Every finding on record at Hunterdon Medical Center Home Health Services

This is a Federal Recertification Survey that was conducted on September 8, 9, and 10, 2021. Hunterdon Medical Center Home Health is in compliance with 42 CFR Part 484 Emergency Preparedness 484.102: Condition of Participation for Home Health Agencies. No deficiencies were identified.

This is a Federal Recertification Survey that was conducted on September 8, 9, and 10, 2021. Hunterdon Medical Center Home Health is not in compliance with 42 CFR Part 484 regulations for Home Health Agencies. Standard level deficiencies were identified. A Focused Infection Control Audit was conducted on September 8, 9, and 10, 2021. Deficiencies were identified.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on staff interview, review of two (2) out of five (5) medical records on 9/9/21 and 9/10/21 and review of facility documents, it was determined that the facility failed to ensure that their policy and procedure for missed visits is implemented. Findings include: Reference: Facility policy, "Missed Visits" states, "... Procedure ... 2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician ... B. Document in the patient's clinical record the following information: ... 4. Description of any unmet needs and how the patient's needs were met 5. Physician notification including date, time, physician name, method of notification and the staff reporting the information ..." 1. A review of Medical Record #6, with Staff #2, revealed the following: a. For certification period 6/14/21 - 8/12/21, the Home Health Certification and Plan of Care states, ".... SN (Skilled Nursing), 6/6/21 1-2 x 1 week (one to two times for one week) ..." b. Review of SN visits for the week of 6/6/21 revealed that no SN visits were conducted, in accordance with the plan of care. (i) The Skilled Nursing Note by the Registered Nurse (RN) in the "Charts/Clinical Notes" section of the medical record dated 6/7/21 stated, "... Patient stated [he/she] will call the agency once [he/she] is settled ... and ready to resume services. ... Team communication sent to the clinical team with patient update." (ii) The documentation by the RN did not specify if physician notification was made and did not include the date, time, physician name, the method of notification and the staff reporting the information. This is not in accordance with the facility policy and procedure. 2. A review of Medical Record #8, with Staff #2, revealed the following: a. For certification period 5/25/21 - 7/23/21, the Home Health Certification and Plan of Care states, ".... AID (Home Health Aid), 6/20/21 2-3 x week x 2 weeks (two to three times a week for two weeks) ..." b. Review of AID visits for the week of 6/27/21 revealed that only one (1) AID visit was conducted, in accordance with the plan of care. (i) The Home Health Aid Note by the AID in the "Charts/Clinical Notes" section of the medical record, dated 6/30/21 stated, "Per ... RN this morning - this patient no longer needs the aide so ... visits have been canceled effective today 6/30/21." (ii) The medical record did not contain documentation by the RN of physician notification of the missed visit which includes the date, time, physician name, and method of notification. A description of how the patient's needs were met was also not documented by the clinician. This is not in accordance with the facility policy and procedure. 3. The above findings were confirmed on 9/10/2021 by Staff #2. N.J.A.C. 8:42 - 6.2(a)6

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview and facility document review, it was determined that the facility failed to ensure that all revisions to the plan of care be authorized and incorporated in an updated plan of care. Findings include: Reference #1: Facility policy titled, "Home Health Monitoring Patient's Response Reporting to Physician" states, "...II Procedure: ... D. All conferences or attempts to communicate with the physician will be documented in the clinical record. ..." Reference #2: Facility policy titled, "Home Health Care Planning Process" states, "... I. Policy: The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient. ... III Procedure: ... J. Clinicians will inform the patient's physician of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes."... 1. On 9/9/2021 at 1:15 PM during a review of Medical Record #2 with Staff #1 and Staff #11, the following was revealed: a. For Certification Period: 7/27/21 - 9/24/21, the 'Home Health Certification and Plan of Care" included the following physician orders: "SN [Skilled Nursing] 7/27/21 3 PRN [as needed]: pleurx complications, 8/1/21: 2-3 x week x 2 weeks" ... RN [registered nurse] perform Pleural catheter site care/sterile dressing change/connection-detachment of sterile Pleural vacuum system .... frequency and drainage amount .... Instruct Pt/CG [patient/caregiver] in sterile Pleural vacuum system connection/detachment regimen. Teach Pt/CG Pleural catheter insertion site care and dressing change to Pleural catheter insertion site ..." (i) On 8/6/2021 at 3:18 PM, Staff #10 documented routine visit note in "Chart/Clinical Notes"...Pt's husband (name) comfortable with draining PleurX and changing dressing 2x/wk [week]. They would like RN [registered nurse] to continue to come 1x/wk for drainage/dressing change and to monitor incision site. ..." b. There was no documented evidence in the medical record that Staff #11 communicated with the physician the need for skilled nursing visits to be revised from 2-3 x/week to 1x / week for the plan of care. (i) There was no documentation to reflect the plan of care was revised for the nursing visit frequencies or a signed and dated authorization was made by the professional authorizing the changes within (5) working days of initiation of the revision. 2. At 2:00 PM, Staff #1 and Staff #11 confirmed the above findings. N.J.A.C. 8:42 - 7.4(a)(1)

