Every finding on record at Caring Hospice Services of Central Jersey, L.L.C.

Based on staff interviews, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure appropriate coordination of care for one of two patients (#9) who experienced a fall while on service. --- Findings include: On 3/4/24, a review of patient (P)9s medical record revealed that he/she experienced falls on the following dates: 1/22/24, 2/12/24, and 2/19/24. The medical record lacks documentation that a case conference occurred with the care team and P9s caregiver. On 3/4/24 at 2:13 PM, Staff (S)2 reported that P9s multiple falls were discussed with his/her caregiver during a home visit on 2/15/23. S2 confirmed that this conversation was not documented in the medical record. P9s falls were discussed at the Interdisciplinary Group (IDG) meetings and P9s plan of care was updated. S2 confirmed that a case meeting with PCM (Patient Care Manager), Social Worker, Case Manager and Caregiver did not occur as a group. Facility policy titled, ";Fall Prevention," last revised date 3/30/19, states, ";...7. Patients with multiple falls will have case conferences as needed with the PCM, social worker, case manager and care giver to assure all possible interventions are being suggested and implemented...." N.J.A.C. 8:42C-7.1

Based on two of two observations (#1, #2) during home visits, staff interview, and a review of facility policy and procedure, it was determined the facility failed to ensure: 1) staff utilize facility supplied alcohol-based hand cleanser when performing patient care; 2) acceptable standards of practice for hand hygiene and infection control are implemented. --- Based on two of two observations (#1, #2) during home visits and a review of facility policy and procedure, it was determined the facility failed to ensure acceptable standards of practice for hand hygiene and infection control are implemented. Findings include: 1. During a home visit for Patient (P) 1, on 2/29/24 at 1:09 PM, the following was observed: Staff (S) 8, a home health aide, began preparing water basins to give P1 a bed bath. S8 failed to perform hand hygiene prior to preparing the water basins. After washing the P1s face, S8 placed a dirty washcloth in the clean basin. After completing the bed bath, S8 doffed gloves and donned new gloves without performing hand hygiene. During oral care, S8 went into bathroom with gloves on to clean P1s dentures. S8 failed to perform hand hygiene and don new gloves after leaving the bathroom to re-insert the dentures into P1s mouth. After completing P1s oral care, S8 washed hands for only 9 seconds and began feeding P1 lunch without donning gloves. 2. During a home visit for P2, on 2/29/24 at 3:00 PM, the following was observed: S9, a Registered Nurse, entered P2s room, removed Chux pads from the dirty compartment in the nursing bag and placed them on P2s tray table. S9 placed nursing bag on the Chux pads and then entered the clean compartment of the nursing bag and removed clean equipment from the compartment without performing hand hygiene. S9 failed to close the clean compartment of the bag and it remained open for the duration of the visit. S9 failed to designate a clean and dirty area for equipment on the Chux pads. While assessing P2s vital signs, S9 placed dirty equipment on top of clean equipment on the Chux pads. S9 doffed gloves after performing vital signs, but failed to perform hand hygiene and don new gloves before cleaning the stethoscope. S9 began cleaning the bell of the stethoscope with an alcohol pad, but failed to clean the tubing or headset of the stethoscope. After cleaning the stethoscope, S9 donned a glove on right hand only, and assessed P2s feet. After assessing the feet, S9 doffed the glove and performed hand washing for 17 seconds. S9 then proceeded to clean equipment with the alcohol pads without donning gloves. S9 placed clean equipment on top of dirty equipment on the Chux pads. S9 failed to clean the sphygmomanometer (blood pressure cuff) before placing it in the clean compartment of the nursing bag. S9 applied hand sanitizer after cleaning equipment, but failed to wash hands. Facility policy titled, "Infection Control – Hand Hygiene", last reviewed on 3/3/21, states, ";... 1. Hospice staff must wash hands: a. before and after touching a patient; b. before performing clean / aseptic procedures; c. after performing tasks that involve risk of exposure to body fluids; d. before and after wearing gloves; e. after any activity involving contact with the patients immediate environment... 5. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 20 seconds..." Facility policy titled, "Bag Technique", last reviewed on 3/30/18, states, "1. All bags must have a designated ";Clean" and ";Soiled" compartment. The ";clean" compartment must not be entered without first washing hands. 2. The ";soiled" compartment should be where your hand washing supplies (soap and paper towels), gloves, and other personal protective equipment and plastic bags should be stored. 3. Your bag should be placed on a clean area on a barrier (Chux pad, newspaper, paper towel)... 4. Wash your hands. 5. Enter bag to obtain all needed equipment for your patient visit. Close bag... 7. When the visit is complete, clean all equipment and wash your hands before replacing in clean compartment of your bag. Close bag..." Facility policy titled, "Cleaning and Disinfecting Equipment", last reviewed on 3/30/18, states, "; ... Stethoscope and Sphygmomanometer: ... All parts of the stethoscope and blood pressure cuff must be wiped down with alcohol after each use..." NJAC 8:42C - 10.2(b) Based on observation, staff interview, and review of facility documentation, it was determined that the facility failed to ensure that staff utilize facility supplied alcohol based hand cleanser when performing patient care. Findings include: On 2/29/24 at 3:20 PM, during a home visit for P2, S9 (Registered Nurse) was observed performing hand hygiene with a hand rub, labelled "JR Cleaning Hand Elixir With Mint." Upon interview, S9 stated that the hand rub was not supplied by the Hospice agency, but that he/she used it because it was better for his/her hands. This surveyor was unable to confirm the percentage of alcohol in the hand sanitizer. On 3/1/24 at 1:00 PM, during a tour of the agency supply closet, S2 provided "GelRite Hand Sanitizer" by DermaRite, with 65% alcohol, which he/she stated was provided to staff for hand sanitizing during patient care. At 1:57 PM, S1 confirmed that agency staff are not permitted to use their own hand sanitizer. These findings were confirmed with S1, S2, S4, and S5 on 3/4/23 at 3:15 PM during exit conference. Facility policy titled, "Infection Control - Hand Hygiene," last revision date 3/3/21, states, "...Procedures: ...3. Hospice clinicians are provided with hand washing supplies, including anti-bacterial soap and/or alcohol-based hand cleanser as part of their routine supply inventory. ..."

