Every finding on record at Tri-County Home and Hospice Care

This report is the result of an unannounced Federal Recertification and State Relicensure Survey completed on May 6, 2026, at Bayada at Inspira, Home Health and Hospice. It was determined the facility is not in substantial compliance with the requirements of Emergency Preparedness regulation §484.102, Condition of Participation for Home Health Agencies (HHAs) for this survey.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on observation, medical record review, staff interview, and review of facility policy, it was determined the facility failed to ensure individual emergency preparedness plans are developed in three of six medical records reviewed (Patients (P) 3, P4, and P5). Findings include: Facility policy titled, "0-9197 Emergency Management Program and Plan – Medicare-Certified Offices," dated 02/06/25, stated, "… Our Procedure: … 4.0 Standards for Emergency Management Planning … 4.1.3 Client-Specific Emergency Plans. At admission, all clients will be educated on the risks of disasters and the importance of emergency planning. 4.1.3.1 As part of the comprehensive assessment, the admitting clinician will develop a Client- Specific Emergency Plan by entering the information into the electronic record and also using 0-9236 – Client -Specific Emergency Plan – Home Health and Hospice … The Client- Specific Emergency Plan will include specific instructions for the client …" On 05/04/26 at 1:45 PM, Staff (S) 9 was observed completing a home visit for P3. At 1:59 PM, a review of P3's admission packet was conducted with S9. A blank "Client-Specific Emergency Plan – Home Health and Hospice Offices" form was observed in the admission packet. The admission packet lacked evidence of a completed individual emergency preparedness plan. At 2:31 PM, an interview was conducted with S9. S9 confirmed P3 did not have a completed individual emergency preparedness plan in his/her admission packet. S9 stated the individual emergency preparedness plan should be completed at the start of care and should be both on paper and electronic, in the patient's medical record. On 05/06/26, a review of P3, P4, and P5's medical record was conducted and revealed the following: For the start of care beginning on 02/09/26 and the recertification period beginning on 04/10/26, P3's medical record lacked evidence of an individual emergency preparedness plan. For the start of care beginning 03/26/26, P4's medical record lacked evidence of an individual emergency preparedness plan. For the start of care beginning 04/14/26, P5's medical record lacked evidence of an individual emergency preparedness plan. On 05/06/26 at 1:16 PM, an interview was conducted with S1, S2, and S3. S1 stated an individualized emergency preparedness plan is completed for each patient during the start of care, resumption of care, recertification, and if there is a change in the plan. S3 stated all emergency preparedness plans should be uploaded to the patient's electronic medical record. S1 stated that registered nurses, physical therapists, and speech-language pathologists are able to complete the patient's emergency preparedness plan. At 2:27 PM, an interview was conducted with S3. S3 confirmed P3, P4, and P5 did not have a completed individual emergency preparedness plan in their electronic medical records. Cross reference: NJAC 8:42-6.1(a)(7)