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 observation, staff interview, and a review of facility documents during 3 of 3 home visits, it was determined that the facility failed to ensure A.) nursing staff implement proper bag technique procedures and B.) staff perform hand hygiene according to facility policy and the Visiting Nurse Associations of America (VNAA) Clinical Procedure Manual. Findings include: Reference #1: Facility policy titled, "Home Health Bag Technique" states: "... II. Procedure A. The bag may have the following contents: 1. Hand washing equipment -- alcohol-based hand rub and skin cleanser, soap, and paper towels ... D. Bag Technique 1. The bag is placed on a clean barrier in the home. ... and should be placed out of reach of children and pets. ... 2. Prior to administering care, ... waterless skin cleanser and paper towels are removed and hand hygiene is performed. These supplies are left available for hand hygiene at the end of the visit. ... 4. When the visit is completed, re-usable equipment is cleaned using agency approved germicidal wipe, ..." Reference #2: The Visiting Nurse Associations of America 19th Edition VNAA Clinical Procedure Manual Section 7: Infection Control Procedure 7.4 Bag technique states, "Key Points ... 2. Keep bag clean and dry ... d. Place the bag in a barrier in a "clean" area of the home: 1) Appropriate areas include a clean hard surface ... e. Keep the bag away from ..., pets ..." 1. On 9/8/21, during entrance conference, Staff #1 indicated that the facility follows the following nationally recognized guidelines and clinical procedures for infection control: CDC (Centers for Disease control and Prevention), VNAA (Visiting Nurse Association of America), and WHO (World Health Organization). 2. On 9/8/21, during an observation of Patient #1's home visit conducted by Staff #3 and Staff #4, the following was observed: a. At 12:29 PM, Staff #3 placed his/her clinician bag on the seat of a chair located in the kitchen. The patient was observed to have a pet dog at the time of arrival that was present multiple times in the kitchen during the visit. (i) At 12:50 PM, while Staff #3 and Staff #4 were providing care to the patient, the pet was observed standing on its hind legs with two paws placed on the clean barrier and then proceeded to touch/sniff several areas on the outside of the bag with its nose. The bag was closed at the the time of the observation. b. At 12:38 PM, Staff #4 arrived to the patient's home. Staff #4 was observed to place his/her clinician bag on a barrier on the seat area of a soft surfaced leather like material chair located in the patient's dining room area. c. At 1:10 PM, Staff #4 was observed sitting on the barrier placed on the kitchen chair where Staff #3's bag was placed. While sitting, Staff #4's back was observed touching the outside surface of Staff #3's clinician bag. 3. On 9/9/21 at 10:38 AM, during an observation of Patient #5's home visit conducted by Staff #6 and Staff #7, the following was observed: a. Prior to administering care, Staff #6 removed supplies from his/her bag which included waterless skin cleanser, paper towels, and 2 electronic devices and placed them onto the clean barrier. Staff #6 then proceeded to apply the waterless skin cleanser to a paper towel and was then observed wiping down the 2 electronic devices with the paper towel containing the waterless skin cleanser and then placing them back onto the clean barrier. (i) Staff #7 indicated on interview during the visit that the one phone device on the barrier was a facility issued electronic device that is utilized by the Home Health Aids (HHAs). (ii) After completion of the visit an interview was conducted with Staff #1 regarding the cleaning and disinfection techniques for facility issued electronic phone devices. Staff #1 explained that Super Sani Cloth wipes or alcohol wipes are utilized for the cleaning and disinfection of facility issued electronic devices, not waterless skin cleanser. 4. The above findings were confirmed by Staff #1 on 9/10/21. N.J.A.C. 8:42-12.2 (b) Findings include: Reference #1: Facility policy titled, "Home Health Hand Hygiene" states: "1. Policy Personnel providing care in the home setting will follow the visiting Nurse Association of America Clinical Procedure manual for Hand Hygiene. ..." Reference #2: The Visiting Nurse Associations of America 19th Edition VNAA Clinical Procedure Manual Section 7: Infection Control Procedure 7.8 Hand Hygiene states, "Key Points ... 7. Hand hygiene must be performed: a. Before entering/re-entering the clinician bag ... Procedure ... 2. Hand washing Soap and Water ... f. use towel to turn off faucet. ..." 1. On 9/8/21 at 12:38 PM, during an observation of Patient #1's home visit, Staff #3 was observed to entered his/hers clinician bag without first performing hand hygiene. 2. On 9/9/21 at 10:38 AM, during an observation of Patient #5's home visit, Staff #6, upon arrival to the home was observed to wash his/hers hands in the kitchen sink using soap and water. Staff #6 did not used his/hers clean hands, not a towel, to turn off the faucet when complete. Staff #6 then proceeded to re-wash his/her hands at the sink with soap and water and again was not observed to use a towel to turn off the faucet. 3. The above findings were confirmed on 9/10/21 with Staff #1. N.J.A.C. 8:42-12.2 (b) Findings include: Reference: Facility policy titled, "Home Health Hand Hygiene" states, "... Procedure: 1. .... Adhere to standard precautions. Perform hand hygiene. .... 3. Establish a clean field .... with all the supplies and equipment that will be necessary. 4. Don gloves. 5. ... Remove soiled dressing. 6. Discard dressing and gloves .... 7 . Perform hand hygiene and don clean gloves. 1. On 9/9/21 during an observation of Patient #4's home visit conducted by Staff #9, the following was observed: a. At 10:20 AM, Staff #9 removed Patient #4's wound dressing with gloved hands, retrieved multiple 4x4 gauze from a clean supply packet without removing his/her dirty gloves and performing hand sanitizing.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on staff interview, review of two (2) of five (5) medical records (#5, #6), and a review of facility documents, it was determined that the facility failed to ensure ongoing assessments are conducted in accordance with facility policy and procedure. Findings include: Reference: Facility policy titled, "Home Health Ongoing Assessments" states: "I. ... Purpose To provide guidelines for assessments of patients during ongoing care. II. Procedure A. During each home visit, the clinician or other discipline will re-evaluate the patient ... B. Using the New Jersey State Practice Acts, American Nursing Association Standards of Care, Visiting Nurse Association of America clinical procedure manual, the clinician will reassess the patient (as appropriate) for: 1. Blood pressure, pulse, respirations, temperature ..." 1. On 9/9/2021, during a review of Medical Record #5, Start of Care (SOC) date 8/14/2021, with Staff #2, skilled nursing visits on the dates indicated below did not contain assessments of the following: a. 9/1/2021 - the patient's temperature b. 9/3/2021 - the patient's temperature and respirations 2. On 9/10/2021, during a review of Medical Record #6, SOC date 5/25/2021, with Staff #2, skilled nursing visits on the dates indicated below did not contain assessments of the following: a. 6/1/2021 - the patient's temperature and respirations 3. The above findings were confirmed on 9/10/2021 at 11:00 AM by Staff #2. N.J.A.C. 8:42 - 7.3(d)4

