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

Based on the findings of an unannounced, onsite Medicare recertification survey conducted October 15 through October 17, 2024, Bayada Home Health Care, Inc. was found not to be in compliance with the following requirement of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on a review of the agency policy/procedure and documentation and based on interview with the administrator (Employee #10), the agency failed to ensure the contact information for the state survey agency (Pennsylvania Department of Health/Division of Home Health) had been included in the emergency management plan (EPP). Findings Include: On October 16, 2024 at approximately 11:40 AM, review of the August 2024 "Emergency Management Agency Contact Information by Federal/State/County/City/Town" revealed the following: Directions: Office are required to include in the communication plan a process for communicating with state...emergency preparedness officials... On October 15, 2024 at approximately 12:50 PM and October 16, 2024 at approximately 11:40 AM, review of the "01/02/2024 Emergency Management Plan Office Specific Clarks Summit Pediatrics" and the August 2024 "Emergency Management Agency Contact Information by Federal/State/County/City/Town" failed to reveal that the contact information for the state survey agency (717-783-1379)) had been included in the EPP. During interview conducted on October 17, 2024 at approximately 10:20 AM, the administrator confirmed the contact information for state survey agency was not included in the EPP prior to 10/15/2024.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted October 15 through October 17, 2024, Bayada Home Health Care, Inc. was found to not be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based on interview with the clinical manager/registered nurse (CM/RN-Employee #4), the clinical educator/registered nurse (CE/RN-Employee #8) and the administrator (Employee #10), the agency failed to ensure documentation of discharge planning was completed in accordance with agency policy procedure for two (2) of two (2) clients (patients) who were discharged from services. (Clients #6 and #7) Findings include: On October 17, 2024 at approximately 5:06 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... 1.1 A client is...discharged from service...for any of the following reasons...a...discharge is necessary for he client's welfare because Bayada and the client's physician agree that Bayada can no longer meet the client's needs based on the client's acuity... 3.1 Discharge...Any revisions to the client's discharge plan will be communicated to the client, the client's representative, all physician's issuing orders for the client's plan of care and the client's primary care practitioner or other health care professional who will be responsible for providing care and services to the client after discharge from the organization...Communication with the client/representative and physician is documented on the coordination of services (COS) note or on a comparable form. Client #6: On October 17, 2024 at approximately 3:54 PM, review of the clinical record revealed the start of care date was 08/29/2023, the client is 5 years old, the primary diagnosis was cerebral palsy and that home health aide (HHA) services were to be provided three (3) to seven (7) hours per day for five (5) days per week as documented on the "Home Health Certification and Plan of Care" for recertification period of 02/25/2024 through 04/24/2024. Review of missed visit report (MVR) documentation for April, May, June and July 2024 revealed client services were on hold. Review of "Addendum to Plan of Care" order documentation dated 09/11/2024 revealed the CM/RN (Employee #4) documented the client was being discharged due to lack of available staff and that the client's last day of services was 04/19/2024. Additional type-written documentation entered below the discharge order revealed the following: Do not agree with plan to discharge and would not sign order to discontinue services. Family aware to look at alternative options if no services currently available through Bayada. The type-written name of the client's physician was entered below the above referenced type-written statement. Review of COS note documentation revealed the discharge order was faxed to the physician on 09/19/2024 and that the order returned by the physician included the above referenced type-written statement. The CM/RN documented that the physician refused to sign the discharge order because the physician "felt the client needed care". There was no documentation in the clinical record which provided evidence the client's responsible party and physician had been involved