Every finding on record at Promise Care of Essex County LLC

The facility is not in substantial compliance with Appendix Z-Emergency Preparedness for All Provider and Supplier Types, Interpretive Guidance 484.22, Conditions of Participation for Home Health Agencies.

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 staff interview and review of ten (10) of ten (10) medical records, it was determined the facility failed to ensure all patient's receive an individualized emergency plan as part of their comprehensive assessment. Findings include: 1. Upon review of the "Episode Emergency Preparedness Report" for Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 on 7/14/20, the following was noted: a. The Evacuation Location was the patients current residence. b. Upon interview on 7/14/21, Staff #6 confirmed the patient's current residence should not be the evacuation location. 2. The above findings were confirmed by Staff #1.

Survey date: July 14, 2021 This was a condition level Federal Recertification, Federal COVID-19 Focused Infection Control Survey, and State Re-licensure Survey. Promise Care NJ is not in compliance with Federal requirements under 42 CFR Part 484 regulations for Home Health Agencies and State requirements under Title 8, Chapter 42, Licensing Standards for Home Health Agencies. The following Conditions were determined to be out of compliance: 484.65 Quality Assessment/Performance Improvement 484.70 Infection Prevention and Control Standard level deficiencies were also cited.

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 staff interviews, review of four (4) of eleven (11) medical records (#2, #6, #7, #11), and review of facility policy and procedure, it was determined the facility failed to ensure services ordered by the physician are provided, as indicated in the plan of care. Findings include: Reference: Facility policy, Missed Visit, states, " ... The clinician will contact the team manager and the physician to advise the patient was not seen and will write a coordination note and MD (Medical Doctor) Communication to that effect, stating efforts made to see the patient and their outcomes. ... ." 1. Upon review of Medical Record #2 on 7/14/21, the following was noted: a. An Occupational Therapy evaluation was ordered on 6/14/21. i. The patient did not receive a visit from an Occupational Therapist the week of 6/14/21. ii. There was no evidence the physician was notified of the missed visit. b. A Speech Therapy evaluation was ordered on 6/14/21. i. The patient did not receive a visit from an Occupational Therapist the week of 6/14/21. ii. There was no evidence the physician was notified of the missed visit. 2. Upon review of Medical Record #6 on 7/14/21, the following was noted: a. Skilled Nursing (SN) was ordered 2wk8 (two times a week for eight weeks) on 5/31/21. i. The patient did not receive two SN visits the week of 6/13/21. ii. There was no evidence the physician was notified of the missed visit. 3. Upon review of Medical Record #7 on 7/14/21, the following was noted: a. SN was ordered 2wk8 (two times a week for eight weeks) on 6/13/21. i. The patient did not receive two SN visits the week of 6/20/21. ii. There was no evidence the physician was notified of the missed visit. 4. Upon review of Medical Record #11 on 7/14/21, the following was noted: a. Home Health Aide (HHA) services were ordered 2wk1 (two times a week for one week), 3wk1 (three times a week for one week), and 3wk5 (three times a week for five weeks) on 1/10/21. i. The patient never received HHA visits. ii. There was no evidence the physician was notified of the missed visits. 5. The above findings were confirmed with Staff #6 on 7/14/21. N.J.A.C. 8.42-6.2(a)2

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on staff interviews, review of one (1) of one (1) medical record for wound care (#4), and review of facility policy and procedure, it was determined the facility failed to ensure patient care is provided according to the written plan of care established and reviewed by a physician. Findings include: Reference: Facility policy, Plan of Care states, "...The physician who initiates home health care is responsible for ongoing plan of care... ." 1. On 7/12/21 at 2:53 PM, during a home visit for Patient #4, Staff #2 was performing wound care. Staff #2 cleaned the wound and applied Santyl, then realized there were no supplies in the home to complete the wound care. a. Staff #2 searched his/her bag for a 4x4 [4 inches by 4 inches] gauze to cover the wound. i. There was no 4x4 in the bag. b. Staff #2 proceeded to cover the wound with three (3) band aide type adhesives. 2. Review of Medical Record #4 on 7/14/2021 indicated the following: a. The Plan of Care/Physician order for Certification Period 5/21/2021 to 7/19/2021 states, "... Skilled nurse to perform / teach wound care ... apply Santyl cover with 4x4 bordered foam [gauze]... ." b. There was no evidence of a physician order for a substitute wound covering. 3. Staff #1 confirmed Staff #2 used a band aide type adhesive to cover Patient #1's wound. N.J.A.C. 8.42-7.3(d)(4)

