Every finding on record at Virtua-West Jersey Health System

This report is the result of an unannounced Federal Recertification and State Re-licensure surveys completed June 25, 2025, at Virtua Home Care at West Jersey. It was determined the facility is in substantial compliance with the requirements of Emergency Preparedness regulation 42 CFR 484.102 Condition of Participation for Home Health Agencies for this survey.

This report is the result of unannounced standard-level Federal Recertification and State Re-licensure surveys, completed June 25, 2025, at Virtua Home Care at West Jersey. 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 medical record review, staff interviews and facility policy review, it was determined that the facility failed to ensure that all patients receive a “Notice of Medicare Non-Coverage” at discharge in one of five discharged patient medical records reviewed (Patient (P) 17). Findings include: Facility policy titled, “Home Care Notification of Medicare Non-Coverage (NOMNC)” states, “…Procedure: A. Home Care uses the approved Notice of Non-Coverage form (CMS-10123) to notify Medicare beneficiaries that Medicare services are ending…C. The RN [nurse] or Social Worker or designee delivers and explains the NOMNC to patient/representative at least two days before the last day of covered care…” On 6/24/25, a review of P17’s medical record took place in the presence of Staff (S)9 (Quality Nurse). On 5/22/25, P17 was discharged from home care services because he/she met established goals. P17’s medical record lacked evidence of a signed “Notice of Medicare Non-Coverage” form. On 6/24/25 at 2:52 PM, S9 confirmed P17 had Medicare, and his/her medical record did not contain a “Notice of Medicare Non-Coverage.”

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (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 medical record review, staff interview, and review of facility policies, it was determined the facility failed to ensure communication with the physician was documented when a missed visit occurred, in two of the five medical records reviewed (Patient (P)10 and P11). Findings include: Facility policy titled, "Cancellation of Visits/Not Home Not Found," last revised on 11/2023, stated, "… II. Purpose: A. To assure patient … receives visits as outlined in the Plan of Care … IX. Definitions: … Not Home Not Found (NHNF) … C. If the clinician is called by the patient or office and notified prior to the visit that the patient is not available … 3) A new visit date and time should be scheduled for the patient. 4) If the visit is not rescheduled within the same Medicare week, the physician must be notified. The clinician will document notification of the physician in the EMR [Electronic Medical Record] under "clinical notes" … E. If the visit is a NHNF the clinician would: … 3) Write a clinical note stating: a. why the visit was missed/changed … d. The rescheduled date and time agreed upon by the patient/CG [Care Giver] … 4) If the visit is not scheduled within the same Medicare week, the physician must be notified. The clinician will document notification of the physician in the EMR under "clinical notes" … F. Any visit that is determined to be NHNF will be considered a missed visit …" On 06/24/25 at 1:10 PM, a review of P10's medical record was conducted with Staff (S)10 (Quality Registered Nurse) and revealed the following: A review of P10’s Plan of Care Orders for the certification period beginning 5/8/25 showed visit orders for the Physical Therapist (PT) as "… 2 visits every week for 4 weeks …" from 5/18/25 to 6/14/25. During the week of 5/18/25 to 5/24/25, the medical record lacked evidence that P10 received PT twice during this week. The medical record lacked evidence that the provider was notified that the patient did not receive any PT visits during the week of 5/18/25 to 5/24/25. The findings were confirmed by S3 (Director of Quality Management and Infection Control) and S10. On 06/24/25 at 1:35 PM, a review of P11's medical record was conducted with S10 and revealed the following: A review of P11’s "Plan of Care Orders" for the certification period beginning 5/24/25 showed orders for the Home Health Aide (HHA) as "… 2 visits every week for 4 weeks …" from 6/8/25 to 7/5/25 and orders for a Registered Nurse (RN) as "… 1 visit every week for 10 weeks …" from 5/24/25 to 7/22/25. During the week of 6/8/25 to 6/14/25, P11 received only one visit by the HHA on 6/12/25. On 06/10/2025 at 10:56 AM, a documented telephone conversation