Initial Comments:Based on the findings of an onsite unannounced Medicare recertification survey conducted May 13, 2025 through May 15, 2025, 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.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced home health agency Medicare recertification survey conducted May 13, 2025, through May 15, 2025, Bayada Home Health Care, Inc., 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 Correction:
484.80(d) STANDARD
12 hours inservice every 12 months
Name - Component - 00
Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient.
Observations:
Based on a review of agency policy, personnel file (PF), and an interview with the agency Administrator, the agency failed to provide Home Health Aide (HHA) documentation of twelve (12) in-service hours per year for one (1) of two (2) HHAs reviewed. PF#3
Findings include:
A review of agency policy titled "Field Employee Orientation, Education, and Inservice Requirement" conducted on 5/15/25, at approximately 1:00 PM states, "In-Service Requirements. Every field employee must complete a minimum number of hours of in-service education each calendar year in addition to in-services completed as part of orientation/training...Home Health Aide (HHA) 12 hours per year including annual retraining for infection prevention, honesty and confidentiality, fire safety and prevention, and emergency preparedness training..."
A review of PF's conducted on 5/15/25, from approximately 12:00PM to 2:00 PM revealed the following:
PF #3, Date of Hire: 11/13/2023, contained documentation of only two (2) hours of in-service education for 2024.
An interview with the Administrator conducted on 5/15/25, at approximately 2:30 PM confirmed the above findings.
Plan of Correction:Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to provide documentation of twelve (12) in-service hours per year for Home Health Aides (HHA). The plan of correction will be completed through comprehensive focused education.
By 6/13/2025 the Director/designee will educate all office staff on policy Field Employee Orientation, Education, and In-service Requirement, 0-963 with emphasis on the requirement for all Home Health Aides working in a Medicare certified office to complete 12 hours of in-service training annually.
Effective 6/16/2025 and until 12/31/2025, the Director/designee will review monthly the records of all active home health aides to ensure they are on track to complete 12 hours of in-service training annually.
The Director has overall responsibility for implementation and oversight of the plan.
Initial Comments:Based on the findings of an unannounced onsite home health agency state re-licensure survey conducted May 13, 2025, through May 15, 2025, Bayad Home Health Care, Inc., was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.
Plan of Correction:
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on a review of agency policy, personnel files (PF), and an interview with the agency Administrator, the agency failed to follow their policy that states a requirement of Home Health Aide (HHA) documentation of twelve (12) in-service hours per year for one (1) of two (2) HHAs reviewed. PF#3
Findings include:
A review of agency policy titled "Field Employee Orientation, Education, and Inservice Requirement" conducted on 5/15/25, at approximately 1:00 PM states, "In-Service Requirements. Every field employee must complete a minimum number of hours of in-service education each calendar year in addition to in-services completed as part of orientation/training...Home Health Aide (HHA) 12 hours per year including annual retraining for infection prevention, honesty and confidentiality, fire safety and prevention, and emergency preparedness training..."
A review of PF's conducted on 5/15/25, from approximately 12:00PM to 2:00 PM revealed the following:
PF #3, Date of Hire: 11/13/2023, contained documentation of only two (2) hours of in-service education for 2024.
An interview with the Administrator conducted on 5/15/25, at approximately 2:30 PM confirmed the above findings.
Plan of Correction:Based on an analysis of the specific deficiencies cited, the corrective plan and actions taken are to address the lack of demonstrated knowledge resulting in failure to provide documentation of twelve (12) in-service hours per year for Home Health Aides (HHA). The plan of correction will be completed through comprehensive focused education.
By 6/13/2025 the Director/designee will educate all office staff on policy Field Employee Orientation, Education, and In-service Requirement, 0-963 with emphasis on the requirement for all Home Health Aides working in a Medicare certified office to complete 12 hours of in-service training annually.
Effective 6/16/2025 and until 12/31/2025, the Director/designee will review monthly the records of all active home health aides to ensure they are on track to complete 12 hours of in-service training annually.
The Director has overall responsibility for implementation and oversight of the plan.
Initial Comments:Based on the findings of an onsite unannounced state re-licensure survey conducted on May 13, 2025, through May 15, 2025, Bayada Home Health Care, Inc, was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced state re-licensure survey conducted on May 13, 2025, through May 15, 2025, Bayada Home Health Care, Inc., was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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