Care, Inc.

This report is the result of an unannounced Federal Recertification survey completed on October 18, 2024 at Bayada Home Health Care, Inc. It was determined that the facility is in substantial compliance with the requirements of Emergency Preparedness regulation 42 CFR, Title 42, Part 484, Conditions of Participation for Emergency Preparedness for this survey.

This report is the result of an unannounced Federal Recertification Survey and State Re-licensure Survey completed on October 18, 2024 at Bayada Home Health Care, Inc. It was determined the facility is not in substantial compliance with Federal requirements of 42 CFR Part 484, Subpart B Conditions of Participation for Home Health Agencies and State requirements of N.J.A.C. Title 8 Chapter 42 Home Health Agency Licensing Standards.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review, staff interviews, and review of facility policies, it was determined that the facility failed to ensure communication with the physician was documented when a missed visit occurred in four (4) out of five (5) medical records reviewed (Patient (P) 6, P10, P13 and P14). Findings include: Facility policy titled “Missed Visits/Hours”, last reviewed on 3/24/24, states “… Our Procedure: 1.0 Communicating Missed Visits/Hours. … 1.1.1.2: Missed Visit Process Flow. The field clinician is responsible for documenting the missed visit in the “Missed Visit Coordination Note” found in the medical record. 1.1.1.2.1: The Missed Visit Coordination Note will include the following: a. Date missed visit occurred; b. Reason for missed visit; and c. Method of notification to physician (verbal or fax).” On 10/17/24 at 11:00 AM, a review of P10’s medical record was conducted and revealed the following: record shows Staff (S) 14, Occupational Therapist (OT), entered a Coordination of Care Note on 10/4/2024 stating “This is a notification of delay in services. The RD [Registered Dietician] evaluation has been delayed until next week due to staffing”. There was no documented method of notification to physician (verbal or fax) for the missed RD visit on 10/4/24 in the medical record. Findings were confirmed by S3 at 10/18/24 at 2:30 PM. On 10/17/24 at 1:37 PM, an interview was conducted with S3, Director. When questioned about the Missed Visit/Hours policy, S3 stated “I would think it is for everyone” when asked if the policy applied to all staff or nursing staff only. On 10/18/24 at 9:50 AM, P13's medical record was reviewed. P13 was receiving home care services for congestive heart failure and a history of falling. P14 had the following orders: "OT Effective 09/22/2024 - 2wk2, 1wk3..." - Occupational Therapy (OT): 2 visits a week for 2 weeks, 1 visit a week for three weeks. P13's medical record revealed a missed OT visit the week of 9/29/24. There was no documented method of notification to the physician (verbal or fax) for the missed OT visit on 10/2/24 in accordance with facility's policy, in the medical record. Findings were confirmed by S1, Division Director, on 10/18/24 at 10:02 AM. On 10/18/24 at 10:14 AM, P14's medical record was reviewed. P14 was receiving home care services for chronic kidney disease and a history of falling. P14 had the following orders: Effective 8/9/24 - "PT 1WK1, 2WK2, 1WK1,..." - Physical Therapy (PT): 1 visit a week for 1 week; 2 visits a week for 2 weeks; 1 visit a week for 1 week. P14’s medical record revealed a missed PT visit the week of 8/25/24. There was no documented method of notification to the physician (verbal or fax) for the missed PT visit on 8/29/24 in accordance with the facility's policy, in the medical record. Findings were confirmed by S1 on 10/18/24 at 10:35 AM. Facility policy titled “Missed Visits/Hours”, last reviewed on 3/24/24, states, “…Our Procedure: 1.0 Communicating Missed Visits/Hours. … 1.1.1.2. Missed Visit Process Flow. The field clinician is responsible for documenting the missed visit in the “Missed Visit Coordination Note” found in the electronic record. 