Every finding on record at Hackensack Meridian Ambulatory Care, Inc

This report is the result of an unannounced Federal Recertification and State Re-licensure Survey completed May 1, 2025, at Hackensack Meridian At Home - Monmouth 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 Survey completed on May 1, 2025, at Hackensack Meridian at Home - Monmouth 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.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on medical record review, interviews with staff, and review of facility documents, it was determined the facility failed to follow facility policy to conduct initial assessments with 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date in three of five medical records reviewed (Patient (P)6, 11, and 14). Findings include: Facility policy titled “Initial and Comprehensive Assessments” last revised 03/2022 states “Purpose: To provide guidelines for the initial assessments of patients admitted to service… Policy: … The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of patient’s discharge from inpatient, on the start of care date ordered by the physician (or other licensed practitioner), at the patient/family request with the approval of the physician (or other licensed practitioner) or within 48 hours of the organization receiving notification of patient’s return home on resumption of care. …” On 5/1/25 at 9:30 AM, a review of P6’s medical record was conducted with Staff (S)6 (Registered Nurse (RN) / Manager of Clinical Practice) and S18 (Clinical Director of Ocean County) and revealed the following: On 3/20/25, P6 received a referral from a physician for home health care. On 4/5/25, P6 was discharged to home from the hospital. On 4/8/25 at 11:20 AM, telephone communication from S6 to P6’s caregiver stated that P6 was “home ok” and agreeable to SOC (start of care). On 4/10/25 at 12:22 PM, RN conducted initial assessment of P6. On 5/1/25 at 10:09 AM, a review of P11’s medical record was conducted with S6 and S18 and revealed the following: On 3/17/25, P11 received a referral from a physician for home health care. On 3/17/25, P11 was discharged to home from the hospital. On 3/18/25 at 4:30 PM, a telephone communication to the patient stated the facility “LVM (left voicemail) to set up HC (home care) svcs (services).” On 3/20/25 at 11:57 AM, a telephone communication to the patient stated “home and agreeable to SOC. All information verified.” On 3/27/25 at 11:07 AM, RN conducted an initial assessment of P11. On 5/1/25 at 10:25 AM, S6 and S18 confirmed that there were no additional communication notes between 3/20/25 and 3/27/25 to explain the delay in the initial assessment. On 5/1/25 at 10:28 AM, a review of P14’s medical record was conducted with S6 and S18 and revealed the following: On 11/5/24, P14’s referral from a physician for home health care was initiated. On 11/6/24, P14 was discharged to home from the hospital. On 11/7/24, physician signed the referral for P14. On 11/8/24 at 11:40 AM, a telephone communication to P14’s daughter stated that P14 was home and “agreeable to SOC.” On 11/10/24 at 12:06 PM, RN conducted an initial assessment of P14. On 5/1/25 at 10:34 AM, when questioned about when P14 should have received an initial assessment per facility policy, S6 stated that “P14 should have been seen on 11/9/24.” S6 and S18 confirmed that there were no additional notes to explain the delay in receiving the initial assessment. Cross Reference: NJAC 8:42-6.1(a)3 - Plan of Care

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 a delay in services, due to staffing, occurrs, in one of five medical records reviewed (Patient (P)2). Findings include: Facility policy titled "Verification of Physician Orders", last revised on 03/2022, states, "Notices To The Physician: ... 2. If fewer visits are provided during the week than ordered, the physician will be notified with documentation in the clinical record that the physician is aware of the missed visit unless the physician has authorized missed visits under specific circumstances …" On 04/30/25 at 2:29 PM, a review of P2's medical record was conducted with Staff (S)6 (Registered Nurse/Manager Clinical Practice) and S18 (Clinical Director Ocean County) and revealed the following: A review of P2's "Home Health Plan of Care" document, for the certification period beginning 3/10/25, showed visit orders for the Home Health Aide (HHA) as “… Aide (HHA) 2 visits every week for 1 week from 3/10/25 to 3/15/25." During the week of 03/10/25 to 03/15/25, P2 was only visited once by the HHA on 03/12/25. On 03/13/2025, a Home Health Aide (HHA) note documented a missed visit for P2. The note explained that P2's spouse cancelled the appointment after he/she arrived at the home. There was no documented method of notification to the physician (verbal or fax) for the missed visit in the medical record. On 04/30/25 at 2:42 PM, the findings were confirmed by S6 and S18. When questioned regarding the missed visit, S18 stated, "The doctor is always notified regardless of reason for the missed visit." Cross reference: NJAC 8:42-6.1(a)3 - Care Plans

