Every finding on record at Mercer Care Partners Medical Home Health Care, LLC

This report is the result of an unannounced Federal Recertification Survey and State Re-Licensure Survey completed on June 3, 2026 at Mercer Care. It was determined the facility is not in substantial compliance with the requirements of Emergency Preparedness regulation 42 CFR 484.102, Condition of Participation for Home Health Agencies (HHAs) for this survey.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on observation, staff and patient interview, a review of facility documents, and medical record review, it was determined the facility failed to develop a policy and procedure to ensure individualized emergency plans are provided to each patient and kept in the patients home for seven of seven patients (P) whose home care visits were observed (P1, P2, P3, P4, P5, P6, and P7). On 06/01/26 at 1:00 PM, a home visit was conducted for P2 with S9. During the visit, a review of P2’s admission packet revealed it lacked evidence of an individualized Emergency Preparedness (EP) plan. At 1:36 PM, an interview was conducted with P2’s spouse. He/she could not recall receiving an individualized EP plan from the facility. A review of P2’s Admission Visit Note completed on 05/05/26, stated “Emergency Preparedness: Evacuation Location: PER MERCER COUNTY. Acuity Status: 2 – SAME DAY…” The note lacked evidence of an individualized evacuation location for P2. On 06/02/26 at 9:30 AM, a home visit was conducted for P5 with S13. During the visit, a review of P5’s admission packet revealed it lacked evidence of an individualized Emergency Preparedness (EP) plan. At 10:00 AM, an interview was conducted with P5. He/she could not recall receiving an individualized EP plan from the facility. A review of P5’s Admission Visit Note completed on 05/06/26, stated “Emergency Preparedness: Evacuation Location: AS PER MERCER. Acuity Status: 2 – SAME DAY…” The note lacked evidence of an individualized evacuation location for P5. On 06/03/26 at 10:00 AM, a home visit was conducted for P7 with S8. During the visit, a review of P7’s admission packet revealed it lacked evidence of an individualized Emergency Preparedness (EP) plan. At 10:07 AM, an interview was conducted with P7’s caregiver. He/she could not recall receiving an individualized EP plan from the facility. A review of P7’s Admission Visit Note completed on 04/28/26, stated “Emergency Preparedness: Evacuation Location: FRONT DOOR. Acuity Status: 2 – SAME DAY…” The note lacked evidence of an individualized evacuation location for P7. Findings include: Facility policy titled “Management of the Environment of Care,” dated 12/09/19, stated “…5. All patients will be triaged for assistance and support needed and their disaster status identified at the Start of Care as part of the comprehensive assessment and additionally if their condition changes. This will be reviewed and revised as needed by the clinician if they are hospitalized during the episode of have significant change in status and at the time of Recertification…” The Emergency Preparedness (EP) plan documented in P1’s Admission "Visit Note Report" completed on 04/03/26, stated “…Evacuation Location: AS PER MERCER COUNTY…Acuity Status: 2.- SAME DAY…Disaster Status: CHAIR BOUND…Interventions Provided: …DETAILS/COMMENTS: ESTABLISHED AN EMERGENCY PLAN…” On 06/01/26 at 12:43PM, a home care visit was conducted for P1. During the visit, P1’s admission packet was reviewed and revealed that it lacked an individualized EP plan. At 12:59 PM, P1 stated that he/she would “call 911” if there were to be an emergency and he/she had to evacuate his/her home. The EP plan documented in P3’s Admission "Visit Report Note" completed on 04/03/26, stated “…Evacuation Location: FRONT DOOR…Acuity Status: 2- SAME DAY…Disaster Status: AMBULATORY W/ ASSIST… Interventions Provided: …ESTABLISHED AN EMERGENCY PLAN…” On 06/01/26 at 01:55 PM, a home care visit was conducted for P3. During the visit, P3 stated that he/she would "grab my oxygen and leave,” if there was an emergency and he/she had to evacuate. P3 reported that he/she did not recall discussing emergency plans with the home care team. The EP plan documented in P4’s Admission "Visit Note Report" completed on 04/22/26, stated “…Evacuation Location: PER MERCER COUNTY…Acuity Status: 2.- SAME DAY…Disaster Status: AMBULATORY W/ ASSIST…Interventions Provided: … ESTABLISHED AN EMERGENCY PLAN…” On 06/02/26 at 10:15 AM, home care visit was conducted with P4. S4 explained that upon admission he/she did discuss with P4 his/her emergency plan. S4 stated that he/she documents the EP plan in the EMR and confirmed that he/she did not provide a written individualized EP plan for P4 to keep in his/her home. The EP plan documented in P6’s Admission Visit Note completed on 04/22/26, stated “…Evacuation Location: AS PER MERCER COUNTY…Acuity Status: 2.- SAME DAY…Disaster Status: CHAIR BOUND…Interventions Provided: … ESTABLISHED AN EMERGENCY PLAN…” On 06/02/26 at 01:05 PM, a home care visit was conducted for P6. the private caregiver for P6 was not aware of a written emergency plan located in the home. He/she stated that P6’s daughter did not discuss that with him/her yet. On 06/03/26 at 01:13 PM, S1 confirmed that there is no written individualized emergency plan provided to patients to keep in their homes. S1 stated that the emergency plan is addressed at the start of care for all patients, and that the “Evacuation Location” in the medical record is supposed to state where the patient would go, such as with family, and was not sure why “FRONT DOOR” would be an option to document. Findings include: On 06/01/26 at 12:43PM, a home care visit was conducted for Patient (P) 1. During the visit, P1’s admission packet was reviewed and revealed that it lacked