Every finding on record at Visiting Nurse Association of Northern New Jersey, Inc.

A Federal Allegation Survey was conducted at The Visiting Nurse Association of Northern New Jersey on February 9 and 10, 2021, which resulted in Standard Level deficiencies. The facility is in compliance with 42 CFR Part 484, Conditions of Participation (CoPs) for Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician may choose to include. This ELEMENT is not met as evidenced by: A. Based on staff interviews, review of facility policies and procedures, and review of one (1) of two (2) medical records, it was determined the facility failed to ensure discharge planning is included in the patient's individualized plan of care. Findings include: Reference #1: Facility policy, Discharge Criteria, states, " ... The patient is informed of discharge plan in a timely manner and acknowledges understanding reason. ... Discharge planning begins at time of admission and will be reflected in the documentation. ... The patient's continuing care needs, if any, are assessed at discharge. ... A complete list of reconciled medications will be provided to each patient on discharge. The list will be explained to the patient/family and interaction documented. ..." 1. Upon review of Medical Record #2, the following was noted: a. According to the Visit Note Report dated 10/8/20, Patient #1's last agency visit was 10/8/20. The visit was performed by a Registered Nurse (RN). The visit type was an RN Subsequent visit. b. According to the Visit Note Report dated 10/31/20, the Visit Type was RN Discharge Data Collection Only - No Visit Made. i. The Narrative states, "Discharge Patient from Agency. Mrs. [name of family member] ... disappointed that services have ended." c. There was no documented evidence that discharge planning was provided to the patient or family while the patient was receiving agency services. d. There was no documented evidence that the patient was informed of a discharge plan in a timely manner and acknowledged understanding of the reason. e. There was no documented evidence the patient's continuing care needs were assessed at discharge. f. There was no documented evidence that a complete list of reconciled medications was provided to the patient on discharge or that the list was explained to the patient or family. 2. The above findings were confirmed with Staff #2 and Staff #4. Reference #2: Facility policy, Discharge Summary, states, "A Discharge Summary form will be completed by the Skilled Nurse or Therapist. The Discharge Summary will include, but is not limited to: ... Reason for Discharge ... Patient/Family post-discharge instructions ... The original Discharge Summary form from each service will be filed in the medical record." 1. Review of the Discharge-Transfer Summary Report for Patient #1, revealed the following: a. The Discharge-Transfer Summary Report was sent to the physician on 10/13/20. b. The reason for discharge says "Other (Please provide details in Coordination Note)." i. No Coordination Note was provided. ii. The reason for discharge was not documented in the discharge summary. c. The Patient/Family post-discharge instructions were not included in the discharge summary. d. The original Discharge Summary form from each service was not filed in the medical record. 2. The above findings were confirmed with Staff #2 and Staff #4. B. Based on staff interviews and review of medical records, it was determined that the facility failed to ensure for (1) one of (2) two medical records the care plan is implemented. Findings include: 1. On 2/10/2021, at 11:30 AM, upon review of Medical Record #3, the following was indicated: a. The Home Health Certification and Plan of Care was reviewed for the Certification Period 12/4/2020 to 2/1/2021 states, " ... Orders of Discipline and Treatments: ... Skilled Nurse to provide and instruct regarding fall prevention interventions. ... ." b. The Home Health Certification and Plan of Care reviewed for the Certification Period 2/2/2021 to 4/2/2021, states, " ... Orders of Discipline and Treatments: ... Skilled Nurse to perform multifactor fall risk assessment and implement intervention to decrease risk of falls. Skilled Nurse to instruct on home safety, impact of polypharmacy, environmental safety, and fall prevention. ... ." 2. Staff interviews indicated the following: a. On 2/10/2021 at 11:30 AM, Staff #3 was asked where the fall assessments and interventions could be viewed in the medical record. b. At 11:45 AM, Staff #3 telephoned Staff #8 to confirm where the Nursing Fall Assessments and Interventions are documented. i. Staff #8 stated that the Nursing Fall Assessments and Interventions would be documented in the Narrative Note section of the Assessment. 3. There were no Fall Assessments nor Interventions documented in the Narrative Note, by the Nurse, on the following dates of the Skilled Nursing Visits: a. January 14, 2021 b. January 19, 2021 c. February 2, 2021 4. Staff #3 had the opportunity to read the record and was not able to find the fall assessments nor interventions. 5. The above was confirmed by Staff #3 and shared with Staff #1, Staff #2, and Staff #4 during the exit conference.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on staff interviews, medical record reviews, and review of facility documents, it was determined that the facility failed to ensure that, for (1) one of (2) two medical records following a patient fall, Skilled Nursing Reassessments are completed. Findings include: Reference #1: The Facility Policy titled, "Fall Reduction Program", states, " ... Purpose: To reduce the risk of patient harm resulting from falls. ... Procedure: ... 2. Reassessment for fall risk will be performed when a patient experiences a fall ... . ... ." 1. On 2/10/2021 at 12:30 PM, upon review of Medical Record #7, the following was indicated: a. The Occupational Therapist visit note, dated 2/5/2021 states," ... Therapy Assessment/Plan: ... Patient reports slid off stand assist chair prior evening. ... . No injury but needed to call police to raise off floor. ... . Care Coordination: ... What Discipline did you communicate with: Supervisor, PT [Physical Therapy], RN [Registered Nurse]. ... ." i. There was no evidence in the medical record that a follow-up visit was made for a post fall reassessment by a Nurse. b. On 2/10/2021 at 1:00 PM, Staff #3 stated that the Occupational Therapist and/or Supervisor should have entered a request for an order for the Nurse Reassessment visit. 2. The above was confirmed by Staff #3, and shared with Staff #1, Staff #2, and Staff #4 during the exit conference.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on one (1) of two (2) home visit observations, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that its policy for handwashing is implemented. Findings include: Reference: Facility policy titled, "Hand Hygiene Policy and Compliance Program" states, "Purpose: To prevent transfer of germs and transmission of infections to patients and caregivers... . Procedure: ... II. Hand hygiene technique (non-surgical) ... B. Hand washing with soap and water... (IB) Wash for 20 seconds." 1. On 12/9/2021 at 1:50 PM, a home visit was conducted to observe the care of Patient #3. At 2:20 PM, Staff #5 washed his/her hands for fifteen (15) seconds. b. Hand hygiene was not performed in accordance with facility policy and procedure. 2. The above findings were reviewed with Staff #1.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on staff interviews and review of one (1) of two (2) medical records, it was determined the agency failed to ensure that services are provided as ordered by the physician and indicated in the plan of care. Findings include: 1. Upon review of Medical Record #1, the following was noted: a. Patient #1's start of care date was 12/14/20. b. The Physician orders for skilled nursing are as follows: two times a week for one week, one time a week for 4 weeks, one every two weeks for four weeks, two PRN (as needed) IV (Intravenous), and one PRN status. c. There was a missed skilled nursing visit the week of 12/27/20 to 1/2/21. 2. The above finding was confirmed with Staff #2 and Staff #4.