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

Based on the findings of an unannounced, onsite Medicare recertification survey conducted May 18 through May 21, 2026, Bayada Home Health Care, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted May 18 through May 21, 2026, Bayada Home Health Care, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on review of agency policy/procedure and documentation and based on interview with the Administrator (Employee #10), the agency failed to ensure documentation was maintained which provided evidence that patient complaints were tracked and analyzed during three (3) of three (3) Quality Assessment/Performance Improvement Meetings (QAPI). (September 2025, November 2025 and March 2026) Findings include: On May 21, 2026 at approximately 2:07 PM, review of agency policy 0-403, titled "Quality Assurance & Performance Improvement (QAPI) Program" revealed the following: 3.0 Governance and Leadership...3.1 The governing body ensures that the QAPI program reflects the complexity and scope of services of Bayada... 4.0 Measures, Outcomes and Goals...4.1 Data Collection and Measurement... 4.1.5 Monitoring other data and other reportable events is gathered, reviewed, and analyzed to assess performance and identify trends requiring further study and intervention. Data includes, but is not limited to...a. Incidents, complaints and adverse events... Between May 18, 2026 at approximately 3:20 PM and May 21, 2026 at approximately 9:15 AM, review of patient complaint log documentation revealed the following as documented on the "QI Event Summary" form: -One (1) complaint was received in July 2025, September 2025 and February 2026 -Two (2) complaints were received in August, October, November and December 2025. Between May 19, 2026 at approximately 1:30 PM and May 21, 2026 at approximately 9:18 AM, review of QAPI meeting minutes revealed QAPI meetings were conducted on 09/21/2025 and during the months of November 2025 and March 2026. There was no documentation on the "QAPI Monthly Meeting" forms which provided evidence the above listed complaints were tracked and analyzed during the QAPI meetings conducted in September and November 2025 nor March 2026. During interview conducted on May 21, 2026 at approximately 4:10 PM, the Administrator confirmed there was no documentation which provided evidence the above listed complaints were tracked and analyzed during the QAPI meetings conducted in September and November 2025 nor March 2026.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of agency policy/procedure, clinical records, personnel files and COVID-19 bulletins issued by the Pennsylvania Department of Health (PA DOH) and based on interview with the Administrator (Employee #10), the agency failed to ensure tuberculosis (TB) screening was conducted in accordance with agency policy/procedure and post COVID-19 pandemic guidance from the PA DOH for three (3) of three (3) staff members who were hired during the COVID-19 pandemic disaster declaration. (Employees #1, #6 and #9) Findings include: On May 21, 2026 at approximately 3:52 PM, review of agency policy 0-1999, titled "TB Risk Assessment & Exposure Plan" revealed the following: Definitions...a. TST-Two (2)-step Mantoux TB skin test...b. IGRA-Interferon-gamma release assay a type of TB blood test...c. TB Screening-a term that encompasses the following...TB testing... 3.0 Initial TB Screening Requirements for New Employees... 3.1 Initial TB Screening Procedure. The following steps meet the requirements for initial TB screening...c. The employee then completes the requirements for TB testing... 3.2 Options for TB Testing During TB Screening...a. TST...b. IGRA... 9.0 State and Program-Specific Amendments...9.6 Pennsylvania: All employees...will receive the baseline two(2)-step TST (or one time IGRA), if the baseline two(2)-step TST is utilized... On May 21, 2026 at approximately 8:05 AM, review of the memorandum titled "REVISED Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic", which was issued by the PA DOH on 05/20/2020, revealed the following under "9. Pre-Employment Health Screening": Any new employee who does not provide evidence of a Mantoux skin test within the previous 12 months must, as a condition of employment, receive the tuberculin skin test as soon as possible following termination of the Governor’s COVID-19 Disaster Declaration. On May 21, 2026 at approximately 8:19 AM, review of the May 11, 2023 PA DOH bulletin titled "UPDATE: Interim Infection Prevention and Control Recommendations for COVID-19 in Healthcare Settings" revealed the COVID-19 Public Health Emergency (PHE) ended on 05/11/2023. Patient #2: On May 19, 2026 at approximately 9:06 AM, review of the clinical record revealed the registered nurse (RN-Employee #1) provided skilled nursing services in May 2026. Patient #7: On May 21, 2026 at approximately 11:08 AM, review of the clinical record revealed the physical therapist (PT-Employee #6) provided PT services in May 2026. Patient #11: On May 21, 2026 at approximately 1:36 PM, review of the