Based on the review of one medical record (#3), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that the Home Hospice Aide's (HHA) documentation of a visit is entered into the patient's medical record. --- Findings include: On 3/1/24, the medical record of Patient (P)3 was reviewed. A physician order for HHA (Home Health Aide) frequency of 5 x (times) week for 10 weeks starting 1/27/2024 was noted. Upon review of the patient's visit calendar for the week of 2/18/24 to 2/24/24, the HHA scheduled visits stated "empty." This finding was confirmed by Staff (S)1 (Patient Care Manager) at the time of discovery. S1 stated that S7 (Volunteer Coordinator) took care of the scheduling of HHA visits and entering notes into the medical record. Upon interview with S7 on 3/1/24 at 2:07 PM, S7 stated that the Home Health Aide was from an agency, and that the "empty" on the calendar meant that the agency Home Health Aide had not yet sent over the notes from the visits. S7 stated that the agency HHAs are supposed to send their notes in weekly to the Hospice so the notes can be entered into the patient's medical record. S1 and S7 confirmed that the notes for the week of 2/18/24 to 2/24/24, should have been received per facility policy, but they had not been. Facility policy, titled, "Documentation Submission Requirements," last reviewed 3/30/18, states, "... 3. Hospice aide notes are submitted to the office weekly. ..." N.J.A.C. 8:42C-7.5(a)1

Based on staff interview, and review of facility documents, it was determined that the facility failed to ensure that a physician is designated by the hospice to act in the absence of the medical director. --- Findings include: On 2/29/24 at 9:35 AM, during entrance conference, S1 (Patient Care Manager) stated that the facility did not have an alternate medical director. On 3/4/24 at 10:16 AM, S2 (Director) confirmed that the last day the previous alternate medical director worked was on 7/31/21.

Based on home visit observations, staff interviews, medical record review, and review of policy and procedures, it was determined that the facility failed to ensure: 1) comprehensive patient assessments are documented in the medical record in one out of five medical records reviewed (#8); 2) patient wounds are assessed and documented according to facility protocol in three of three patients who had wounds (#2, #8, #9). --- · Findings include: 1.) On 3/4/24, a review of Patient (P) 8s medical record revealed that P8 was seen by the hospice nurse on the following dates: 2/15/24, 2/22/2024 and 2/29/24. P8s medical record lacked documentation of the hospice nurses comprehensive assessments for these dates. The blank assessments for the above dates were confirmed with Staff (S) 2, Director of Hospice, on 3/4/24 at 1:35 PM. On 3/4/24 at 2:59 PM, S2 reported there is not a policy that speaks to the amount of time allowed between the comprehensive assessment completion and the documentation of the assessment in the medical record. Both S1, Patient Care Manager, and S2 stated that 24 to 48 hours is best practice and it is the expectation that is taught to staff. 2.) On 2/29/24 at 3:00 PM, a nursing home visit was observed for P2 at his/her long-term care (LTC) facility. During the home visit, S9, a Registered Nurse (RN), explained that doctors at the facility order the wound care for the patients and the facility nurses perform the wound care. S9 indicated that he/she does not need to do the wound care for patients at this facility because the nurses usually do it for him/her. Observation of S9s assessment of P2 revealed that S9 assessed P2s dressings but he/she did not remove the dressing and assess or measure the wound. On 3/4/24, a review of medical records revealed that P8 and P9 had wounds present and wound care orders. On 3/4/24, a review of P8 and P9's medical records revealed the following: P8s Interdisciplinary Group (IDG) note indicates that he/she has eight wounds. P8 was seen by the hospice RN on 2/15/24, 2/22/24, and 2/29/24. P8s wound care assessment and measurements were blank in the medical record. P9 experienced multiple falls in his/her home. As a result of one of the falls, P9 incurred a large skin tear to his his/her arm. A review of P9s medical record lacked evidence that his/her skin tear was assessed and measured on 2/28/24. The missing wound documentation for the above dates was confirmed with S2 on 3/4/24 at 1:35 PM. Facility protocol titled, ";Wound Care Documentation Protocol," last revised date 3/30/18, states, ";Protocol: 1. Wounds will be assessed by RN every visit and all areas of skin integrity section of nursing note will be completed including: location of wound, type, size, drainage, amount, odor, stage, appearance of surrounding skin, and wound care order. 2. Wound measurements will be documented in centimeters (length, width, depth) weekly by Nurse Case Manager – every Monday or on first visit of the week...." N.J.A.C. 8:42C-7.2(a) N.J.A.C. 8:42C-6.3(a)9