Every finding on record at Robert Wood Johnson Visiting Nurses, Inc

This was a Federal Complaint Survey and Federal Focused Infection Control Survey conducted on September 24, 2021. Robert Wood Johnson Visiting Nurses is not in compliance with 42 CFR Part 484, Conditions of Participation for Home Health Agencies for this complaint (NJ00147677).

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 (#1), staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure all patients receive services in accordance with physician orders. Findings include: Reference: Facility policy, "Plan of Care" states, "... 1. At the time of initial assessment, the clinician communicates with the HCP to develop the patient's plan of care based upon the patient's identified needs. ... 6. The plan of care is based upon the physician's orders and may include equipment, supplies and services required to meet the patient's needs. ... ." 1. Review of Medical Record #1 on 9/24/21 revealed the following: a. An intake referral update entered on 6/15/21 states, "Updated referral information: As per phone conversation with [name of physician's assistant], PA for [name of physician]; Cleanse surgical site with sterile water and DSD; 3 times a week." b. The "Home Health Certification and Plan of Care" for certification period 6/16/21 to 8/14/21 states, "Orders of Discipline and Treatments: Skilled nurse to provide evidence based wound care treatments per physician order as follows: As per phone conversation with [name of physician's assistant] PA for [name of physician]; Mid lumbar cleanse surgical site with sterile/normal saline water pat dry cover with dry dressing 3 times a week and PRN... ." c. The frequency of visits for SN indicated on the "Home Health Certification and Plan of Care" states, "SN 2wk2, 1wk2" (skilled nursing visit two times per week for two weeks, once a week for two weeks). The frequency of visits identified on the plan of care was not in accordance with the physician's order. d. Review of SN visit notes indicated that the patient was admitted to the agency on 6/16/21. For week 6/16/21 to 6/20/21, the patient received two (2) SN visits. 2. Upon interview at 1:35 PM, Staff #1 stated, "I was not aware that the physician ordered services for the patient three (3) times per week."

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on medical record review (#1), staff interview, and review of facility policies and procedures, it was determined the facility failed to ensure that plans for discharge are communicated with patients and/or their representatives and a discharge summary is sent to the patient's primary care provider within five (5) business days of discharge. Findings include: Reference #1: Facility policy, "Patient Assessment and Reassessment Process" states, "... 5. Ongoing communication with the interdisciplinary team including the patient, representative, and HCP will be documented in the patient's record. This communication will include, but not limited to... d. Discharge Planning. ... Process: Discharge from Agency... Who: New Jersey licensed RN, PT, SLP, OT... Assessment Tool... The Discharge Summary is sent to the primary care provider and any health care professionals who will be responsible for providing care to the patient in the community. ... Time Frame: Within 5 business days of discharge or notification of discharge. .. ." Reference #2: Facility policy, "Coordination/Communication of Care" states, "... 4. The staff will document, in the patient's electronic medical record (EMR), the coordination of care and communication between the Home Care team, patient, legal and/or patient selected representative (if any), caregiver, the patient's physician, and other physicians who are directly related to the patient's POC. ... ." 1. Review of Medical Record #1 on 9/24/21 revealed the following: a. A Client Coordination Note entered on 6/23/21 by Staff #1 states, "TCT (telephone call to) patient... Patient was offered skill nurse visit for today, instructed patient's caregiver to change dressing on Friday. Patient declined visit and all further homecare agency services stating 'I get [sic] my staples removed on Monday anyway and will no longer need services anyway.'" (i) A Case Communication Note entered on 6/23/21 by Staff #1 states, "TCT [name of physician] office. No answer. Voicemail left with this writer callback number." b. There was no evidence in the medical record that plans for discharge were communicated with the patient or his/her representative. c. There was no evidence in the medical record that Staff #1 spoke with the physician, or someone from his/her office, informing them that the patient was discharged from the agency. d. There was no evidence in the medical record that a discharge summary was sent to the patient's primary care provider within five (5) days of the patient's discharge. 2. Upon interview at 2:05 PM, Staff #1 confirmed that the medical record lacked evidence of the patient receiving discharge instructions. He/she stated, "I gave the patient discharge instructions, but I didn't document it."

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 staff interviews and review of facility policy and procedure, it was determined the facility failed to ensure that all visitors are screened for COVID-19 prior to entering the building. Findings include: Reference: Facility policy, "COVID-19 Health Screening and Medical Management" states, "... 1. Visitors/non-employees will complete daily health screening (printer, emailed or verbal). 2. May be assessed by an on-site designated screener prior to entering the building and submit to Employee Health for record keeping. ... ." 1. Upon arrival to the facility on 9/24/21 at 9:45 AM, this surveyor was greeted by Staff #6, who asked this surveyor the nature of the visit and notified Staff #1 of the visit. Staff #1 arrived to the lobby area and escorted this surveyor to an office for privacy. a. Staff #1 or Staff #6 did not request this surveyor complete a daily health screening or screen this surveyor for COVID-19, prior to entering the building. 2. Upon interview at 11:00 AM, Staff #4 confirmed that all visitors are required to complete a daily health screening prior to entering the building.