1.1.1.2.1 The Missed Visit Coordination Note will include the following: a. Dated missed visit occurred; b. Reason for missed visit; and c. Method of notification to physician (verbal or fax)….” On 10/17/2024 at 11:00 AM, P10’s medical record was reviewed and revealed the following: P10 had the following order: “Registered Dietician [effective ___ ] _WK_, _WK_, etc.” – Review of P10’s medical record revealed a missed RD visit the week of 10/4/2024. “Care Coordination Note” written on 10/4/2024 lacked documentation of notification to the provider for the missed RD visit as per facility policy. On 10/17/2024 at 1:37 PM an interview was conducted with S3 (Director). When questioned about the Missed Visit/Hours policy, S3 stated “I would think it is for everyone” when asked if policy applied to all staff or nursing staff only. These findings were confirmed by S3 on 10/18/2024 at 2:30 PM. On 10/18/24 at 9:50 AM, P13's medical record was reviewed. P13 had the following orders: "OT Effective 09/22/2024 - 2wk2, 1wk3..." - Occupational Therapy (OT): 2 visits a week for 2 weeks, 1 visit a week for three weeks. P13's medical record revealed a missed OT visit the week of 9/29/24. There was no documented method of notification to the physician (verbal or fax) for the missed OT visit in accordance with facility's policy, in the medical record. Findings were confirmed by S1, Division Director, on 10/18/24 at 10:02 AM. On 10/18/24 at 10:14 AM, P14's medical record was reviewed. P14 had the following orders: Effective 8/9/24 - "PT 1WK1, 2WK2, 1WK1,..." - Physical Therapy (PT): 1 visit a week for 1 week; 2 visits a week for 2 weeks; 1 visit a week for 1 week. P14’s medical record revealed a missed PT visit the week of 8/25/24. There was no documented method of notification to the physician (verbal or fax) for the missed PT visit in accordance with the facility's policy, in the medical record. Findings were confirmed by S1 on 10/18/24 at 10:35 AM. Facility policy titled “Missed Visits/Hours”, last reviewed on 3/24/24, states “… Our Procedure: 1.0 Communicating Missed Visits/Hours. … 1.1.1.2: Missed Visit Process Flow. The field clinician is responsible for documenting the missed visit in the “Missed Visit Coordination Note” found in the medical record. 1.1.1.2.1: The Missed Visit Coordination Note will include the following: a. Date missed visit occurred; b. Reason for missed visit; and c. Method of notification to physician (verbal or fax).” On 10/18/24 at 10:00 AM, P6’s medical record was reviewed. P6’s Plan of Care (“Home Health Certification and Plan of Care”), for Start of Care 9/12/2024, contained the following order: · “SN 1WK2, 2WK1, 1WK1, 1Q3WK3…” – Skilled nurse (SN): 1 visit a week for 2 weeks; 2 visits a week for 1 week; 1 visit a week for 1 week; 1 visit every 3 weeks times 3. P6’s medical record revealed a missed nursing visit the week of 9/22/24 and a second missed nursing visit the week of 9/29/24. The medical record did not have evidence of communication to the provider regarding the missed nursing visits as per facility policy. On 10/18/24 at 11:00 AM, Staff (S), 3, Director, confirmed that P6 had 2 missing nursing visits and the medical record lacked documentation of communication to the physician regarding these visits.

