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

An unannounced on-site recertification survey was conducted 01/20/2026-01/22/2026. No deficiencies for Emergency Preparedness were identified.

An unannounced on-site recertification survey was conducted 01/20/2026-01/22/2026. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review, incident report review, and staff interviews, the agency failed to track and analyze a patient fall with an injury for 1 of 1 patient experiencing a fall with an injury (patient #3). Findings included: A policy 0-933 Incident Reporting & Documentation (revised 06/02/2025) received on 01/22/2026 at 9:09 AM from the agency administrator #5 stated, “The following incidents must be reported regardless of their classification as defined in the Sentinel or Serious Adverse Events, Adverse Events, Cyber-Incidents, and Other Reportable Incidents sections below… Any client fall(s) that results in injury…” Patient #3 was admitted on 07/18/2025 with a diagnosis of Type 2 Diabetes Mellitus (condition where the boy doesn’t produce or use insulin effectively) with Diabetic Chronic Kidney Disease (reduced kidney function). The plan of care for 07/18/2025-09/15/2025 included orders for physical therapy (PT) 1 time a week for 6 weeks. During the PT visit on 08/28/2025 PT #17 documented, “Patient went to Urgent Care followed by emergency department and was diagnosed with UTI [urinary tract infection] as well as two fractured ribs from a fall a few weeks ago.” There was no documentation of the fall with rib fractures in the agency’s incident report log. During an interview on 01/22/2026 at 8:45 AM PT #17 stated, “I remember this client, I believe that there were other disciplines in there…. I did one [incident report] for the infection, I thought that another clinician would have done the other one [fall report].” During an interview conducted on 01/22/2026 at 8:51 AM agency administrator #1 stated, “The expectation would have been for an incident report to have been completed when we were made aware of the fall.”

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 agency policy, observation, and staff interviews, the agency failed to perform hand hygiene and glove changes during wound care for 1 of 5 home visits conducted. Findings included: A policy, 0-1169 Hand Hygiene (revised 06/03/2024) received on 01/21/2026 at 4:55 PM from the agency administrator #1 stated, “Hands are decontaminated… Before applying and after removing gloves… Remove gloves and perform hand hygiene: … Before touching clean items; … When moving from client contact to the environment or the environment to client contact… During a single procedure when moving from dirty to clean, such as during wound care…” Patient #18 was admitted on 09/27/2025 with a diagnosis of laceration (wound) without foreign body, left lower leg. The plan of care for 11/26/2025-01/24/2026 included orders for skilled nurse visits 2 times a week for 2 weeks, 3 times a week for 1 week, 2 times a week for 1 week, 3 times a week for 1 week, 2 times a week for 2 weeks, and 3 times a week for 1 week, and “Wound change every other day or 3 times per week. Remove old dressing. Cleanse wound with normal saline or Vashe [name brand cleanser], apply Urgoclean [name brand dressing] … cover with ADB pad [absorbent dressing], wrap in place with kerlix [rolled gauze dressing], and then ace bandage…” During a home visit conducted on 01/21/2026 at approximately 2:00 PM registered nurse (RN) #12 failed to perform hand hygiene after removing soiled gloves and putting on clean gloves during wound care and failed to remove soiled gloves and perform hand hygiene after completing the wound care, putting patient #18’s shoe on, before cleaning up the unused supplies and returning them to the patient’s storage area. During an interview conducted on 01/22/2026 at 9:20 AM RN #12 stated, “I should have [performed hand hygiene] before putting on the second pair of gloves and I should have removed the gloves and performed hand hygiene after I put her shoe back on.” During an interview conducted on 01/22/2025 at 9:22 AM administrator #1 stated, ““The hand hygiene and infection control should have been per protocol [agency policy].”

