Every finding on record at Valley Home Care Inc.

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 Recertification and State Re-licensure survey conducted at Valley Home Care on 4/16-4/18/2024, to determine compliance with 42 CFR Part 484 - Conditions of Participation for Home Health Agencies; and State requirements under Title 8, Chapter 42 - Home Health Agency Licensing Standards. Standard-level deficiencies were cited.

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 observation, medical record review, staff interview, and review of policy and procedure, it was determined that the facility failed to ensure: 1) patient pain is assessed in accordance with physician orders and facility policy; and 2) patient medications are reviewed in accordance with physician orders and facility policy. Findings include: 1.) Facility policy "Pain Assessment, Reassessment, and Symptom Management," approved 4/22, states, "... Procedure: I. Assessment: … B. Each patient receiving skilled services will have a comprehensive pain assessment initially and on an ongoing basis using established criteria, including: 1. Location 2. Intensity 3. Duration 4. Frequency 5. Character (e.g., throbbing, aching, sharp, etc.) 6. Current pain therapy or treatment 7. Effectiveness of current therapy or treatment … D. The patient's assessment of the pain is conducted by using a standardized and validated tool appropriate for age and developmental status. … " On 4/16/24 at 12:42 PM, during a home visit of Patient (P) 1, Staff (S)12, a Registered Nurse, was observed performing P1's wound care. S12 stated, "Does it hurt?" and P1 replied, "a little, not bad." At 12:44 PM, while wrapping the patient's leg, P1 indicated the leg was, " very sensitive" and S12 stated, "I think this is the leg you always have a lot of pain with." As S12 was wrapping the patient's leg, P1 was observed flinching and stated, "Ouch" and S12 stated "sorry." An assessment of the patient's pain, using a standardized pain tool or criteria established in the facility policy was not observed. On 4/17/24 at 2:45 PM, S12's Visit Note Report from P1's 4/16/24 visit was reviewed. S12 documented the following Pain Assessment: “Was Pain Assessed? Yes; Was Pain Subjectively Assessed? Yes; Does the Client Report Pain? No; Indicate Standardized Pain Tool Used to Determine Patient's Pain Level: Numeric; Numeric: Standardized Pain Tool Used to Determine Patient's Pain Level: 0- Patient has no pain; Were Objective Symptoms observed? No; Are there any additional Details that need to be provided to Describe the Client's Pain? No.” Review of P1's "Home Health Certification Period and Plan of Care" for Certification Period 4/8/24 - 6/6/24 revealed P1's Orders of Discipline and Treatments, including "...Skilled Nurse for observation and assessment of pain, pain management regimen and skilled teaching related to pain management. Skilled Nurse to intervene with increased pain level to minimize complications. …" On 4/18/24 at 1:40 PM, these findings were reviewed with S1 (Manager of Clinical Education). 2.) Facility policy titled, "Medication Management and Administration," approved 3/23 states, "...II Medication Management A. As part of the initial comprehensive and ongoing clinical assessments conducted by nursing and therapy staff, a review of all medications the patient currently uses will be performed in order to identify any potential adverse effects, drug reactions, and duplicate therapy. …" On 4/16/24 at 12:19 PM, S12, a Registered Nurse, was observed during a home visit for P1. During the visit, a review of patient medications was not observed. On 4/17/24 at 2:45 PM, S12's Visit Note Report from P1's 4/16/24 visit was reviewed. In the Narrative, S12 documented "Medication Reconciliation Conducted: Y [YES]. Medication Reconciliation Issues Identified and Resolved: Y [YES]". On 4/18/24 at 1:45 PM, during an interview with S1(Manager of Clinical Education), S1 stated that a comprehensive medication reconciliation is completed at every start of care visit, and for subsequent visits, the nurse will ask if there are any changes to the patient's medications, or any new medications. The above finding was confirmed with S1. N.J.A.C. 8:42-6.2(a)(4)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure the ordered frequency of skilled nursing visits corresponds with skilled nursing visits conducted in two (2) out of 17 patients (Patients (P)5 and P10). Reference the facility policy titled, “Care Planning, Assessment, and Reassessment” approved 4/24, states, “The Plan of Care is consulted with the physician or allowed practitioner and approved by the physician or allowed practitioner. …2. Planning and development of the patient care plan will include: …d. The frequency and duration of visits …”. On 4/17/24 at 10:50 AM, medical record review of P10 revealed on 4/3/24 at 6:17 PM, a “Physician Order” that stated, “Order Description: ADD SN [skilled nurse] VISITS FOR WOUND CARE… Service Changes: Calendar Frequency: SN EFFECTIVE 03/31/2024 5WK1 [five visits for one week] …”. P10’s medical record lacked evidence five skilled nurse visits were conducted the week of 3/31/24. On 4/18/24 at 10:50 AM, S3 confirmed on the week of 3/31/24 the frequency of nurse visits ordered was five and P10 only had four skilled nursing visits conducted. P10’s medical record revealed on 4/6/24 at 1:19 PM, a “Physician Order” that stated, “Order Description: ADDITIONAL SN VISIT FOR WOUND CARE…. Service Changes: Calendar Frequency: SN Effective 04/07/2024 4WK1 [four visits a week for one week] …”. P10’s medical record lacked evidence four skilled nurse visits were conducted on the week of 4/7/24. On 4/18/24 at 11:20 AM, S1 stated, “The nurses will call the doctor and verbalize a request for more visits, the doctor will verbalize the approval of additional visits, then the nurse goes into the patient’s calendar and adds in the visits.” S1 indicated the nurse should indicate in the “Description” of the “Physician Order” note how many visits the doctor approved. S1 confirmed there were discrepancies between the calendar frequency and visits completed according to the medical record. On 4/18/24, review of Patient (P) 5's medical record revealed a "Physician Order" on 4/8/24 at 11:34 AM, with the following documented: "Order Description: Add SN [skilled nurse] visits for WD [wound] care, recert [recertify] home care." There was no documentation of the amount of skilled nurse visits to be added in the description. "Service Changes: Calendar Frequency: SN [skilled nurse] effective 4/07/2024 4WK1 [4 visits a week for 1 week] …" P5's medical record lacked documentation that four nursing visits were conducted the week of 4/7/24. At 11:30 AM, S1 (Manager of Clinical Education) confirmed there was no additional documentation of the number of skilled nursing visits ordered by the physician, and that the week of 4/7/24, three nursing visits had occurred instead of four. N.J.A.C. 8:42-6.2(a)(6)