The facility is not in substantial compliance with Appendix Z-Emergency Preparedness for All Provider and Certified Supplier Types Interpretive Guidance 484.22, Condition of Participation for Home Health.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on review of three (3) of four (4) medical records (#1, #2, #4) reviewed for the patient's emergency preparedness plan, and review of facility documents, it was determined the facility failed to ensure a patient-specific Emergency Preparedness plan is developed, reviewed with the client or caretaker, kept in the home, and entered in the medical record. 2. Review of Medical Record #2 on 1/27/22 lacked evidence that a patient-specific emergency preparedness plan was developed and reviewed with the patient or his/her caretaker. 3. During a home visit for Patient #2 on 1/25/2022 at 2:00 PM, the following was indicated: a. Review of the patient's folder revealed that the emergency preparedness form was present, however, noted to be blank. b. At 2:35 PM, Patient #2's caregiver stated that facility staff did not discuss an emergency preparedness plan with him/her. 4. The above findings were confirmed by Staff #7 and Staff #13 on 1/27/22. 5. Review of Medical Record #4 on 1/27/22 revealed the following: a. In the Emergency Preparedness section of the electronic medical record (EMR), the tab marked "Evacuation Location" states, "Neighbors." i. The evacuation location does not indicate a specific evacuation address the patient will be evacuated to in the event of an emergency. b. There was no evidence in the medical record that a patient-specific emergency preparedness plan was developed and reviewed with the patient or his/her caretaker. 6. The above findings were confirmed with Staff #1, Staff #2, and Staff #6 on 1/27/22. N.J.A.C. 8:42-3.5 Findings include: Reference: Facility policy titled, "0-9197 Emergency Management Program and Plan-Home Health, Medicare Certified Home Care and Hospice Offices" states, "...4.1.3 Client-Specific Emergency Plans. ... 4.1.3.1 As part of the comprehensive assessment, the admitting clinician will develop a Client-Specific Emergency Plan by entering the information into the electronic record... At each reassessment, the Client-Specific Emergency Plan will be reviewed with the client/responsible party and updated if necessary. The Client-Specific Emergency Plan will include specific instructions for the client. 4.1.3.3 A copy of the Client-Specific Emergency Plan will be kept in the client's home and a copy will be returned to the paper office electronic office chart. ... ." 1. Review of Medical Record #1 on 1/27/22 revealed the following: a. In the Emergency Preparedness section of the electronic medical record (EMR), the tab marked "Evacuation Location" states, "Will go to rehab." i. The evacuation location does not indicate the name or address of the rehab the patient will be evacuated to in the event of an emergency. b. There was no evidence in the medical record that a patient-specific emergency preparedness plan was developed and reviewed with the patient or his/her caretaker.

This was a Federal Recertification survey, Mandatory Vaccination Investigation, and State Relicensure survey conducted January 25, 26, and 27, 2022. Bayada Home Health Care-Cherry Hill is not in compliance with 42 CFR Part 484, Conditions of Participation for Home Health Agencies and N.J.A.C. 8:42 - Home Health Agency Licensing Standards.

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 six (6) of seventeen (17) medical records (#2, #3, #4, #10, #15, #18), staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure documentation of missed visits and physician notification of missed visits, are documented in the patient's medical record. Findings include: Reference: Facility policy titled, "0-6277 Missed Visits/Hours" states, "...1.1 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. 1.1.1 Documentation-Home Health (visits) & Hospice. 1.1.1.1 Missed Visit Notification note to capture the reason that the visit was missed as well as evidence that the physician was informed verbally or by fax...of this variation from the plan of care must be entered in the electronic record." 1. Review of Medical Record #2 on 1/27/22 revealed the following: a. The Home Health Plan of Care effective 12/19/21 states, "HHA (Home Health Aid) 2wk1 (two times per week for one week), 3wk1 (three times per week for one week), 2wk2 (two times per week for two weeks)." i. During the week of 12/19/21, there was one (1) missed HHA visit. There was no evidence of a Missed Visit Notification note indicating why the visit was missed. There was no evidence that the physician was notified of the missed visit. ii. During the week of 12/26/21, there were two (2) missed HHA visits. There was no evidence of Missed Visit Notification notes indicating why the visits were missed. There was no evidence that the physician was notified of the missed visits. iii. During the week of 1/9/22, there was one (1) missed HHA visit. There was no evidence of a Missed Visit Notification note indicating why the visit was missed. There was no evidence that the physician was notified of the missed visit. 