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the home health aide (HHA) failed to follow the plan of care for 1 of 3 patients receiving HHA services (patient #9). Findings included: A policy, 0-998 Understanding & Following the Home Health Aide Care Plan (reviewed 04/27/2023) received on 01/22/2026 at 9:10 AM from agency director #5 stated, “Employees are instructed to read the Home Health Aide Care Plan at each visit before providing care, and to provide only the care indicated.” Patient #9 was admitted on 12/14/2025 with a diagnosis of unspecified open wound, right lower leg. The plan of care for 12/14/2025-02/11/2026 included orders for home health aide (HHA) visits 1 time a week for 3 weeks and “assist with shower every visit min [minimum] to mod [moderate] assist.” Review of the clinical record revealed that during the HHA visit on 12/26/2025 HHA #4 documented, “Client is bed bound. Gave full bed bath.” During the HHA visit of 12/31/2025 HHA #4 documented, “Gave client a total bed bath because he is primarily bed bound.” During the HHA visit on 01/14/2025 HHA #4 documented, “Not required this visit. Client is bed bound. Gave client a full bed bath.” An interview conducted on 01/22/2026 at 9:00 AM with HHA #4 revealed that the plan of care should be followed or the plan of care should be updated by the registered nurse. An interview conducted on 01/22/2026 at 9:13 AM with administrator #1 revealed that the plan of care should be reviewed prior to the visit.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the agency inaccurately documented home health aide (HHA) supervisory visits for 1 of 3 patients receiving HHA visits (patient #9) Findings included: Patient #9 was admitted on 12/14/2025 with a diagnosis of unspecified open wound, right lower leg. The plan of care for 12/14/2025-02/11/2026 included orders for skilled nurse visits 2 times a week for 3 weeks, 1 time a week for 6 weeks, occupation therapy (OT) 1 time a week for 1 week, 1 time every other week for 2 weeks, 1 time a week for 1 week, 1 time every other week for 2 weeks, and home health aide (HHA) visits 1 time a week for 3 weeks. Review of the clinical record revealed that on 12/26/2025 registered nurse (RN) #13 documented an HHA supervisory visit prior to the HHA conducting any visits and on 01/09/2026 OT #14 conducted a supervisory visit for HHA #4 and documented, “Does the supervised homecare aide follow care plan orders… Yes” Further review revealed that HHA #4 was not following the orders in the plan of care. During an interview conducted on 01/22/2026 at 9:27 AM RN #13 stated, “I do not know why I would have documented that.” An interview conducted on 01/22/2026 at 9:29 AM with administrator #1 revealed that supervisory visits cannot be completed before the HHA completes a visit. During an interview conducted on 01/22/2026 at 9:10 AM OT #13 stated, supervisory visits are completed by, “I communicate with the patient and caregiver about the established aide care plan, also communicating with her [HHA name], I should have a copy of that [the HHA care plan] when completing the supervisory visit.” An interview conducted on 01/22/2026 at 9:13 AM with administrator #1 revealed that the HHA care plan should be looked at to make sure it matches.

An onsite, unannounced complaint investigation was conducted 11/06/23-11/07/23. Deficiencies to the Medicare Conditions of Participation were identified.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, complaint log review, on-call log review, and employee interview, the agency failed to document follow-up of a complaint and failed to document a formal client complaint for 1 of 1 record reviewed with a complaint documented in the clinical record (Patient #1). Findings included: Policy 11-368, titled “Client Complaints”, and last revised 01/01/21 was received from the agency director on 11/06/23 at 12:13 PM. This policy revealed, “The Client Services Manager, Clinical Manager and/or Director investigate and respond to complaints from clients or their representatives promptly and in accordance with applicable state requirements…All complaints, verbal and written, are documented in the applicable electronic system…In the event that the online complaint system cannot be accessed, the CLIENT COMPLAINT REPORT…remain published as paper back-up documentation. If the paper back-up must be used, it will be scanned and attached to the online incident system when available.” Patient #1 was admitted to the agency 08/30/23 with diagnoses including partial intestinal obstruction, chronic kidney failure, and history of prostate cancer. Plan of Care from 08/30/823 to 10/28/23 revealed orders for skilled nursing three times per week for one week and one time per week for eight weeks. The Plan of Care included orders for skilled nursing to collect labs weekly on Monday and to change the PICC dressing weekly. Review of the agency’s on-call log revealed that Patient #1’s caregiver contacted the agency after hours to inquire about the schedule for nursing visits on 10/09/23, 10/15/23, and 10/29/23. There was no evidence in the clinical record that the calls on 10/15/23 or 10/29/23 were returned. Employee #4, clinical manager, documented a coordination note dated 10/09/23. The coordination note revealed that Patient #1’s caregiver had called the agency because she had not heard from the skilled nurse to schedule the Monday nursing visit and she was “worried about the lab [sic] being drawn”. Additional documentation from this call revealed, “…client and spouse are in agreement that they will go to [name of independent lab company] today…but starting next week he [Patient #1] will need RN [registered nurse] or [name of agency contracted mobile lab company] to draw the labs and continue to change the PICC line dressing”. There was no evidence that a formal complaint process was initiated to address this concern. There was no documentation in the clinical record regarding any additional follow-up related to this concern after Employee #4’s coordination note dated 10/09/23. In an interview on 11/07/23 at 9:38 AM, Employee #1, agency director, stated that she had spoken to Patient #1’s caregiver on more than one occasion and stated, “I spoke with her [Patient #1’s caregiver] …about our staffing…and felt like it [the complaint] was resolved…looking back, it probably would have been better to have put in a formal complaint...”