This report is the result of an unannounced standard-level Federal Recertification and State Relicensure Survey completed on May 6, 2026 at Bayada at Inspira, Home Health and Hospice. It was determined the facility is not in substantial compliance with Federal requirements of 42 CFR Part 484, Subpart B Conditions of Participation for Home Health Agencies and State requirements of N.J.A.C. Title 8 Chapter 42 Home Health Agency Licensing Standards.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on observation, staff interview, facility document review, and review of medical records, it was determined the facility failed to ensure that all patients with Medicare coverage received a Notice of Medicare Non-Coverage (NOMNC) no later than two days prior to discharge, as per facility policy, for three of six discharged Medicare patients (Patients (P)4, P14, and P16). On 05/04/26 at 3:14 PM, Staff (S) 6 was observed, in the presence of S10, completing a discharge from agency home visit for P4. At 3:54 PM, P4 was observed signing a paper NOMNC form. At 4:06 PM, P4 was observed signing an electronic NOMNC form on a computer tablet. At 4:24 PM, an interview was conducted with S6. When asked about the NOMNC being signed the day of the discharge from the agency, S6 stated that it is usually filled out at least 48 hours prior to discharge, but this wasn't possible since the patient is only seen once a week. S6 explained that P4 saw a Licensed Practical Nurse (LPN) during the previous week's visit and that the NOMNC wasn't completed at that time because only Registered Nurse's (RN) can complete NOMNC's. A review of P4's medical record was conducted and revealed the following: On 05/04/26, P4 was discharged from Home Care services by S6. The NOMNC was completed on 05/04/26 and signed by P4, less than two days prior to discharge. Findings include: Facility Policy titled, “0-322 Home Health Change of Care Notice (HHCCN), Advanced Beneficiary Notice of Non-Coverage (ABN), Notice of Medicare Non-Coverage (NOMNC) and Fast Track Appeal Review Procedures” dated January 1, 2025, stated “… Our Procedure: …3.0: Notice of Medicare Noncoverage (NOMNC). 3.1: A standardized Review Notice, NOTICE OF MEDICARE NON-COVERAGE (NOMNC), #0-3195, is given on paper or electronically, to all beneficiaries when Medicare coverage is about to end based on the physician’s orders and all home healthcare is ending, (except those admitted to a facility or hospital) no later than two (2) days prior to discharge…3.2: The Initial Notice of Medicare Provider Non-Coverage is delivered as follows: a. Face to face and signed and dated by the client and representative, b. If the Initial Notice of Medicare Provider Non-Coverage cannot or will not be signed, a notation is made on the notice explaining why and dated… 5.0: Retention Requirements: The original notice(s) must be retained in the client’s chart…” On 05/05/26, a review of P14 and P16’s medical records was conducted and revealed the following: On 05/15/25, P14 was discharged from Home Care services by Staff (S)12. The NOMNC was completed on 05/15/25 and signed by P14, less than two days prior to discharge. On 11/13/25, P14 was discharged from Home Care services by S18. The NOMNC was completed on 11/13/25 and signed by P14, less than two days prior discharge. On 03/09/26, P16 was discharged from Home Care services by S5. P16’s electronic medical record (EMR) lacked evidence of a NOMNC. On 05/05/26 at 2:30 PM, an interview was conducted with S1, S2, and S3. When asked about the process for discharge, S1 stated that the NOMNC is provided to the client 48 hours prior to discharge. S1 stated, the signed NOMNC is then uploaded to the EMR by the clinician. At 3:23 PM, S3 confirmed that the NOMNC for P14’s discharges on 05/15/25 and 11/13/15 had both been completed on the same date as discharge and should have been completed at least two days prior to discharge. S3 confirmed that the NOMNC for P16 had not been uploaded to the EMR per facility policy.

Survey date: November 28- November 30, 2023 The facility is in compliance with Appendix Z-Emergency Preparedness for All Provider and Supplier Types, Interpretive Guidance 484.22, Conditions of Participation for Home Health Agencies for this survey.