an individualized EP plan. At 12:59 PM, P1 stated that he/she would “call 911” if there were to be an emergency and he/she had to evacuate his/her home. A review of P1's Admission Visit Note completed on 04/03/26, stated, "Emergency Preparedness: Evacuation Location: AS PER MERCER COUNTY…Acuity Status: 2 - SAME DAY…" The note lacked evidence of an individualized evacuation location for P1. On 06/01/26 at 1:00 PM, a home visit was conducted for P2 with S9. During the visit, a review of P2’s admission packet revealed it lacked evidence of an individualized Emergency Preparedness (EP) plan. At 1:36 PM, an interview was conducted with P2’s spouse. He/she could not recall receiving an individualized EP plan from the facility. A review of P2’s Admission Visit Note completed on 05/05/26, stated, “Emergency Preparedness: Evacuation Location: PER MERCER COUNTY. Acuity Status: 2 – SAME DAY…” The note lacked evidence of an individualized evacuation location for P2. On 06/01/26 at 01:55 PM, a home care visit was conducted for P3. During the visit, P3 stated that he/she would "grab my oxygen and leave,” if there was an emergency and he/she had to evacuate. P3 reported that he/she did not recall discussing emergency plans with the home care team. A review of P3’s Admission Visit Note completed on 04/03/26, stated, "Emergency Preparedness: Evacuation Location: FRONT DOOR…Acuity Status: 2- SAME DAY…" The note lacked evidence of an individualized evacuation location for P3. On 06/02/26 at 10:15 AM, home care visit was conducted with P4 with S4. S4 explained that upon admission he/she did discuss with P4 his/her emergency plan. S4 stated that he/she documents the EP plan in the EMR and confirmed that he/she did not provide a written individualized EP plan for P4 to keep in his/her home. A review of P4’s Admission Visit Note completed on 04/22/26The EP plan documented in P4’s Admission "Visit Note Report" completed on 04/22/26, stated “…Evacuation Location: PER MERCER COUNTY…Acuity Status: 2.- SAME DAY…Disaster Status: AMBULATORY W/ ASSIST…Interventions Provided: … ESTABLISHED AN EMERGENCY PLAN…” On 06/02/26 at 9:30 AM, a home visit was conducted for P5 with S13. During the visit, a review of P5’s admission packet revealed it lacked evidence of an individualized Emergency Preparedness (EP) plan. At 10:00 AM, an interview was conducted with P5. He/she could not recall receiving an individualized EP plan from the facility. A review of P5’s Admission Visit Note completed on 05/06/26, stated “Emergency Preparedness: Evacuation Location: AS PER MERCER. Acuity Status: 2 – SAME DAY…” The note lacked evidence of an individualized evacuation location for P5. The EP plan documented in P6’s Admission Visit Note completed on 04/22/26, stated “…Evacuation Location: AS PER MERCER COUNTY…Acuity Status: 2.- SAME DAY…Disaster Status: CHAIR BOUND…Interventions Provided: … ESTABLISHED AN EMERGENCY PLAN…” On 06/02/26 at 01:05 PM, a home care visit was conducted for P6. the private caregiver for P6 was not aware of a written emergency plan located in the home. He/she stated that P6’s daughter did not discuss that with him/her yet. On 06/03/26 at 10:00 AM, a home visit was conducted for P7 with S8. During the visit, a review of P7’s admission packet revealed it lacked evidence of an individualized Emergency Preparedness (EP) plan. At 10:07 AM, an interview was conducted with P7’s caregiver. He/she could not recall receiving an individualized EP plan from the facility. A review of P7’s Admission Visit Note completed on 04/28/26, stated “Emergency Preparedness: Evacuation Location: FRONT DOOR. Acuity Status: 2 – SAME DAY…” The note lacked evidence of an individualized evacuation location for P7. On 06/03/26 at 01:13 PM, S1 confirmed that there is no written individualized emergency plan provided to patients to keep in their homes. S1 stated that the emergency plan is addressed at the start of care for all patients, and that the “Evacuation Location” in the medical record is supposed to state where the patient would go, such as with family, and was not sure why “FRONT DOOR” would be an option to document.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on personnel record review, review of facility documents, and staff interview, it was determined the facility failed to ensure staff received emergency preparedness training annually in accordance with facility policy for four of five personnel files reviewed (Staff (S) 1, S2, S9, and S11). Findings include: Facility policy titled, “Emergency or Disaster Preparedness” dated 12/09/19, stated, “…Procedure…18. There will be initial in-servicing [sic] for all new employees and annual training on our Disaster Policy and Plan for all direct staff and those providing service under contract. Staff knowledge will be demonstrated through competency testing…” Facility document titled, “[Facility Name] All Hazard Emergency Preparedness Plan” dated 01/26/26, stated, “…Planning: Administration:…4. All staff will receive emergency preparedness training appropriate for their position at orientation and then on a yearly basis. Staff will understand their roles and response protocols…” On 06/03/26, the personnel files for S1, S2, S9, and S11 were reviewed and lacked evidence of annual Emergency Preparedness training. On 06/03/26 at 12:02 PM, an interview was conducted with S1. S1 explained he/she felt that participation in the mock drill would cover a staff member’s annual education. S1 reported all staff receive an email with information about the mock drill and emergency preparedness prior to the facility’s mock drills. S1 was unable to provide a copy of the email sent to the staff or evidence of staff receipt of this education. S1 confirmed that only staff working on the day of the mock drill participate in this training.