2. Review of Medical Record #3 on 1/26/22 revealed the following: a. The Home Health Plan of Care effective 11/16/21 states, "HHA 2wk2 (twice a week for two weeks) effective 12/5/21; HHA 2wk1 (twice a week for one week) effective 12/19/21." A Missed Visit Notification note documented on 12/20/21 indicated a HHA missed visit occurred on 12/13/21. There was no evidence the physician was notified of the missed visit. b. A HHA note dated 12/27/21 indicated the HHA missed a visit on 12/27/21. There was no evidence the physician was notified of the missed visit. c. Staff #2 confirmed that there was no evidence the physician was notified of the missed visits on 1/26/22 at 12:54 PM. 3. Review of Medical Record #4 on 1/27/22 revealed the following: a. The Home Health Plan of Care effective 1/3/22 states, “HHA 1wk1 (one time a week for one week), 2wk5 (two times a week for five weeks)." i. During the week of 1/3/22, there was one (1) missed HHA visit. There was no evidence that the physician was notified of the missed visit. ii. During the week of 1/9/22, there were two (2) missed HHA visits. There was no evidence that the physician was notified of the missed visits. b. The above findings were confirmed with Staff #1, Staff #2, and Staff #6 on 1/27/22. 4. Review of Medical Record #10 on 1/26/22 revealed the following: a. The Home Health Plan of Care effective 11/28/21 states, "HHA 1wk1 (once per week for one week), 2wk4 (twice per week for four weeks)." b. For week 12/5/21 to 12/11/21, there were no HHA visits made. A HHA note dated 12/8/21 indicated the HHA missed a visit on 12/8/21. There was no evidence the physician was notified of the missed visit. c. There was no evidence of a Missed Visit Notification note or physician notification for the second HHA visit missed during the week of 12/5/21 to 12/11/21. d. On 1/26/22 at 3:10 PM, Staff #2 confirmed that there was no evidence of a Missed Visit Notification note or evidence of physician notification of the missed visits. 5. Review of Medical Record #15 on 1/27/22 revealed the following: a. The Home Health Plan of Care effective 8/11/21 states, "SN (Skilled Nurse) 2wk4 (twice per week for four weeks), 1wk5 (once per week for five weeks)." b. A Missed Visit Notification note indicated that the SN missed a visit on 9/7/21. There was no evidence the physician was notified of the missed visit. c. On 1/27/22 at 11:30 AM, Staff #2 confirmed that there was no evidence the physician was notified of the missed visit. 6. Review of Medical Record #18 on 1/27/22 revealed the following: a. The Home Health Plan of Care states, "PT (Physical Therapy), 3wk2 (three times per week for two weeks)." i. During the week of 8/8/21, there was one (1) missed PT visit. There was no evidence of a Missed Visit Notification note indicating why the visit was missed. There was no evidence that the physician was notified of the missed visit. 7. The above findings were confirmed on 1/26/22 and 1/27/22 by Staff #12 and Staff #13. N.J.A.C. 8:42-6.2(a)2

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure physician's sign all verbal orders, in accordance with facility policy. Findings include: Reference: Facility policy titled, "Physician's Orders" states, "... 6.0 When changes in orders are received verbally from the physician...the verbal order received is sent to the physician for signature. ... ." 1. Review of Medical Record #6 on 1/27/22 revealed the following: a. A physician's order dated 1/5/22 at 3:57 PM states, "...Verbal order: Y [yes]...Order Description: Change physical therapy visit to telephone call." i. Upon interview on 1/27/22 at 11:35 AM, Staff #2 confirmed the order dated, 1/5/22 at 3:57 PM, was a verbal order. b. There was no evidence that the physician signed the verbal order. On the physician order form next to the section labeled "Physician Signature" it states, "Do not send." There was no physician signature on the form. N.J.A.C. 8:42-6.2

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on staff interviews, review of two (2) of two (2) medical records (#1, #4) of patients requiring case coordination, and review of facility policies and procedures, it was determined the facility failed to ensure integrative services are provided to all patients. Findings include: Reference #1: Facility policy titled, "Fall Prevention Program" states, “… Assessment Principles… Does the client need any assistive devices to improve safety?” Reference #2: Facility policy titled, "Client Care Coordination" states, “… Case coordination involves identification of additional services needed, contacting community resources for these services… Integrating services, whether services are provided directly or under arrangement, to assure the identification of client needs and factors that could affect client safety and treatment effectiveness and coordination of care provided by all disciplines.” 