clinical record revealed the PT (Employee #9) provided PT services in May 2026. Between May 20, 2026 at approximately 2:10 PM and May 21, 2026 at approximately 3:51 PM, review of personnel file documentation revealed the following: Employee #1: The date of hire of the RN was 11/29/2021. There was no documentation in the personnel file which provided evidence a two (2)-step TST nor a single-step IGRA screening had been performed. Employee #6: The date of hire of the PT was 06/06/2022. There was no documentation in the personnel file which provided evidence a two (2)-step TST nor a single-step IGRA screening had been performed. Employee #9: The date of hire of the PT was 02/28/2022. There was no documentation in the personnel file which provided evidence that the second step of the two(2)-step TST had been performed. During interview conducted on May 21, 2026 at approximately 4:10 PM, the Administrator confirmed TB screening had not been conducted in accordance with agency policy/procedure, nor the PA DOH post-pandemic screening guidance, for the above identified employees.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted May 23 through May 26, 2023, Bayada Home Health Care, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted May 23 through May 26, 2023, Bayada Home Health Care, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator, the agency failed to ensure patient (client) rights forms included notification that the agency is to notify the patient that discharge is being considered for two (2) of two (2) patients who were discharged for cause (non-compliance with the home health plan of treatment/care). (Patients #3 and #4) Findings include: On May 23, 2023 at approximately 1:16 PM, review of agency policy 0-9301, titled "Client Rights-Medicare Certified Home Care and Home Health Offices" revealed the following: Our Policy: Bayada Home Health Care honors client rights and informs clients of their responsibilities upon admission and prior to the delivery of services... Our Procedure...2.0 Written and Verbal Notification of Client Rights and Timeframe...2.1 Written Notice of Client Bill of Rights-Medicare Certified Offices...is provided to each Medicare-certified client... 4.0 Client Rights...4.3 receive Bayada's transfer and discharge policies... On May 26, 2023 at approximately 1:23 PM, review of agency policy 0-9307, titled "Client Discharge and Transfer-Medicare Certified Home Care and Home Health Offices" revealed the following: Our Procedure...1.4 Discharge for Cause Due to Disruptive Behavior and Documentation Requirements...Uncooperative is defined as the client's repeated declination of services...1.4.1. Advise the client...that a discharge for cause if being considered and when discharge becomes imminent. On May 23, 2023 at approximately 10:06 AM, review of the patient admission folder revealed there was no evidence that the patient rights notification forms included a description of the discharge policies/procedures included under items 1.4 and 1.4.1 of policy 0-0307. On May 23, 2023 at approximately 12:55 PM, review of "Discharge Report" documentation revealed patients #3 and #4 were discharged in 2023 due to non-compliance with the plan of treatment. Patient #3: On May 23, 2023 at approximately 12:59 PM, review of the clinical record revealed the start of care date was 01/05/2023, the primary diagnosis was encounter for surgical aftercare following surgical amputation, that skilled nursing (SN) services were to be provided one (1) time a week for one (1) week, then two (2) times a week for one (1) week followed by one (1) time a week for three (3) weeks and that skilled nursing (SN) was to provide wound care to the left foot amputation site as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/05/2023 through 03/05/2023. Review of interim physician order documentation dated 02/05/2023 revealed the following SN visit frequency order was obtained: Additional SN visits for wound care--two (2) times a week for one (1) week followed by one (1) time a week for three (3) weeks. Review of interim physician order documentation dated 02/15/2023 revealed physician orders were obtained for SN to provide wound care to the right foot, left lateral ankle, left foot amputation site and left heel. Review of SN "Visit Note Report" documentation dated 02/08/2023 revealed wound care was provided by the licensed practical nurse (LPN-Employee #7) and that the following wound measurements (length by width by depth) and assessment finding were documented by the LPN: -Wound #1 (Left foot-dorsal (top) surgical wound): 0.1 centimeters (cm) by 10 cm by 0 cm. Sutures in place. -Wound #2 (Left ankle diabetic ulcer): 3.0 cm by 6.0 cm by 0 cm with scant (minimal) serosanguineous (blood-tinged) drainage. -Wound #3 (Left heel diabetic ulcer): 2.5 cm by 5 cm by 0 cm with scant amount of serosanguineous drainage. Review of "Client Care Coordination Note" documentation revealed SN visits were not performed during the agency treatment weeks beginning 01/22, 01/29, 02/12 02/19 and 02/26/2023 due to patient