Initial Comments:Based on the findings of an onsite unannounced state license survey completed January 8, 2023, Bayada Home Health Care, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Plan of Correction:
484.60(c)(1) ELEMENT
Promptly alert relevant physician of changes
Name - Component - 00
The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to alert the physician to any changes in the patient's condition or needs that suggest that outcomes are not being achieved or the plan of care should be altered for three (3) of seven (7) records (CR1-CR3).
Findings included:
Review of agency policy on January 5, 2024, at 12:30 p.m. showed, "0-986 COMMUNICATING WITH PHYSICIANS ... 3.0 COMMUNICATING CHANGES IN STATUS. 3.1 Throughout the duration of service, whenever a change in client status occurs that requires the physician to be notified, the communication will be documented. This can be documented on the Clinical Notes, Nurses Notes, or on a Coordination of Services Form."
Review of agency policy on January 8, 2024, at 10:30 a.m. showed, "Percutaneous Endoscopic Gastrostomy, Gastrostomy, and Jejunostomy Tube Care (Home Health) ... 18. Elevate the head of the bed at least 30 degrees when feedings are infusing."
Review of CR1 on January 2, 2024, at 12 p.m. showed a physician ordered plan of care for an initial certification period from 11/27/2023 to 1/25/2024. Orders included skilled nursing (SN) to see the patient for care and assessment related to cerebral palsy diagnosis. The patient was to "wear AFOS [ ankle foot orthotic - supportive device for lower extremity] while awake [as] tolerated." Further review of CR1 did not show patient was wearing their AFOs and on 12/5 the nurse documented, "Client was dressed for the day shoes put on, mom still hold AFOs at this time until she can work him back up to the length of time that he needs to wear them." Review of treatment sheets showed the nurse documented an "H" for 11/28, 11/29, and 11/30/2023 to show that the patients AFOs were on hold and not being used. Further review of CR1 on January 5, at 9:30 a.m. did not show that agency notified the physician that the patient's AFOs were on hold.
Review of CR2 on January 4, 2024, at 9:30 a.m. showed a physician ordered plan of care with a recertification period from 11/17/2023 to 1/15/2024. The patient's diagnosis included "encounter for attention to gastrostomy [tube inserted into stomach]." SN was to provide care 5-7 nights per week. Review of "Nurse's Shift Note" from 12/18/2023 showed the patient's mom did not elevate the patient's head while the patient was receiving a feeding via their gastrostomy tube, "HOB [head of bed] flat - Mom previously educated on importance of elevating HOB with TF [tube feed] via GT [gastrostomy tube] to avoid aspiration [stomach contents getting into lungs] , verbalized understanding- requests client lay flat this shift." Further review of CR2 on January 5, 2024, at 9:40 a.m. did not show that agency notified the physician concerning patient being fed via GT while lying flat which could increase the patient's risk of aspiration.
Review CR3 on January 4, 2023, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 6/28/2023 to 8/26/2023. SN was to see patient for care and assessment related to seizures. Orders included, "Apply bilateral AFO's as per recommendation of PT/OT/physician. ... Maintain and encourage safe use of mobility aides and orthotics [AFOs] to decrease risk for falls; notify CM and/or physician regarding concerns." On 6/29/2023, the SN documented, "1:15pm ... Unable to wear AFO's due to improper fit with current shoes." Further review of CR3 on January 5, 2024, at 10 a.m. did not show the physician was notified concerning the improper fir of AFOs.
During an interview with EMP3 (manager of clinical operations) on January 5, 2023, from 9:30 a.m. to 11:30 a.m., he/she reviewed the above records and confirmed 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 alert the physician to any changes in the patient's condition or needs that suggest that outcomes are not being achieved or the plan of care should be altered. The plan of correction will be completed through comprehensive focused education.
Client #1 no longer receives services from this agency.
On 1/16/2024, client #2's physician was notified of the identified instance of the caregiver laying the client flat while being fed, increasing the risk of aspiration.
Client #3 no longer receives services from this agency.