between S20 (Medical Assistant) and the family member of P11 stated, "spoke with patient’s [child] who agreed to HHA visits 2x/wk [week] on Tues/Thurs. … starting on 6/12/25 …" The medical record lacked evidence of notification to the provider regarding the missed visits. The findings were confirmed by S3 and S10. During the week of 6/15/25 to 6/21/25, the medical record lacked evidence that P11 received an RN visit during this week. On 6/12/2025, an RN note documented that P11 requested for the next visit on 6/18/25 to be cancelled due to a doctor’s appointment. The medical record lacked evidence of notification to the provider for the missed visit. The findings were confirmed by S3 and S10. On 06/24/25 at 1:40 PM, when questioned about missed visits, S10 stated, "The doctor should be made aware of missed visits." NJAC 8:42-6.1(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 observations in three out of three home visits (Patient (P)1, P2, and P5), staff interviews, and a review of facility policies, it was determined the facility failed to ensure: 1) staff follow infection control procedures when entering the clinical bag and the cleaning and disinfection equipment, to prevent the risk of cross-contamination; 2) maintain sterility during a PleurX drainage procedure. Findings include: 1) Facility policy titled, "Bag Technique and Contents," dated 5/2024, stated, "… II. Purpose: A. The purpose of this policy is to prevent the infection/ and avoid cross contamination of the clinical bag and its equipment … X. Procedure … **Remember** if you need to re-enter the clinical bag during the visit, hand hygiene MUST be performed after unzipping before re-entering the clinical bag … XI. Set Up of Fields: … 10. Used equipment will be cleaned and disinfected … 11. Clean equipment is placed on the clean field to air dry … 12. … perform hand hygiene and return the cleaned equipment to the clinical bag …" On 06/23/25 at 12:14 PM, in the presence of Staff (S)5 (Rehab Supervisor), S4, a Speech Language Pathologist (SLP) was observed providing care for P1. At 12:15 PM, S6 accessed his/her bag without washing and/or sanitizing his/her hands and proceeded to set up the clean and dirty barriers for patient care. On 06/23/25 at 2:09 PM, in the presence of S7 (Team Manager Home Health), S6, a Registered Nurse (RN) was observed providing care for P2. At 2:12 PM, while completing a medication reconciliation, S6 touched medication bottles and then proceeded to access his/her bag without washing and/or sanitizing his/her hands. At 2:20 PM, S6 completed vital signs on P2. During this process, P2 had a pulse oximeter on his/her left index finger and placed his/her left hand on the clean barrier field. At 2:25 PM, S6 cleaned the pulse oximeter, stethoscope, thermometer, and sphygmomanometer (blood pressure cuff) and placed them on the potentially contaminated clean barrier field. S6 then replaced the items into his/her bag without recleaning them. On 06/24/25 at 8:46 PM, in the presence of S7, S8, a RN was observed providing care for P5. At 9:04 AM, S8 accessed his/her bag without washing and/or sanitizing his/her hands and proceeded to put away the pulse oximeter, stethoscope, thermometer, and sphygmomanometer. On 06/23/25 at 2:54 PM, S6 confirmed the above findings and stated that hand hygiene should be performed prior to entering his/her bag. 2) Facility policy titled, "Pleural [thin linings that surround the lungs] and Peritoneal [refers to tissue that lines the abdominal cavity] Drainage System Care & Management," last revised on 3/2025, stated, "… II. Purpose: A. To provide the means for drainage of accumulating pleural fluid [liquid in the small space surrounding the lungs] … III. Policy: A. To minimize risk of infection … XI. Procedure: A. Adhere to Standard precautions and hand hygiene protocol … G. Open kit and establish sterile field … Section III, B. Intermittent Vacuum Drainage: PleurX [small flexible tube inserted into the chest or abdomen to drain excess fluid]: Prepare to Drain: 1. Set up a clean, clear workspace on a table or counter … 7. Open the Procedure Pack pouch … 8. Set bundle with sterile wrapping on the workspace … Carefully unfold the sterile wrapping … The items and the inside of the wrapping are sterile. Do not touch them with ungloved hands or other non-sterile items. 