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: Based on agency document review, clinical record review, and employee interview, the agency failed to document investigation of variances in the peripherally inserted central catheter (PICC) measurements for 1 of 2 records reviewed of patients with a PICC. Findings included: A document titled, “Skills: Peripherally Inserted Central Cather: Maintenance and Dressing Change [Home Health Care]” and published 05/2023, was received from the agency director on 11/06/23 at 3:15 PM. This policy revealed, “…Assess for catheter migration [movement of the catheter that could place the patient at risk for complication]. Observe the external catheter length and compare it to the insertion record...” Patient #1 was admitted to the agency 08/30/23 with diagnoses including partial intestinal obstruction, chronic kidney failure, and history of prostate cancer. Plan of Care from 08/30/823 to 10/28/23 revealed orders for skilled nursing three times per week for one week and one time per week for eight weeks. This Plan of Care included orders for skilled nursing to change the PICC dressing weekly. Employee #5, registered nurse, conducted a skilled nursing visit on 09/05/23 and documented the PICC measurements as 5.5 centimeters from the insertion site (the point where the catheter exits the skin) to the hub (the end cap on the PICC). Employee #3, registered nurse, conducted a skilled nursing visit on 10/23/23 and documented the PICC measurements as 0.0 centimeters from the insertion site to the hub. There was no documented explanation for the variance in measurements between the 09/05/23 and 10/23/23 visits. There was no evidence that the potential that the PICC had moved was investigated. In an interview on 11/07/23 at 9:15 AM, Employee #3 stated, “Normally, I just follow the procedure in the policy and I just measure [the length from the insertion site to the hub] …a lot of times…they normally send documentation about if it is exposed [the external catheter]” and “I normally look at the referral information…” In an interview on 11/07/23 at 9:24 AM, Employee #1, agency director, stated “I do think it is best practice to see what other notes have been documented so that you can get a feel of what has occurred, if there is migration [movement], etc.”

An onsite recertification survey was conducted February 20, 2023-February 22, 2023. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted February 20,2023-February 22, 2023. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 agency policy, clinical record review, home visits, staff interviews, the agency failed to include all medications in the plan of care for 1 of 17 patients (#10). Findings included: A policy 0-3546 Chart Data Requirements and Format – Home Health Practice (revised 02/01/21) was received from the agency director on 02/23/23 at approximately 1:20 P.M. The Policy stated, “Medication updates… If there is a …medication bottle in the home, the medication list will be updated…” Patient #10 was admitted on 01/13/23 with diagnoses of sepsis (microorganisms causing inflammation throughout the body), pneumonia (inflammation of the lungs), hypertension (high blood pressure) and acute cholecystitis (inflammation of the gall bladder). The plan of care for 01/13/23 to 03/13/23 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 4 weeks and 1 time a week for 2 weeks. During the skilled nurse visit of 02/07/23 registered nurse (RN) # 5 stated that the patient had a “rash” and “applied [Lotrisone] cream [a prescription medication for fungal infections].” There was no evidence of Lotrisone cream on the plan of care. An interview was conducted on 02/22/23 at approximately 1:50 P.M. with the Clinical Manager. The Clinical Manager stated the expectation is for the nurse “to verify the medication with the physician and add it [the medication] to the med list [medication profile].”