This was a Federal Recertification and State Re-licensure survey conducted at Bayada at Inspira, Home Health and Hospice on November 28, 29 & 30, 2023, to determine compliance with 42 CFR Part 484 - Conditions of Participation for Home Health Agencies; and State requirements under Title 8, Chapter 42 - Home Health Agency Licensing Standards. Standard-level deficiencies were cited.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure 1.) hand hygiene is performed before having contact with a patient's intact skin and re-usable equipment; 2.) re-useable equipment is cleaned in accordance with manufacturer's instructions and facility policy, during two of three home visits for Patient 4 (P4) and P5. Findings include: Facility policy titled, "Hand Hygiene" states, "....1.0 Indications for Hand Decontamination. …a. Before and after having and direct client contact with intact skin (bathing, dressing, performing physical examinations, taking a blood pressure or pulse, transferring/lifting, etc.). b. Before applying and after removing gloves... " Facility policy titled, "Infection Prevention Procedures for Point of Care Devices" states, "... 3.0 Bayada Issued Tablet or Phone Transported from Home to Home … 3.3 Decontaminate hands when moving from direct client care to tablet. …" 1.) On 11/29/23 at 10:21 AM, during a home visit for P5, Staff 11 (S11), a Physical therapist, was observed applying gloves without first performing hand hygiene. While wearing gloves, S11 proceeded to take the patient's blood pressure, pulse, and temperature and was observed entering information on his/her tablet wearing the same gloves and without decontaminating hands. S11 then brought P5 his/her walker, and followed the patient into the hallway and into the Wellness Center, wearing the same gloves, and holding the tablet in one hand. At 10:30 AM, P5 ambulated out of the Wellness Center, and S11 was observed holding the door open with his/her gloved hand. P5 ambulated back to the room with S11, and S11 was then observed removing a paper from a folder in the patient's room, placing the paper near the patient on the counter, touching the patient's walker, and utilizing his/her tablet, while wearing the same gloves. At 10:35 AM, P5 ambulated back to his/her chair and sat down. S11 was observed holding the patient's wrist to check a pulse, still wearing the same gloves, without performing hand hygiene before contact with P5's skin. P5 removed his/her socks and shoes, and S11 physically examined each of the patient's feet, using his/her gloved hand, without first performing hand hygiene. At 10:41 AM, S11 removed his/her gloves, performed hand hygiene, applied new gloves, and began using his/her tablet. S11 provided P5 the paper from the counter, and then rechecked P5's blood pressure and pulse oximeter, wearing the same gloves, without performing hand hygiene before contact with P5's skin. S11 picked up the tablet, wearing the same gloves. 2.) Review of the facility policy titled, "Infection Prevention Procedures for Point of Care Devices" states, "... 3.4 Bayada Issued Tablet or Phone Transported from Home to Home … 3.4 "Disinfect tablet or phone using an approved EPA registered disinfectant wipe, and stylus using a 70% isopropyl alcohol wipe or EPA registered disinfectant wipe with gloved hands, at the following time: 3.4.1 Beginning of visit … 3.4.2 Before and after client visit verification signature 3.4.2.1 Client finger - Disinfect tablet screen before and after client touches screen to sign for visit verification with a manufacturer's approved EPA registered disinfectant wipe following the manufacturer's recommended contact time. Note: The manufacturer's approved wipe for the Galaxy device is the PDI brand. …" On 11/28/23 at 12:45 PM, during a home visit for P4, S8 (Physical Therapist) was observed using a tablet asking P4 questions. S8 was not observed disinfecting the tablet at the beginning of the visit. At 1:19 PM, S8 was observed placing the tablet on the table in front of P4 without disinfecting the tablet. P4 used his/her finger to sign the tablet. On 11/29/23 at 10:21 AM, during a home visit for P5, S11 (Physical Therapist) was observed using a tablet while checking P5's vital signs. S11 was not observed disinfecting the tablet at the beginning of the visit.. At 10:54 AM, S11 was observed disinfecting a tablet with a wipe. Five seconds later, S11 handed the tablet to P5 to hold and provide signature. S11 did not allow the tablet to remain wet for a full two minutes. At 11:02 AM, upon interview, S11 confirmed that he/she used a PDI Super Sani Cloth to clean the tablet. PDI Super Sani-Cloth Large Wipe Directions for use state, "...To disinfect and Deodorize: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two minutes. …" N.J.A.C. 8:42-12.2(b)(6)

The facility is in substantial compliance with Appendix Z-Emergency Preparedness for All Provider and Supplier Types, Interpretive Guidance 484.22, Condition of Participation for Home Health Agencies for this survey.

This was a Federal Recertification Survey conducted on November 29, November 30, December 1, and December 2, 2021. Bayada at Inspira Home Health is not in compliance with 42 CFR Part 484, Subpart B requirements, for Home Health Agencies. As a result of this survey, Standard level deficiencies were cited.

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 on a medical record review for six (6) patients (Patient #3, #5, #6, #7, #8, #15), review of facility policy and procedure, and staff interview, it was determined the facility failed to implement the Plan of Care and their policy and procedure for missed visits for one (1) out of six (6) patients (#8). Findings include: Reference: Facility Policy titled, "0-6277 Missed Visits/Hours" states, "... . Our policy: Bayada Home Health Care has a process for communication and documentation related to missed visits/hours that are not provided at the frequency stated on the plan of care. Our Procedure: 1.0 Communication missed visits/hours. 1.1 Physician ordered services-The Physician must be notified when the plan of care is altered due to fewer visits or hours of service being provided as ordered. Notification of the missed visits/hours is timely, and as directed on a schedule determined in collaboration with the Physician. ... . 1.1.1.2 Missed visit process flow-Field clinician is responsible for documenting the missed visit in the "Missed Visit Coordination Note" found in the electronic record. ... ." 1. On 12/2/21, upon medical record review, the following was indicated: a. The Plan of Care for Patient #8 was reviewed for the Certification Period 9/4/21 through 11/2/21. The Start of Care date was 9/4/21. (i) The Frequency/Duration of Visits per Physician Order state, "PT [Physical Therapy] 1 WK 1 [one time per week for one week], 2 WK 3 [two times per week for three weeks], and 1 Wk 3 [one time per week for three weeks] ... ." b. On 12/2/21 at 2:10 PM, upon interview, Staff #2 stated that the agency's calendar week begins on Sundays. c. Patient #8 had one (1) PT visit for the week of 9/19/21; there should have been two (2) visits. (i) There was no documentation in the medical record of the missed visit for that week or Physician notification. 2. The above was confirmed by Staff #2. N.J.A.C 8:42-13.1(b)(6)

