Initial Comments:
Based on the findings of an onsite unannounced state relicense survey completed 2/25/2025, Bayada Home Health Care Inc. was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on review of agency policy and procedure, complaint log and staff (EMP) interview, it was determined the agency failed to report an alleged instance in writing of misappropriation of consumer property for (1) of thirty-two (32) complaints reviewed.
Findings Included:
Review of the agency documents on 2/25/2025 at approximately 11:00 AM revealed, "PRIVACY NOTICE ...There are some situations where (Agency) is legally required to share your PHI without seeking your authorization. They are defined in federal and state laws and regulations, which we must follow. Some examples include ...For health oversight activities such as a accreditation, licensing, credentialing or audits, inspections and investigations, including compliance or medical reviews. When a government regulatory agency or oversight board asks to see your records for investigations, inspections, disciplinary actions or to ensure that we are conforming to other laws and regulations, including the Health Insurance Portability and Accessibility Act (HIPAA) and similar state or local laws. For public health activities including controlling disease, injury or disability, reporting to the Federal Food and Drug Administration concerning problems with products, product recalls or reporting deaths as required by State law. When we reasonably believe that you are a possible victim of abuse, neglect, domestic violence or other crimes or to help prevent any possible threat or injury to you..."
A review of the consumer complaint log was conducted on 2/25/2025 at appoximately 10:52 AM which revealed the following. "Nature of Complaint: Other Compliance concern, Complaint Reported By: Client, Date Case Occurred: 8/15/2024...Summary/Overview: Received an email and then phone call from client stating that she was missing roughly 30 pain pills., Resolution: We are specking with each staff member that works there and working with the client to get this resolved in the event that medications may have been misplaced inadvertently. (Client) shared who she thought had taken the money and pills but did not have any physical evidence. As office was following up with each staff member regarding incident, one staff member became immediately defensive and angry and quit on the spot."
The surveyor asked EMP1 to confirm if complaint was submitted to the
PA Department of Health (PA-DOH) Event Notification Internet Site...Event Reporting System ...ERS system. During an interview on 2/25/2025 at approximately 11:23 AM, EMP1 confirmed the complaint information was not submitted as an ERS event/report.
An interview was conducted with director on 2/25/2025, at 2:20 PM to confirmed above findings.
Plan of Correction:H008
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 an alleged instance in writing of misappropriation of client property. The plan of correction will be completed through comprehensive focused education.
The identified incident was reported in the State Event Reporting System (ERS).
By 4/4/2025 the Director/designee will educate all office staff on policy Event Reporting - PA, 37-3551 and the requirement to report in the ERS all allegations of misappropriation of client's property.
Effective 4/7/2025 for three months, the Director/designee will review daily all incidents to ensure timely reporting in the ERS for all reportable events, including allegations of misappropriation of client property.
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 2/25/2025, 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 H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
611.52(a) LICENSURE
Criminal Background Checks
Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on a review of personnel files (PF's), agency policy and staff (EMP) interview, the agency failed to ensure each applicant for employment as a direct care worker submitted a criminal history report obtained at the time of application or within 1 year immediately preceding the date of hire for one (1) of seven (7) PF's reviewed (PF3).
Findings included:
Review of the agency documents on 2/25/2025 at approximately 12:50 PM revealed, "REHIRING, REACTIVATING, TRANSFERRING, SHARING FIELD EMPLOYEES ...PURPOSE...1.2 In all cases, the director will review the employee file for completeness and office or program specific requirements...3.3 Complete a criminal background check if interruption of work was one (1) year or more in the absence of stricter state requirements..."
PF3, DOH 11/8/23, was reviewed on 2/25/2025 at approximately 11:48 AM, documentation reviewed within the PF had signatures and dates from February of 2019. EMP1 confirmed the staff member was rehired. Per documentation the original hire date was 02/18/2019 the date the employee resigned was 10/18/2022. The most recent hire date was 11/08/2023. Review of PF3 revealed a Pennsylvania State Police Criminal Record Check from 2/22/2019 and 4/15/2024. Per agency policy a criminal background check was not completed with over one (1) year break in employment.
An interview was conducted with EMP1 on 2/24/2025, at 2:20 PM to confirmed above findings.
