Adoration Home Health

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure a Governing Body was established to oversee the Home Health Agency. §484.105(a): Governing Body §484.105(b)(1): Administrator §484.105(b)(2): Alternate Administrator §484.105(e)(2): Written Agreement”

“Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to— (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. This Standard is not met as evidenced by: Based on facility policy, staff interview, observation, and medical record review, it was determined the facility failed to ensure patients with limited English proficiency are provided a translator in their preferred language (Patient (P6)). On 12/10/25 at 12:31 PM, Staff (S)13 was observed providing care to Patient (P)6. P6’s family member was present during the visit and identified him/herself as P6’s primary caregiver. At 12:36 PM, while S13 provided care and education to P6, it was observed P6 had a limited understanding of English. S13 spoke to P6 in English and P6 would respond in a mix of Spanish and English. S13 was observed conducting P6’s medication reconciliation and education on medications in English accompanied with limited Spanish. At 12:45 PM, conducted a comprehensive assessment of P6. Throughout the assessment surveyors observed P6’s family member providing English to Spanish translation for questions that involved complex vocabulary. At 1:25 PM, S13 was observed providing diabetes education to P6. While providing the education, P6’s family member stated, “[he/she] won’t understand you, I’ll tell [him/her] what you’re saying.” S13 was agreeable and continued educating P6 in English. Surveyors did not observe S13 ask P6 during the visit if P6’s family member was an acceptable option for interpretation from English to Spanish. A review of P6’s medical record was conducted and revealed the following: On 11/19/25, P6’s admission visit and initial assessment were conducted by S13. In the “Assessment” section of the Visit Note Report, S13 documented P6’s response to the question, “What is your preferred language?” as “Spanish”. S13 documented P6’s response to the question, “Do you need or want an interpreter to communicate with a doctor or health care staff?” as “Yes”. On 11/26/25 at 6:28 PM, an In-Home Visit Note Report was documented by a physical therapist that stated, “… Patient is … Spanish speaking …” On 12/10/25 at 11:46 PM, an In-Home Visit Note Report written by S13 stated, “…Educationm [sic] was done with son present and explaining to patient in Spanish …” P6’s medical record lacked evidence that P6 requested to use his/her family member as an interpreter. P6’s medical record lacked evidence that an agency-provided language interpreter was offered to P6. On 12/11/25 at 12:53 PM, an interview was conducted with S1 and S9. When asked how a situation with a patient who has limited English proficiency should be handled, S1 stated, staff should utilize the interpreter application found on the facility provided tablet. S1 stated, staff are able to open the application and choose which language is needed for interpretation services. When asked what occurs if a patient requests to utilize a family member as their interpreter, S9 stated, “we try not to use family and encourage an interpreter.” At 2:30 PM, S1 confirmed that a Limited English Proficiency (LEP) patient should be offered the option of having an interpreter during his/her visit. S1 stated, if the patient requests to have his/her family member as an interpreter, the staff member must document the request in the patient’s medical record. Facility policy titled, “Limited English Proficiency Persons (LEP)” (revised 07/01/24) stated, “…Policy … The agency will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits … All interpreters, translators, and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients/clients and their families will be informed of the availability of such assistance free of charge … Language assistance will be provided through use of competent bilingual staff, staff interpreters, contact or formal arrangements with organizations providing interpretation or translation services, or technology and telephonic interpretation services … Procedure … 5. Family and friends may not be used to interpret or translate unless client/LEP person is made aware of the availability of interpreters … When a family member or friend is specifically requested by the patient to provide language interpretation, the agency will encourage the addition of an agency-provided language interpreter to be available to the family/patient … Such an offer and the response will be documented in the patient’s medical record.” On 12/11/25 at 12:53 PM, an interview was conducted with S1 and S9. When asked how a situation with a patient who has limited English proficiency should be handled, S1 stated staff should utilize the interpreter application found on the facility provided tablet. S1 stated staff are able to open the application and choose which language is needed for interpretation services. When asked what occurs if a patient requests to utilize a family member as their interpreter, S9 stated, “we try not to use family and encourage an interpreter.” On 12/11/25 at 2:00 PM, P6’s medical record was reviewed and revealed the following: On 11/19/25, during P6’s initial assessment and admission to the facility, an assessment note by a Registered Nurse (RN) was documented and stated: “What is your preferred language? Spanish Do you need or want an interpreter to communicate with a doctor or health care staff? 