refusal or failure of the patient to return SN visit scheduling calls. Review of client care coordination note documentation dated 02/04/2023 revealed a registered nurse (RN-Employee #8) spoke to the patient by phone and when asked if the patient wished to continue home health services, the patient reported that the patient had been busy due to the recent death of the patient's parent but that the patient wanted to "start fresh" the following week. Review of physician order documentation revealed the patient was discharged from services on 03/04/2023 due to inability to reach patient after many attempts over multiple weeks. There was no documentation in the clinical record which provided evidence the patient was provided written notification of the discharge policies/procedures included under items 1.4 and 1.4.1 of policy 0-0307. Patient #4: On May 23, 2023 at approximately 2:10 PM, review of the clinical record revealed the start of care date was 02/18/2023, the primary diagnosis was infection of amputation stump left upper extremity (arm), that SN services were to be provided one (1) time a week for four (4) weeks as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/05/2023 through 03/05/2023. Review of interim physician order documentation dated 02/21/2023 revealed physician orders were obtained for SN to provide wound care to the stage 2 (open) pressure ulcers of the left and right buttocks. Review of the start of care "Visit Note Report" revealed the RN (Employee #6) documented that the patient attended dialysis treatments on Monday-Wednesday-Friday and that the patient had a physician appointment scheduled for 02/28/2023. Review of SN "Visit Note Report" documentation dated 02/21/2023 revealed wound care was provided by the RN (Employee #6) and that the following wound measurements and assessment finding were documented by the RN: -Wound #2 (Left buttock): 0.5 cm by 0.2 cm by 0.2 cm with scant serosanguineous drainage. -Wound #3 (Right buttock): 0.5 cm by 0.5 cm by 0.2 cm with scant serosanguineous drainage. Review of client care coordination note documentation revealed the RN (Employee #6) documented that missed SN visits occurred on the following dates: -02/28/2023 which was the date of the physician appointment documented in the SOC assessment. -03/03/2023 which was the same day (Friday) the patient attended dialysis treatment. Review of discharge "Visit Note Report" revealed the RN completed the discharge assessment on 03/03/2023 without performing an onsite SN visit. There was no documentation in the clinical record which provided evidence that SN services were provided after 03/03/2023. There was no documentation in the clinical record which provided evidence the patient was provided written notification of the discharge policies/procedures included under items 1.4 and 1.4.1 of policy 0-0307. During interview conducted on May 26, 2023 at approximately 1:35 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence the above referenced patients were provided written notification of the discharge policies/procedures included under items 1.4 and 1.4.1 of policy 0-0307.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator, the agency failed to ensure patient (client) rights forms included notification that the agency is to make efforts to resolve the behavioral issues for two (2) of two (2) patients who were discharged for cause (non-compliance with the home health plan of treatment/care). (Patients #3 and #4) Findings include: On May 23, 2023 at approximately 1:16 PM, review of agency policy 0-9301, titled "Client Rights-Medicare Certified Home Care and Home Health Offices" revealed the following: Our Policy: Bayada Home Health Care honors client rights and informs clients of their responsibilities upon admission and prior to the delivery of services... Our Procedure...2.0 Written and Verbal Notification of Client Rights and Timeframe...2.1 Written Notice of Client Bill of Rights-Medicare Certified Offices...is provided to each Medicare-certified client... 4.0 Client Rights...4.3 receive Bayada's transfer and discharge policies... On May 26, 2023 at approximately 1:23 PM, review of agency policy 0-9307, titled "Client Discharge and Transfer-Medicare Certified Home Care and Home Health Offices" revealed the following: Our Procedure...1.4 Discharge for Cause Due to Disruptive Behavior and Documentation Requirements...Uncooperative is defined as the client's repeated declination of services...1.4.2 Every effort to resolve the problem(s) presented by the client's behavior...The problem(s) and effort(s) to resolve the problem(s) must be documented as follows...b. A plan to resolve the issues... On May 23, 2023 at approximately 10:06 AM, review of the patient admission folder revealed there was no evidence that the patient rights notification forms included a description of the discharge policies/procedures included under items 1.4 and 1.4.2 of policy 0-0307. On May 23, 2023 at approximately 12:55 PM, review of "Discharge Report" documentation revealed patients #3 and #4 were discharged in 2023 