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to document the correct medication frequency for 1 of 17 records reviewed (Patient #15). Findings include: Policy 0-990 titled Medication Management and Administration was received from the agency’s Divisional Director on 02/23/23 at 1:00 PM. This policy revealed, “…Reconcile all medications…against the medication list provided by the discharging facility or primary care provider.” Patient #15 was admitted to the agency 01/23/23 with diagnoses including dysphagia (difficulty swallowing) and Parkinson’s disease. Patient #15 was a resident of a memory-care/assisted living facility. Plan of Care (POC) from 01/23/23 to 03/23/23 included orders for speech therapy 1 time per week for 6 weeks and 1 time every 2 weeks for 2 weeks. The client medication report provided by the agency and the POC from 01/23/23 to 03/23/23 included a medication order for Lorazepam 0.5 milligram tablet, 2 times daily. However, the facility physician’s orders included an order for Lorazepam 0.5 milligrams, 2 times daily PRN (as needed) for anxiety. In an interview on 2/22/23 at 1:43 pm, Employee #7, Speech Therapist, stated, “I do believe it is PRN, just because I know he gets agitated and such frequently. That could be an oversight on my end.” In an interview on 2/22/23 at 1:50 PM, Employee #6, Clinical Manager, stated, “Clinicians enter the medication during the visit and we (Clinical Managers) verify it in the office. I would verify with the provider as to whether it is scheduled or PRN and change it accordingly…”

An onsite recertification survey was conducted February 2-4, 2021. No deficiencies to Emergency Preparedness program were identified.

An onsite recertification survey was conducted February 2-4, 2021. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interviews the agency failed to document a caregiver complaint in accordance with agency policy for 1 of 1 complaints [#12]. The findings include: The policy titled, "Client Complaints" [revised date of 1/2021] was provided by the agency director on 2/4/21 at approximately 1 pm. The policy stated, " ...A formal complaint is defined as voicing grievances in writing or verbally to ______[name of agency] regarding client ' s treatment or care that fails to be furnished, is furnished inconsistently or inappropriately ...All complaints ...are documented in the applicable electronic system ...Do not enter documentation into client chart or employee file ..." Patient # 12 had a Start of Care [SOC] date of 1/6/21 and diagnoses of Alzheimer ' s Disease and Dementia. A review of the Plan of Care [POC] for the certification period 1/6/21 to 3/6/21 revealed orders for SN [skilled nursing] 2 times a week for 3 weeks; 1 time a week for 2 weeks. A review of the clinical record revealed RN # 25 made a routine visit on 1/18/21. A review of the visit note report revealed RN # 25 documented the following information, " ...RN assessment indicates client alert ...daughter arrived and was very agitated at lack of coordination/follow through by facility, DMHC [Doctors Making House Calls], and private CG [caregiver] service. RN allowed daughter to vent briefly ..." A phone interview was conducted with RN #25 on 2/4/21 at approximately 11:30 am. During the interview RN # 25 confirmed the daughter was upset "frustrated" about the care the patient was receiving. RN # 25 confirmed she did not document the incident in the complaint log. "We had resolved it and I really didn ' t think about saying anything about it." An interview was conducted with the clinical manager on 2/4/21 at approximately 12:05 pm. The clinical manager confirmed the incident should have been documented in accordance with agency policy.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based clinical record review and staff interview, the agency failed to notify the physician that the patient was not performing glucose monitoring as ordered by the physician for 1 of 11 patients with diabetes (Patient #2). Findings include: Patient #2 was admitted to the agency on 12/27/20 with diagnoses including Type 2 diabetes and cellulitis (a type of skin infection) of the left and right legs. Clinical record review of the Plan of Care (POC) for 12/27/20-02/24/21 included an order for skilled nursing 1 time per week for 1 week, 2 times per week for 2 weeks and 1 time per week for 3 weeks to observe and assess diabetes status including monitoring blood glucose. Clinical exception notes in the clinical record of 01/07/21, 01/14/21, and 01/21/21 revealed that Patient #2 ' s blood glucose level was not recorded during skilled nursing visits. In an interview with Employee #2 on 02/04/21 at 9:15 AM, Employee #2 , a licensed practical nurse (LPN), stated that Patient #2 did not perform blood glucose monitoring and did not want to purchase the equipment to do so. Employee #2 stated that she told Patient #2 that the doctor had ordered that the patient perform blood glucose monitoring and stated the patient "didn't think she needed it." Employee #2 stated that she would have notified the doctor if she found that the patient was not performing blood glucose monitoring during a second visit. Employee #2 did not make any additional visits to Patient #2. On 02/04/21 at 9:22 AM, Employee #3, the nurse case manager, stated that the physician did not require the patient to perform blood glucose monitoring. Employee #3 stated that this directive was "probably documented in a coordination note from a previous episode" when the patient was being seen by the agency. When asked if the POC was updated to reflect this reported change, Employee #3 stated, "No, I didn ' t." On 02/04/21 at 9:20 AM, the Agency Director (Employee #27) stated that she would expect nurses to "call the doctor immediately" when a patient was not following the POC.

