Every finding on record at Hackensack Meridian Ambulatory Care, Inc

This report is the result of an unannounced Federal Recertification and State Re-licensure surveys completed on June 6, 2025, at Hackensack Meridian at Home - Ocean County. It was determined the facility is in substantial compliance with the requirements of Emergency Preparedness regulation 42 CFR 484.102 Condition of Participation for Home Health Agencies for this survey.

This report is the result of an unannounced standard-level Federal Recertification and State Re-licensure surveys, completed June 6, 2025, at Hackensack Meridian at Home - Ocean County. It was determined the facility is not in substantial compliance with Federal requirements of 42 CFR Part 484, Subpart B Conditions of Participation for Home Health Agencies and State requirements of N.J.A.C. Title 8 Chapter 42 Home Health Agency Licensing Standards.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and review of facility policies, it was determined the facility failed to ensure communication with the physician is documented, when services are not provided according to the patients' care plan, in two of 17 medical records reviewed (Patient (P)14 and P15). On 6/5/25, in the presence of Staff (S)19 (Staff Development) and S20 (Clinical Director), medical record review was conducted and revealed the following: A review of P14's "Home Health Plan of Care" document, for the certification period beginning 3/20/25, showed visit orders for the Physical Therapy (PT) as “...3 visits every week for 1 week 3/23/25 to 3/29/25…2 visits every week for 2 weeks 3/30/25 to 4/12/25." On 3/26/25, P14 had a missed PT [Physical Therapy] visit. The “PT Missed Visit Note” stated, “…Communication Details: Missed visit pending insurance authorization/approval…”. P14’s medical record lacked documentation of notification to the physician for the missed visit. On 4/3/25, P14 had a missed PT visit. The “PT Missed Visit Note” stated, “…Communication Details: Missed PT visit due to pending insurance auth [authorization]…”. P14’s medical record lacked documentation of notification to the physician for the missed visit. On 6/5/25 at 1:42 PM, the findings were confirmed by S19 and S20. NJAC 8:42-6.2(a)3 Findings include: Facility policy titled, "Monitoring Patient's Response/Reporting to Physician" last reviewed on 3/2022 states, "...Procedure:...3. The patient's physician (or other licensed practitioner) will be contacted on the same day when any of the following occur:...G. When a visit is missed for any reason.." On 6/6/25, P15’s medical record was reviewed in the presence of Staff (S)1 (Clinical Director) and S21 (Staff Development Educator). The medical record revealed the following: On 3/4/25 at 11:07 AM, P15 signed the “Notice of Medicare Non-Coverage” indicating Home Care services will end on 3/6/25. On 3/5/25 at 6:11 AM, a “Case Communication” note written by the Occupational Therapist (OT) to the Physical Therapist (PT) states, “Hello; I missed one visit this week due to scheduling conflicts and I am extending until next week; dtr [daughter] told me to go to pts [patient’s] home next visit as well. Thanks [name] OT.” On 3/8/25, an “OT Missed Visit” note states, “…Communication Details: one missed visit…” S21 confirmed that this note lacked evidence of communication to the physician. On 3/14/25, P15 was discharged from Home Care services. On 6/5/25 at 1:51 PM, S1 explained that after the Notice of Medicare of Non-Coverage is signed, the clinician would need to obtain an order from the physician for additional visits. S1 and S21 confirmed that P15’s medical record lacked evidence of communication with the physician regarding the missed visit and there was no communication requesting additional visits after the Notice of Medicare of Non-Coverage date.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations in one of seven home visits (Patient (P) P3), review of facility documents, staff interview, and review of nationally recognized guidelines, it was determined the facility failed to provide a sanitary environment by ensuring: 1) proper hand hygiene practices are implemented according to facility policy and Centers for Disease Control and Prevention (CDC) guidelines; and 2) environmental cleaners and disinfectants are used in accordance with the manufacturer's instructions for use (IFUs). Findings include: 1) Reference: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee [HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states, “Recommendations 1. Indications for handwashing and hand antisepsis A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA) (66). B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J…Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C–J…F. Decontaminate hands after contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient)… I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient… J. Decontaminate hands after gloves…” Facility policy titled: “Hand Hygiene,” reviewed on 08/19/2024 states, “Introduction: Hand hygiene is a general term used by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to refer to handwashing, antiseptic handwashing, antiseptic hand rubbing, and surgical hand asepsis. It’s the single most important procedure in preventing infection. To protect a patient from health-care associated infection, hand hygiene must be performed routinely and thoroughly…YOUR FIVE MOMENTS FOR HAND HYGIENE:… (1) BEFORE TOUCHING A PATIENT (2) BEFORE CLEAN/ASEPTIC PROCEDURE (3) AFTER BODY FLUID EXPOSURE RISK (4) AFTER TOUCHING A PATIENT (5) AFTER TOUCHING PATIENT SURROUNDINGS… On 6/4/25 at 1:02 PM, during a home care visit with Patient (P) 3, a Registered Nurse (RN) Staff (S) 10, was observed to remove and insert a foley catheter (flexible tube used to drain urine from the bladder) for P3 as per physician’s orders. At 1:02 PM, S10 repositioned P3’s legs and placed a pillow under P3’s calves, removed his/her gloves, failed to perform hand hygiene, then opened the sterile foley catheter kit and removed the sterile gloves. At 1:11 PM, S10 was observed to attempt to insert P3’s foley catheter. After a failed attempt in inserting the foley catheter, S10 doffed his/her gloves, failed to perform hand hygiene, and then touched his/her face. At 1:19 PM, S10 was observed to perform a skin assessment on P3’s bilateral heels, doffed gloves, failed to perform hand hygiene, and then touched his/her face. At 1:27 PM, S10 was observed to dispose of a “dirty” disposable pad that was used for “dirty” medical equipment, failed to perform hand hygiene, and then went into P3’s bag that contained his/her medications. N.J.A.C. 8:42-12.3 (a)4 2) The “Super Sani-Cloth General Germicidal Disposable Wipes” Instructions For Use (IFU) was reviewed and stated, “Super Sani-Cloth Germicidal Disposable Wipe: Effective against, Bacteria… Multi-Drug Resistant Bacteria… Viruses… Bloodborne Pathogens… Precautionary Statements Hazards to Humans and Domestic… Avoid contact with skin. …” On 6/4/25 at 1:19 PM, during an observation of S10 providing care to P3, S10 was observed to use a stethoscope, pulse oximeter, thermometer, and blood pressure cuff to obtain vital signs for P3. The “dirty” medical equipment was placed on a disposable barrier. S10 failed to don gloves and wiped each piece of medical equipment using a “Super Sani-Cloth Germicidal Disposable Wipe”. On 6/4/25 at 1:32 PM, an interview was conducted with S10. When asked whether it was necessary to wear disposable gloves when handling the disposable wipes, S10 stated, “you should.” On 6/5/25 at 11:12 AM, S3 (Director of Quality Improvement and Staff Development) indicated when cleaning the medical equipment, it is not required to wear gloves. S3 reviewed the IFU, and confirmed gloves should be used when handling the disposable wipes. NJAC 8:42-12.2(b) - Infection Control Policies and Procedures