due to non-compliance with the plan of treatment. Patient #3: On May 23, 2023 at approximately 12:59 PM, review of the clinical record revealed the start of care date was 01/05/2023, the primary diagnosis was encounter for surgical aftercare following surgical amputation, that skilled nursing (SN) services were to be provided one (1) time a week for one (1) week, then two (2) times a week for one (1) week followed by one (1) time a week for three (3) weeks and that skilled nursing (SN) was to provide wound care to the left foot amputation site as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/05/2023 through 03/05/2023. Review of interim physician order documentation dated 02/05/2023 revealed the following SN visit frequency order was obtained: Additional SN visits for wound care--two (2) times a week for one (1) week followed by one (1) time a week for three (3) weeks. Review of interim physician order documentation dated 02/15/2023 revealed physician orders were obtained for SN to provide wound care to the right foot, left lateral ankle, left foot amputation site and left heel. Review of SN "Visit Note Report" documentation dated 02/08/2023 revealed wound care was provided by the licensed practical nurse (LPN-Employee #7) and that the following wound measurements (length by width by depth) and assessment finding were documented by the LPN: -Wound #1 (Left foot-dorsal (top) surgical wound): 0.1 centimeters (cm) by 10 cm by 0 cm. Sutures in place. -Wound #2 (Left ankle diabetic ulcer): 3.0 cm by 6.0 cm by 0 cm with scant (minimal) serosanguineous (blood-tinged) drainage. -Wound #3 (Left heel diabetic ulcer): 2.5 cm by 5 cm by 0 cm with scant amount of serosanguineous drainage. Review of "Client Care Coordination Note" documentation revealed SN visits were not performed during the agency treatment weeks beginning 01/22, 01/29, 02/12 02/19 and 02/26/2023 due to patient refusal or failure of the patient to return SN visit scheduling calls. Review of client care coordination note documentation dated 02/04/2023 revealed a registered nurse (RN-Employee #8) spoke to the patient by phone and when asked if the patient wished to continue home health services, the patient reported that the patient had been busy due to the recent death of the patient's parent but that the patient wanted to "start fresh" the following week. Review of physician order documentation revealed the patient was discharged from services on 03/04/2023 due to inability to reach patient after many attempts over multiple weeks. There was no documentation in the clinical record which provided evidence the patient was provided written notification of the discharge policies/procedures included under items 1.4 and 1.4.2 of policy 0-0307. Patient #4: On May 23, 2023 at approximately 2:10 PM, review of the clinical record revealed the start of care date was 02/18/2023, the primary diagnosis was infection of amputation stump left upper extremity (arm), that SN services were to be provided one (1) time a week for four (4) weeks as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/05/2023 through 03/05/2023. Review of interim physician order documentation dated 02/21/2023 revealed physician orders were obtained for SN to provide wound care to the stage 2 (open) pressure ulcers of the left and right buttocks. Review of the start of care "Visit Note Report" revealed the RN (Employee #6) documented that the patient attended dialysis treatments on Monday-Wednesday-Friday and that the patient had a physician appointment scheduled for 02/28/2023. Review of SN "Visit Note Report" documentation dated 02/21/2023 revealed wound care was provided by the RN (Employee #6) and that the following wound measurements and assessment finding were documented by the RN: -Wound #2 (Left buttock): 0.5 cm by 0.2 cm by 0.2 cm with scant serosanguineous drainage. -Wound #3 (Right buttock): 0.5 cm by 0.5 cm by 0.2 cm with scant serosanguineous drainage. Review of client care coordination note documentation revealed the RN (Employee #6) documented that missed SN visits occurred on the following dates: -02/28/2023 which was the date of the physician appointment documented in the SOC assessment. -03/03/2023 which was the same day (Friday) the patient attended dialysis treatment. Review of discharge "Visit Note Report" revealed the RN completed the discharge assessment on 03/03/2023 without performing an onsite SN visit. There was no documentation in the clinical record which provided evidence that SN services were provided after 03/03/2023. There was no documentation in the clinical record which provided evidence the patient was provided written notification of the discharge policies/procedures included under items 1.4 and 1.4.2 of policy 0-0307. During interview conducted on May 26, 2023 at approximately 1:35 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence the above referenced patients were provided written notification of the discharge policies/procedures included under items 1.4 and 1.4.2 of policy 0-0307. Repeat Deficiency. Previously cited on 09/11/2020.