By 2/23/2024 the Manager of Clinical Operations/designee will educate all licensed clinicians on agency policy Communicating With Physicians, 0-986 with emphasis on the requirement to communicate with the physician throughout the duration of care, whenever a change in client status occurs, including when treatments are placed on "hold" by the clinician in the home and when the caregiver is observed performing treatments out of compliance with safety standards. Education included the requirement for documentation of notification to the physician and caregiver education.
Effective 2/26/2024 for three months, the Clinical Manager/designee will review bi-weekly the clinical records of 10 clients to determine if a change in client status has occurred, and if so, that documentation of notification to the physician by a licensed clinician is present in the clinical record. The goal for compliance will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.
The Director has overall responsibility for implementation and oversight of the plan.
484.60(d)(3) ELEMENT
Integrate all services
Name - Component - 00
Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines.
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to integrate services to assure the coordination of care provided by all disciplines for one (1) of two (2) discharged records (CR3).
Finding included:
Review of policy on January 5, 2023, at 12:30 p.m. showed, "Client Care Coordination ... 4.0 When more than one service is provided, whether directly or through contact, the Client Service Manager and Clinical Manager work together to assure that the actions and goals of the individual services are complementary. ... When service is provided through liaison with other organizations or individuals, coordination of services is maintained by the team effort of the Client Services Manager and Clinical Manager, and the information is documented in the client chart."
Review CR3 on January 4, 2023, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 6/28/2023 to 8/26/2023. SN was to see patient for care and assessment related to seizures. Orders included, "Apply bilateral AFO's as per recommendation of PT/OT/physician." CR3 was receiving PT/OT services from another organization. On 6/29/2023, the SN documented, "1:15pm ... Unable to wear AFO's due to improper fit with current shoes." Further review of CR3 on January 5, 2024, at 10 a.m. to include treatment records, did not show patient had worn their AFOs until 8/10/2023 and just prior to the end of episode. There was nothing in the record to show what PT/OT recommended concerning the patient's AFOs.
During a staff interview on January 5, 2023, at 10:30 a.m., EMP3 (manager of clinical operations) reviewed the above records and confirmed findings. EMP3 noted he/she could not view or see what the PT/OT recommendations were because they were kept in the patient's home.
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 integrate services to assure the coordination of care provided by all disciplines. The plan of correction will be completed through comprehensive focused education.
Client #3 no longer receives services from this agency.
By 1/26/2024 the Manager of Clinical Operations/designee will educate all Clinical Managers on policy Client Care Coordination, 0-944 with emphasis on the requirement to document in the clinical record (home and office record) coordination of services provided through other organizations or individuals, including specifications of therapy orders when referenced in the nursing plan of care. Education will also include the requirement for documentation of client progress/lack of progress in response to interventions found in the plan of care.
Effective 1/29/2024 for three months, the Manager of Clinical Operations/designee will review weekly clinical records of all new admissions receiving therapy services to ensure specific orders are present in the home and office chart when therapy orders are referenced in the nursing plan of care. The goal for
compliance will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.
The Director has overall responsibility for implementation and oversight of the plan.
484.75(b)(7) ELEMENT
Communication with physicians
Name - Component - 00
Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care;
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the licensed practical nurse failed to report changes in the patient's condition to the physician for three (3) of seven (7) clinical records (CR1-CR3).
Findings included:
Review of agency policy on January 5, 2023, at 12:30 p.m. showed, "JOB DESCRIPTION AND PERFORMANCE EVALUATION LICENSED PRACTICAL NURSE [LPN] ... CLINICAL RESPONSIBILITIES ... 3. Reports any changes in the client's condition to the physician; executes and properly documents any new doctor's orders."