1. Review of Medical Record #1 on 1/27/22 revealed the following: a. The Initial Assessment Physical Therapy note on 1/11/22 states, “… Safety Measures… Fall Precautions… Client is a 77-year-old female admitted to [name of hospital] on 12/24/21 following a fall at home. Client reports… lost her balance and unable to get up. She crawled on her knees to get her phone to call her son. … client lives alone… cannot afford to get a life alert… .” b. There was no evidence in the medical record that the physical therapist notified the nurse or medical social worker about the patient's financial need for assistance in obtaining a life alert device for safety. c. The above finding was confirmed with Staff #6 on 1/27/22 at 11:00 AM. 2. Review of Medical Record #4 on 1/27/22 revealed the following: a. The Initial Assessment Physical Therapy note on 1/3/22 states, “… Presents with reported 10–20-pound weight loss but denies need for referral to RD (Registered Dietician). Using Ensure… Patient is at a high nutritional risk.” b. The Medical Social Worker visit note on 1/10/22 states, “… Nutritional… Client underweight due to emotional or physical issue… MSW (Medical Social Worker)… encouraged client to speak with the nurse, he is currently paying under the table, in order to provide him with more regular help throughout the week. MSW provided client with 3 private duty home care agencies.” c. The Occupational Therapy visit note on 1/14/22 states, “… Client reports he is not eating enough because it is difficult to feed himself.” d. There was no evidence that the facility provided skilled nursing or a registered dietician to evaluate the patient and determine his/her needs. e. The above findings were confirmed with Staff #2 on 1/27/22 at 11:00 AM. N.J.A.C. 8.42-3.5

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, staff interviews, and review of facility documents, it was determined the facility failed to ensure N95 face masks are worn when caring for patients with symptoms of COVID-19. Findings include: Reference #1: Facility document, "COVID-19 Safety Strategies" states, "... Universal Masking: We encourage willing family members to wear a mask, although we do not require clients or household members to wear a mask. ... We are still able to safely provide care as long as our clinicians are following our PPE standards based on client/household scenario per our PPE Standards-at-a-Glance." Reference #2: Facility document, "[Name of facility] PPE Standard At-A-Glance As of 11/1/21" states, "... Clients with symptoms or COVID-19-positive or awaiting rest results with symptoms... N95 mask; Eye protection (goggles/face shield); Contact protection (gown/gloves)." 1. During a home visit for Patient #3 on 1/26/22, in the presence of Staff #8, the following was observed: a. Upon entry into the patient's home, Staff #8 was wearing a surgical mask, face shield, and goggles. Patient #3 was not wearing a face mask. b. During a patient interview at 10:00 AM, Patient #3 indicated he/she was taking a new medication for "a runny nose, sore throat, sneezing, and coughing." Staff #8 continued the home visit wearing a surgical mask, face shield, and goggles. c. Staff #8 failed to don an N95 mask or gown after the patient indicated he/she had symptoms consistent with COVID-19. 2. Staff #1 and Staff #2 confirmed the above findings on 1/27/22 at 2:00 PM.

This is a Federal Allegation Survey (NJ00142370) conducted on February 4, 2021 at Bayada Home Health Care to investigate 42 CFR Condition of Participation for Home Health Agencies 484.75: Skilled Professional Services. This facility is in compliance with 42 CFR Condition of Participation for Home Health Agencies 484.75: Skilled Professional Services. Standard level deficiencies were identified.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: A. Based on staff interview, review of facility documentation, and review of five (5) medical records, it was determined that the facility failed to ensure that the re-evaluation of the patient's needs were communicated between the nursing staff and the physician in one (1) of five (5) medical records. Findings include: Reference #1: Policy titled, "Chart Data Requirements and Format - Home Health Practice" states, " ...4.10 NURSE'S NOTE - HOME HEALTH ... Nursing documentation should include the following information: a. Physical and psychological symptoms ... b. The care and services provided ... c. Any new service or treatment initiated d. Response to services ... e. Ongoing documentation of identified problems and any changes in the client's status ... g. Documentation of communication with the physician on a COORDINATION OF SERVICES (COS) NOTE ...". Reference #2: Policy titled, "Client Care Coordination- NJ Medicare Certified Offices" states, "... Our Procedure: ...2.0 [Facility] regularly communicates with the client's physician or authorized individuals to ensure that care and services are coordinated..... Achieving care or service goals requires ongoing communication with client/caregiver(s), physician and other employees providing care. Communication must be: a. Appropriate to the needs and abilities of the client b. Inclusive of all employees providing care, and c. Timely and relevant to the care and services being provided....." 