Plan of Correction:S300
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 obtain a criminal history report obtained at the time of application or within 1 year immediately preceding the date of hire. The plan of correction will be completed through comprehensive focused education.
By 4/4/2025 the Director/designee will educate all office staff on policy Rehiring, Reactivating, Transferring, & Sharing Field Employees -37-2385 and the requirement to complete a criminal background check if interruption of work was one (1) year or more in the absence.
Effective 4/7/2025 for three months, the Director/designee will review weekly the records of all reactivated field staff to ensure if the interruption of work was for 1 year or more, a criminal background check was completed.
The Director has overall responsibility for implementation and oversight of the plan.
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based on a review of the agency policy, personnel files (PFs) and staff (EMP) interview it was determined the agency failed to show proof of residency in this Commonwealth for the 2 years preceding the date of hire (DOH) for one (1) of seven (7) PFs reviewed (PF7).
Findings included:
Review of the agency documents on 2/25/2025 at approximately 11:00 AM revealed, "CRIMINAL BACKGROUND CHECK, CLEARANCES, & REQUIRED SCREENINGS-PA ...3.0 GENERAL REQUIREMENTS...3.4 Any employee who has separated from BAYADA and is returning to work must comply with this policy before being re-hired ...5.0 BACKGROUND CHECK PROCESS 5.1 Home Care (non-Medical) Licensed Offices. All office, field, contracted staff, and owner, whether or not they may have direct contract with client, are required to undergo as applicable, State Police, FBI, and child abuse checks. 5.1.1 One of the following documents must be obtained in order to demonstrate proof of residency for two (2) years preceding the date of application for a criminal background chesk, or a State police criminal background check as described below: *Motor vehicle records ...*Housing records, such as mortgage record or rent receipts. *Public utility records and receipts ...* Local tax records ...*A completed and signed, and signed, Federal (FBI), State, or local income tax return with the employee's name and address preprinted on it *Employment records, including records of unemployment compensation *If proof of residency cannot be obtained, the employee must undergo a Federal (FBI) criminal background check as described below. 5.3.2 Federal/FBI Background Checks. FBI Background checks are completed through IdentoGO, the State approved vendor to process FBI checks. 5.3.2.1 Pennsylvania Department of Aging. An FBI Background checks conducted through the PA Dept. of Aging..."
A review of PF7 was conducted on 2/25/2025 approximately between 12:48 PM, which revealed a date of hire 4/24/2024. A Pennsylvania driver's license was available with an issue date of 2/7/2023. A Pennsylvania State Police Criminal Record Check was conducted 4/22/2024. A FBI FINGERPRINTING CLEARANCE was conducted on 12/3/2024. There was no additional documentation in PF to confirm the agency verified proof of residency in this Commonwealth for two (2) years immediately preceding the date of hire to 12/3/2024.
An interview was conducted with EMP1 on 2/25/2025, at 2:20 PM to confirmed above findings.
Plan of Correction:S330
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 obtain documentation of proof of residency. The plan of correction will be completed through comprehensive focused education.
By 4/4/2025 the Director will educate all office staff on policy Criminal Background Checks, Clearances, and Required Screenings – PA Offices, 0-17105 and the requirement to obtain proof of residency for two years preceding the date of the request for a criminal history report for all prospective employees utilizing one of the following that clearly demonstrates length of residency: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification. (2) Housing records, such as mortgage records or rent receipts. (3) Public utility records and receipts, such as electric bills. (4) Local tax records. (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it. (6) Employment records, including records of unemployment compensation. Education will include utilizing the correct code to conduct a federal criminal record check if proof of residency is unable to obtained.
Effective 4/7/2025 for three months, the Director/designee will review weekly the records of all new hires to ensure proof of residency is present and if not, that the employee has a federal criminal record check on file.
The Director has overall responsibility for implementation and oversight of the plan.
611.57(a) LICENSURE
Consumer Rights
Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
Observations:
Based on a review of the agency policy, consumer records (CR) and staff (EMP) interview, the agency failed to involve the consumer in the service planning process and to receive services with reasonable accommodation of individual needs and preferences for six (6) of seven (7) CRs reviewed (CR2-CR7).
Findings included:
Review of the agency documents on 2/25/2025 at approximately 11:00 AM revealed, "CLIENT RIGHTS AND RESPONSIBILITIES SUPPLEMENT...*To be involved with the service planning process and to receive services with reasonable accommodation of the individual needs and preferences, except where the health and safety of the direct care worker is a risk..."
Review of the agency documents on 2/25/2025 at approximately 11:00 AM revealed, "CLIENT AGREEMENT FORM SUPPLEMENT (PA Home Care Services) DESCRIPTION OF SERVICES TO BE PROVIDED...NAME OF EMPLOYEE(S):___...DAYS/HOURS OF SERVICES..."
A review of the CR2 with a start of services of 2/19/2024 was conducted on 2/25/2025 at approximately 1:35 PM which revealed, documentation within the CR listed under the "CLIENT AGREEMENT FORM SUPPLEMENT (PA Home Care Services)...DAYS/HOURS OF SERVICES 40 hours/week." No days or times for services were provided. The surveyor could not confirm from the agency documentation that planning needs and preferences were reviewed, or if needs and preferences were reviewed with the consumer or consumer representative.
A review of the CR3 with a start of services of 6/18/2024 was conducted on 2/25/2025 at approximately 1:43 PM which revealed, documentation within the CR listed under the "CLIENT AGREEMENT FORM SUPPLEMENT (PA Home Care Services)...DAYS/HOURS OF SERVICES 68 hours/wk." No days or times for services were provided. The surveyor could not confirm from the agency documentation that planning needs and preferences were reviewed, or if needs and preferences were reviewed with the consumer or consumer representative.
A review of the CR4 with a start of services of 7/11/2024 was conducted on 2/25/2025 at approximately 1:47 PM which revealed, documentation within the CR listed under the "CLIENT AGREEMENT FORM SUPPLEMENT (PA Home Care Services)...DAYS/HOURS OF SERVICES 35 hrs/wk." No days or times for services were provided. The surveyor could not confirm from the agency documentation that planning needs and preferences were reviewed, or if needs and preferences were reviewed with the consumer or consumer representative.
A review of the CR5 with a start of services of 10/29/2024, was conducted on 2/25/2025 at approximately 1:50 PM which revealed, documentation within the CR listed under the "CLIENT AGREEMENT FORM SUPPLEMENT (PA Home Care Services)...DAYS/HOURS OF SERVICES 4 HHA/WK and 3 HMKR/WK." No days or times for services were provided. The surveyor could not confirm from the agency documentation that planning needs and preferences were reviewed, or if needs and preferences were reviewed with the consumer or consumer representative.
A review of the CR6 with a start of services of 10/8/2024, was conducted on 2/25/2025 at approximately 1:55 PM which revealed, documentation within the CR listed under the "CLIENT AGREEMENT FORM SUPPLEMENT (PA Home Care Services)...DAYS/HOURS OF SERVICES: 28 hrs/Week." No days or times for services were provided. The surveyor could not confirm from the agency documentation that planning needs and preferences were reviewed, or if needs and preferences were reviewed with the consumer or consumer representative.
A review of the CR7 with a start of services of 9/14/2023, was conducted on 2/25/2025 at approximately 2:00 PM which revealed, documentation within the CR listed under the "CLIENT AGREEMENT FORM SUPPLEMENT (PA Home Care Services)...DAYS/HOURS OF SERVICES: 41 hours/WK." No days or times for services were provided. The surveyor could not confirm from the agency documentation that planning needs and preferences were reviewed, or if needs and preferences were reviewed with the consumer or consumer representative.
The surveyor could not confirm from the agency documentation the change in schedule, or if the service planning needs and preferences were reviewed with the consumer or a consumer representative.
An interview was conducted with EMP1 on 2/25/2025, at 2:20 PM to confirmed above findings.
Plan of Correction:S800
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 involve the client in the service planning process and to receive services with reasonable accommodation of individual needs and preferences. The plan of correction will be completed through comprehensive focused education.
By 4/4/2025, for the identified clients (#2, #3, #4, #5, #6, #7), the schedule in the electronic system will be updated to reflect the client's days/times of service, per their preference. During their next regularly scheduled supervisory visit, an updated client agreement form will be obtained identifying the intended days/hours for services, reviewed and signed by the client indicating their agreement and participation in planning.
Effective 4/4/2025, the Clinical Manager will obtain an updated Client Agreement form indicating intended days/hours of service for all active clients, reviewed with and signed by the client at their next regularly scheduled supervisory visit.
By 4/4/2025 the Director/designee will educate all office staff on form Client Agreement Form Supplement – Home Care – PA, 0-5035 with emphasis on the requirement to document intended days/hours of services, taking into consideration client preference. Education will include the requirement to document in the client record agreement of the client when there are significant changes in days/hours of services to ensure the client is in agreement with their preferences taken into consideration.
Effective 4/7/2025 three months, the Director/designee will review weekly the records of all new admissions to ensure form Client Agreement Form Supplement – Home Care – PA, 0-5035 includes documentation of intended service days/hours.
The Director has overall responsibility for implementation and oversight of the plan.
611.57(c) LICENSURE
Information to be Provided
Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.
Observations:
Based on a review of consumer records (CR) and staff (EMP) interview, the agency failed to provide required information in writing to consumers/consumer representatives prior to the commencement of services for six (6) of seven (7) CRs reviewed (CR2-CR7).
Findings included:
Review of the agency documents on 2/25/2025 at approximately 11:00 AM revealed, "CLIENT AGREEMENT FORM SUPPLEMENT (PA Home Care Services) DESCRIPTION OF SERVICES TO BE PROVIDED...NAME OF EMPLOYEE(S):___...DAYS/HOURS OF SERVICES..."
Review of the agency documents on 2/25/2025 at approximately 11:00 AM revealed, "CLIENT RIGHTS AND RESPONSIBILITIES SUPPLEMENT...*To be involved with the service planning process and to receive services with reasonable accommodation of the individual needs and preferences, except where the health and safety of the direct care worker is a risk..."
A review of the CR2 with a start of services of 2/19/2024 was conducted on 2/25/2025 at approximately 1:35 PM which revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of the CR3 with a start of services of 6/18/2024 was conducted on 2/25/2025 at approximately 1:43 PM which revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of the CR4 with a start of services of 7/11/2024 was conducted on 2/25/2025 at approximately 1:47 PM which revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of the CR5 with a start of services of 10/29/2024, was conducted on 2/25/2025 at approximately 1:50 PM which revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The identity of the direct care worker who would provide services.
2. The hours when services would be provided.
A review of the CR6 with a start of services of 10/8/2024, was conducted on 2/25/2025 at approximately 1:55 PM which revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
A review of the CR7 with a start of services of 9/14/2023, was conducted on 2/25/2025 at approximately 2:00 PM which revealed, No documentation was made available to confirm the consumer/consumer representative was provided an information packet containing the following:
1. The hours when services would be provided.
An interview was conducted with EMP1 on 2/25/2025, at 2:20 PM to confirmed above findings.
Plan of Correction:S820
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 information in writing to the client prior to commencement of services. The plan of correction will be completed through comprehensive focused education.
By 4/4/2025, for the identified clients (#2, #3, #4, #5, #6, #7), the schedule in the electronic system will be updated to reflect the identity of the direct care worker providing services and the intended days/hours for services. During their next regularly scheduled supervisory visit, an updated client agreement form will be obtained identifying the intended days/hours for services, reviewed and signed by the client indicating their agreement and participation in planning.
Effective 4/4/2025, the Clinical Manager will obtain an updated Client Agreement form indicating identity of the direct care worker providing services and the intended days/hours of service for all active clients, reviewed with and signed by the client at their next regularly scheduled supervisory visit.
By 4/4/2025 the Director/designee will educate all office staff on form Client Agreement Form Supplement – Home Care – PA, 0-5035 with emphasis on the requirement to document the identity of the direct care worker who will be providing services and to document intended days/hours of services, taking into consideration client preference. Education will include the requirement to document in the client record agreement of the client when there are significant changes in days/hours of services to ensure the client is in agreement with their preferences taken into consideration.
Effective 4/7/2025 three months, the Director/designee will review weekly the records of all new admissions to ensure form Client Agreement Form Supplement – Home Care – PA, 0-5035 was provided to the client upon admission and that it includes identification of the direct care worker who will provide services and documentation of intended service days/hours.
The Director has overall responsibility for implementation and oversight of the plan.
Initial Comments:
Based on the findings of an onsite unannounced state relicense survey completed 2/25/2025, 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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