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on medical record review, staff and family interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure a copy of the home health aide plan of care is maintained in the patient's home. Findings include: Reference: Facility policy titled, "Home Health Certified Home Health Aide Plan of Care and Supervision" states, "... II Procedure: ... G. A current copy of the CHHA [Certified Home Health Aide] plan of care will be maintained in the patient's home. ..." 1. On 9/9/2021 at 8:05 AM, during a visit to Patient #3's home while conducting an observational visit for certified home health aide services, the following was revealed: a. At 8:15 AM, while observing Staff #8 perform care to the patient, an inquiry to Patient #3's spouse was made regarding how the patient and/or spouse knows what the home health aide's assigned responsibilities are to be performed. The spouse presented a form titled, "Patient Care Plan," which has individual sections for the different assigned staff disciplines to complete with information related to that discipline's service/treatment for the the patient. (i) Documented in the "Home Health Aide" section was: "For Personal Care and assistance with activities of daily living." b. At 8:20 AM, upon request, Staff #8, the certified home health aide, confirmed he/she uses his/her phone to view the details of the current home health aide care responsibilities assigned specific for the patient. (i) Staff #8 confirmed the care plan the aide reviews for his/her assigned responsibilities is from the agencies program 'NetSmart' that details the patient-specific assigned responsibilities for the aide to provide care. c. At 8:40 AM, the spouse confirmed, he/she does not exactly know what [name of Staff #8] is suppose to do, but that Staff #8 assists with ADLs [activities of daily living] and stated, "I don't ask [her/him] to do laundry." 2. On 9/10/2021 at 11:10 AM, during review of Medical Record #3 with Staff #1 and Staff #11, the following was revealed: a. Upon request, the current assigned home health aide's care plan/responsibilities for patient #3 was provided and included twenty-two (22) detailed responsibilities with correlating visit frequencies. (i) There was no provided evidence a copy of the aide's assigned responsibilities were provided or maintained in the patient's home. 3. Staff #1 and Staff #11 confirmed the above findings at the time of review. N.J.A.C. 8:42 - 7.5(a)(2)(i)