in the discharge planning process between 04/19/2024 and 09/11/2024. Client #7: On October 17, 2024 at approximately 4:32 PM, review of the clinical record revealed the start of care date was 04/06/2016, the client is 33 years, the primary diagnosis was type-1 diabetes mellitus (diabetes) and that skilled nursing (SN) services were to be provided 26 to 45 hours for one (1) week then 36 to 53 hours on the alternate week for 60 days as documented on the "Home Health Certification and Plan of Care" for recertification period of 02/24/2024 through 04/23/2024. Review of SN visit documentation revealed SN services were provided through 03/14/2024. Review of the discharge comprehensive assessment revealed the CE/RN performed an off-site discharge assessment on 04/23/2024. Review of "Addendum to Plan of Care" order documentation dated 04/25/2024 revealed the CE/RN (Employee #8) documented the client was being discharged from the agency. There was no documentation in the clinical record which provided evidence the client and physician had been involved in the discharge planning process prior to the completion of the discharge assessment. During interview conducted on October 17, 2024 at approximately 5:30 PM, the CM/RN, CE/RN and the administrator confirmed documentation of discharge planning was not completed in accordance with agency policy/procedure for the above referenced clients.

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, documentation and Pennsylvania Department of Health (PA DOH) website reports and based on interview with the administrator (Employee #10), the agency failed to submit a report of five (5) of eight (8) reports of Health Department Reportable Diseases to the PA DOH Event Reporting System (ERS) website which were received after 06/01/2023. Findings included: On October 17, 2024 at approximately 5:00 PM, review of agency policy 0-933, titled "Incident Reporting and Documentation", revealed the following: Our Policy...Bayada Home Health Care report, investigate, document employee and client accidents, injuries, and safety hazards related to the care and services provided... Our Procedures...2.0 Definitions of Incidents... 2.2...Incidents defined as Adverse Events include, but are not limited to... f. Safety risks or endangerment of employees or clients may include... j. Exposure to infection or communicable disease... On October 16, 2024 at approximately 11:51 AM, review of agency policy 9-582, titled "Infection Prevention Program" revealed the following: Our Procedure...4.0 Strategies for Infection Prevention... 4.4 Reporting and Tracking of Infections...4.4.2 Each individual service office's clinical staff are responsible for reporting client infections... On October 16, 2024 at approximately 9:34 AM, review of agency policy 0-403, titled "Quality Assurance & Performance Improvement (QAPI) Program revealed the following: 4.0 Measures, Outcomes and Goals...4.1 Data Collection and Measurement...4.1.5 Monitoring of other data and reportable events is gathered, reviewed and analyzed to assess performance and to identify trends requiring further...intervention. Data includes, but is not limited to...d. Infections... On October 17, 2024 at approximately 7:45 AM, review of the PA DOH website (https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx) revealed influenza and respiratory syncytial virus are Health Department Reportable Diseases. On 10/17/2024 at approximately 8:04 AM, review of agency incident/adverse event report documentation revealed the following client-related contagious disease reports were received by the agency: 06/15/2023, 12/08/2023 and 05/17/2024: Influenza 11/15/2023 and 11/20/2023: RSV. On October 17, 2024 at approximately 10:45 AM, review of the PA DOH ERS website failed to reveal that the agency had submitted a report of the above referenced Health Department Reportable Diseases. During interview conducted on October 17, 2024 at approximately 5:30 PM, the administrator confirmed the agency failed to submit a report of the above referenced Health Department Reportable Diseases to the PA DOH ERS website.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted October 4 through October 6, 2021, 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 October 4 through October 6, 2021, Bayada Home Health Care, Inc. was found not to be compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, clinical records and OASIS (Outcome and Assessment Information Set) assessment transmission data, and based on interview with the clinical managers/registered nurses (employees #1 and #2) and the administrator, the agency failed to ensure corrected OASIS assessment data was transmitted to the iQIES (Information Quality Improvement and Evaluation System) database for two (2) of two (2) adult clients (patients) for whom OASIS assessment data was rejected after transmission to the iQIES database. (Clients #1 and #2) Findings include: On October 6, 2021 at approximately 3:20 PM, review of agency policy 37-334, titled "OASIS Assessments: Transmissions and Acceptance/Rejection Entry" revealed the following: Our Policy: Bayada Home Health Care has the following procedures to transmit OASIS assessments to the Centers for Medicare and Medicaid Services...and to correct all submitted OASIS information as needed... Our Procedure... 