9. Remove the bottle with the drainage line from the bag. The items in the drainage kit bag are sterile … 11. … Be careful not to let the outside of the gloves touch anything non-sterile … Put on gloves …" At 2:33 PM, S6 was observed performing the pleural fluid drainage procedure for P2. S6 washed his/her hands, opened the PleurX drainage bottle package, and placed the bottle on the table using his/her bare hands. S6 pushed his/her computer aside with his/her bare hand and then with the same hand repositioned the PleurX drainage bottle on the table. S6 did not perform hand hygiene after touching his/her computer and PleurX drainage bottle. S6 opened the PleurX Procedure Kit and without performing hand hygiene, put on the sterile gloves. While wearing the sterile gloves, S6 touched the potentially contaminated, non sterile PleurX drainage bottle, and repositioned it on the table. While wearing the same gloves, S6 removed the cap on the PleurX drainage bottle and connected the tubing to P2’s left indwelling catheter (thin flexible drainage tube). After the drainage procedure was completed, S6 disconnected the tubing and applied a sterile dressing to the P2’s left indwelling catheter. On 06/23/25 at 2:54 PM, an interview was conducted with S6. When the findings were reviewed with S6, S6 nodded in agreement and stated that the PleurX drainage procedure is a sterile procedure. On 06/25/25 at 10:41 AM, an interview was conducted with S21, the Infection Prevention Manager, S21 stated that the PleurX drainage procedure is a sterile procedure performed in a clean environment. NJAC 8:42-12.2(b)

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on observation, staff interview, medical record review, and review of facility documents, it was determined the facility failed to complete accurate and appropriate records in accordance with the facility’s Home Health Aide (HHA) education and job description. Facility document titled, “Overview” date of last change 02/20/2025 states, “… Job profile Name: Home Health Aide… Position Responsibilities: Knowledgeable of and supports the plan of care under the direction of the RN… Submits all documentation (care plan, time sheets, API, etc) accurately and timely…” Facility policy titled, “Home Health Aide Education” last revised 06/2024 states, “Procedure: A. The Home Health Aide (HHA) will be asked to demonstrate a series of personal care skills to establish competency in these areas… 2) Observation, reporting, and documentation of patient status, care, and services furnished.” On 06/23/2025 at 2:02 PM, a home care visit was conducted with Patient (P)3, in the presence of Staff (S)12 (Clinical Manager) and S13 (Home Health Aide [HHA]). S13 was observed assisting P3 with foot care with the use of a collapsible foot bath basin. S13 was observed washing P3’s feet, dried them with a small towel, and applied lotion. At 2:15 PM, S13 bathed P3’s back, dried with small towel, and applied lotion to P3’s back. At 2:18 PM, S13 assisted P3 with the application of compressions socks per P3’s request. P3 ambulated himself/herself back into bed. No further care observed or offered. On 06/24/2025 at 12:59 PM, medical record review for P3 revealed “Aide Home Visit… Care Plan Visit Documentation… [check mark] Intervention: Aide encourage patient fluid intake... [check mark] Intervention: Aide incontinence care and change adult diaper… [check mark] Intervention: Aide assist with oral care…” Surveyor did not observe the care documented as completed to have been provided to P3 during this home visit. Further medical record review for P3 revealed “Aide Home Visit… Care Plan Visit Documentation… Intervention: Aide meal preparation [Exclamation] Variance: Patient refused… Intervention: Aide catheter care [Exclamation] Variance: Patient refused Visit Notes: Patient refused… Intervention: Aide assist with shaving [Exclamation] Variance: Patient refused Visit Notes: Patient refused… Intervention: Aide perform hair care [Exclamation] Variance: Patient refused Description: Aide to assist patient in hair grooming including to Shampoo Hair and Brush Hair. Visit Notes: Patient refused…” Surveyor did not observe the P3 to have been asked for the care documented as refused to have been offered to P3 during this home visit. On 06/24/2025 at 1:50 PM, an interview was conducted with S3 (Director of Quality Management and Infection Control) and S10 (Quality Registered Nurse). Upon interview, S10 confirmed that the HHA should provide each task on the patients’ care plan. S10 confirmed that a “check mark” on a patients’ care plan indicates completed care that was provided during their home visit. The above findings were reviewed with S3 and S10. N.J.A.C. 8:42-7.5(3)