This report is the result of an unannounced standard-level Federal Recertification and State Re-licensure Survey completed on June 3, 2026 at Mercer Care. 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.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on staff interview, facility document review, and review of medical records, it was determined the facility failed to ensure all patients with Medicare coverage receive a “Notice of Medicare Non-Coverage (NOMNC)” at least two days prior to the date of discharge in four of five discharged Medicare patients (Patients (P) 13, P14, P15, and P16) reviewed. Findings include: Reference: 42 CFR 405.1200 (b)(1): Timing of notice. A provider must notify the beneficiary of the decision to terminate covered services no later than 2 days before the proposed end of the services. If the beneficiary's services are expected to be fewer than 2 days in duration, the provider must notify the beneficiary at the time of admission to the provider. If, in a non-residential setting, the span of time between services exceeds 2 days, the notice must be given no later than the next to last time services are furnished. A review of P13’s medical record revealed a “Visit Note Report” dated 03/14/26, which stated, ““…Visit Type:.. PT [Physical Therapy] Discharge from Agency…” A “Client Coordination Note Report” dated 03/17/26, stated, “…Notice of Medicare Provider Non-Coverage was mailed to patient 3/17/26…” This was three days after P13 was discharged. The medical record lacked evidence that P13 received a NOMNC at least two days prior to the date of discharge. On 06/02/26 at 1:25 PM, Staff (S) 1 explained that after P13’s discharge, it was identified that his/her medical record was missing a NOMNC. S1 reported that once this was identified, the NOMNC was mailed to the patient. A review of P14’s medical record revealed a “Visit Note Report” dated 03/05/26, which stated, “… Visit Type: ... PT Discharge from Agency…” P14's medical record contained a NOMNC signed by P14's caregiver on 03/05/26, the same day P14 was discharged. The medical record lacked evidence the patient received the NOMNC at least two days prior to the date of P14’s discharge. On 06/02/26 at 1:25 PM, S1 confirmed P14’s NOMNC was provided on the day of discharge, not at least two days prior. A review of P15’s medical record revealed the patient was discharged from the Home Health Agency (HHA) on 12/30/25. The medical record lacked evidence the patient received a NOMNC prior to discharge. On 06/02/26 at 1:25 PM, S1 confirmed P15’s medical record was missing a signed NOMNC. A review of P16’s medical record revealed a “Client Coordination Note Report” dated, 12/23/25, which stated, “…Note…Patient seen for discharge from agency…” A NOMNC was signed by P16 on 12/23/25, the same day as discharge. The medical record lacked evidence of a signed NOMNC at least two days prior to the date of P16’s discharge. On 06/02/26 at 2:15 PM, S1 confirmed P16’s NOMNC was signed on the day of discharge, not at least two days prior. On 06/03/26 at 11:47 AM, a NOMNC policy was requested. S1 reported the facility does not have a NOMNC policy.

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 review of facility policy and procedure, it was determined the facility failed to ensure: 1. staff perform hand hygiene in accordance with facility policy, and 2. disinfect reusable patient care equipment and electronic medical devices in accordance with facility policy and/or instructions for use (IFU) of cleaning supplies, in one of seven home visits conducted (Patient (P)2). Findings include: 1. Facility policy titled, “Hand Hygiene," dated 10/07/13, stated, “… Procedure: 1. Hand-hygiene technique: When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry…” On 06/01/26 at 1:00 PM, Staff (S)9 was observed providing care for P2 during a home visit. At 1:20 PM, after assisting P2 transfer from the toilet to a rollator (wheeled walker), S9 applied hand sanitizer. S9 rubbed his/her hands together and then blew on his/her hands. S9 stated, “Have to make sure they are dry.” S9 then contacted P2 with his/her hands and began therapy exercises. At 1:42 PM, an interview was conducted with S9. When asked about the process for hand hygiene, S9 stated, he/she applies the hand sanitizer and waits for his/her hands to dry. S9 stated, if they are not completely dry, he/she might blow on them. S9 stated, he/she has never spit on his/her hands while blowing on them and would reapply hand sanitizer if he/she felt spit on his/her hands. On 06/03/26 at 1:00 PM, an interview was conducted with S1. When asked about the process for drying hands after applying hand sanitizer, S1 stated, hands should be rubbed together until dry. S9 stated, staff should not blow on their hands to speed the drying process. 