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 review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator, the agency failed to ensure the patient (client) rights forms included notification that the agency was required to provide the names and contact information for other agencies/providers which would be available to provide home health services for two (2) of two (2) patients who were discharged for cause (non-compliance with the home health plan of treatment/care). (Patients #3 and #4) Findings include: On May 23, 2023 at approximately 1:16 PM, review of agency policy 0-9301, titled "Client Rights-Medicare Certified Home Care and Home Health Offices" revealed the following: Our Policy: Bayada Home Health Care honors client rights and informs clients of their responsibilities upon admission and prior to the delivery of services... Our Procedure...2.0 Written and Verbal Notification of Client Rights and Timeframe...2.1 Written Notice of Client Bill of Rights-Medicare Certified Offices...is provided to each Medicare-certified client... 4.0 Client Rights...4.3 receive Bayada's transfer and discharge policies... On May 26, 2023 at approximately 1:23 PM, review of agency policy 0-9307, titled "Client Discharge and Transfer-Medicare Certified Home Care and Home Health Offices" revealed the following: Our Procedure...1.4 Discharge for Cause Due to Disruptive Behavior and Documentation Requirements...Uncooperative is defined as the client's repeated declination of services...1.4.3 The client...will be provided with the contact information for other agencies or providers which may be able to provide care... On May 23, 2023 at approximately 10:06 AM, review of the patient admission folder revealed there was no evidence that the patient rights notification forms included a description of the discharge policies/procedures included under items 1.4 and 1.4.3 of policy 0-0307. On May 23, 2023 at approximately 12:55 PM, review of "Discharge Report" documentation revealed patients #3 and #4 were discharged in 2023 due to non-compliance with the plan of treatment. Patient #3: On May 23, 2023 at approximately 12:59 PM, review of the clinical record revealed the start of care date was 01/05/2023, the primary diagnosis was encounter for surgical aftercare following surgical amputation, that skilled nursing (SN) services were to be provided one (1) time a week for one (1) week, then two (2) times a week for one (1) week followed by one (1) time a week for three (3) weeks and that skilled nursing (SN) was to provide wound care to the left foot amputation site as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/05/2023 through 03/05/2023. Review of interim physician order documentation dated 02/05/2023 revealed the following SN visit frequency order was obtained: Additional SN visits for wound care--two (2) times a week for one (1) week followed by one (1) time a week for three (3) weeks. Review of interim physician order documentation dated 02/15/2023 revealed physician orders were obtained for SN to provide wound care to the right foot, left lateral ankle, left foot amputation site and left heel. Review of SN "Visit Note Report" documentation dated 02/08/2023 revealed wound care was provided by the licensed practical nurse (LPN-Employee #7) and that the following wound measurements (length by width by depth) and assessment finding were documented by the LPN: -Wound #1 (Left foot-dorsal (top) surgical wound): 0.1 centimeters (cm) by 10 cm by 0 cm. Sutures in place. -Wound #2 (Left ankle diabetic ulcer): 3.0 cm by 6.0 cm by 0 cm with scant (minimal) serosanguineous (blood-tinged) drainage. -Wound #3 (Left heel diabetic ulcer): 2.5 cm by 5 cm by 0 cm with scant amount of serosanguineous drainage. Review of "Client Care Coordination Note" documentation revealed SN visits were not performed during the agency treatment weeks beginning 01/22, 01/29, 02/12 02/19 and 02/26/2023 due to patient refusal or failure of the patient to return SN visit scheduling calls. Review of client care coordination note documentation dated 02/04/2023 revealed a registered nurse (RN-Employee #8) spoke to the patient by phone and when asked if the patient wished to continue home health services, the patient reported that the patient had been busy due to the recent death of the patient's parent but that the patient wanted to "start fresh" the following week. Review of physician order documentation revealed the patient was discharged from services on 03/04/2023 due to inability to reach patient after many attempts over multiple weeks. There was no documentation in the clinical record which provided evidence the patient was provided written notification of the discharge policies/procedures included under items 1.4 and 1.4.3 of policy 0-0307. Patient #4: On May 23, 2023 at approximately 2:10 PM, review of the clinical record