1.0 Transmission of OASIS Information to the National Database... 1.3 All corrected OASIS data will be resubmitted... 2.0 Acceptance/Rejection Entry of OASIS Batches... 2.1 The OASIS assessment submitted to the CMS National Assessment Database are accepted or rejected... 2.1.1 Service Office Responsibilities. All assessments that have been rejected must be corrected... Client #1: Between 10/04/2021 at approximately 1:54 PM and 10/05/2021 at approximately 1:01 PM, review of the clinical record revealed the start of care date was 12/03/2010, the primary diagnosis was cerebral palsy, the client was 34 years old, that skilled nursing (SN) services were to be provided for 25 hours per month per caregiver request and that the following orders were included on the "Home Health Certification and Plan of Care" for the recertification period of 02/21/2020 through 04/20/2020: -22 Fr (size) JGT (feeding tube) with 7 to 10 milliliter (ml) balloon to be maintained with 10 ml of water; -Enteral feeds (tube feeding) via JT only: Osmolite 3 to 4 ounces every 2 hours with 1 ounce of water added; and -Silvadene (ointment) to stoma (site where feeding tube is inserted). On October 5, 2021 at approximately 7:00 AM, review of the iQIES (Information Quality Improvement and Evaluation System) database revealed the following OASIS assessments were transmitted to the iQIES database: -Transmission dates 01/06/2020 and 01/21/2020. The recertification assessments failed to include a M0090 (completion) date; -Transmission date 03/06/2020 for the recertification assessment for which the M0090 date was 02/20/2020; and -Transmission date 09/04/2020 for the start of care assessment for which the M0090 date was 08/16/2020. OASIS final validation report documentation revealed the OASIS assessment data transmitted on 01/06/2020, 01/21/2020, 03/06/2020 and 09/04/2020 had been rejected. There was no documentation in the clinical record which provided evidence that the above referenced OASIS assessments were corrected and resubmitted to the iQIES database. Client #2: Between 10/04/2021 at approximately 2:37 PM and 10/05/2021 at approximately 1:23 PM, review of the clinical record revealed the start of care date was 03/06/2019, the client was 18 years old, the primary diagnosis was gastrostomy status (feeding tube), that SN services were to be provided for 8 hours per day for 7 days per week and that the following orders were included on the "Home Health Certification and Plan of Care" for the recertification period of 02/22/2021 through 04/22/2021: -20 Fr GT (feeding tube) inserted to 15-centimeter point; -Enteral feeds: Peptamen 1.0--250 ml 4 times a day to be infused at the rate of 200 ml per hour, hold 1 feed for each meal client eats by mouth; and -Flush GT with 50 ml of water after each GT feeding. On October 5, 2021 at approximately 7:08 AM, review of the iQIES database revealed the following OASIS assessments were transmitted to the iQIES database: -Transmission dates for 01/06/2021 and 01/27/2021 for the resumption of care assessment for which the M0090 date was 01/12/2021; and -Transmission date 05/12/2021 for the discharge assessment for which the M0090 date was 02/12/2021. OASIS final validation report documentation revealed the OASIS assessment data transmitted on 01/06/2021, 01/27/2021 and 05/12/2021 were rejected. There was no documentation in the clinical record which provided evidence that the above referenced OASIS assessments were corrected and resubmitted to the iQIES database. During interview conducted on October 6, 2021 at approximately 3:50 PM, the clinical managers/registered nurses (employees #1 and #2) and the administrator confirmed that there was no documentation in the clinical record which provided evidence that the above referenced OASIS assessments had been corrected and resubmitted to the iQIES database.