2. Facility policy titled, “Bag Technique and Equipment”, stated, “…VIII. Management of Electronic Medical Records Devices in the Home: … B. Wipe down Electronic Medical Record devices, i.e. smart phones, tablets, etc. with agency-approved disinfectant wipes, such as alcohol wipes, after completing each patient visit… Allow to dry.” Disinfecting wipes labeled, “Sani-Cloth Germicidal Disposable Wipes,” stated, “Directions For Use: … TO DISINFECT AND DEODORIZE HARD, NONPOROUS SURFACES: … Unfold wipe and thoroughly wet surface. Allow surface to remain visibly wet for one (1) minute. Let air dry… FOR USE ON HARD, NONPOROUS SURFACES ONLY.” On 06/01/26 at 1:00 PM, S9 was observed providing care for P2 during a home visit. At 1:03 PM, S9 was observed taking P2’s blood pressure using an automatic wrist blood pressure monitor. The material on the cuff of the monitor was a light gray, soft, porous fabric with visible light brown stains on the fabric. At 1:27 PM, S9 used a Sani-Cloth wipe to clean the wrist blood pressure monitor and cuff. At 1:29 PM, P2 used his/her finger to sign S9’s tablet. At 1:30 PM, S9 used a Sani-Cloth wipe to clean the tablet. After cleaning the tablet, S9 placed it in his/her bag immediately without allowing one-minute dry time. At 1:42 PM, an interview was conducted with S9. When asked about the wrist blood pressure monitor, S9 stated, he/she had purchased the monitor and it was not supplied by the facility. When asked about cleaning of equipment, S9 stated he/she uses Sani-Cloth wipes supplied by the agency which have a dry time of one minute. On 06/03/26 at 1:00 PM, an interview was conducted with S1. When asked about cleaning of vital sign equipment, S9 stated, staff using their own blood pressure monitor and cuff should clean it with disinfecting wipes just like a regular blood pressure monitor and cuff provided by the facility. When asked if the Sani-Cloth disinfecting wipes provided by the agency were effective for cleaning a soft, porous surface such as the fabric on the cuff of the Wrist Blood Pressure Monitor used by S2, S9 stated she was not sure and would have to look into it. S9 stated, after staff clean a tablet with a Sani-Cloth wipe, the tablet should be allowed to dry for at least one minute before it is returned to the bag. Cross reference: NJAC 8:42-12.2(b)(3)

Survey date: February 12-15, 2024 The facility 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 Mercer Care, February 12-15, 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.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to ensure Patient (P)16 received written notice of non-covered care, prior to discharge. Findings include: On 2/15/24, a review of P16’s medical record indicated he/she was discharged from homecare services on 9/7/23. Review of P16's medical record lacked evidence that he/she received a Notice of Medicare Non-Coverage (NOMNC); a notice that indicates when care is set to end from a home health agency. On 2/15/24, S2 (Clinical Supervisor), confirmed these findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to ensure, that services ordered by the physician are provided, as indicated in the plan of care. Facility policy titled, “Missed Visits” revised 10/2021, states, “I. Policy Visit patterns are determined during the care planning phase and are included as part of physician orders. Missed visits cause alterations to these visit patterns and physicians should be informed of these changes and the reason for the alteration. II. Procedure: 1. If there is an alteration to the visit pattern causing the visits to fall under the number ordered on the 485 or most recent physician verbal order, the physician should be notified via phone or other method – i.e.. electronic notification, fax, secure email or other agency approved mechanism. The missed visit reason should be included in this communication to the physician and accessible to the interdisciplinary team. …”. On 2/14/24 during a review of Patient (P)8’s medical record, the “Home Health Certification and Plan of Care" for Patient (P) 8, for the certification period of 12/22/23 to 2/19/24, revealed the following: The section labeled Frequency/Duration of Visits stated, "PT [Physical Therapy] 1WK1, 2EVERY2WK2, 2WK3, 2WK3, 1WK1 [one time a week for one week, two times a week every 2 weeks for 2 weeks, two times a week for three weeks, and once a week for one week]." The week of 1/14/24, P8’s medical record indicated only one physical therapy visit was made. The “Client Coordination Note Report” dated 1/21/24 states “…Note Type: MISSED VISIT NOTIFICATION. …Note: MUST DOCUMENT IF RESCHEDULING VISIT AND/OR THAT MD HAS BEEN CALLED FOR NOTIFICATION OF ALTERATION IN THE ORDERED VISIT PATTERN (DOCUMENT NAME OF MD CALLED & NAME/TITLE OF WHO YOU SPEAK WITH AT MD OFFICE) SNOWING. “ On 2/15/24 at 2:15PM, S2 (Clinical Director) confirmed that the missed visit notification for the visit scheduled on 1/19/24, by the Physical Therapist, was documented late, on 1/21/24. The missed visit notification did not indicate the physician was aware of the missed visit. On 2/15/24, during a review of P16’s medical record, the “Home Health Certification and Plan of Care," for the Certification Period of 8/16/2023 through 10/14/2023, revealed the following: “Social [SW] effective 8/20/23 1WK1 [one visit each week for one week]” and the following orders for Home Health Aide visits: “HHA [Home Health Aide] effective 8/20/23 1WK5 [one visit each week for five weeks]. The week of 8/20/23, P16’s medical record indicated