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on staff interviews, review of facility documents, and review of facility policies and procedures, it was determined the facility failed to ensure an effective, ongoing, data-driven quality assessment and performance improvement (QAPI) program, is maintained. Findings include: 1. The facility failed to ensure that the QAPI program tracks, measures, and analyzes quality indicators of performance (Cross refer to Tag G-642). 2. The facility failed to ensure performance improvement activities focused on high risk, high volume, or problem prone areas. (Cross refer to Tag G-646). 3. The facility failed to collect, measure, and analyze data to monitor the effectiveness of safety and quality of care (Cross refer to Tag G-654). 4. The facility failed to conduct annual performance improvement projects (Cross refer to Tag G-658). N.J.A.C. 8.42- 14.2(b) N.J.A.C. 8.42- 14.2(d)(1)

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on review of facility documents and staff interview, it was determined the facility failed to ensure its QAPI (quality assurance performance improvement) program measures, analyzes, and tracks quality indicators of performance. Findings include: 1. Upon review of the Risk Management Meeting Minutes dated April 2020, the following was noted: a. There were twelve (12) patient occurrences. All were unwitnessed falls. 2. Upon review of the Risk Management Meeting Minutes dated October 2020, the following was noted: a. There were nine (9) patient occurrences. All were unwitnessed falls. 3. Staff #1 was unable to provide evidence that the QAPI program tracks, measures, and analyzes falls or other adverse events. N.J.A.C. 8.42- 14.2(b)

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure performance improvement activities focused on high risk, high volume, or problem prone areas. Findings include: Reference: Facility policy, Performance Improvement Plan, states, "... The development and implementation of corrective action plans when problems or areas requiring improvement are detected. ... ." 1. Upon review of the Risk Management Meeting Minutes dated April 2020, the following was noted: a. There were twelve (12) patient occurrences. All were unwitnessed falls. 2. Upon review of the Risk Management Meeting Minutes dated October 2020, the following was noted: a. There were nine (9) patient occurrences. All were unwitnessed falls. 3. Review of the Complaint and Grievance Log identified Patient #11 and Patient #12 as having issues with not receiving supplies. 4. Review of the Complaint and Grievance Log identified Patient #11 as having issues with not getting a home health aide. 5. Upon interview, Staff #12 confirmed that the above problem prone areas were not being addressed by performance improvement. N.J.A.C. 8.42- 14.2(b) N.J.A.C. 8.42- 14.2(d)(1)

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure performance improvement activities, analyze adverse patient events, and implement preventive actions. Findings include: 1. On 7/12/21 during a home visit for Patient #4, it was observed and confirmed by Staff #2 that there were no supplies in the home. a. Review of the nurses note dated 7/8/2021 states, "SN ordered supplies needed from (Name of Supplier)." b. Review of the Complaint and Grievance Log identified Patient #11 and Patient #12 as having issues with not receiving supplies. c. A request was made to Staff #1 for the data collected regarding patients not receiving supplies. d. Staff #1 stated they did not analyze patient supply issues in order to implement preventive actions. 2. Upon review of the Risk Management Meeting Minutes dated April 2020, the following was noted: a. In the meeting minutes dated April 2020, there were twelve (12) patient occurrences. All were unwitnessed falls. b. In the meeting minutes dated October 2020, there were nine (9) patient occurrences. All were unwitnessed falls. c. Staff #1 stated that they did not analyze patient falls in order to implement preventive actions. N.J.A.C. 8.42- 14.2(b) N.J.A.C. 8.42- 14.2(d)(1)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on staff interview, it was determined the facility failed to ensure that performance improvement projects are conducted annually. Findings include: 1. Upon interview on 7/14/2021, Staff #1 stated Staff #12 is responsible for the agency's QAPI program. 2. Upon request, Staff #1 was unable to provide documented evidence of any performance improvement projects.