1. On 2/4/2021, the medical record of Patient #1 was reviewed and the following was identified: a. A Client Coordination Note Report written by Staff #4, a nurse, on 10/26/2020, stated a urine sample from Patient #1 was dropped off at a local laboratory and the results were to be given to Staff #7, a physician. b. A Client Coordination Note Report written by Staff #4 on 11/9/2020 revealed the urinalysis results were not received by Staff #7, and that Staff #4 faxed the results to Staff #7's office. c. A Client Coordination Note Report written by Staff #8, a nurse, on 12/3/2020 revealed the patient's family member inquiring about the results of the urinalysis, and Staff #8 indicated that he/she would reach out to the physician. d. A Client Coordination Note Report written by Staff #9, a nurse, on 12/3/2020 revealed that Patient #1 was admitted to a local hospital with a diagnosis of metabolic encephalopathy, acute kidney injury, and a urinary tract infection. 2. The medical record of Patient #1 lacked evidence of the communication between the physician and the nursing staff regarding the patient's urinalysis results. 3. An interview with Staff #2, an administrator, on 2/4/2021 confirmed that there was a lack of coordination of care between the physician and the nursing staff regarding the results of the patient's urinalysis and ongoing urinary issues. B. Based on staff interview, review of facility documentation, and the review of five (5) medical records, it was determined that the facility failed to ensure the nursing notes did not reflect the care that was provided to the patient in one (1) of five (5) medical records. Findings include: Reference: Policy titled, "Chart Data Requirements and Format - Home Health Practice" states, " ...4.10 NURSE'S NOTE - HOME HEALTH ... Nursing documentation should include the following information: a. Physical and psychological symptoms ... b. The care and services provided ... c. Any new service or treatment initiated d. Response to services ... e. Ongoing documentation of identified problems and any changes in the client's status ... g. Documentation of communication with the physician on a COORDINATION OF SERVICES (COS) NOTE ...". 1. On 2/4/2021, the medical record of Patient #3 was reviewed, and a Visit Note Report written by Staff #6 on 11/20/2020, indicated that Staff #6 made a PRN (as needed) RN (registered nurse) visit due to a Foley catheter check. a. The Visit Note Report did not contain documentation of what interventions and care were provided by Staff #6 at the time of the visit. 2. An interview with Staff #2, an administrator, confirmed that the note lacked documentation of the services provided by Staff #6 on the 11/20/2020 PRN visit.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on staff interview, review of facility documentation, and the review of five (5) medical records, it was determined that the facility failed to ensure that the patient's family received communication regarding the patient's condition and evolving needs in one (1) out of five (5) medical records. Findings include: Reference #1: Policy titled, "Client Assessment and Reassessment" states, "...4.2 All other practices. Assessments and Reassessments will reflect, as appropriate: ...m. Availability of a willing an capable caretaker, n. Client/family expectations and perception of service...". Reference #2: Policy titled, "Client Complaints" states, "...DOCUMENTATION. 4.1 All complaints, verbal and written, are documented in the applicable electronic system. This includes the nature of the complaint, the investigation findings, any follow-up action that is needed and the date of follow-up with the client....." 1. On 2/4/2021, the medical record of Patient #1 was reviewed, and the following was identified: a. A Client Coordination Note Report written by Staff #4, a nurse, on 10/26/2020, stated a urine sample from Patient #1 was dropped off at a local laboratory and the results were to be given to Staff #7, a physician. b. A Client Coordination Note Report written by Staff #4 on 11/9/2020 revealed the urinalysis results were not received by Staff #7, and that Staff #4 faxed the results to Staff #7's office. c. A Client Coordination Note Report written by Staff #8, a nurse, on 12/3/2020 revealed the patient's family member inquiring about the results of the urinalysis, and Staff #8 indicated that he/she would reach out to the physician. 2. An interview with Staff #2, an administrator, on 2/4/2021 at 12:13 PM confirmed that the medical record lacked evidence of the results of the urinalysis being communicated with the patient's family. 3. A second interview with Staff #2 at 1:00 PM on 2/4/2021 confirmed that the family member had called the agency several times with concerns and complaints. Staff #2 stated that he/she had tried to call the family member twice to resolve the issue. Staff #2 confirmed that there was no documentation to support that the complaint was addressed by the agency.