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 medical record review, staff interview and document review, it was determined that the facility failed to implement the Plan of Care. Findings include: Reference: Facility policy titled, "Missed Visits/Hours" states, "Our Procedure: 1.0 Communicating Missed Visits/Hours. 1.1 Physician Ordered Services. The physician must be notified when the plan of care is altered due to fewer visits or hours of service being provided as ordered. Notification of the missed visits/hours is timely, and as directed on a schedule determined in collaboration with the physician. 1.1.1. 1 Missed Visit Notification note to capture the reason that the visit was missed as well as evidence that the physician was informed verbally or by fax...of this variation from the plan of care must be entered in the electronic record 1.1.1.2 Missed Visit Process Flow. Field clinician is responsible for documenting the missed visit in the "Missed Visit Coordination Note" found in the electronic record. ..." 1. Review of Medical Record #2 on 12/1/21, revealed the following: a. The Plan of Care states " PT [Physical Therapist] 2WK3" [two times per week for three weeks]. (i) During the week of 10/31/21, there was a missed Physical Therapy visit. (ii) There was no evidence that the Physician was notified of the missed visit. (iii) There was no evidence that a Missed Visit Coordination Note was completed. b. The Plan of Care states, "OT [Occupational Therapy] effective 11/07/2021 1WK1 [once per week for one week]." (i) There was no OT visit during the week of 11/7/21. (ii) On 12/1/21 at 1:50 PM, upon interview, Staff #14 stated that the OT visit was rescheduled to the following week. (iv) There was no evidence of a Missed Visit Coordination note to indicate the reason the visit was rescheduled. 2. Review of Medical Record #11 on 12/1/21, revealed the following: a. The Plan of Care states, "SN [Skilled Nurse] 2WK2 [two times per week for two weeks]." (i) There was only one (1) SN visit conducted during the week of 9/26/21. b. On 12/2/21 at 1130 AM, upon interview, Staff #14 stated that during the week of 9/26/21, the Skilled Nurse visit was cancelled. (i) There was no evidence that the Physician was notified of the missed visit. (ii) There was no evidence of a Missed Visit Coordination note. 3. The above findings were confirmed by Staff #14. N.J.A.C. 8:42-6.2(a)2

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, review of facility policies and procedures, and staff interviews, it was determined the facility failed to ensure infection prevention procedures are implemented when using Point of Care Devices and that Equipment and Supplies are being cleaned and disinfected in accordance with the organization policy and procedure for one (1) of (5) five observed visits. Findings include: Reference #1: Facility Policy and Procedure titled, "0-4858 Infection Prevention Procedures for Point of Care Devices" states, "... . Our Procedure: Point of care devices require specific Infection Prevention procedures as categorized by device type and location of device below to ensure the safety of the client and employee. ... . a. Point of Care Devices-Tablet or phone used to electronically document client care and visit verification. ... . 3.4 Disinfect tablet or phone using an approved EPA registered disinfectant wipe, and stylus using 70 % isopropyl alcohol wipe or EPA registered disinfectant wipe with gloved hands, at the following times: 3.4.1 Beginning of visit, before returning device to supply bag, and more frequently as needed, if contaminated. ... . 3.4.2 Before and after client visit verification signature. 3.4.2.1 Client finger-Disinfect tablet screen before and after client touches the screen to sign for the visit with a manufacturer's approved EPA registered disinfectant wipe following manufacturer's recommended contact time. ... ." Reference #2: Facility Policy and Procedure titled, "0-1570 Equipment and Supplies Maintenance" states, "1.0 General Information. 1.1 Handle client care equipment in a manner that prevents skin and mucous membrane exposure , contamination of clothing, and exposure to other environments. Gloves must be worn for cleaning or disinfecting of equipment. ... . 2.1 Non-critical items: ... . These items can undergo a low level of disinfection using isopropyl or ethyl alcohol (70-90 %); germicidal wipes; 1:100 dilution of bleach and water; germicidal detergent solutions... . Examples of non-critical items include, but are not limited to : ... . e. stethoscope; f. blood pressure apparatus; ... .j. pulse oximeters. ... ." Reference #3: Facility Policy and Procedure titled, "0-1169 Hand Hygiene" states, "... .1.0 Indications for hand decontamination. ... . a. Before and after having any direct client contact with clients ... . Between contact with the environment and the client ... ." 1. On 11/30/21 at 1:25 PM, during a home visit for Patient #6, the following was noted: a. During the Home Health Visit, Staff #9 assessed vital signs of Patient #6 with gloved hands. He/she used a stethoscope, blood pressure apparatus and pulse oximeter for the assessment. He /she then doffed (removed) gloves, applied hand sanitizer, and proceeded to wipe down all equipment with un-gloved hands, using an agency supplied alcohol wipe. (i) Staff #9 did not don (put on) gloves for cleaning of the above equipment. b. At the conclusion of the visit, Staff #9 asked Patient #6 to sign for verification of the visit on the electronic tablet device. Patient #6 touched the electronic tablet device with fingers, completed the signature, then returned the tablet to Staff #9 . (i) Staff #9 placed the tablet under his/her arm pit against his/her clothing and walked out to his/her car without disinfecting the tablet. (ii) Staff #9 did not perform hand hygiene prior to exiting the home at the conclusion of the visit. (iii) With bare hands, Staff #9 wiped the tablet with an alcohol wipe outside at his/her car. 2. The above findings were reviewed with and confirmed by Staff #9 at the conclusion of the visit. N.J.A.C. 8:42-12.2 (b)(6)(i) N.J.A.C 8:42-12.3(a)(4)