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 during home visits of two of two patients (Patient (P)2, and P7), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that re-useable equipment is decontaminated after each use. Findings include: On 4/16/24 at 12:07 PM, during a home visit of P2, Staff (S)2, the Registered Nurse (RN) was observed placing his/her bag on a clean barrier. S2 then removed a second bag that contained medical equipment, including a blood pressure cuff and stethoscope. At 12:13 PM, S2 was observed applying the blood pressure cuff directly to P2’s exposed skin. After obtaining P2’s blood pressure, S2 then placed the used blood pressure cuff back into the second bag without disinfecting the blood pressure cuff. S2 then used the stethoscope on P2 and disinfected the diaphragm of the stethoscope. The entirety of the stethoscope was not disinfected. S2 then placed the stethoscope on top of the dirty blood pressure cuff in the second bag. On 4/17/24 at 11:25 AM, during a home visit with P7, S9 an RN was observed using a stethoscope on P7. S9 then disinfected the diaphragm of the stethoscope and returned it to the bag. The entirety of the stethoscope was not disinfected. S9 then applied a blood pressure cuff directly to P7’s exposed skin. After obtaining P7’s blood pressure, S9 then returned the used blood pressure cuff to the bag without disinfecting it. On 4/18/24 at 2:20 PM, these findings were reviewed with S1, the Manager of Clinical Education. S1 indicated that he/she is in charge of infection prevention for the facility. S1 stated, “the blood pressure cuff and stethoscope should be cleaned after being used. S1 also stated, “any equipment that touches a patients skin needs to be disinfected.” S1 indicated that disposable plastic sleeves are available to use rather than putting the blood pressure directly on the patient’s skin. Facility policy titled, “Infection Control: Bag Technique,” approved 4/22, states, “Purpose: To maintain the integrity of the clinician bag and prevent transmission of infection. …3. Open reusable equipment section to access equipment needed for patient care. 4. Clean diaphragm of stethoscope, thermometer, pulse ox and stylus with alcohol wipe before and after patient contact. Once cleaned with alcohol return equipment to reuse section of the clinician bag. …” N.J.A.C. 8:42-12.2(b)(3)

The facility is 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, for this survey only.

Survey dates: July 6, 7, 8, 2021 This was a Federal Recertification Survey, a Federal COVID-19 Focused Infection Control Survey, and State Re-licensure Survey. Valley Home Care 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.