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, documentation and Pennsylvania (PA) Department of Health (DOH) website reports, and based on interview with the clinical educator/clinical manager/registered nurse (employee #3) and the administrator, the agency failed to submit two (2) of three (3) reports for non-COVID-19 related Health Department Reportable Diseases to the PA DOH Event Reporting System (ERS) website. Findings included: On October 6, 2021 at approximately 3:17 PM, review of agency policy 0-933, titled "Incident Reporting and Documentation", revealed the following: Our Policy...Bayada Home Health Care report, investigate, document employee and client accidents, injuries, and safety hazards related to the care and services provided... Our Procedures...2.0 Definitions of Incidents... 2.2 Incidents defined as Adverse Events include, but are not limited to... f. Safety risks or endangerment of employees or clients may include... -Environmental...bug or rodent infestations... i. Exposure to infection or communicable disease... On October 6, 2021 at approximately 3:18 PM, review of agency policy 37-3551, titled "Event Reporting-PA" revealed the following: 1.0 Incident Reporting to the Department of Health-All PA Offices. 1.1 Each office must report the events listed below section 1.4 within 24 hours of occurrence or discovery through confidential Electronic Event Reporting System... 1.4.f...Health Department Reportable Diseases... On October 5, 2021 at approximately 10:14 AM, review of the PA DOH website (https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx) revealed that giardiasis and bedbugs (home health facilities only) are Health Department Reportable Diseases. On 10/04/2021 at approximately 11:35 AM, review of agency incident/adverse event report documentation revealed the following patient-related contagious disease reports were received/created by the agency: -08/28/2020: Giardiasis; and -11/02/2020: Bedbugs. On October 5, 2021 at approximately 11:14 AM, review of the PA DOH ERS website failed to reveal that the agency had submitted a report of the above referenced Health Department Reportable Diseases. On October 4, 2021 at approximately 1:46 PM, the clinical educator/clinical manager/registered nurse (employee #3) reported that all infection data is forwarded to and analyzed/processed by the corporate office in New Jersey. During interview conducted on October 6, 2021 at approximately 3:50 PM, the clinical educator/clinical manager/registered nurse (employee #3) and the administrator confirmed the agency failed to submit the above referenced reports to the PA DOH ERS website.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based upon review of PA state licensure regulations, agency policies/procedures, personnel files and clinical records, based observation of the photo identification (ID) badges, and based on interview with administrator, the governing body failed to ensure the job title occupied a 1/2-inch-tall strip as close to the bottom edge of the photo ID badge as practicable for three (3) of three (3) clinical managers/registered nurses as required under the Pennsylvania Health Care Facilities Act 35 P.S., Section 448.809b. (Employees #1, #2 and #3) Findings include: On October 4, 2021 at approximately 4:07 PM, review of the Pennsylvania Health Care Facilities Act 35 P.S., Section 448.809b revealed the photo identification badge requirements included, but were not limited to, the following: The badge must include the following: -The employee's title... Guidance: This title should be the descriptive name of an individual's health care occupation, such as would be indicated on a professional license, certification or registration. Those individuals who do not possess such a designation shall use a title that reflects the job function they perform and that would be most helpful to the patient in identifying the individual's job...The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge. The following titles must be used when applicable... -A Registered Nurse shall have the title "Registered Nurse." -A Licensed Practical Nurse shall have the title "Licensed Practical Nurse." Guidance: This section of the statute is very specific on the location and size of the title. This section also requires that the badge contain the terms "physician", "registered nurse" and "licensed practical nurse" in full and not any abbreviation. Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency. Guidance: The Department does not recommend that the badge contain abbreviated titles. As noted in the guidance above, the statute requires that physicians, registered nurses and licensed practical nurses use their complete titles and not "MD", "RN" or "LPN." As these titles, whose abbreviations are generally familiar, are to be stated in full, it is recommended that complete titles be listed for all individuals. The use of the full title should serve to reduce confusion or misunderstanding... On October 6, 2021 at approximately 3:11 PM, review of agency policy 0-5485, titled "Employee Identification Badge-PA Office" revealed the following: Our Policy...Bayada Home Health Care provides home health...employees who deliver direct care to clients in the home or other care setting with required identification in accordance with state regulation... 