that a Social Worker visit was missed. The medical record lacked documentation that a Physician was notified. On 2/15/24 at 1:40 PM, S2 confirmed the medical records lacked documentation that a physician was notified of the missed visit for the week of 8/20/23. The week of 8/27/23, P16’s medical record indicated that a Home Health Aide (HHA) visit was missed. A “Missed Visit Notification” entered by the HHA, from 8/30/23, stated, “…Note…PATIENT NO HOME, NO ANSWER FONO [sic].” On 2/15/24 at 11:52 AM, S2 stated, “The HHA would not notify a physician, they would notify the office and the office would notify the physician of the missed visit.” S2 confirmed the medical record lacked evidence the physician was notified of the missed visit from the HHA or from office staff. On 2/15/23, during a review of P17's medical record, the “Home Health Certification and Plan of Care" revealed the following orders, “…effective 8/27/23 HHA [Home Health Aide] 2WK2 [two visits every week for two weeks], 1WK2 [one visit a week for two weeks] 2WK1 [two visits a week for one week] …” The week of 8/27/23, P17’s medical record indicated two HHA visits were missed. P17's medical record lacked evidence that the physician was notified of the two missed visits the week of 8/27/2023. On 2/15/23 at 1:25 PM, during an interview with S2, S2 indicated providers should be notified “within a timely manner.” S2 confirmed the medical record lacked evidence that the physician and/or office staff was notified of the missed visits. N.J.A.C. 8:42-6.2(a)(6)

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, facility policy review, staff interviews, and 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; 2) proper bag technique practices are implemented according to facility policy. Findings include: 1) Reference: The “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 stated, “Recommendations 1. Indications for handwashing and hand antisepsis: ... I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient …” It was determined that the facility practice is not in accordance with the CDC Guideline. Facility policy titled, “Hand Hygiene” dated 3/21, stated, “… If hands are not visibly soiled … use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations, … after contact with inanimate objects or known dirty areas, …” On 2/12/24 at 12:40 PM, Staff (S) 9, an Occupational Therapist (OT), was observed removing a disposable pad from underneath a patient and then rolling it up to throw away, with bare hands. S9 failed to don PPE (Personal Protective Equipment) or perform hand hygiene. On 2/12/24 at 1:45 PM, S10, a Registered Nurse (RN), was observed touching a patient’s urine leg bag, and failed to perform hand hygiene before opening his/her bag. 2) Facility policy titled, “Bag Technique and Equipment” dated 10/23, stated, “… II. Procedure. … C. Place bag on a clean field (plastic, paper, or newspaper barrier, etc.) or clean surface. Do not place on floor. ... E. Prepare a clean area or use a clean field to lay out equipment or supplies. F. Use hand hygiene before removing contents of the bag. …H. After care is given, clean equipment. …VIII. Management of Electronic Medical Record Devices in the Home. … B. Wipe down Electronic Medical Record devices, i.e., smart phones, tablets, etc. with agency-approved disinfectant wipes, such as alcohol wipes, after completing each patient visit. …” On 2/12/24 at 12:05 PM, S3 (Home Health Aide), was observed entering the home, verbally greeting the patient (P4), and setting his/her bag on the living room floor. During an interview with S3 at 1:11 PM, S3 indicated that although the facility provides HHA’s with bags for equipment such as Personal Protective Equipment (PPE), the bag he/she was carrying was his/her personal bag. On 2/15/24 at 1:47 PM, during an interview with S2 (Clinical Director), S2 indicated that bag technique is routinely reviewed with staff; and that all disciplines, including HHA’s, are expected to follow the bag technique and care outlined in the policy. S2 also indicated this applies to any bag carried into the patient’s home; personal or facility issued. On 2/14/24 at 9:35 AM, during a home visit of P6, S4 (Registered Nurse) was observed using a blood pressure cuff and scissors for P6 during the visit. When S4 was finished with the dirty items, he/she placed the items down on the disposable pad, he/she then cleaned them using a Micro-Kill One cloth wipe and immediately placed the items back down on the dirty area of the disposable cloth to dry. On 2/12/24 at 12:40 PM, during an observation with S9, after obtaining vital signs on a patient, S9 was observed picking up the “dirty” blood pressure cuff, cleaning it with a sanitizing wipe, then immediately placing it back into his/her bag. S9 did not utilize a “clean” area, outside of the bag, keeping the dirty and clean equipment separated, nor did he/she allow any time for the blood pressure cuff to dry. On 2/12/24 at 1:45 PM, during an observation with S10, he/she was observed using the sanitizing wipes to clean the dirty equipment, then placed the cleaned equipment back on the “dirty” area where the used equipment came from. S10 did not wipe down the tablet after the patient used it for a signature. S10 also failed to perform hand hygiene before leaving the patient’s room. On 2/15/24 at 2:37 PM, S1(Administrator) and S2 indicated that staff should always utilize two distinct areas; one for clean items and one for dirty items. N.J.A.C. 8:42-12.3 (a)4

