QA Investigation Results

Pennsylvania Department of Health
BAYADA HOME HEALTH CARE, INC.
Health Inspection Results
BAYADA HOME HEALTH CARE, INC.
Health Inspection Results For:


There are  4 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed on 1/8/2021, 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:




484.55(c)(5) ELEMENT
A review of all current medications

Name - Component - 00
A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.

Observations:


Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking for two (2) of seven (7) MR's reviewed (MR4 and MR5).

Findings Included:

Review of the agency policy and procedures was conducted on 1/8/2021 at approximately 2:00 PM which revealed, Policy " 0-990 MEDICATION MANAGEMENT AND ADMINISTRATION ...1.0 MEDICATION ORDERS, 1.1 Acceptable Medication Orders must contain these basic elements: a. Physician name b. Date c. Client name d. Medication name (generic and brand names are acceptable) e. Dosage including milligrams/milliliters f. Frequency g. Route h. Indication for use if " PRN " i. Parameters for increase/decrease in dosage ...PRE-ADMINISTRATION PROCEDURES ...2.2 Verify that there are acceptable, written physician ' s orders for all drugs the client is taking. If there is no order or prescription for a drug, including over-the-counter medications and herbal products, an Addendum must be completed and sent for signature ... "
Review of MR4 on 1/6/2021 at approximately 2:15 PM revealed, "Home Health Certification and Plan of Care" with a start of care date of 10/23/2020 and a current certification period starting 10/23/2020 and ending 12/21/2020. The primary diagnosis was "Secondary Malignant Neoplasm of Bone." The Home Health Certification and Plan of Care listed under section ordered " SN (skilled nursing) TO CHECK PULSE OX EACH SHIFT AND PRN STATUS CHANGE. CLIENT MAY HAVE OXYGEN UP TO 5L(liters)/MIN (Minute) via NC (nasal cannula) per (Patient) COMFORT LEVEL ... " Review of the Medication profile and plan of care did not list Oxygen under the medication section.

Review of MR6 on 1/8/2021 at approximately 10:05 AM revealed, "Home Health Certification and Plan of Care" with a start of care date of 7/25/2018 and a current certification period starting 11/14/2020 and ending 01/12/2021. The primary diagnosis was "ENCOUNTER FOR ATTENTION TO GASTROSTOMY." The Home Health Certification and Plan of Care listed under section " ...21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration) ...ADMINISTER OXYGEN VIA TRILOGY, START O2 AT 0.5L PM CAN TITRATE UP BY 0.5LPM TO MAX OF 4LPM. MAINTAIN SPO2 93% & ABOVE ... " Review of the medication profile and plan of care did not list Oxygen under the medication section.

An exit interview with the following staff: (via phone) senior associate, director regulation compliance, division director and division director (onsite) director, director, and clinical manager. The exit interview was conducted on 1/8/2021 at approximately 3:30 PM which 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 maintain an accurate medication profile to ensure a review of all medications taken. The plan of correction will be completed through comprehensive focused education.

By 1/13/2021 oxygen was added to the medication list and plan of care for the identified clients.

By 1/22/2021 the records of all active clients with oxygen were reviewed to ensure oxygen is present on the medication list and plan of care.

By 1/15/2021 the Supervising RN/designee educated all Clinical Managers on policy Client Care Plan, 0-945 with emphasis on the requirement for the individualized plan of care to include all medications and treatments. Education also included a review of the requirement to include oxygen on the medication list.

Effective 1/25/2021 for three months, the Supervising RN/designee will review weekly the client records of all new admissions with oxygen to ensure that oxygen is present on the medication list and the plan of care. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee. Monitoring will be evaluated monthly for efficacy. If 100% compliance has been achieved after one month, the frequency of the audit will be reduced to a bi-weekly review. Subsequently, sustained improvement will be monitored through quarterly clinical record reviews conducted as a required component of the organizations Quality Assurance and Performance Improvement program.

The Director has overall responsibility for implementation and oversight of the plan.



484.60(c)(3)(i) ELEMENT
Revisions communicated to patient and MDs

Name - Component - 00
(i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the HHA plan of care.

Observations:


Based on review of agency policy and procedure, a medical record review (MR) and staff (EMP) interview the agency failed to communicate to all caregivers the agency plan of care for one (1) of seven (7) MR reviewed (MR4).