2.0 ID Badge Requirements: 2.1...The employee's title will be as large as possible in block type and will occupy a 1/2-inch-tall strip as close to practical to the bottom edge of the badge... Patient #1: Between 10/04/2021 at approximately 1:54 PM and 10/05/2021 at approximately 1:01 PM, review of the clinical record revealed the "Client Progress Report" dated 02/20/2020 included patient assessment data obtained by the clinical manager/registered nurse (employee #2). Patient #2: Between 10/04/2021 at approximately 2:37 PM and 10/05/2021 at approximately 1:23 PM, review of the clinical record revealed the "Recertification/Follow-Up Assessment" dated 02/19/2021 included patient assessment data obtained by the clinical manager/registered nurse (employee #1). Patient #3: Between 10/05/2021 at approximately 11:59 AM and 10/06/2021 at approximately 6:40 AM, review of the clinical record revealed the comprehensive pediatric nursing assessment dated 09/24/2021 included patient assessment data obtained by the clinical educator/clinical manager/registered nurse (employee #3). Review of personnel files on 10/06/2021 at approximately 9:35 AM revealed the following: Employee #1: The date of hire of the clinical manager/registered nurse was 10/07/2003. Employee #2: The date of hire of the clinical manager/registered nurse was 07/11/2010. Employee #3: The date of hire of the clinical educator/clinical manager/registered nurse was 04/22/2002. Between 10/04/2021 at approximately 11:49 AM and 4:05 PM, review of the photo ID badges revealed the following: Employee #1: The information included in the 1/2-inch-tall strip located at the bottom of the photo ID badge of the clinical manager/registered nurse included the term "Pediatrics", the employee ID number and the date the photo ID badge was issued (05/2018). The title of "Clinical Manager" was located above the aforementioned information and was above the 1/2-inch-tall strip at the bottom of the badge. The professional title of registered nurse was not included on the badge. Employee #2: The information included in the 1/2-inch-tall strip at the bottom of the photo ID badge of the clinical manager/registered nurse included the term "Pediatrics", the employee ID number and the date the photo ID badge was issued (09/2019). The title of "Clinical Manager" was located above the aforementioned information and was above the 1/2-inch-tall strip at the bottom of the badge. The professional title of registered nurse was not included on the badge. Employee #3: The information included in the 1/2-inch-tall strip at the bottom of the photo ID badge of the clinical educator/clinical manager/registered nurse included the employee ID number and the date the photo ID badge was issued (03/2021). The title of "Clinical Educator" was located above the aforementioned information and was above the 1/2-inch-tall strip at the bottom of the badge. The professional title of registered nurse was not included on the photo ID badge. During interview conducted on October 6, 2021 at approximately 3:50 PM, the administrator confirmed the professional title of the above referenced registered nurses did not occupy the 1/2-inch tall-strip as close to the bottom edge of the photo ID badge as practicable.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, clinical records and OASIS (Outcome and Assessment Information Set) assessment transmission data, and based on interview with the clinical managers/registered nurses (employees #1 and #2) and the administrator, the agency failed to ensure admission or discharge procedures were coordinated with the attending physician for four (4) of seven (7) clients (patients). (Clients #1, #2, #4 and #6) Findings include: On October 6, 2021 at approximately 3:28 PM, review of agency policy 0-451, titled "Admission Criteria and Procedure-Medicare Certified Offices" revealed the following: Our Policy: Bayada Home Health Care admits only clients whose needs can be met by the services it provides, and provides those services in compliance with Medicare Conditions of Participation. Our Procedure... 9.0 A registered nurse...must conduct an initial assessment visit to determine the immediate care and support needs of the client...Any delay or altered time frame for the initiation of services beyond those stated, including those due to client preference, medically contraindicated, etc., are communicated to the physician and to the client, and documented in the client chart... 