Every finding on record at Jeffhome PA, LLC

Based on the findings of an unannounced on-site Medicare recertification survey conducted January 12, 2026, through January 15, 2026, Jefferson Health at Home by Bayada 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 on-site Medicare recertification survey conducted January 12, 2026, through January 15, 2026, Jefferson Health at Home by Bayada was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on a review of agency policy, personnel files (PF), and an interview with the agency Director, the agency failed to ensure annual employee performance evaluations were conducted for six (6) of eight (8) PF reviewed (PF #1, 2, 4, 5, 7, and 8). Findings include: Review of agency policy ‘0-117 – Field Employee Policies & Benefits’ on January 14, 2026, at approximately 2:30 PM stated, “Our Procedure: 12.0 Performance Evaluations. Every Bayada field employee receives a performance evaluation annually (within 12 months from the date of hire (NHO status) or previous evaluation), which is incorporated into the employee’s permanent employee file…” A review of personnel files conducted on January 13, 2026, from approximately 10:10 AM to 12:00 PM revealed the following: PF#1, date of hire January 17, 2024, contained no documentation that a performance evaluation was completed in 2025. PF#2, date of hire February 16, 2023, contained no documentation that a performance evaluation was completed in 2024 and 2025. PF#4, date of hire September 26, 2022, contained no documentation that a performance evaluation was completed in 2023, 2024, and 2025. PF #5, date of hire May 4, 2022, contained no documentation that a performance evaluation was completed in 2023, 2024, and 2025. PF #7, date of May 10, 2022, contained no documentation that a performance evaluation was completed in 2025. PF #8, date of hire June 6, 2022, contained no documentation that a performance evaluation was completed in 2025. An interview with agency Director on January 14, 2026, at approximately 2:45 PM confirmed the above findings.

Based on the findings of an onsite unannounced Medicare recertification survey conducted January 23, 2023, through January 26, 2023, and concluded offsite on February 2, 2023, Jefferson Health at Home by Bayada, 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 onsite unannounced Medicare recertification survey conducted January 23, 2023, through January 26, 2023, and concluded offsite on February 2, 2023, Jefferson Health at Home by Bayada, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based upon clinical record review, and an interview with the Director of Nursing and Administrator, it was determined the agency failed to provide services according to the plan of care for four (4) of seventeen (17) clinical records reviewed. (CR # 7, 9, 14 and 17) and the agency failed to follow their policy to provide all services ordered on the physician referral for Home Health Services for one (1) of seventeen (17) clinical records reviewed (CR#13). Findings include: Policies were reviewed on 1/26/22 at approximately 10:00 AM and revealed the following: Policy No.0-6277 titled, "Missed Visits/Hours" states, "The physician must be notified when the plan of care is altered due to fewer visits or hours of service being provided as ordered..." Policy No.0-672 titled, "Admission Criteria and Procedure-Medicare Certified Offices" states, "When multiple disciplines are ordered and/or evaluation for services are ordered at the time of referral or added on during treatment, initial of each initial discipline-specific assessment/evaluation will be completed as soon as is necessary to meet the client's care needs in coordination with the physician and client..." Clinical records were reviewed on 1/23/22 at approximately 1:00 PM, 1/24/22 and 1/25/22 at approximately 9:30 AM and revealed the following: CR #7 (Start of Care: 12/16/22). Certification period reviewed: 12/16/22-2/13/23. Skilled Nursing ordered for one (1) time weekly for two (2) weeks, then two (2) times weekly for two (2) weeks, then one (1) time weekly for five (5) weeks. During the week of 1/1/23-1/7/23 there was one (1) missed skilled nursing visit. There was no documented evidence of physician notification and/or physician order to revise the plan of care. CR #9 (Start of Care: 9/27/22). Certification period reviewed: 9/27/22-11/25/22. Skilled Nursing ordered for two (2) times a week for four (4) weeks, then one (1) time a week for five (5) weeks. Patient was discharged on 11/1/23. During the week of 10/2/22-10/8/22 there was one (1) missed skilled nursing visit. There was no documented evidence of physician notification and/or physician order to revise the plan of care. CR#13 (Start of Care: 1/16/23). Certification period reviewed: 1/16/23-3/16/23. The referral for Home Health Services dated 1/11/23 states the following disciplines to be ordered: RN, PT, OT. There was no documentation of any nursing visits provided by the agency or refusal of skilled nursing services. In addition, there was no documented evidence of physician notification. CR#14. (Start of Care: 12/12/22). Certification period reviewed: 12/12/22-2/9/23. Skilled Nursing ordered for two (2) times a week for three (3) weeks, then one (1) time a week for one (1) week. During the following weeks: 12/18/22-12/24/22 and 12/25/22-12/31/22 there was one (1) missed skilled nursing visit each week. There was no documented evidence of physician notification and/or physician order to revise the plan of care. CR#17. (Start of Care: 12/2/22). Certification period reviewed: 12/2/22-1/30/23. Skilled Nursing ordered for one (1) time a week for one (1) week, then two (2) times a week for one (1) week, then three (3) times a week for seven (7) weeks, then one (1) time a week for one (1) week and 2 visits as needed. There was a verbal order written on 1/13/23 stating new skilled nursing frequency of one (1) time per week for one (1) week then four (4) times a week for one (1) week. During the week of 1/15/23-1/21/23 there were three (3) missed skilled nursing visits. There was no documented evidence of physician notification and/or physician order to revise the plan of care. An interview the Director of Nursing and Administrator on 1/26/23 at approximately 1:00 PM confirmed the above findings.