Findings Included:

Review of the agency policy and procedures was conducted on 1/8/2021 at approximately 9:51 AM which revealed, Policy "0-944 CLIENT CARE COORDINATION...Our Procedure: 1.0 Coordination of client services is the shared responsibility of the Client Services Manager and Clinical Manager. Both are qualified professionals, with an adequate amount of experiences and knowledge to do the job effectively. 2.0 Both professionals regularly communicate with the staff directly providing care to the clients. The Client Services Manager remains in the office, Providing full time case coordination. The Clinical Manager provides on-site supervision, oversees the direct care of clients and coordinates referrals. Together, they provide full service coordination. 3.0 Case coordination involves identification of additional services needed, contacting community resources for these services, discussions of the client ' s needs and status and follow-up, as appropriate. 4.0 When more than one service is provided, whether directly or through contract, the Client Services Manager and clinical Manager work together to assure that the actions and goals of the individual services are complementary. Regular communication is maintained among supervisors, field employees, and clients by telephone, written reports, on-site supervisory visits, and interdisciplinary conferences. Documentation of such is made in the client chart; all updated care plans are also kept in the home, to which all service providers have access. Communication can be documented on COORDINATION OF SERVICES (COS) NOTE, #786. 5.0 The clinical manager will review the goals presented by all disciplines and communicate the pertinent goals to all health care team members. Also, the Clinical Manager is responsible for reviewing the care plans for clients who are receiving several services, making sure that there is no duplication of services. When duplication does occur, there is an immediate effort made to correct the situation, which is documented in the client chart. 6.0 When service is provided through liaison with other organizations or individuals, coordination of services is maintained by the team effort of the Client Services and Clinical Managers, and the information is documented in the client chart. Communication from other sources, such as reports from the aides/field nurses and additional collateral contacts, must be documented in the client chart..."
Review of MR4 on 1/6/2021 at approximately 2:15 PM revealed, "Home Health Certification and Plan of Care" with a start of care date of 10/23/2020 and a current certification period starting 10/23/2020 and ending 12/21/2020. The primary diagnosis was "Secondary Malignant Neoplasm of Bone." The Home Health Certification and Plan of Care listed under section "21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)...CLIENT IS UNDER THE CARE OF...HOSPICE..." Documentation within the medical record confirmed communication between the (agency) and the hospice agency providing services. The surveyor requesting documentation of the agency providing the plan of care to the hospice agency or the plan of care received from the hospice agency to confirm coordination of care between the two agencies.

An interview was conducted with EMP1 on 1/8/2021 at approximately 11:10 AM which confirmed, documentation was not available to confirm a plan of care was provided to the hospice agency or a request for the plan of care from the hospice agency.

An exit interview with the following staff: (via phone) senior associate, director regulation compliance, division director and division director (onsite) director, director, and clinical manager. The exit interview was conducted on 1/8/2021 at approximately 3:30 PM which 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 communicate to all caregivers the Agency plan of care. The plan of correction will be completed through comprehensive focused education.

The identified client is no longer receiving services from this Agency.

By 1/29/2021 the records of all active clients who are receiving services from another Agency will be reviewed to ensure documentation is present of coordination of services including evidence that the plan of care was provided to the outside Agency and evidence of receipt of the outside Agency's plan of care for the client.

By 1/15/2021 the Supervising RN/designee educated all Clinical and Client Services Managers on policy Client Care Coordination, 0-944 with emphasis on the requirement to ensure, when services are provided through liaison with other organizations or individuals, coordination of services is maintained by the Client Services and Clinical Managers, and coordination is documented in the client chart, including sharing information such as the plan of care.

Effective 1/25/2021 for three months, the Director/designee will review weekly the records of all clients this Agency shares with another agency for nursing and/or home health aide services to ensure documentation of coordination of services is present. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee. Monitoring will be evaluated monthly for efficacy. If 100% compliance has been achieved after one month, the frequency of the audit will be reduced to a bi-weekly review. Subsequently, sustained improvement will be monitored through quarterly clinical record reviews conducted as a required component of the Organizations Quality Assurance and Performance Improvement program.

The Director has overall responsibility for implementation and oversight of the plan.




Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey completed on 1/8/2021, 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 relicensure survey completed on 1/8/2021, 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 the agency policies and procedures, medical records (MR) and staff (EMP) interview, the agency failed to maintain liaison with another agency providing services to the patient and assure effective documentation was provided to support the objectives outlined in the plan of care for one (1) of seven (7) MR reviewed (MR4).