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, staff interview, and a review of facility policies, it was determined the facility failed to follow the facility policy to prevent the transmission of infections and communicable diseases, in four of seven home visit patients (Patient (P)1, P3, P4, and P6). Findings include: On 4/30/25 at 9:19 AM, during a home visit with Patient (P) 4, in the presence of Staff (S)10 (Licensed Practical Nurse) and S11 (Manager of Clinical Practice), S10 was observed setting up his/her laptop computer on a clean barrier on the patient's table. At 9:25 AM, while speaking with the patient, S10 was then observed walking around the table, touching and adjusting the backs of the chairs, prior to using the laptop computer. S10 was not observed performing hand hygiene before using the laptop computer. The computer was not disinfected after use. At 1:46 PM, during an interview with S4 (Director of Quality), he/she provided documentation of their procedure for cleaning the laptop computers. Review of facility document titled "Procedure for Care, Cleaning, and Infection Prevention Practices for the Computer and Other Electronic Devices" revealed the following: ".Purpose: ...Electronic devices include, but are limited to, computers, tablets, and mobile phones. ..Care and Cleansing of the Computer/Electronic Device:. All electronic devices should be disinfected daily when visibly soiled or contaminated. ...Special instructions: Always remove gloves and perform hand hygiene before touching all electronic devices, including the computer, screen, keyboard, stylus, and mouse. ..." S4 confirmed that the laptops are cleaned at the end of each day, and that staff are to perform hand hygiene prior to using the laptop computer. At 2:01 PM, S4 confirmed that when S10 touched the chairs in P4's home, the expectation was that S10 would perform hand hygiene prior to using the laptop. Findings include: Facility policy titled "Hand Washing and Hand Hygiene", last revised on 07/2024, stated, “Policy: … hand hygiene will be performed in accordance with the CDC guidelines … cleaning your hands by using either handwashing with soap and water or antiseptic hand rub with alcohol-based hand sanitizer … Procedure: Hands are a common transfer mechanism for potential pathogens from one patient to another, from a contaminated article from the patient or patient’s environment or from healthcare personnel to the patient … C. Hand Washing/Hand Hygiene Indications: … Before and after contact with patient or environment …” Facility undated policy titled “Cleaning & Disinfecting Guidelines for Patient Care Equipment, stated, “Policy: … has been established to prevent the transmission of pathologic organisms between patients and caregivers … Procedure: 1. Thermometer, stethoscope (bell) and pulse oximeter: Cleaned between each patient use … 2. … non-critical items, including, but not limited to, blood pressure cuffs … must be cleaned/disinfected after use on patient … 3. Separation must be maintained between clean and soiled equipment to prevent cross-contamination …” Facility policy titled "Bag Technique", last revised on 03/2022, stated, “… 5. Remove supplies from clean area … and place on the clean barrier … 12. Clean equipment per policy prior to returning it to the clinician bag …” Facility undated policy titled "Procedure for Care, Cleaning, and Infection Prevention Practices for the Computer & Other Electronic Devices", stated, “Care and Cleansing of the Computer/Electronic Device: All electronic devices should be disinfected daily and when … contaminated … Special Instructions: Always remove gloves and perform hand hygiene before touching all electronic devices, including the computer …” On 04/29/25 at 11:35 AM, in the presence of Staff (S)8 (Therapy Supervisor), S12, an Occupational Therapist (OT) was observed providing care for P6. At 11:14 AM, while completing a medication reconciliation with P6’s spouse, S12 touched medication bottles and then proceeded to touch his/her computer without washing and/or sanitizing his/her hands multiple times. At 11:51 AM, S12 touched P6's arm and then proceeded to touch his/her computer without washing and/or sanitizing his/her hands. At 12:07 PM, S12 completed vital signs on P6. During this process, S12 touched P6 multiple times and then proceeded to touch his/her computer without washing and/or sanitizing his/her hands. At 12:14 PM, S12 closed and picked up his/her computer, without cleaning the computer, and proceeded to exit the home. On 04/30/25 at 12:15 PM, in the presence of S8, S15, a Physical Therapist (PT) was observed providing care for P1. At 11:18 AM, S15 placed three barrier pads on P1's dresser for patient care. S15's laptop and paperwork were placed on the left barrier pad. At 11:20 AM, while completing a medication reconciliation with P1’s private aide, the private aide handed S15 a plastic bin filled with medications. S15 placed the medications on center barrier pad. While S15 was reviewing the medications with his/her computer, P1's private aid placed papers on the right barrier pad. At 11:22 AM, S15 completed a set of vital signs for P1 utilizing the following equipment: blood pressure cuff, pulse oximeter, thermometer, and stethoscope. S15 placed dirty equipment on the center barrier pad. At 11:25 AM, S15 utilized disinfectant wipes to clean the equipment (blood pressure cuff, pulse oximeter, thermometer, and stethoscope). S15 placed clean equipment on the right barrier pad to dry. At 11:58 AM, S15 set up P1’s next appointments for physical therapy and updated a dry erase board calendar. At 12:01 PM, P1’s private aid placed the updated dry erase board calendar on top of the clean equipment on the right barrier pad. At 12:05 PM, S15 placed the equipment back in the nursing bag without re-cleaning the equipment. At 12:06 PM, S15 closed and picked up his/her computer, without cleaning the