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, staff interviews, review of facility policies and procedures, and review of nationally recognized guidelines, it was determined the facility failed to ensure its infection control program adheres to acceptable standards of practice. Findings include: 1. The facility failed to ensure its infection control program adheres to acceptable standards of practice (Cross refer to Tag G-682). 2. The facility failed to ensure its infection control program includes methods for surveillance, identification, prevention, and investigation of communicable diseases (Cross refer to Tag G-684). 3. The facility failed to ensure its infection control program includes a qualified infection control nurse (Cross refer to Tag G-686). N.J.A.C. 8.42-12.1(b) N.J.A.C. 8.42-12.2(b) N.J.A.C. 8.42-12.2(b)3

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 observation during one (1) of four (4) home visits, staff interviews, and review of facility documents, it was determined the facility failed to ensure their infection prevention policies regarding manufacturer's instructions for use, are followed. Findings include: Reference: SaniZide Plus Germicidal Solution manufacturer's instruction for use states, "... Contact time [Between One (1) to Ten (10) minute contact time depending on the organism]." 1. During a home visit on 7/12/21, Staff #3 was observed spraying SaniZide Plus Germicidal Solution to disinfect patient equipment and then placed the equipment in the bag without waiting for the appropriate contact time. 2. The above findings were confirmed by Staff #1. B. Based on observation and staff interview in three (3) of four (4) home visits, it was determined the facility failed to ensure that laptops/tablets are cleaned according to facility policy. Findings include: Reference: Facility policy, Care Maintenance and Use of Laptop Computer/Tablet/Device, states, "...14. No stickers should be put on the computer. 15. The exterior of the notebook should be kept clean with a soft, damp cloth. No alcohol or detergent should be used. 16. The Screen/LCD/monitor should be wiped with a soft, dry cloth. No glass cleaner, alcohol or detergent should be used. 17. The patient is to sign a visit verification on the tablet at the conclusion of the visit. When the patient is signing, the clinician should hold the tablet for the patient to prevent cross contamination and the patient signs with stylus [sic] after which the clinician wipes the stylus with an alcohol wipe." 1. During a home visit for Patient #1 on 7/12/21, the following was observed: a. After documentation on the tablet was completed and Patient #1 signed the laptop using his/her finger, Staff #2 placed the laptop back into his/her bag without cleaning it. i. The screen was visibly dirty. 2. During a home visit for Patient #3 on 7/12/21, the following was observed: a. Staff #3 placed the tablet directly on the bed, on top of the patient's bedsheets. b. After documentation on the tablet was completed, Staff #3 sprayed the tablet with SaniZide Plus Germicidal Solution. c. At the end of the patient visit, Staff #3 handed the tablet and stylus to Patient #3's caretaker and requested a signature. Staff #3 proceeded to place the laptop back into his/her bag without cleaning the tablet or wiping the stylus with an alcohol pad. 3. During a home visit for Patient #4 on 7/12/21, the following was observed: a. After documentation on the tablet was completed, Staff #2 placed the laptop in front of Patient #4 for a signature. Patient #4 pulled the tablet towards her/him and rested it on her/his chest to sign. The stylus was not wiped down with an alcohol pad. i. The screen was visibly dirty. 4. The above findings were confirmed by Staff #1. N.J.A.C. 8.42- 12.2(b) C. Based on observation and staff interview in one (1) of four (4) home visits, it was determined the facility failed to ensure separation between clean and soiled equipment was maintained. Findings include: 1. On 7/12/21, during a home visit for Patient #4, the following was noted: a. Staff #2 placed a barrier on a clean surface and placed a blood pressure cuff, stethoscope, pulse oximeter and oral thermometer on the barrier. b. After taking the patient's temperature with an oral thermometer, Staff #2 placed the oral thermometer on the left side of the barrier. c. After checking the patient's oxygen level, Staff #2 placed the pulse oximeter on the left side of the barrier next to the oral thermometer. d. After checking the patient's blood pressure and listening to the patient's heart rate, Staff #2 sprayed the blood pressure cuff and stethoscope with SaniZide Plus Germicidal Solution and then placed the blood pressure cuff and stethoscope directly next to the pulse oximeter and oral thermometer, which had not been disinfected. 2. The above findings were confirmed with Staff #1. D. Based on observation during three (3) of four (4) home visits, staff interviews, and review of facility documents, it was determined the facility failed to ensure hand hygiene is performed in accordance with facility policy. Findings include: Reference: Facility policy, Hand Washing, states, " ...Procedure: A. Wet hands under warm water and apply soap. B. Rub hands together vigorously for at least 15 seconds C. Rinsed thoroughly ... Indications for Handwashing and Hand Antisepsis: C. If gloves are changed during a procedure and hands are not visibly soiled... "waterless antiseptic hand cleaner may be used to decontaminate between glove changes... ." 1. On 7/12/21, during a home visit for Patient #1, the following was noted: a. Staff #2 was washing his/her hands at the kitchen sink. Staff #2 rubbed his/her hands vigorously for ten (10) seconds. 2. On 7/12/21, during a home visit for Patient #2, the following was noted: a. Staff #4 was discarding trash with gloved hands. Staff # 4's gloved hand touched the lid of the garbage can. Staff #4 did not immediately remove his/her gloves and wash his/her hands. 3. On 7/12/21, during a home visit for Patient #4, the following was noted: a. Staff #2 was performing wound care while his/her cell phone began ringing. Staff #2, while wearing gloves, silenced the cell phone. b. Staff #2 continued with wound care without removing his/her gloves and performing hand hygiene. i. Staff #2 failed to disinfect her/his cell phone device. 4. The above findings were confirmed with Staff #1 and #13. N.J.A.C. 8.42-12.2(b) N.J.A.C. 8.42-12.2(b)3