revealed the start of care date was 02/18/2023, the primary diagnosis was infection of amputation stump left upper extremity (arm), that SN services were to be provided one (1) time a week for four (4) weeks as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/05/2023 through 03/05/2023. Review of interim physician order documentation dated 02/21/2023 revealed physician orders were obtained for SN to provide wound care to the stage 2 (open) pressure ulcers of the left and right buttocks. Review of the start of care "Visit Note Report" revealed the RN (Employee #6) documented that the patient attended dialysis treatments on Monday-Wednesday-Friday and that the patient had a physician appointment scheduled for 02/28/2023. Review of SN "Visit Note Report" documentation dated 02/21/2023 revealed wound care was provided by the RN (Employee #6) and that the following wound measurements and assessment finding were documented by the RN: -Wound #2 (Left buttock): 0.5 cm by 0.2 cm by 0.2 cm with scant serosanguineous drainage. -Wound #3 (Right buttock): 0.5 cm by 0.5 cm by 0.2 cm with scant serosanguineous drainage. Review of client care coordination note documentation revealed the RN (Employee #6) documented that missed SN visits occurred on the following dates: -02/28/2023 which was the date of the physician appointment documented in the SOC assessment. -03/03/2023 which was the same day (Friday) the patient attended dialysis treatment. Review of discharge "Visit Note Report" revealed the RN completed the discharge assessment on 03/03/2023 without performing an onsite SN visit. There was no documentation in the clinical record which provided evidence that SN services were provided after 03/03/2023. There was no documentation in the clinical record which provided evidence the patient was provided written notification of the discharge policies/procedures included under items 1.4 and 1.4.3 of policy 0-0307. During interview conducted on May 26, 2023 at approximately 1:35 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence the above referenced patients were provided written notification of the discharge policies/procedures included under items 1.4 and 1.4.3 of policy 0-0307. Repeat Deficiency. Previously cited on 09/11/2020.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, documentation and the Pennsylvania (PA) Department of Health (DOH) website reports, and based on interview with the administrator, the agency failed to submit ten (10) of ten (10) COVID-19 related reports to the PA DOH Event Reporting System (ERS) website prior to May 23, 2023. (Employees #1, #2, #3, #4, #5, #7 and #8) Findings include: On May 26, 2023 at approximately 1:10 PM, review of agency policy 0-933, titled "Incident Reporting and Documentation", revealed the following under "3.0 Client and Employee Incident Documentation": 7.0 If the incident involves and employee and any health concern, including occupational exposure to infection....an Employee Incident Report is completed... The...Office will retrieve the information and initiate appropriate action as needed... On May 26, 2023 at approximately 1:11 PM, review of agency policy 37-3551, titled "Event Reporting-PA", revealed the following under "1.0 Incident Reporting to the Department of Health-All PA Offices": 1.4 The events must be reported to the PA Department of Health using the corresponding codes, include but are not limited to: g. IW Health Department Reportable Diseases. On May 23, 2023 at approximately 8:45 AM, review of the PA DOH website (https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx) revealed Health Department Reportable Diseases, subcategory COVID-19, is a PA DOH reportable event. On May 26, 2023 at approximately 11:58 AM, review of the employee COVID-19 tracking log revealed the following: Employee #1: The registered nurse (RN) received a positive COVID-19 result on 02/20/2022. Employee #2: The home health aide received a positive COVID-19 result on 10/01/2021. Employee #3: The physical therapist received positive COVID-19 results on 05/17/2022 and 01/02/2023. Employee #4: The occupational therapist received a positive COVID-19 result on 07/22/2022. Employee #5: The RN received a positive COVID-19 result on 02/05/2022. Employee #7: The licensed practical nurse received positive COVID-19 results on 12/27/2021, 12/31/2021 and 12/13/2022. Employee #8: The RN received a positive COVID-19 result on 08/16/2022. On May 23, 2023 at approximately 8:45 AM, review of the PA DOH ERS website failed to reveal the agency had submitted reports of the above referenced COVID-19 positive results to the PA DOH ERS website prior to 05/23/2023. During interview on May 26, 2023 at approximately 1:35 PM, the administrator confirmed the agency failed to submit reports of the above referenced COVID-19 results to the PA DOH ERS website prior to 05/26/2023.