10.0 During the initial visit, if the client is appropriate for services, the registered nurse...will perform all admission procedures, along with the assessment... On October 6, 2021 at approximately 3:37 PM, review of agency policy 0-945, titled "Client Care Plan" revealed the following: Our Procedures: 1.0 Development of the Care Plan...For all skilled nursing...an original care plan is created by the Clinical Manager or designated registered nurse, and is based on the initial client assessment... On October 6, 2021 at approximately 3:46 PM, review of agency policy 0-986, titled "Communications with Physicians" revealed the following: Our Policy: There is ongoing communication with the client's physician when indicated including written summaries throughout service delivery and at discharge... Our Procedure...4.1.1.2 Any revision related to the plans for client's discharge must be communicated to all physicians issuing orders for the plan of care and the client's primary care practitioner... Client #1: Between 10/04/2021 at approximately 1:54 PM and 10/05/2021 at approximately 1:01 PM, review of the clinical record revealed the start of care date was 12/03/2010, the primary diagnosis was cerebral palsy, the client was 34 years old, that skilled nursing (SN) services were to be provided for 25 hours per month per caregiver request and that the following orders were included on the "Home Health Certification and Plan of Care" for the recertification period of 02/21/2020 through 04/20/2020: -22 Fr (size) JGT (feeding tube) with 7 to 10 milliliter (ml) balloon to be maintained with 10 ml of water; -Enteral feeds (tube feeding) via JT only: Osmolite 3 to 4 ounces every 2 hours with 1 ounce of water added; and -Silvadene (ointment) to stoma (site where feeding tube is inserted). Review of OASIS discharge assessment documentation dated 04/20/2020 revealed the client's date of discharge was 04/20/2020 as documented by the clinical manager/registered nurse (employee #2). Review of the physician order included on the "Addendum to Plan of Care" dated 07/17/2020 revealed the client was discharged from the agency effective 05/20/2020. On October 5, 2021 at approximately 7:00 AM, review of the iQIES (Information Quality Improvement and Evaluation System) database revealed an OASIS admission/start of care (SOC) assessment was completed on 08/16/2020 and that SOC assessment was transmitted to the iQIES database on 09/04/2020. Review of "Nurse Shift Note & Time Record" documentation revealed 7 hours of SN services were provided between 11:00 AM and 6:51 PM on 08/16/2020 and that SN services included, but were not limited to, administration of JGT flushes and medication administration. There was no documentation in the clinical record which provided evidence that the clinical manager/registered nurse (employee #2) had coordinated the client admission on 08/16/2020 with the client's physician as there was no documented evidence that a referral for home health services/physician orders had been received for the SN admission assessment performed on 08/16/2020 nor the SN services provided on 08/16/2020. Client #2: Between 10/04/2021 at approximately 2:37 PM and 10/05/2021 at approximately 1:23 PM, review of the clinical record revealed the start of care date was 03/06/2019, the client was 18 years old, the primary diagnosis was gastrostomy status (feeding tube), that SN services were to be provided for 8 hours per day for 7 days per week and that the following orders were included on the "Home Health Certification and Plan of Care" for the recertification period of 02/22/2021 through 04/22/2021: -20 Fr GT (feeding tube) inserted to 15-centimeter point; -Enteral feeds: Peptamen 1.0--250 ml 4 times a day to be infused at the rate of 200 ml per hour, hold 1 feed for each meal client eats by mouth; and -Flush GT with 50 ml of water after each GT feeding. Review of OASIS discharge comprehensive SN assessment documentation dated 02/12/2021 revealed the client's date of discharge was 02/12/2021 as documented by the clinical manager/registered nurse (employee #1) but OASIS recertification/follow-up assessment documentation dated 02/19/2021 revealed employee #1 completed a recertification (for home health services) SN assessment and a client progress/summary report on 02/19/2021 which was 7 days after employee #1 completed the discharge assessment. Review of the physician order documented on the "Addendum to Plan of Care" dated 04/22/2021 revealed the client was discharged from the agency effective 02/12/2021. Review of "Nurse Shift Note & Time Record" documentation revealed SN services were provided between 8:00 AM and 4:01 PM on 02/24/2021 and that SN services included, but were not limited to, the administration of the GT