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to ensure a supervisory visit was conducted by a Registered Nurse for a patient receiving Home Health Aide Services. Policy titled “Guidelines for Home Health Aide Service," revised 2/19, states, “…II. The services of a Home Health Aide will be supervised by the Registered Nurse. … SUPERVISION OF THE HOME HEALH AIDE …5. If the patient received skilled Medicare services including Home Health Aide Services, the Registered Nurse must perform the on-site supervisory visit to the patient’s home a minimum of every 14 days either while the Aide is present to observe care or when the Aide is not present to interview the patient/family about the care. ....” On 2/15/24, a review of P16’s medical record Plan of Care, for the Certification Period of 8/16/2023 through 10/14/2023, indicated the following orders for Home Health Aide visits: “HHA [Home Health Aide] effective 8/20/23 1WK5 [one visit each week for five weeks]; effective 9/24/23 1WK2 [one visit each week for two weeks]," and the following orders for Skilled Nurse visits: “Skilled Nurse [SN] effective 8/16/23 1WK6 [one visit each week for six weeks], 4 PRN [as needed]; effective 9/17/23 1WK1 [one visit each week for one week]." P16's medical record revealed he/she received HHA visits on 8/23/23 and 9/6/23. P16's medical record revealed he/she received RN visits on 8/23/23, 8/31/23, and 9/6/23. P16’s medical record lacked evidence that an on-site supervisory visit was conducted by a Registered Nurse (RN). On 2/15/24 at 1:40 PM, during an interview with S2, he/she indicated the RN is able to document in the medical record if a visit is a supervisory visit. S2 confirmed there was no documentation of a supervisory visit conducted by a RN in P16’s medical record. N.J.A.C. 8:42-7.5 (a) 2 iii

The facility is in substantial compliance with Appendix Z-Emergency Preparedness for All Provider and Supplier Types, Interpretive Guidance 484.22, Condition of Participation for Home Health Agencies for this survey.

This was a Federal Recertification survey conducted on 3/24/2021, 3/25/2021 and 3/26/2021 which resulted in Standard and Condition level Federal deficiencies. The facility is not in compliance with 42 CFR Part 484, Subpart B requirements, for Home Health Agencies. The facility is not in compliance with the following Condition of Participation: 484.70 Infection Prevention and Control.

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 review of one (1) of six (6) medical records (#7), staff interview, and review of facility policy, it was determined that the facility failed to ensure that missed visit documentation includes physician notification of the missed visit and the reason for the missed visit. Findings include: Reference: Facility policy, "Missed Visits" states, "... If there is an alteration to the visit pattern causing the visits to fall under the number ordered on the 485 or most recent physician verbal order, the physician should be notified via phone or other method... The missed visit reason should be included in this communication to the physician and accessible to the interdisciplinary team." 1. Upon interview on 3/26/21, Staff #2 stated that clinical staff are required to enter missed visit notes in the medical record and notify the physician when visits are missed. 2. Review of Medical Record #7 on 3/26/21 revealed the following: a. For certification period 12/9/20 - 2/6/21, the Home Health Certification and Plan of Care states, "Frequency/Duration of Visits: HHA (Home Health Aide), 1WK1 (once a week for one week), 2WK4 (twice a week for four weeks)... ." b. Review of HHA visits for week 12/9/20 - 12/12/20 revealed one (1) HHA visit was made on 12/10/20, in accordance with the plan of care. c. Review of HHA visits for week 12/13/20 - 12/19/20 revealed one (1) HHA visit made on 12/14/20. The plan of care called for two (2) HHA visits to be made this week. (i) There was no evidence of a missed visit note in the medical record indicating why the visit was missed. (ii) There was no evidence in the medical record that the physician was notified about the missed visit. 3. Staff #2 confirmed the above finding on 3/26/21 at 11:26 AM.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, review of facility policies and procedures, review of nationally recognized guidelines, and staff interview, it was determined that the facility failed to ensure that its infection control program adheres to acceptable standards of practice. Findings include: 1. The facility failed to ensure that its infection control program adhered to acceptable standards of practice (Cross refer to Tag G-682). 2. The facility failed to ensure that its infection control program includes methods for surveillance, identification, prevention, and investigation of communicable diseases (Cross refer to Tag G-684).