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 clinical record review, staff interviews, and patient interviews, the agency failed to follow the plan of care for 1 out of 9 diabetic patients (Patient #23). Findings include: Patient #23 had a start of care [SOC] date of 8/8/2020 and diagnoses of Aftercare Following Joint Replacement Surgery, Pressure Ulcer of Left Heel Stage 1, and Type 2 Diabetes Mellitus Without Complications. A review of the plan of care for the certification period of 8/8/2020-10/6/2020 revealed orders for skilled nursing to "perform blood glucose monitoring as ordered" and to "observe/assess diabetes status and presence of complications." A review of the visit notes for patient #24 revealed that on 7 of 10 visits between 8/10/20 and 9/17/20, the nurse did not record a blood glucose taken at the time of the visit. On 9/17/2020 the nurse noted that the patient had started prednisone [an oral steroid known to cause elevated blood glucose] and documented teaching the patient to adhere to her diabetic diet. No blood glucose value was recorded for the visit. A review of a note labeled "Potentially Avoidable Event Notification" dated 09/27/2020 revealed Nurse #15 documented, "emergent care for hypo/hypoglycemia. Patient was started on prednisone 15mg daily cause BS [blood sugar] to be out of control." A review of the discharge summary dated 10/6/2020 revealed the patient was admitted to the hospital on 9/27/2020 with a diagnosis of Uncontrolled type 2 Diabetes Mellitus. Nurse #15 was unavailable for interview. A telephone interview on 2/2/21 at 12:00pm with the patient's primary caregiver revealed that the patient checked her blood glucose daily in the morning and kept a log. Interview revealed the nurse did not look at the log but did ask the patient about her blood glucose during visits. Interview revealed the caregiver could not recall the patient's specific blood glucose numbers leading up to her hospitalization.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the RN [registered nurse] failed to provide accurate documentation related to education provided to a patient for 1 of 1 records [#20]. The findings include: Patient # 20 had a Start of Care [SOC] date of 12/14/20 and a diagnosis of Emphysema [condition in which the air sacs of the lungs are damaged causing breathlessness]. A review of the Plan of Care [POC] for the certification period 12/14/20 to 2/11/21 revealed orders for SN [skilled nursing] 2 times a week for 1 week; 1 time a week for 2 weeks. A review of the clinical record revealed RN # 23 made a routine visit on 1/27/21. A review of the narrative note for that date revealed the following information, " ...She is continuing to cough up small amounts of green sputum. States it tastes like infection ...Patient reviewed her chest x ray results with SN which states "unresolved pneumonia" ...Patient states she has not heard from her PCP [primary care physician] regarding follow up results ...Patient asked SN what HBV [hepatitis B] was regarding her pap smear result from October 2020. SN googled HBV for the patient and reviewed/showed patient response. Patient inquired as to why her PCP [primary care provider] has not treated patient for the STD [sexually transmitted disease] virus [sic] ..." A phone interview was conducted with RN # 23 on 2/4/21 at approximately 10:30 am . During the interview this surveyor questioned RN # 23 about the content of her narrative note. RN #23 stated, "Oh, that should have been HPV [human papillomavirus infection]. Her pap smear indicated she had HPV not HBV". An interview was conducted with the clinical manager on 2/4/21 at approximately 11:00 am . During the interview the clinical manager confirmed the RN ' s narrative note was incorrect.