feeding. The SN visit performed on 02/24/2021 was 12 days after the agency discharge date included on the OASIS discharge comprehensive assessment and the "Addendum to the Plan of Care". There was no documentation in the clinical record which provided evidence that the clinical manager/registered nurse (employee #1) notified the physician that the final SN visit was performed on 02/24/2021. Patient #4: On October 6, 2021 at approximately 6:49 AM, review of the clinical record revealed the start of care date was 02/20/2020, the primary diagnosis was eosinophilic esophagitis (inflammation of the esophagus), that the patient is 11 years old, and that SN services were to be provided for 8 hours per day for 5 days per week as documented on the "Home Health Certification and Plan of Care" for the recertification period of 08/13/2021 through 10/11/2021. Review of signature form documentation revealed the patient's parent or responsible party signed the consent/agreement for services forms on 09/13/2019. Review of "Service Record" documentation revealed the following: -The initial referral was received on 09/05/2019; -The admission was completed on 09/13/2019 (consent/agreement for services signatures obtained); -The request for authorization was forwarded to the insurance carrier on 10/03/2019; -January 13, 2020 was the start date; -Meetings were scheduled with the intermediate unit on 01/06/2020 and with the parent on 01/30/2020; -Final authorization for services received on 02/07/2020; and -Per note dated 02/10/2020, start of care would effective 02/20/2020. Review of start of care comprehensive SN assessment revealed the initial registered nurse assessment was completed by the clinical manager/registered nurse (employee #1) on 02/20/2021. There was no documentation in the clinical record that which provided evidence that the clinical manager/registered nurse (employee #1) notified the attending physician that the start of care would be delayed until 02/20/2020. Patient #6: On October 6, 2021 at approximately 1:07 PM, review of the clinical record revealed the start of care date was 02/12/2020, the primary diagnosis is atresia of the foramina of Luschka and Magendie (condition which can lead to hydrocephalus-fluid on the brain), that the patient is 3 years old, and that SN services were to be provided for 16 hours per day for 7 days per week and that the following orders were included on the "Home Health Certification and Plan of Care" for the recertification period of 08/26/2021 through 10/24/2021: -14 Fr Mini-One GT inserted to 1.5-centimeter point; -Enteral feeds: Compleat Pediatric Organic--350 ml via feeding pump at 600 ml per hour at 6:00 AM, 10:00 AM, 2:00 PM and 6:00 PM; and -Flush GT with 10 ml of water before and after each GT feeding. Review of signature form documentation revealed the patient's parent/responsible party signed the consent/agreement for services forms on 02/04/2020. Review of the above listed "Home Health Certification and Plan of Care" revealed the start of care date was documented as being 02/12/2020. Review of "Nurse Shift Note & Time Record" documentation revealed the initial SN shift was completed on 04/28/2020. There was no documentation in the clinical record that which provided evidence that the clinical manager/registered nurse (employee #2 notified the attending physician that the initial SN shift would be delayed until 04/28/2020. During interview conducted on October 6, 2021 at approximately 3:50 PM, the clinical managers/registered nurses (employees #1 and #2) and the administrator confirmed that there was no documentation in the clinical record which provided evidence that the admission and/or discharge procedures had been coordinated with the attending physician for the above identified patients.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation, clinical records and OASIS (Outcome and Assessment Information Set) assessment transmission data, and based on interview with the clinical managers/registered nurses (employees #1 and #2) and the administrator, the agency failed ensure agency forms were incorporated into the clinical record as required per agency policy/procedure for two (2) of seven (7) clients (patients). (Clients #1 and #2) Findings include: On October 6, 2021 at approximately 3:20 PM, review of agency policy 9-586, titled "Chart Data Requirements and Format-Home Care", revealed the following: Our Policy: Bayada Home Health maintains a complete client chart, on paper or electronically, for every client receiving home care services. Our Procedure... 1.0 Applicability. This policy is applicable to all Medicare Certified ...Offices. 2.0 Chart Entry. 