Review of CR1 on January 2, 2024, at 12 p.m. showed a physician ordered plan of care for an initial certification period from 11/27/2023 to 1/25/2024. Orders included skilled nursing (SN) to see the patient for care and assessment related to cerebral palsy diagnosis. The patient was to "wear AFOS [ ankle foot orthotic - supportive device for lower extremity] while awake [as] tolerated." Further review of CR1 did not show patient was wearing their AFOs and on 12/5 the LPN documented, "Client was dressed for the day shoes put on, mom still hold AFOs at this time until she can work him back up to the length of time that he needs to wear them." Review of treatment sheets showed the LPN documented an "H" for 11/28, 11/29, and 11/30/2023 to show that the patients AFOs were on hold and not being used. Further review of CR1 on January 5, at 9:30 a.m. did not show that agency notified the physician that the patient's AFOs were on hold.
Review of CR2 on January 4, 2024, at 9:30 a.m. showed a physician ordered plan of care with a recertification period from 11/17/2023 to 1/15/2024. The patient's diagnosis included "encounter for attention to gastrostomy [tube inserted into stomach]." SN was to provide care 5-7 nights per week. Review of "Nurse's Shift Note" by the LPN from 12/18/2023 showed the patient's mom did not elevate the patient's head while the patient was receiving a feeding via their gastrostomy tube, "HOB [head of bed] flat - Mom previously educated on importance of elevating HOB with TF [tube feed] via GT [gastrostomy tube] to avoid aspiration [stomach contents getting into lungs] , verbalized understanding- requests client lay flat this shift." Further review of CR2 on January 5, 2024, at 9:40 a.m. did not show that agency notified the physician concerning patient being fed via GT while lying flat which could increase the patient's risk of aspiration.
Review CR3 on January 4, 2023, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 6/28/2023 to 8/26/2023. SN was to see patient for care and assessment related to seizures. Orders included, "Apply bilateral AFO's as per recommendation of PT/OT/physician. ... Maintain and encourage safe use of mobility aides and orthotics [AFOs] to decrease risk for falls; notify CM and/or physician regarding concerns." On 6/29/2023, the LPN documented, "1:15pm ... Unable to wear AFO's due to improper fit with current shoes." Further review of CR3 on January 5, 2024, at 10 a.m. did not show the physician was notified concerning the improper fir of AFOs.
During an interview with EMP3 (manager of clinical operations) on January 5, 2023, from 9:30 a.m. to 11:30 a.m., he/she reviewed the above records and confirmed 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 of the licensed practical nurse to report changes in the patient's condition to the physician. The plan of correction will be completed through comprehensive focused education.
Client #1 no longer receives services from this agency.
On 1/16/2024, client #2's physician was notified of the identified instance of the caregiver laying the client flat while being fed, increasing the risk of aspiration.
Client #3 no longer receives services from this agency.
By 2/23/2024 the Manager of Clinical Operations/designee will educate all licensed clinicians on agency policy Communicating With Physicians, 0-986 with emphasis on the requirement to communicate with the physician throughout the duration of care, whenever a change in client status occurs, including when treatments are placed on "hold" by the clinician in the home and when the caregiver is observed performing treatments out of compliance with safety standards. Education included the requirement for documentation of notification to the physician and caregiver education.
Effective 2/26/2024 for three months, the Clinical Manager/designee will review bi-weekly the clinical records of 10 clients to determine if a change in client status has occurred, and if so, that documentation of notification to the physician by a licensed clinician is present in the clinical record. The goal for compliance will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.
The Director has overall responsibility for implementation and oversight of the plan.
Initial Comments:Based on the findings of an onsite unannounced state license survey completed January 8, 2023, 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 state license survey completed January 8, 2023, Bayada Home Health Care, Inc. was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
601.21(h) REQUIREMENT
COORDINATION OF PATIENT SERVICES
Name - Component - 00
601.21(h) Coordination of Patient
Services. All personnel providing
services maintain liason to assure
that their efforts effectively
complement one another and support the
objectives outlined in the plan of
treatment. (i) The clinical record
or minutes of case conferences
establish that effective interchange,
reporting, and coordinated patient
evaluation does occur. (ii) A
written summary report for each
patient is sent to the attending
physician at least every 60 days.
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to ensure all personnel providing services maintained liason to assure that their efforts effectively complemented one another and supported the objectives outlined in the plan of treatment for one (1) of two (2) discharged records (CR3).