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 observation and staff interview, it was determined the agency failed to ensure COVID-19 screening questions are completed prior to visitors entering the facility. Findings include: Reference: Facility policy, Agency Office Visitor Screening Protocol, states, "1. Any visitor who presents in the office will be screened in the reception area. Screening will include for fever and symptom monitoring [sic]. ...The screening will be documented on the Standard Screening Tool." 1. Upon arrival to the reception area on July 12, 13, & 14, 2021, staff did not screen visitors for fever or ask visitors questions regarding COVID-19 symptoms. 2. The above findings were confirmed by Staff #1. N.J.A.C. 8.42- 8.42-12.2(b)

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 staff interviews conducted on 7/12/2021 and 7/14/2021, it was determined that the facility failed to ensure that the facility had a qualified day to day infection control nurse. Findings include: 1. On 7/12/2021 at 10:05 AM, Staff #1 stated that Staff #12 was the day to day infection control nurse. 2. Review of Staff #12's personnel file in the presence of Staff #6, failed to show any documents that identified Staff #12 as the day-to-day infection control nurse. a. Review of the Staff #12's job description indicated he/she was the QAPI/PI Coordinator. 3. Upon telephone interview with Staff #13 on 7/14/2021 at 1:53 PM, Staff #13 confirmed he/she did not have any additional infection control training. 4. The above findings were confirmed with Staff #1, Staff #6 and Staff #13. N.J.A.C. 8.42-12.1(b)

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on staff interview, review of one (1) of one (1) medical record for wound care (#4), and review of facility policies and procedures, it was determined the facility failed to ensure skilled professionals practice according to the facility's wound care policies and procedures. Findings include: Reference: Facility policy, Wound Care states, "To provide wound care... Equipment: Dressing (as needed)... ." 1. On 7/12/21 at 2:53 PM, during a home visit for Patient #4, Staff #2 was performing wound care. Staff #2 cleaned the wound and applied Santyl, then realized there were no supplies in the home to complete wound care. a. Staff #2 searched her/his bag for a 4x4 [4 inches by 4 inches] gauze to cover the wound. i. There was no 4x4 in the bag. 2. Upon interview on 7/14/2021 at 12:14 PM, Staff #1 confirmed Staff #2 should have had a 4x4 gauze dressing in his/her bag in case there weren't any in the patient's home. N.J.A.C. 8.42-7.2(b)