Findings Included:

Review of the agency policy and procedures was conducted on 1/8/2021 at approximately 9:51 AM which revealed, Policy "0-944 CLIENT CARE COORDINATION...Our Procedure: 1.0 Coordination of client services is the shared responsibility of the Client Services Manager and Clinical Manager. Both are qualified professionals, with an adequate amount of experiences and knowledge to do the job effectively. 2.0 Both professionals regularly communicate with the staff directly providing care to the clients. The Client Services Manager remains in the office, Providing full time case coordination. The Clinical Manager provides on-site supervision, oversees the direct care of clients and coordinates referrals. Together, they provide full service coordination. 3.0 Case coordination involves identification of additional services needed, contacting community resources for these services, discussions of the client ' s needs and status and follow-up, as appropriate. 4.0 When more than one service is provided, whether directly or through contract, the Client Services Manager and clinical Manager work together to assure that the actions and goals of the individual services are complementary. Regular communication is maintained among supervisors, field employees, and clients by telephone, written reports, on-site supervisory visits, and interdisciplinary conferences. Documentation of such is made in the client chart; all updated care plans are also kept in the home, to which all service providers have access. Communication can be documented on COORDINATION OF SERVICES (COS) NOTE, #786. 5.0 The clinical manager will review the goals presented by all disciplines and communicate the pertinent goals to all health care team members. Also, the Clinical Manager is responsible for reviewing the care plans for clients who are receiving several services, making sure that there is no duplication of services. When duplication does occur, there is an immediate effort made to correct the situation, which is documented in the client chart. 6.0 When service is provided through liaison with other organizations or individuals, coordination of services is maintained by the team effort of the Client Services and Clinical Managers, and the information is documented in the client chart. Communication from other sources, such as reports from the aides/field nurses and additional collateral contacts, must be documented in the client chart..."
Review of MR4 on 1/6/2021 at approximately 2:15 PM revealed, "Home Health Certification and Plan of Care" with a start of care date of 10/23/2020 and a current certification period starting 10/23/2020 and ending 12/21/2020. The primary diagnosis was "Secondary Malignant Neoplasm of Bone." The Home Health Certification and Plan of Care listed under section "21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)...CLIENT IS UNDER THE CARE OF...HOSPICE..." Documentation within the medical record confirmed communication between the (agency) and the hospice agency providing services. The surveyor requesting documentation of the agency providing the plan of care to the hospice agency or the plan of care received from the hospice agency to confirm coordination of care between the two agencies.

An interview was conducted with EMP1 on 1/8/2021 at approximately 11:10 AM which confirmed, documentation was not available to confirm a plan of care was provided to the hospice agency or a request for the plan of care from the hospice agency.

An exit interview was conducted with the following staff: (via phone) senior associate, director regulation compliance, division director and division director (onsite) director, director, and clinical manager. The exit interview was conducted on 1/8/2021 at approximately 3:30 PM which 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 maintain liaison with another Agency providing services to the client and assure effective documentation was provided to support the objectives outlined in the plan of care. The plan of correction will be completed through comprehensive focused education.

The identified client is no longer receiving services from this Agency.

By 1/29/2021 the records of all active clients who are receiving services from another Agency will be reviewed to ensure documentation is present of coordination of services including evidence that the plan of care was provided to the outside Agency and evidence of receipt of the outside Agency's plan of care for the client.

By 1/15/2021 the Supervising RN/designee educated all Clinical and Client Services Managers on policy Client Care Coordination, 0-944 with emphasis on the requirement to ensure, when services are provided through liaison with other organizations or individuals, coordination of services is maintained by the Client Services and Clinical Managers, and coordination is documented in the client chart, including sharing information such as the plan of care.

Effective 1/25/2021 for three months, the Director/designee will review weekly the records of all clients this Agency shares with another agency for nursing and/or home health aide services to ensure documentation of coordination of services is present. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee. Monitoring will be evaluated monthly for efficacy. If 100% compliance has been achieved after one month, the frequency of the audit will be reduced to a bi-weekly review. Subsequently, sustained improvement will be monitored through quarterly clinical record reviews conducted as a required component of the Organizations Quality Assurance and Performance Improvement program.

The Director has overall responsibility for implementation and oversight of the plan.