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: A. Based on staff interview, and review of CDC guidance, it was determined that the facility failed to ensure visitors are screened for COVID-19 with temperature checks and COVID-19 screening questions, prior to entry into the facility. Findings include: Reference: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations. html, updated February 10, 2021 states, "... Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 or exposure to others with suspected or confirmed SARS-CoV-2 infection... ." 1. Upon arrival to the facility on 3/24/21 at 9:45 AM, the survey team was greeted by Staff #9. He/she asked the survey team about the nature of the visit, then alerted Staff #1 about the visit. Staff #1 escorted the survey team into a conference room at 10:00 AM. a. Staff #1 and Staff #9 did not perform temperature checks on the survey team or ask the survey team COVID-19 screening questions. b. Temperature checks or COVID-19 screening questions were not conducted for the survey team upon their arrival to the facility on 3/25/21 and 3/26/21. 2. Upon interview on 3/26/21 at 9:40 AM, Staff #2 confirmed the facility does not have a COVID-19 screening policy for visitors. He/she stated, "Because we really don't get visitors, we haven't really thought about it." 3. Staff #1 and Staff #2 confirmed the above findings on 3/26/21 at 1:42 PM. B. Based on three (3) of five (5) observations, staff interview, and review of facility policies, it was determined the facility failed to ensure staff perform handwashing for a minimum of fifteen (15) seconds, between glove changes, and prior to entering the bag. Findings include: Reference #1: Facility policy, "Hand Hygiene" states, "... 2. If hands are not visibly soiled... use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations... at the beginning and end of all procedures (i.e. wound care...)... after contact with body fluids or excretions... and wound dressings if hands are not visibly soiled... if moving from a contaminated-body site to a clean-body site during patient care... after removing gloves... IV. Procedure... When washing hands with soap and water... rub hands together vigorously for at least 15 seconds... ." Reference #2: Facility policy, "Bag Technique and Equipment" states, "... F. Use hand hygiene before removing contents of the bag. If additional equipment/supplies are needed from the bag during the visit, the hand hygiene procedure should be repeated if hands have come in contact with blood or body fluids or contaminated materials. ... ." 1. During a home visit for Patient #2 on 3/25/21 at 9:35 AM, the following was observed: a. At 9:40 AM, Staff #3 washed his/her hands for nine (9) seconds. b. At 10:05 AM, Staff #3 washed his/her hands for eight (8) seconds. 2. During a home visit for Patient #4 on 3/25/21 at 12:00 PM, the following was observed: a. At 12:10 PM, Staff #6 was preparing to perform wound care on the patient's stage 2 sacral ulcer. While wearing gloves, Staff #6 cleaned fecal matter from the patient's rectum and buttocks. He/she then doffed his/her gloves, donned a new pair of gloves, and began measuring the wound. (i) Staff #6 did not perform hand hygiene after doffing his/her contaminated gloves and prior to donning a new pair of gloves. b. At 12:11 PM, Staff #6 doffed his/her gloves, then entered the bag and retrieved a pen and additional gloves. After using the pen to write down the wound measurements, Staff #6 donned the new gloves and began to clean the patient's wound. (i) Staff #6 did not perform hand hygiene after doffing his/her gloves, before entering the bag, or prior to donning a new pair of gloves. 3. During a home visit for Patient #5 on 3/25/21 at 11:40 AM, the following was observed: a. At 11:58 PM, Staff #7 washed his/her hands for eleven (11) seconds. b. At 12:02 PM, 12:03 PM, 12:04 PM, 12:05 PM, 12:09 PM, 12:10 PM and 12:11 PM, Staff #7 donned and doffed gloves without performing hand hygiene. c. At 12:14 PM, Staff #7 washed his/her hands for eight (8) seconds. 4. Staff #1 and Staff #2 confirmed the above findings on 3/26/21 at 1:42 PM. C. Based on staff interview, and review of facility documents, it was determined the facility failed to ensure that regular communication and updated CDC Guidelines are shared with staff in order to prevent the transmission of COVD-19. 1. Upon request to Staff #1, the Administrator, on 3/24/2021 for COVID-19 communication documents for 2020, eleven (11) months of Nursing Meeting notes were presented to this surveyor on 3/25/2021. a. The topic of COVID-19 was on the agenda three (3) times; March, April, and November of 2020. 2. Staff #1 and Staff #2 confirmed the above findings on 3/26/21 at 10:50 PM.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on random observation, staff interview, and review of facility policies and procedures, it was determined that the facility failed to develop policies and procedures addressing prevention and control strategies to mitigate the spread of COVID-19. Findings include: 1. During the entrance conference on 3/24/21 at 10:10 AM, Staff #1 confirmed that the facility follows the CDC for its infection control guidelines. a. Upon arrival to the facility on 3/24/21, 3/25/21, and 3/26/21, temperature checks and COVID-19 screening questions were not performed for the survey team. (i) Upon interview on 3/26/21 at 9:40 AM, Staff #2 confirmed the facility does not have a COVID-19 screening policy for visitors. b. During the entrance conference on 3/24/21 at 10:25 AM, Staff #2 stated that the facility does not admit COVID-19 positive patients. He/she also stated that all new admissions are placed on a fourteen (14) day quarantine and monitored for symptoms of COVID-19 and that staff are required to wear N95 masks for the first fourteen (14) days when visiting new patients. (i) During a home visit for Patient #1 on 3/24/21 at 2:55 PM, Staff #4 was asked if he/she wears an N95 mask for new patients. Staff #4 stated, "If the patients are a hospital or rehab referral, then we wear an N95 mask. If the patient is a community referral, then we just wear our regular masks." (ii) During