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 of one (1) of three (3) skilled nursing visits, staff interviews, review of facility policies and procedures, and review of Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to ensure separation of clean and soiled equipment is maintained and standard precautions and bag technique are performed in accordance with facility policy. Findings include: Reference #1: Facility policy, "Infection Control - Standard Precautions" states, "... II. Hand Hygiene A. ... Perform hand rubbing with an alcohol based preparation before and after patient contact, immediately after gloves are removed... when moving from a dirty body site to a clean site on the same patient... . III. Gloves A. Wear gloves (clean, nonsterile gloves are adequate) when touching... and contaminated items. B. Put on clean gloves just before touching... non-intact skin. C. Change gloves and wash hands between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. D. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces... . E. Perform hand hygiene immediately to avoid transfer of microorganisms to other patients or environments. ... ." Reference #2: CDC 2007, "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings," (http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf), page 50 states, "During patient care, transmission of infectious organisms can be reduced by adhering to the principles of working from 'clean' to 'dirty', and confining or limiting contamination to surfaces that are directly needed for patient care." Reference #3: Facility policy, "Infection Control: Bag Technique" states, "Procedure... 2. Perform hand hygiene before entry into bag. ... ." 1. During a home visit for Patient #2, on 7/6/21, the following was observed: a. Staff #6 removed the patient's neck-wound dressing with ungloved hands. i. Staff #6 sanitized his/her hands, touched the back and seat cushion of a chair, recontaminating his/her hands. Staff #6 then donned gloves to perform care to the neck wound. ii. During wound care, while wearing contaminated gloves, Staff #6 retrieved clean supplies from the supply bag without first performing hand hygiene and changing his/her gloves. iii. At 1:45 PM, Staff #6 removed his/her gloves and picked up a barrier drape, and retrieved additional supplies from the supply bag. Staff #6 did not perform hand hygiene after removing his/her gloves. b. At 2:10 PM, using only one (1) glove on his/her right hand, Staff #6 performed a saline cleanse to the skin around the tracheotomy site. i. Staff #6 removed and placed his/her glove, used alcohol wipes, gauze and wrappers, onto the patient's kitchen table next to a pile of clean dressing supplies, co-mingling the clean supplies and used items. ii. With ungloved hands, Staff #6 picked up and discarded used wound dressings, into a plastic bag on the floor, then entered his/her bag without performing hand hygiene. iii. Staff #6 retrieved a computer tablet from his/her bag without performing hand hygiene. He/she then placed the tablet on the contaminated area of the kitchen table, picking up the computer tablet without performing hand hygiene. 2. The above findings were confirmed with Staff #1 and Staff #3 on 7/6/21 at 2:25 PM. N.J.A.C. 8.42-12.2(b) N.J.A.C. 8.42-12.2(b)3 N.J.A.C. 8.42-12.2(b)(6)i

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on review of two (2) of three (3) medical records (#3 and #6), staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure the registered nurse includes appropriate elements to the Home Health Aides assignment for rendering safe and effective care. Findings include: Facility policy, "Home Health Aides - Assignment & Supervision Policies" states, "... Procedures: I. Assignment of Home Health Aides... Home Health Aide care plan is developed by a Registered Nurse... The Home Health Aide plan of care will include... The type of service/procedure to be provided. ... Specific procedure to be performed including... frequency... ." 1. Review of Medical Record #3, on 7/8/21, revealed the following: a. The patient's Start of Care (SOC) date was 6/23/2021. On the "Aide Care Plan Report," the RN chose for "Frequency" - "Per Patient Request" for the following: i. Fall Risk ii. Observe Physical/Mental Changes iii. Report Falls iv. Report S/S [signs and symptoms] of Infection To RN v. Report Change in Pain Level To RN vi. Impaired Hearing 2. Review of Medical Record #6 on 7/8/21, revealed the following: a. The patient's Start of Care (SOC) date was 6/4/2021. On the "Aide Care Plan Report," the RN chose for "Frequency" - "Per Patient Request" for the following: i. Fall Risk ii. Observe Physical/Mental Changes iii. Report S/S [signs and symptoms] of Infection To RN iv. Report Change in Pain Level To RN v. Do Not Resuscitate 3. Upon interview on 7/8/21 at 2:40 PM, Staff #3 confirmed that "Frequency" for the above care/services should not be "Per Patient Request" and should have been "Every Visit." N.J.A.C. 8:42-6.2(a)