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 the review of agency policies/procedures, clinical records and web-based nursing assessment guidance (Pressbooks.pub), and based on interview with the administrator, the agency failed to ensure the external length of the peripherally-inserted central catheter (PICC-intravenous) and corresponding arm circumference were measured with each skilled nursing (SN) visit for two (2) of two (2) patients for whom PICC assessment line orders were included on the "Home Health Certification and Plan of Care". (Patients #13 and #14) Findings include: On May 26, 2023 at approximately 12:05 PM, review of the agency policy/procedure titled "Infusion Therapy-Central Line Type: PICC" revealed the following on page 243: 11. Verify that external catheter length visible outside corresponds to initial placement measurement. If it does not notify the physician before continuing care. On May 26, 2023 at approximately 3:35 PM, review of the web-based "Nurse Advanced Skills" assessment guidance (https://wtcs.pressbooks.pub/nursingadvancedskills/chapter/4-3-applying-the-nursing-process/) revealed the following under "4.3 Applying the Nursing Process": Measure the external catheter length…Compare the measurement results to the initial placement verification results to detect any catheter migration or dislodgement. Measure the upper arm circumference for PICC line…Monitor circumference measurements...Increasing measurements may indicate possible edema and deep vein thrombosis (DVT blood clot)... Home health nurses will assess the site and arm circumference during each visit. Patient #13: On May 26, 2023 at approximately 11:03 AM, review of the clinical record revealed SN interventions included the following as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 05/16/2023 through 07/14/2023: -SN to observe and assess intravenous (IV) access site and for signs/symptoms of complications of IV therapy. Review of the start of care (SOC) comprehensive assessment dated 05/16/2023 revealed a PICC line was present in the right upper arm. There was no documentation in the clinical record which provided evidence the registered nurse (RN-Employee #9) measured the right upper arm circumference during the 05/16/2023 SOC SN visit. Patient #14: On May 26, 2023 at approximately 11:21 AM, review of the clinical record revealed SN interventions included the following as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 03/26/2023 through 05/24/2023: -SN to observe and assess intravenous (IV) access site and for signs/symptoms of complications of IV therapy. Review of SN visit documentation revealed the following: -SOC 03/26/2023: The external length of the PICC line was 0.0 cm. -PICC line dressing changes were completed during the SN visits on 03/30, 04/06, 04/18 and 05/16/2023. -Resumption of care (ROC) 05/13/2023: The external length of the left upper arm PICC line was 0.0 -Recertification assessment 05/24/2023: The RN (Employee #14) documented the RN experienced difficulty flushing both lumens of the PICC line. The RN documented the external length of the PICC line had increased to 2.0 cm. There was no documentation in the clinical record which provided evidence the RN (Employee #9) measured the left upper arm circumference during the 03/26/2023 SOC SN visit. There was no documentation in the clinical record which provided evidence the RN (Employee #11) measured the left upper arm circumference during the SN visits performed on 03/30, 04/06, 04/18, 05/13 nor 05/16/2023 nor was documentation present which provided evidence that the RN measured the external length of the PICC during the SN visits performed on 03/30, 04/06 nor 05/16/2023. There was no documentation in the clinical record which provided evidence the RN (Employee #14) measured the left upper arm circumference during the 05/24/2023 recertification SN visit. During interview conducted on May 26, 2023 at approximately 1:35 PM, the administrator confirmed there was no documentation in the clinical records which provided evidence that measurement of the external length of the PICC line and corresponding arm circumference had been obtained on the above referenced dates for the above identified patients.