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

An unannounced Home Health Agency Medicare Medicaid recertification survey was conducted June 6-8, 2022 by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found to be in compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

An unannounced Medicare Medicaid Home Health Agency recertification survey was conducted June 6-8, 2022 at the above captioned agency by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. The agency reported 525 unduplicated admissions in the last twelve (12) months with an active census of 110 patients. The following were completed/reviewed in conjunction with the survey: Five (5) home visits, Fourteen (14) clinical records, nine (9) personnel files, a review of selected policies and procedures, the agency's complaint log, emergency preparedness plan, and COVID vaccination records. Interviews were also conducted. Deficiencies were identified and cited in this report The agency was found to not be in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies (HHAs).

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 review of clinical records and staff interview it was determined the agency failed to ensure all patients' individualized plans of care included all medications required in one (1) of fourteen (14) clinical records reviewed in the survey sample. Specifically, the agency failed to include oxygen on the patient's medication list. (Clinical record #3). The findings were: Fourteen (14) clinical records were reviewed in read-only mode on 6/06-08/2022. Clinical record #3 revealed skilled nursing notes contained documentation on 2/15/2022, 2/23/2022, 3/1/2022 and physical therapy notes documented on 2/16/2022 and 2/21/2022 that the patient was on Oxygen therapy. The plan of care failed to contain Oxygen in the medication profile. An interview conducted with the Associate Director, employee #1 on 6/8/2022 at 12:55 PM confirmed the patient was on Oxygen and it was not added to the plan of care and Medication profile.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on a review of clinical records and an interview it was determined the agency staff failed to follow the plan of care for two (2) of fourteen (14) patients in the survey sample (clinical records #2 and 6). The findings were: Fourteen (14) clinical records were reviewed offsite in read-only mode on 6/06-08/2022. 1. Clinical record #2 was reviewed for the certification period of 2/15/2022 through 4/15/2022. The patient had a plan of care/physician orders for occupation therapy (OT) to visit the patient one (1) time per week for one (1) week, one (1) time Q (every) three (3) weeks for three (3) weeks, two (2) times per week for one week. and one (1) time per week for four (4) weeks. The OT made visits one (1) time per week for one (1) week, skipped two weeks and then went one time per week for six (6) weeks. The OT documented services were provided on 3/14/2022 and 3/25/2022 when no visits were due according to the physician's order. 2. Clinical record #6 was reviewed for the certification period of 4/13/2022 through 6/11/2022. The patient had a plan of care/physician orders for physical therapy (PT) to visit one (1) time per week for one (1) week, two (2) times per week Q (every) two (2) weeks for two (2) weeks, two (2) times per week for three (3) weeks and one (1) time per week for three (3) weeks. The PT made visits one (1) time a week for one (1) week, skipped a week then went two (2) times per week for four (4) weeks and one (1) time per week for two (2) weeks. The PT provided services on 5/3/2022, 5/5/2022, 5/16/2022 and 5/18/2022 when no visits were due according to the physician's order. An interview with the Associate Director, employee #1 on 6/08/2022 at 12:55 PM revealed "the frequency is right but I see where it is confusing". Employee #1 explained the computer generates the order and it does not appear as an order would normally be written for the frequency. It is a problem with the electronic software. In the case of clinical record #6, the PT skipped week two (2) because the patient's regular therapist would not be available and the patient did not want another therapist to come. This Medical Facilities Inspector (MFI) explained to employee #1 the skipped visit still did not change the additional orders for either patient that indicated the staff would go every (3) weeks for clinical record #2 and every (2) weeks for clinical record #6 and the discipline visiting went every week. The agency did not have a policy on writing visit frequency.