601.31(d) REQUIREMENT
CONFORMANCE WITH PHYSICIAN'S ORDERS

Name - Component - 00
601.31(d) Conformance With
Physician's Orders. All prescription
and nonprescription (over-the-counter)
drugs, devices, medications and
treatments, shall be administered by
agency staff in accordance with the
written orders of the physician.
Prescription drugs and devices shall
be prescribed by a licensed physician.
Only licensed pharmacists shall
dispense drugs and devices. Licensed
physicians may dispense drugs and
devices to the patients who are in
their care. The licensed nurse or
other individual, who is authorized by
appropriate statutes and the State
Boards in the Bureau of Professional
and Occupational Affairs, shall
immediately record and sign oral
orders and within 7 days obtain the
physician's counter-signature. Agency
staff shall check all medicines a
patient may be taking to identify
possible ineffective drug therapy or
adverse reactions, significant side
effects, drug allergies, and
contraindicated medication, and shall
promptly report any problems to the
physician.

Observations:



Based on a review of clinical records (CR), agency policy and staff (EMP) interview it was determined to agency failed to maintain an accurate medication list per physician orders for two (2) of seven (7) MR's reviewed (MR4 and MR5).

Findings Included:

Review of the agency policy and procedures was conducted on 1/8/2021 at approximately 2:00 PM which revealed, Policy " 0-990 MEDICATION MANAGEMENT AND ADMINISTRATION ...1.0 MEDICATION ORDERS, 1.1 Acceptable Medication Orders must contain these basic elements: a. Physician name b. Date c. Client name d. Medication name (generic and brand names are acceptable) e. Dosage including milligrams/milliliters f. Frequency g. Route h. Indication for use if " PRN " i. Parameters for increase/decrease in dosage ...PRE-ADMINISTRATION PROCEDURES ...2.2 Verify that there are acceptable, written physician ' s orders for all drugs the client is taking. If there is no order or prescription for a drug, including over-the-counter medications and herbal products, an Addendum must be completed and sent for signature ... "

Review of MR4 on 1/6/2021 at approximately 2:15 PM revealed, "Home Health Certification and Plan of Care" with a start of care date of 10/23/2020 and a current certification period starting 10/23/2020 and ending 12/21/2020. The primary diagnosis was "Secondary Malignant Neoplasm of Bone." The Home Health Certification and Plan of Care listed under section ordered " SN (skilled nursing) TO CHECK PULSE OX EACH SHIFT AND PRN STATUS CHANGE. CLIENT MAY HAVE OXYGEN UP TO 5L(liters)/MIN (Minute) via NC (nasal cannula) per (Patient) COMFORT LEVEL ... " Review of the Medication profile and plan of care did not list Oxygen under the medication section.

Review of MR6 on 1/8/2021 at approximately 10:05 AM revealed, "Home Health Certification and Plan of Care" with a start of care date of 7/25/2018 and a current certification period starting 11/14/2020 and ending 01/12/2021. The primary diagnosis was "ENCOUNTER FOR ATTENTION TO GASTROSTOMY." The Home Health Certification and Plan of Care listed under section " ...21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration) ...ADMINISTER OXYGEN VIA TRILOGY, START O2 AT 0.5L PM CAN TITRATE UP BY 0.5LPM TO MAX OF 4LPM. MAINTAIN SPO2 93% & ABOVE ... " Review of the medication profile and plan of care did not list Oxygen under the medication section.

An exit interview was conducted with the following staff: (via phone) senior associate, director regulation compliance, division director and division director (onsite) director, director, and clinical manager. The exit interview was conducted on 1/8/2021 at approximately 3:30 PM which 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 maintain an accurate medication list per physician orders. The plan of correction will be completed through comprehensive focused education.

By 1/13/2021 oxygen was added to the medication list and plan of care for the identified clients.

By 1/22/2021 the records of all active clients with oxygen were reviewed to ensure oxygen is present on the medication list and plan of care.

By 1/15/2021 the Supervising RN/designee educated all Clinical Managers on policy Client Care Plan, 0-945 with emphasis on the requirement for the individualized plan of care to include all medications and treatments. Education also included a review of the requirement to include oxygen on the medication list.

Effective 1/25/2021 for three months, the Supervising RN/designee will review weekly the client records of all new admissions with oxygen to ensure that oxygen is present on the medication list and the plan of care. The expected compliance threshold will be 100%. Failure to achieve 100% will be addressed through focused education with the individual staff members by the Director/designee. Monitoring will be evaluated monthly for efficacy. If 100% compliance has been achieved after one month, the frequency of the audit will be reduced to a bi-weekly review. Subsequently, sustained improvement will be monitored through quarterly clinical record reviews conducted as a required component of the organizations Quality Assurance and Performance Improvement program.

The Director has overall responsibility for implementation and oversight of the plan.





Initial Comments:


Based on the findings of an onsite unannounced State relicensure survey completed 1/8/2021, 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 relicensure survey completed 1/8/2021, Bayada Home Health Care Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: