Every finding on record at Cedar Crest Village, Inc. Home Health Department

Survey date: July 29- July 31, 2024 Cedar Crest Village 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 Re-Certification Survey conducted at Cedar Crest Village, July 29 - July 31, 2024, to determine compliance with 42 CFR Part 484, Subpart B Conditions of Participation for Home Health Agencies. Standard level deficiencies were cited in conjunction with this survey.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, medical record review, and staff interview, it was determined the facility failed to assess pulse oximetry, as per a physician's order, on two of four home visits conducted (Patient #1 and Patient #4). On 7/29/24 at 12:02 PM, during a home visit with Patient (P) 1, Staff (S) 4, a Registered Nurse, was observed performing an assessment of P1’s vital signs. S4 began the assessment by first obtaining a measurement of P1’s blood pressure, followed by radial pulse, respirations, temperature, and a pain assessment. An assessment of P1’s pulse oximetry was not observed to be performed by S4. On 7/30/24 at 10:30 AM, during medical record (MR) review of P1, documentation by S4 for a visit dated 7/29/24, stated, “…Lungs/Breath Sounds [:] … Dyspnea [shortness of breath]: 2 - With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet) [.] Pulse Ox [Oximetry]: [blank] % …” The CMS - 485 Form, for certification period from 7/11/2024 to 9/8/2024, states, “… 21. Orders for Discipline and Treatments … [:] … CARE PLAN INTERVENTIONS: … Assess pulse oximeter with admit and prn [as needed] dyspnea – Active 07/11/2024 …” On 7/30/24 at 12:00 PM, during a home visit with P4, S5, a Physical Therapist, was observed obtaining P4’s vital signs. After obtaining the blood pressure, pulse, and respirations, S5 stated to P4, “what about your breathing?” P4 stated, “what about my breathing? Yeah, I’ve been short of breath.” S5 responded, “do you want a pulse ox [pulse oximetry reading]?” P4 then continued, “...you know, they said I had CHF [Congestive Heart Failure], but then they said I didn’t.” S5 then responded, “what about your pain, are you having any pain right now?” P4 stated, “right now, no.” At 12:10 PM, S5 then began physical therapy exercises with P4 as ordered. An assessment of P4’s pulse oximetry was not observed to be performed by S5. On 7/31/24 at 10:40 AM, during review of P4's MR, documentation by S5 for a visit dated 7/30/24, stated, “… Vital Signs [:] … PO2 [Pulse Oximetry]: Not Assessed … Dyspnea [:] Dyspnea Severity Scale: 2 …” The CMS - 485 Form for certification period from 7/11/2024 to 9/8/2024 states, “… 21. Orders for Discipline and Treatments … [:] … CARE PLAN INTERVENTIONS: … Assess pulse oximeter as orderer [sic] [ordered] AT SOC [Start Of Care] AND IF DYSPNEA OCCURS – Active 06/13/2024 …” On 7/31/24 at 12:07 PM, during an interview with S1, the Director of Nursing (DON), when asked about the dyspnea numerical scale, indicated on both home health visit observations with P1 and P4, that a numerical scale is utilized for both nursing and physical therapy to assess the level of dyspnea. Nursing uses a scale of 0-4, and a reported score of 2 [two] indicates shortness of breath, “with moderate exertion such as walking distances less than 20 feet.” Whereas physical therapy uses a scale of 0-10. S1 confirmed via a telephone call with S5 (Physical Therapist), that a reported score of 2 [two] indicates “minimal” shortness of breath. S1 confirmed that in both of these instances, a pulse oximetry assessment was not assessed and documented on P1 and P4 as ordered. N.J.A.C. 8:42-13.2(a)(6)

This is a Federal Recertification and State Relicensure survey conducted on October 5 to October 7, 2021. This facility is in substantial compliance with 42 CFR Part 484 Conditions of Participation for Home Health Agencies and in substantial compliance with N.J.A.C. Title 8 Chapter 42- Licensing Standards for Home Health Agencies. Standard level deficiencies were identified. A Federal Focused Infection Control Audit was also conducted on October 5 to October 7, 2021. Standard level deficiencies were identified.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on one (1) of three (3) home visits (#7), staff interviews and review of policy and procedure, it was determined that the facility failed to ensure implementation of their policy and procedure for Pain Assessment. Findings include: Reference: Facility policy titled, "Pain Assessment, Management and Education" states, "... Policy: ...When pain is identified, a more comprehensive pain assessment will be completed. .... Procedure: ... 2. When .... the clinician identifies pain, the following in-depth pain assessment information should be obtained whenever possible: A. Pain intensity using a rating scale .... . Pain intensity notation should include a patients initial intensity level of pain and the pain intensity level after medication regime or pain relief modalities. ... . 1. On 10/6/2021 during a routine home visit with Patient #7 by Staff #6, a nurse, the following was revealed: a. At 11:30 AM, Staff #6 conducted an assessment of Patient #7's right foot for his/her cellulitis and swelling of the area. Staff #6 touched the top of the patient's foot and asked the patient, "On a scale of 1 - 10, what is your pain rating?" The patient answered, "there's more pain when you touch it." Staff #7 then asked for a number and the patient stated, "10." Staff #6 then proceeded to measure the area. 2. At 11:55 AM, after leaving the patient's home, upon interview, Staff #6 confirmed he/she did not ask the patient to provide a pain level when the foot is not touched. 3. The above findings were confirmed by Staff #2 on 10/7/2021 at 12:15 PM. N.J.A.C. 8:42-6.2(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on medical record review of current patients, staff interview, and review of other facility documentation, it was determined that the facility failed to ensure that a "Risk for Infection" care plan is developed for each patient to ensure the consistent screening method for COVID-19 in one (1) out of six (6) medical records (#8). Findings include: 1. An interview with Staff #1, an administrator, on 10/7/2021 at 10:56 AM, identified the process of creating a "Risk for Infection" care plan to assess all patients for COVID-19. 2. A facility document was provided by Staff #1 that detailed an attendance sheet for a staff meeting dated 9/29/2021, that discussed the introduction of the "Risk for Infection" care plan for a new Start of Care (SoC). 3. A review of the medical record of Patient #8, revealed a SoC date of 10/04/2021. This medical record did not contain a "Risk of Infection" care plan. 4. The above findings were confirmed with Staff #1 at the time of discovery.

Integrate all services CFR(s): 484.60(d)(3) 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. This ELEMENT is not met as evidenced by: Based on staff interview and medical record review, it was determined that the facility failed to ensure that coordination of care regarding the patient's blood pressure is addressed in one (1) out of six (6) medical records (#1) reviewed. Findings include: Reference: Facility policy titled, "Care/Service Coordination" states, "...Procedure: ...4. Care Coordination will include, but not be limited to: ...c. Regularly occurring telephone or e-mail communication among team members..... e. Timely documentation of coordination of care activities.... 8. Written evidence of care coordination will be in the plan of care/service, case conference summary forms, clinical notes in the patient's clinical record and/or interdisciplinary group meeting notes....." 1. The medical record of Patient #1 was reviewed and an Interdisciplinary Communication "Case Conference" note written by Staff #7 on 9/28/2021 at 9:13 AM was identified that stated: "CC'ed with RN (Registered Nurse) [Staff #6] regarding pt's (patient's) low BP (Blood Pressure), RN to follow up with pt... ." The medical record lacked evidence of acknowledgement by Staff #4 to Staff #7's Case Conference note. 2. The next Skilled Nurse visit was conducted on 10/1/2021 by Staff #4. The visit note lacked evidence that addressed the concern by Staff #7. 3. The above findings were confirmed with Staff #1 at the time of discovery.

Ensure training/competency requirements CFR(s): 484.80(h)(5)(iii) Ensuring that home health aides who provide services under arrangement have met the training or competency evaluation requirements, or both, of this part. This ELEMENT is not met as evidenced by: Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure the competency and terms of service for the home health aides used under special arrangement. Findings include: 1. An interview with Staff #2, a clinical manager, on 10/5/2021 at 1:09 PM. identified that the agency will use home health aides from the management company but not specifically hired by the home health agency. 2. Upon request of Staff #2, the facility was unable to provide a service agreement between the agency and the management company for the use of the home health aides. 3. Upon request to Staff #2, a list of the home health aides the agency used from the management company for the year 2021 was provided. The list was presented for review. 4. The yearly competencies of the home health aides from the management company that were conducted with the agency were requested of Staff #2. The agency was unable to provide evidence of competencies for the home health aides from the management company.