computer, and proceeded to exit the home. On 05/01/25 at 12:02 PM, an interview was conducted with S19 (Staff Development). When questioned about infection control related to bag technique, S19 explained that during orientation, new staff are trained on infection control, which includes bag technique. S19 further explained that all staff members review bag technique on a yearly basis. S19 stated that if an item that is considered dirty is placed on the clean barrier with already cleaned supplies, then the supplies would be required to be re-cleaned. When questioned about infection control related to staff computers, S19 stated, "We tell staff to think of your computer as always clean because you wash your hands before you touch it." S19 explained that computers are not cleaned during every visit since they are only touched with cleaned hands; instead, they are cleaned at the end of every week. S19 revealed that staff are trained on the “Procedure for Care, Cleaning, and Infection Prevention Practices for the Computer & Other Electronic Devices” policy during orientation and then every three years. Cross reference: NJAC 8:42-12.2(b) On 04/30/25 at 9:32 AM, in the presences of Staff (S) 6 (Manager of Clinical Practice), S5, Registered Nurse (RN) was observed providing care for P3. At 9:35 AM, S5 spoke with P3's spouse regarding P3's medications, glucose (sugar) levels, diet, balance, pain, and upcoming schedule for the week. At 10:02 AM, S5 placed a barrier pad on P3's table and placed the nursing bag on the barrier pad. S5 performed hand hygiene and placed a second barrier down on the table. S5 removed "Super Sani Cloth" (germicidal wipes) and placed the wipes and the hand sanitizer on the second barrier. At 10:06 AM, S5 began vital sign assessment on P3. At 10:12 AM, S5 finished taking P3's vital signs and began cleaning the equipment with a "Super Sani Cloth." After using the disinfectant wipes on the vital sign equipment (stethoscope, pulse oximeter, and blood pressure cuff), S5 placed the clean equipment onto the barrier where the hand sanitizer and "Super Sani Cloth" were located. At 10:14 AM, S5 began to drain P3's pleurx catheter (a tube placed into the body to drain excess fluid) and when finished draining, S5 changed P3's dressing. At 10:28 AM, S5 performed hand sanitized and repeated P3's vital signs. at 10:36 AM, S5 cleaned the equipment with a "Super Sani Cloth" and placed the clean equipment onto the second barrier on top of the "Super Sani Cloth" package. On 04/30/25 at 10:16 AM, S6 stated that "Super Sani Cloths" are contained within the "dirty" section of the nursing bag. On 05/01/25 at 12:03 PM, the observed nursing procedure during P3's home visit was described to S19 (Staff Development). S19 explained that clean vital signs equipment should not have been placed on the barrier with the hand sanitizer and the "Super Sani Cloth" and he/she stated, "oh no, you need a whole separate barrier, at least 5-6 per visit." When asked if the "Super Sani Cloth" were considered "dirty" S 19 stated that they are clean and kept in the "clean" section of the nursing bag. Facility policy, titled, "Bag Technique," last revised 03/2022, states, "...Bag Setup...Small Side Zipper Area (A): The "dirty" section. Meridian provided soap, Epiclenz gel, paper towels, alcohol swabs, Sani-Wipes, Gluco-chlor wipes, Barriers....Main Zipper Area (B): The "Clean Section." All dressing supplies, foleys, blood tubing, clean gloves, suture removal kits, single use thermometers, OSHA bag, spill kit, and any clean supplies needed for patient care..."

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure a written agreement is in place for social work services provided by a separately certified Home Health Agency (HHA). Findings Include: On 4/29/25 on 9:49 AM, during a review of services offered by the Home Care, Staff (S) 2 (Director of Home Care) reported that the facility did not utilize any contracted services. On 5/1/25 at 9:30 AM, the medical record revealed that Patient (P)6 was seen by social worker on 4/12/25. On 5/1/25 at 9:53 AM, during medical record review, S20 (Clinical Director), in the presence of S19 (Staff Development), reported that the facility’s only social worker was on medical leave. On 5/1/25 at 12:15 PM, a review of the facility’s staff list revealed only one social worker is employed by the HHA. On 5/1/25 at 12:39 PM, an interview was conducted with S2 and S3 (Vice President of Home Care). S2 explained that the HHA employs one social worker, and he/she is currently on a medical leave. According to S2, the Social Worker began medical leave in mid-March. S2 explained that the Ocean County HHA is providing social work coverage. According to S2, when a patient has a social work referral, the scheduling department contacts the director of Ocean County HHA to confirm social work availability before placing the patient on the Ocean County social worker’s caseload. S2 reported that if the consult is urgent, this is communicated during scheduling. S3 explained that the social worker job description, electronic medical record, and training, at both HHAs is the same. S2 reported there are currently 17 patients being followed by social work. Upon request, the facility failed to provide a written agreement between the two HHAs. On 5/1/25 at 1:30 PM, S22 (Senior Vice President) confirmed the facility does not have a written agreement regarding the use of social work services from the Ocean County HHA. Cross Reference: NJAC 8:42-3.7(a) - Written Agreements