Finding included:
Review of policy on January 5, 2023, at 12:30 p.m. showed, "Client Care Coordination ... 4.0 When more than one service is provided, whether directly or through contact, the Client Service Manager and Clinical Manager work together to assure that the actions and goals of the individual services are complementary. ... When service is provided through liaison with other organizations or individuals, coordination of services is maintained by the team effort of the Client Services Manager and Clinical Manager, and the information is documented in the client chart."
Review CR3 on January 4, 2023, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 6/28/2023 to 8/26/2023. SN was to see patient for care and assessment related to seizures. Orders included, "Apply bilateral AFO's as per recommendation of PT/OT/physician." CR3 was receiving PT/OT services from another organization. On 6/29/2023, the SN documented, "1:15pm ... Unable to wear AFO's due to improper fit with current shoes." Further review of CR3 on January 5, 2024, at 10 a.m. to include treatment records, did not show patient had worn their AFOs until 8/10/2023 and just prior to the end of episode. There was nothing in the record to show what PT/OT recommended concerning the patient's AFOs.
During a staff interview on January 5, 2023, at 10:30 a.m., EMP3 (manager of clinical operations) reviewed the above records and confirmed findings. EMP3 noted he/she could not view or see what the PT/OT recommendations were because they were kept in the patient's home.
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 ensure all personnel providing services maintained liaison to assure that their efforts effectively complemented one another and supported the objectives outlined in the plan of treatment. The plan of correction will be completed through comprehensive focused education.
Client #3 no longer receives services from this agency.
By 1/26/2024 the Manager of Clinical Operations/designee will educate all Clinical Managers on policy Client Care Coordination, 0-944 with emphasis on the requirement to document in the clinical record (home and office record) coordination of services provided through other organizations or individuals, including specifications of therapy orders when referenced in the nursing plan of care. Education will
also include the requirement for documentation of client progress/lack of progress in response to interventions found in the plan of care.
Effective 1/29/2024 for three months, the Manager of Clinical Operations/designee will review weekly clinical records of all new admissions receiving therapy services to ensure specific orders are present in the home and office chart when therapy orders are referenced in the nursing plan of care. The goal for compliance will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.
The Director has overall responsibility for implementation and oversight of the plan.
601.31(c) REQUIREMENT
PERIODIC REVIEW OF PLAN OF TREATMENT
Name - Component - 00
601.31(c) Periodic Review of Plan of
Treatment. The total plan of
treatment is reviewed by the attending
physician and agency personnel as
often as the severity of the patient's
condition requires, but at least once
every 60 days. Agency professional
staff promptly alert the physician to
any changes that suggest a need to
alter the plan of treatment
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the agency failed to promptly alert the physician to any changes in the patient's condition that suggest a need to alter the plan of treatment (care) for three (3) of seven (7) records (CR1-CR3).
Findings included:
Review of agency policy on January 5, 2024, at 12:30 p.m. showed, "0-986 COMMUNICATING WITH PHYSICIANS ... 3.0 COMMUNICATING CHANGES IN STATUS. 3.1 Throughout the duration of service, whenever a change in client status occurs that requires the physician to be notified, the communication will be documented. This can be documented on the Clinical Notes, Nurses Notes, or on a Coordination of Services Form."
Review of agency policy on January 8, 2024, at 10:30 a.m. showed, "Percutaneous Endoscopic Gastrostomy, Gastrostomy, and Jejunostomy Tube Care (Home Health) ... 18. Elevate the head of the bed at least 30 degrees when feedings are infusing."
Review of CR1 on January 2, 2024, at 12 p.m. showed a physician ordered plan of care for an initial certification period from 11/27/2023 to 1/25/2024. Orders included skilled nursing (SN) to see the patient for care and assessment related to cerebral palsy diagnosis. The patient was to "wear AFOS [ ankle foot orthotic - supportive device for lower extremity] while awake [as] tolerated." Further review of CR1 did not show patient was wearing their AFOs and on 12/5 the nurse documented, "Client was dressed for the day shoes put on, mom still hold AFOs at this time until she can work him back up to the length of time that he needs to wear them." Review of treatment sheets showed the nurse documented an "H" for 11/28, 11/29, and 11/30/2023 to show that the patients AFOs were on hold and not being used. Further review of CR1 on January 5, at 9:30 a.m. did not show that agency notified the physician that the patient's AFOs were on hold.
