Every finding on record at Patient Care New Jersey, Inc

Patient Care is in substantial compliance with Appendix Z - Emergency Preparedness for all Provider and Supplier Types Interpretive Guidance 484.22, Requirements for Home Health Agencies.

This was a Federal Recertification Survey, State Re-Licensure Survey, and Mandatory Vaccination Investigation conducted on February 14, 15, and 16, 2023. Patient Care is not in compliance with 42 CFR Part 484, Conditions of Participation for Home Health Agencies and State requirements under N.J.A.C. 8:42, Home Health Agency Licensing Standards.

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 observation of two of three patients (#3, #16), staff interviews, review of medical records, and review of facility policy and procedure, it was determined the facility failed to ensure that ongoing interdisciplinary assessment findings are incorporated into the plan of care. Findings include: Facility policy titled, "Patient Assessment, Initial and Reassessment (reviewed 01/06/23) states, " … Procedure: … 1. Upon admission and reassessments, the qualified clinician performs the following assessment activities and collects the following data: … b. Patient's strengths, goals, and care preferences, including information that may be used to demonstrate patient's progress toward achievement of goals identified by patient … . " During a home visit for Patient #3 (P3) on 02/14/23 at 3:07 PM, a family member asked Staff #5 (Registered Nurse) what the criteria was for the patient to restart physical therapy services, stating that the patient wanted to increase the use of his/her walker. Staff #5 stated that the patient had just been recertified and "when [his/her] certification period is up again, I'll make sure that the doctor orders it." Upon interview on 02/16/23 at 9:50 AM, Staff #1 (Executive Director) stated that if a patient or family is expressing a need for additional services in the middle of a certification period, the staff member "would call the physician or clinical manager" for evaluation. A review of P3's medical record was conducted, including Staff #3's Visit Note from 02/14/23. There was no documentation of a request for evaluation of physical therapy services. Staff #1 confirmed that there was no documentation in the medical record regarding a request for evaluation of physical therapy services. During a home visit for Patient #16 (P16) on 02/15/23, the following was indicated: Upon interview at 10:40 AM in the presence of Staff #11 (Speech Therapist), P16 was asked if there were any services he/she felt were needed that he/she was not receiving. P16 stated, "I'm not sure if I need a Home Health Aide, but my daughter says that I could use one. So maybe a Home Health Aide." On 02/16/23, review of Staff #11's Visit Note for the home visit conducted for P16 on 02/15/23, revealed that there was no documentation that Staff #11 discussed P16's desire for a Home Health Aide with the RN case manager or the physician. Upon interview on 02/16/23 at 9:58 AM, Staff #1 stated, "If the patient is requesting another service, the clinician would call the doctor directly and report that the patient wanted another service. If the clinician was busy, they may request the help of the PCM (Patient Care Manager) to call the doctor." Staff #1 confirmed that there was no evidence in P16's medical record that Staff #11 notified the nurse of physician that P16 was requesting another service.

This was a Federal Complaint investigation conducted on March 23, 2021. Patient Care Home Health Agency is not in compliance with 42 CFR Part 484, Conditions of Participation for Home Health Agency for this visit (NJ00143680).

Communication with all physicians CFR(s): 484.60(d)(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 review of one (1) of one (1) medical record, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that a physician is updated concerning a change in the patient's status or condition. Findings include: Reference: Facility policy titled, "Coordination of Care, From Admit Through Discharge" states, " ...Procedure: ...In the event that a physician cannot be reached to communicate the status of a patient the following will occur: Medical Director and/or Supervisor will be contacted for assistance with contacting physician ..." 1. On 3/23/21 at 11:05 AM, a review of Medical Record #1 revealed the following: a. On 2/12/21, Staff #5 documented in the "Client Coordination Note Report" that he/she received a telephone call from a family member stating that Patient #1 had a temperature of 101 degrees Fahrenheit since the previous night. (i) Staff #5 documented that he/she was unable to reach anyone at the patient's physician office, and that he/she left a message stating, "pt [patient] is increasingly unstable and requesting return call." (ii) The medical record lacked documentation of a return call from the physician's office or of any further attempts by the facility to contact the physician. 2. The above findings were confirmed with Staff #2 at 12:35 PM.