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on review of three (3) of seventeen (17) medical records, staff interview and document review, it was determined that the facility failed to ensure that all physician orders are authenticated. Findings include: Reference #1 Facility policy titled, "0-986 Communicating With Physicians" states, "...4.0 Skilled Cases. 4.1 A home health Certification and Plan of Care (CMS 485), signed by the Physician, is required for all clients receiving skilled services. Skilled services include Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Registered Dietician, and Medical Social Work. 4.2 For skilled cases, the Clinical Manager or RN [Registered Nurse] designee establishes the client's plan of care in conjunction with the Physician and the client/caregiver...Verbal orders are obtained from the Physician to initiate the plan of care which is documented in Locator 23 and signed, and dated by the Clinical Manager, designated RN or therapist. ...4.3 A reassessment is performed at least every (60) days or earlier based on the clients needs ...at which time the plan of care is updated and signed by the Physician. ..." Reference #2 Facility policy titled, "0-983 Physician's Orders" states, "...1.0 Immediately after the RN or Therapist (PT, SLP) assesses a client with the need for skilled services, he/she fills out the CMS 485 and sends it to the client's physician for signature. ..." 1. Review of Medical Record #2 on 12/1/21 revealed the following: a. A Physician Order, dated 11/11/21 and timed 3:56 PM states, "Order Type: Physician Order, Order Description: Move OT [Occupational Therapy] Eval [Evaluation] to next calendar week..." (i) The line next to "Physician Signature" states, "Do not send." (ii) There was no evidence that the Physician Order was authenticated. 2. Review of Medical Record #4 on 12/2/21 revealed the following: a. On the Plan of Care, dated 11/6/21, the section that states, "Attending Physician's Signature and Date Signed" was blank. b. On 12/2/21 at 11:30 AM, upon interview, Staff #7 stated that the Plan of Care was sent to the Physician on 11/12/21 and expected to be signed by 11/26/21. c. There was no evidence that the Plan of Care was authenticated. 3. Review of Medical Record #11 on 12/1/21 revealed the following: a. The Plan of Care indicated that Patient #11's SOC (Start Of Care) was initiated on 9/20/21. Patient #11 received the following services: Physical Therapy, Occupational Therapy and Skilled Nursing. (i) The Plan of Care was not signed and dated by the Physician. b. A Physician Order, dated 9/22/21 and timed for 9:48 AM, states, "...Verbal Order: Y [Yes] ...Order Type: Add on Discipline" was not signed by a Physician. (i) The line next to "Physician Signature" states, "Do not send." (ii) There was no evidence that the Physician's Order was authenticated. c. A Physician's Order dated 9/29/21 and timed for 1:25 PM states, "..."Send to Physician: Y [yes] Verbal Order: Y...Order type: Add on Discipline..." (i) The line next to "Physician Signature" was blank. (ii) There was no evidence that the Physician's Order was authenticated. d. A Physician Order dated 10/5/21 states, "Verbal Order: Y [Yes] ...Order Type: Physician Order Order Description: Increase Metformin to 500 MG [milligrams]...Add Nursing visits weekly x2 [times 2] weeks to monitor blood sugar then D/C [discontinue] when goals..." (i) The line next to "Physician Signature" states, "Do not send." (ii) There was no evidence that the Physician Order was authenticated. 4. Staff #14 confirmed the above findings. N.J.A.C. 8:42-11.2(b)

This was a Federal Complaint Survey conducted on July 27, 2021. Bayada at Inspira Home Health and Hospice is not in compliance with the requirements of 42 CFR Part 484, Subpart B requirements for Home Health Agency for this complaint investigation (C# NJ00146875).