Review of CR2 on January 4, 2024, at 9:30 a.m. showed a physician ordered plan of care with a recertification period from 11/17/2023 to 1/15/2024. The patient's diagnosis included "encounter for attention to gastrostomy [tube inserted into stomach]." SN was to provide care 5-7 nights per week. Review of "Nurse's Shift Note" from 12/18/2023 showed the patient's mom did not elevate the patient's head while the patient was receiving a feeding via their gastrostomy tube, "HOB [head of bed] flat - Mom previously educated on importance of elevating HOB with TF [tube feed] via GT [gastrostomy tube] to avoid aspiration [stomach contents getting into lungs] , verbalized understanding- requests client lay flat this shift." Further review of CR2 on January 5, 2024, at 9:40 a.m. did not show that agency notified the physician concerning patient being fed via GT while lying flat which could increase the patient's risk of aspiration.
Review CR3 on January 4, 2023, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 6/28/2023 to 8/26/2023. SN was to see patient for care and assessment related to seizures. Orders included, "Apply bilateral AFO's as per recommendation of PT/OT/physician. ... Maintain and encourage safe use of mobility aides and orthotics [AFOs] to decrease risk for falls; notify CM and/or physician regarding concerns." On 6/29/2023, the SN documented, "1:15pm ... Unable to wear AFO's due to improper fit with current shoes." Further review of CR3 on January 5, 2024, at 10 a.m. did not show the physician was notified concerning the improper fir of AFOs.
During an interview with EMP3 (manager of clinical operations) on January 5, 2023, from 9:30 a.m. to 11:30 a.m., he/she reviewed the above records and confirmed 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 promptly alert the physician to any changes in the patient's condition that suggest a need to alter the plan of treatment. The plan of correction will be completed through comprehensive focused education.
Client #1 no longer receives services from this agency.
On 1/16/2024, client #2's physician was notified of the identified instance of the caregiver laying the client flat while being fed, increasing the risk of aspiration.
Client #3 no longer receives services from this agency.
By 2/23/2024 the Manager of Clinical Operations/designee will educate all licensed clinicians on agency policy Communicating With Physicians, 0-986 with emphasis on the requirement to communicate with the physician throughout the duration of care, whenever a change in client status occurs, including when treatments are placed on "hold" by the clinician in the home and when the caregiver is observed performing treatments out of compliance with safety standards. Education included the requirement for documentation of notification to the physician and caregiver education.
Effective 2/26/2024 for three months, the Clinical Manager/designee will review bi-weekly the clinical records of 10 clients to determine if a change in client status has occurred, and if so, that documentation of notification to the physician by a licensed clinician is present in the clinical record. The goal for compliance will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.
The Director has overall responsibility for implementation and oversight of the plan.
601.32(c) REQUIREMENT
DUTIES OF THE QUALIFIED LPN
Name - Component - 00
601.32(c) Duties of the Qualified
Licensed Practical Nurse. The
qualified licensed practical nurse:
(i) provides services in accordance
with agency policies,
(ii) prepares clinical and progress
notes,
(iii) assists the physician and/or
registered nurse in performing
specialized procedures,
(iv) prepares equipment and
materials for treatments observing
aseptic technique as required, and
(v) assists the patient in
learning appropriate self-care
techniques.
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the licensed practical nurse failed to report changes in the patient's condition to the physician in accordance with agency policy for three (3) of seven (7) clinical records (CR1-CR3).
Findings included:
Review of agency policy on January 5, 2023, at 12:30 p.m. showed, "JOB DESCRIPTION AND PERFORMANCE EVALUATION LICENSED PRACTICAL NURSE [LPN] ... CLINICAL RESPONSIBILITIES ... 3. Reports any changes in the client's condition to the physician; executes and properly documents any new doctor's orders."