2.1 All paper chart contents, if paper needed to be used, must be entered into the client's office chart...Clinical Managers must complete electronic documentation as soon as possible but not greater than seven (7) days after the visit... 2.2 Client charts will contain the original version of documents completed by Bayada employees... 3.3 Discharge Instructions...are found in the Adult Nursing or Pediatric Chart. A copy is sent at the time of discharge to all clients receiving any skilled services... 5.0 Clinical Manager/Field Nurse... 5.3 Reassessments...The Recertification OASIS Assessment (form #17301)...is found in the Medicare Adult Nursing Services Chart and contains reassessment information... On October 4, 2021 at approximately 1:59 AM, review of agency form #17301, titled "Recertification/Follow-Up Assessment" revealed the paper form included areas to input hand-written entries related for OASIS data (Outcome and Assessment Information Set) assessment findings, physical assessment findings, and items required to complete the CMS-485 ("Home Health Certification and Plan of Care") form. Client #1: Between 10/04/2021 at approximately 1:54 PM and 10/05/2021 at approximately 1:01 PM, review of the clinical record revealed the start of care date was 12/03/2010, the primary diagnosis was cerebral palsy, the client was 34 years old, that skilled nursing (SN) services were to be provided for 25 hours per month per caregiver request and that the following orders were included on the "Home Health Certification and Plan of Care" for the recertification period of 02/21/2020 through 04/20/2020: -22 Fr (size) JGT (feeding tube) with 7 to 10 milliliter (ml) balloon to be maintained with 10 ml of water; -Enteral feeds (tube feeding) via JT only: Osmolite 3 to 4 ounces every 2 hours with 1 ounce of water added; and -Silvadene (ointment) to stoma (site where feeding tube is inserted). On October 5, 2021 at approximately 7:00 AM, review of the iQIES (Information Quality Improvement and Evaluation System) database revealed a recertification (for home health services) assessment completed on 02/20/2020 was transmitted to the iQIES database on 03/06/2020 and that a start of care assessment completed on 08/16/2020 was transmitted to the iQIES database on 09/04/2020. There was no documentation in the clinical record which provided evidence that the completed "Recertification/Follow-Up Assessment" #17301 form dated 02/20/2020, nor the completed start of care comprehensive SN assessment form dated 08/16/2020, had been incorporated into the clinical record. Client #2: Between 10/04/2021 at approximately 2:37 PM and 10/05/2021 at approximately 1:23 PM, review of the clinical record revealed the start of care date was 03/06/2019, the client was 18 years old, the primary diagnosis was gastrostomy status (feeding tube), that SN services were to be provided for 8 hours per day for 7 days per week and that the following orders were included on the "Home Health Certification and Plan of Care" for the recertification period of 02/22/2021 through 04/22/2021: -20 Fr GT (feeding tube) inserted to 15-centimeter point; -Enteral feeds: Peptamen 1.0--250 ml 4 times a day to be infused at the rate of 200 ml per hour, hold 1 feed for each meal client eats by mouth; and -Flush GT with 50 ml of water after each GT feeding. Review of OASIS discharge comprehensive SN assessment documentation dated 02/12/2021 revealed the client's date of discharge was 02/12/2021 as documented by the clinical manager/registered nurse (employee #1) but OASIS recertification/follow-up assessment documentation dated 02/19/2021 revealed the clinical manager/registered nurse completed a recertification (for home health services) SN assessment and a client progress/summary report on 02/19/2021 which was 7 days after the employee #1 completed the discharge assessment. Review of the physician order included on the "Addendum to Plan of Care" dated 04/22/2021 revealed the client was discharged from the agency effective 02/12/2021. Review of "Nurse Shift Note & Time Record" documentation revealed SN services were provided between 8:00 AM and 4:01 PM on 02/24/2021 which was 12 days after the agency discharge date which was documented on the OASIS discharge comprehensive assessment and the "Addendum to the Plan of Care". There was no documentation in the clinical record which provided evidence that a copy of the discharge instructions form had been incorporated into the clinical record. During interview conducted on October 6, 2021 at approximately 3:50 PM, the clinical managers/registered nurses (employees #1 and #2) and the administrator confirmed that there was no documentation in the clinical record which provided evidence that the above referenced documents had been incorporated into the clinical record for clients #1 and #2.