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on staff interviews, the review of four (4) medical records, review of facility policies, procedures, and documents, it was determined that the facility failed to ensure that an investigation was conducted, and findings and resolutions documented, for patient complaints in one (1) out of four (4) patients. Findings Include: Reference: The facility policy and procedure titled, "11-368 Client Complaints" states, " ... . Our Procedure: 1.0 Definition: A formal complaint is defined as voicing grievances in writing or verbally to Bayada regarding client's treatment or care ... . 3.0 Complaint Process: 3.1 Clients may register complaints orally or in writing to Bayada. ... . 3.3 The Client Services Manager, Clinical Manager, and/or Director investigate and respond to complaints from clients or their representatives promptly and in accordance with applicable state requirements. The client is informed of the findings of the investigation and the decisions rendered to resolve the complaint. 4.0 Documentation: 4.1 All complaints, verbal and written, are documented in the applicable electronic system. This includes the nature of the complaint, the investigation finding, any follow-up action that is needed, and the date of follow-up with the client. Notification to the client is also documented. ... ." 1. On 7/27/21, upon staff interviews regarding patient complaints, the following was indicated: a. At 11:00 AM, Staff #2 stated that in the event of a patient complaint or grievance, our staff are instructed to reach out to the Manager of the Team of the Office Branch the patient is assigned. The complaint is entered in our electronic system and addressed immediately in real time. b. At 2:30 PM, a telephone interview was conducted with Staff #3, in the presence of Staff #1 and Staff #2. Staff #3 stated that Patient #1 had reached out to him/her sometime between 7/16/21 and 7/20/21. Staff #3 verbally shared the notes that were taken during the call and summarized the notes in an email. (i) An email written by Staff #3 stated, "This is what I have logged on the call I took, I don't have an exact date, but would have been between 7/16 and 7/20. (Last Name of Patient-Patient #1): PT [Physical Therapy] was great; (Name of Therapist-Staff #5) was wonderful and helpful. (Name of Therapist-Staff #4) came on and was "cooky" and did nothing but create problems; it was dark out when he/she called; took my walker and changed the wheels; seems mad he/she got a call at night." c. At 2:50 PM, Staff #3 stated that the verbal complaint/grievance from Patient #1 should have been electronically entered into their complaint system for follow-up and communication to the patient. 2. The above was confirmed with Staff #1 and Staff #2.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA 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). This ELEMENT is not met as evidenced by: Based on staff interviews, review of four (4) medical records, and review of facility policy and procedure, it was determined the facility failed to ensure that discharge planning is implemented according to facility policy and procedure for one (1) of four (4) patients. Findings include: Reference: Facility policy titled, "0-9307 Client Transfer and Discharge-Medicare Certified Home Health and Home Care Offices" states, "... . Our Policy: Appropriate information is exchanged when a client is discharged or transferred. Our Procedure: 3.0 Communication and Documentation Requirements for Discharge and Transfer: ... . 3.1.3 Clients are provided with Discharge Instructions, 0#-2003 upon discharge from (Name of the Facility). ... . A copy of the Discharge Instructions, #0-2003 are kept in the client chart. ... ." 1. On 7/27/21, upon staff interviews, the following was indicated: a. At 12:30 PM, Staff #1 stated that when a patient is discharged from the facility, there are several documents that require patient or care giver signage, such as Notice of Medicare Non-coverage, Home Health Change of Care Notice, and Discharge Instructions. b. At 12:35 PM, Staff #2 stated that when a patient is discharged from all services at the facility, Discharge Instructions are provided to the patient and/or caregiver. After staff review of instructions with the patient, the patient and/or caregiver will be asked to sign the instructions. A copy of the signed discharge instructions are filed in the medical record. 2. On 7/27/21, upon review of Medical Record #1, the following was noted: a. Patient #1 was discharged from the facility on 4/30/21. (i) There was no copy in the medical record of the patient's signed discharge instructions. 3. Staff #1 and Staff #2 confirmed that there were no discharge instructions in Medical Record #1.