Review of CR1 on January 2, 2024, at 12 p.m. showed a physician ordered plan of care for an initial certification period from 11/27/2023 to 1/25/2024. Orders included skilled nursing (SN) to see the patient for care and assessment related to cerebral palsy diagnosis. The patient was to "wear AFOS [ ankle foot orthotic - supportive device for lower extremity] while awake [as] tolerated." Further review of CR1 did not show patient was wearing their AFOs and on 12/5 the LPN documented, "Client was dressed for the day shoes put on, mom still hold AFOs at this time until she can work him back up to the length of time that he needs to wear them." Review of treatment sheets showed the LPN documented an "H" for 11/28, 11/29, and 11/30/2023 to show that the patients AFOs were on hold and not being used. Further review of CR1 on January 5, at 9:30 a.m. did not show that agency notified the physician that the patient's AFOs were on hold.
Review of CR2 on January 4, 2024, at 9:30 a.m. showed a physician ordered plan of care with a recertification period from 11/17/2023 to 1/15/2024. The patient's diagnosis included "encounter for attention to gastrostomy [tube inserted into stomach]." SN was to provide care 5-7 nights per week. Review of "Nurse's Shift Note" by the LPN from 12/18/2023 showed the patient's mom did not elevate the patient's head while the patient was receiving a feeding via their gastrostomy tube, "HOB [head of bed] flat - Mom previously educated on importance of elevating HOB with TF [tube feed] via GT [gastrostomy tube] to avoid aspiration [stomach contents getting into lungs] , verbalized understanding- requests client lay flat this shift." Further review of CR2 on January 5, 2024, at 9:40 a.m. did not show that agency notified the physician concerning patient being fed via GT while lying flat which could increase the patient's risk of aspiration.
Review CR3 on January 4, 2023, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 6/28/2023 to 8/26/2023. SN was to see patient for care and assessment related to seizures. Orders included, "Apply bilateral AFO's as per recommendation of PT/OT/physician. ... Maintain and encourage safe use of mobility aides and orthotics [AFOs] to decrease risk for falls; notify CM and/or physician regarding concerns." On 6/29/2023, the LPN documented, "1:15pm ... Unable to wear AFO's due to improper fit with current shoes." Further review of CR3 on January 5, 2024, at 10 a.m. did not show the physician was notified concerning the improper fir of AFOs.
During an interview with EMP3 (manager of clinical operations) on January 5, 2023, from 9:30 a.m. to 11:30 a.m., he/she reviewed the above records and confirmed 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 report changes in the patient's condition to the physician in accordance with agency policy. The plan of correction will be completed through comprehensive focused education.
Client #1 no longer receives services from this agency.
On 1/16/2024, client #2's physician was notified of the identified instance of the caregiver laying the client flat while being fed, increasing the risk of aspiration.
Client #3 no longer receives services from this agency.
By 2/23/2024 the Manager of Clinical Operations/designee will educate all licensed clinicians on agency policy Communicating With Physicians, 0-986 with emphasis on the requirement to communicate with the physician throughout the duration of care, whenever a change in client status occurs, including when treatments are placed on "hold" by the clinician in the home and when the caregiver is observed performing treatments out of compliance with safety standards. Education included the requirement for documentation of notification to the physician and caregiver education.
Effective 2/26/2024 for three months, the Clinical Manager/designee will review bi-weekly the clinical records of 10 clients to determine if a change in client status has occurred, and if so, that documentation of notification to the physician by a licensed clinician is present in the clinical record. The goal for compliance will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee.
The Director has overall responsibility for implementation and oversight of the plan.
Initial Comments:
Based on the findings of an onsite unannounced state license survey completed January 8, 2023, Bayada Home Health Care, Inc. was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced state license survey completed January 8, 2023, Bayada Home Health Care, Inc. was found to be in compliance with the requirement of 35 P.S. § 448.809 (b).
Plan of Correction:
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