a home visit for Patient #2 on 3/25/21 at 10:23 AM, Staff #3 was asked if he/she wears an N95 mask for new patients. Staff #3 stated, "When the patients come from a rehab or a hospital, we have to wear an N95 for fourteen (14) days. Other than that, we wear our regular masks." (iii) During a home visit for Patient #4 on 3/25/21 at 12:40 PM, Staff #6 was asked if he/she wears an N95 mask for new patients. Staff #6 stated, "We wear an N95 for fourteen (14) days when the patient comes from a hospital or rehab. I don't think we have to wear it when the patient comes from the doctor's office, but I wear mine anyway." d. A request was made to Staff #1 on 3/24/21 for the facility's policy on PPE and the use of N95 facemasks. Staff #1 and Staff #2 confirmed that the facility does not have a policy on PPE or on the use of N95 facemasks. e. During the entrance conference on 3/24/21 at 10:30 AM, a request was made to Staff #1 and Staff #2 for the following COVID-19 and infection control related policies and procedures: COVID-19 testing for patients and staff, employees returning to work after COVID-19 exposure or positive diagnosis, and the reporting of communicable diseases. No policies and procedures were provided. f. On greater than four (4) occasions between 3/24/21 and 3/26/21, Staff #9 was observed sitting at his/her desk without wearing a facemask. Staff #9's desk is located in an open common area near the entrance to the facility. Staff members were observed walking past Staff #8's desk while he/she was not wearing his/her facemask. Staff #8, whose desk is near Staff #9's desk, was present at his/her desk while Staff #9 was not wearing his/her mask.g. During a home visit for Patient #5, on 3/25/21 at 11:40 AM, the following was observed: a. At 11:40 AM, 11:44 AM, 11:58 AM, and 12:03 PM, Staff #7's mask was observed dropping below his/her nose. Staff #7 repeatedly touched his/her mask by pulling it up, and failing to perform hand hygiene. h. Upon interview on 3/26/21, Staff #2 confirmed that the facility does not have a policy regarding the use of facemasks. 2. At 11:50 AM, Staff #1 confirmed that the facility did not have personal protective equipment policies and procedures.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on three (3) of five (5) home visit observations, staff interview, and review of manufacturer's instructions for use (IFUs), it was determined that the facility failed to educate staff on maintaining the recommended contact time for approved disinfectants. Findings include: Reference: Product label, Super Sani-Cloth Germicidal Disposable Wipe states, "... To Disinfect and Deodorize... Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry. ... ." 1. During a home visit for Patient #4, on 3/25/21 at 12:24 PM, the following was revealed: a. Upon interview, Staff #6 indicated he/she uses Super Sani-Cloth germicidal wipes to clean his/her equipment after use. Staff #6 was asked for the contact time of the Super Sani-Cloth germicidal wipes. Staff #6 stated he/she did not know the contact time and was not familiar with that term. Staff #6 was asked how long he/she needed to keep the equipment wet when cleaning it with the Super Sani-Cloth germicidal wipe. Staff #6 stated, "I'm not sure."2. During a home visit for Patient #3, on 3/25/21 at 10:00 AM, the following was revealed: a. Upon interview, Staff #5 indicated he/she uses Super Sani-Cloth germicidal wipes to clean his/her equipment after use. Staff #5 was asked for the contact time of the Super Sani-Cloth germicidal wipes. b. Upon interview, on 3/25/2021 at 10:57 AM, Staff #5 stated he/she was unaware of the contact time for the Super Sani-Cloth germicidal wipes. 3. During a home visit for Patient #5, on 3/25/21, the following was revealed: a. Upon interview on 3/25/2021 at 12:12 PM, Staff #7 handed the tablet to Patient #5, to be signed. Patient #5 used his/her index finger to sign the tablet. b. Staff #7, did not wipe down the tablet after patient use. c. Upon interview, on 3/25/2021 at 12:17 PM, Staff #7 indicated he/she uses Super Sani-Cloth germicidal wipes to clean his/her equipment after use. d. Staff #7 was asked the contact time of the Super Sani-Cloth germicidal wipes. Staff #7 was unaware of the contact time. 2. Staff #1 and Staff #2 confirmed the above findings on 3/26/21 at 1:42 PM.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on review of one (1) of six (6) medical records (#7), staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure registered nurses conduct home health aide (HHA) supervisory visits, a minimum of every fourteen (14) days. Findings include: Reference: Facility policy, "Guidelines for Home Health Aide Service" state, "... 5. If the patient received skilled Medicare services including Home Health Aide services, the Registered Nurse must perform the on-site supervisory visit to the patient's home a minimum of every two weeks either while the Aide is present to observe care or when the Aide is not present to interview the patient/family about the care. ... ." 1. Review of Medical Record #7 on 3/26/21, revealed the following: a. For certification period 12/9/20 - 2/6/21, the Home Health Certification and Plan of Care states, "Frequency/Duration of Visits: SN (Skilled Nurse), 2WK1 (twice a week for one week), 1WK5 (once a week for five weeks); HHA (Home Health Aide), 1WK1 (once a week for one week), 2WK4 (twice a week for four weeks), 1WK1, 1EVERY3WK3 (once every three weeks for three weeks)." b. Review of SN visits revealed SN visits were conducted on 12/9/20 and 12/15/20. Review of HHA visits revealed HHA visits were conducted on 12/10/20, 12/14/20, 12/24/20, and 12/28/20. (i) A nursing note dated 12/29/20, indicated that visits were placed on hold for fourteen (14) days pending the patient's COVID-19 test result. c. There was no evidence that supervisory visits were conducted from 12/9/20 to 12/28/20. The nursing visit note dated 12/15/20 states, "Supervisory Functions - Were Supervisory Functions Performed? No; Indicate Reason Supervisory Functions Not Performed: Not Applicable to Today's Visit." 2. Staff #2 confirmed the above finding on 3/26/21 at 12:30 PM.