1. Yes …” On 11/26/25 at 6:28 PM, an In-Home Visit Note Report was documented by a physical therapist that stated, “… Patient is … Spanish speaking …” On 12/10/25 at 11:46 PM, an In-Home Visit Note report was documented by S13 stating, “…Educationm [sic] was done with son present and explaining to patient in Spanish …” On 12/10/25 at 12:31 PM, arrival at Patient (P)6’s residence occurred. Entrance to P6’s residence occurred in the presence of Staff (S)13. P6 was accompanied by his/her son/daughter. On 12/10/25 at 12:36 PM, S13 was observed providing care for P6. While S13 provided care and education to P6, it was observed P6 had a limited understanding of English and that P6’s son/daughter was providing translation to Spanish throughout the visit. S13 was observed educating P6 in English accompanied with limited Spanish. On 12/10/25 at 1:25 PM, S13 was observed providing education to P6. While providing education, P6’s son/daughter stated, “[he/she] won’t understand you, I’ll tell [him/her] what you’re saying.” S13 was agreeable and continued educating P6 in English. S13 failed to confirm with P6 if utilizing P6’s son/daughter was an acceptable option for interpretation from English to Spanish. P6’s medical record lacked evidence of P6’s son/daughter as being utilized as P6’s interpreter. S13 failed to offer a facility provided interpreter as an option for interpreting English to Spanish due to P6’s limited English proficiency. P6’s medical record lacked evidence of an interpreter being utilized . On 12/11/25 at 2:30 PM, S1 confirmed that a LEP patient should be offered the option of having an interpreter during his/her visit. S1 stated if the patient requests to have his/her family member as an interpreter, the staff member must document this in the patient’s medical record. NJAC 8:42-13.2 (5) Findings include: Facility policy titled, “Limited English Proficiency Persons (LEP)” (revised 07/01/24) stated, “…Policy … The agency will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits … All interpreters, translators, and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients/clients and their families will be informed of the availability of such assistance free of charge … Language assistance will be provided through use of competent bilingual staff, staff interpreters, contact or formal arrangements with organizations providing interpretation or translation services, or technology and telephonic interpretation services … Procedure … 5. Family and friends may not be used to interpret or translate unless client/LEP person is made aware of the availability of interpreters … When a family member or friend is specifically requested by the patient to provide language interpretation, the agency will encourage the addition of an agency-provided language interpreter to be available to the family/patient … Such an offer and the response will be documented in the patient’s medical record.” On 12/10/25 at 12:31 PM, Staff (S)13 was observed providing care to P6. P6’s family member was present during the visit and identified him/herself as P6’s primary caregiver. At 12:36 PM, while S13 provided care and education to P6. S13 spoke to P6 in English and P6 would respond in a mix of Spanish and English. S13 was observed conducting P6’s medication reconciliation and education of medications in English and using limited Spanish words. At 12:45 PM, S13 conducted a comprehensive assessment of P6. Throughout the assessment, surveyors observed P6’s family member providing English to Spanish translation for questions that involved complex vocabulary. At 1:25 PM, S13 was observed providing diabetes education to P6. While providing the education, P6’s family member stated, “[he/she] won’t understand you, I’ll tell [him/her] what you’re saying.” S13 was agreeable and continued educating P6 in English. Surveyors did not observe S13 ask P6 during the visit if P6’s family member was an acceptable option for interpretation from English to Spanish. A review of P6’s medical record was conducted and revealed the following: On 11/19/25, P6’s admission visit and initial assessment were conducted by S13. In the “Assessment” section of the Visit Note Report, S13 documented P6’s response to the question, “What is your preferred language?” as “Spanish.” S13 documented P6’s response to the question, “Do you need or want an interpreter to communicate with a doctor or health care staff?” as “Yes.” On 11/26/25 at 6:28 PM, an In-Home Visit Note Report was documented by a physical therapist that stated, “… Patient is … Spanish speaking …” On 12/10/25 at 11:46 PM, an In-Home Visit Note Report written by S13 stated, “…Educationm [sic] was done with son present and explaining to patient in Spanish …” P6’s medical record lacked evidence that P6 requested to use his/her family member as an interpreter. P6’s medical record lacked evidence that an agency-provided language interpreter was offered to P6. On 12/11/25 at 12:53 PM, an interview was conducted with S1 and S9. When asked how a situation with a patient who has limited English proficiency should be handled, S1 stated that staff should utilize the interpreter application found on the facility provided tablet. S1 stated that staff are able to open the application and choose which language is needed for interpretation services. When asked what occurs if a patient requests to use a family member as their interpreter, S9 stated, “we try not to use family and encourage an interpreter.” At 2:30 PM, S1 confirmed that a Limited English Proficiency (LEP) [understanding of English] patient should be offered the option of having an interpreter during his/her visit. S1 stated, if the patient requests to have his/her family member as an interpreter, the staff member must document the request in the patient’s medical record.”

“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, staff interview, and review of facility policies, it was determined the facility failed to ensure that facility policies to prevent the transmission of infections and communicable diseases, related to cleaning of equipment, hand hygiene, and bag protocol, in four of seven home visits (Patient (P)1, P2, P3, and P7) are adhered to by all staff. Facility policy titled “Hand Hygiene”, dated 09/05/25, stated, “… Procedure: 1. Staff performs hand hygiene by hand washing with soap and water or an alcohol-based hand sanitizer …” Facility policy titled “Bag Protocol Policy,” dated 11/25/25, stated, “… Procedure … Infection Control Practices C. Perform hand hygiene before removing or returning supplies to the bag … G. Prior to returning equipment to the home care bag, equipment must be cleaned using gloves with the appropriate disinfectant (refer to Policy 8.006 – Cleaning of Re-Usable Equipment) …” On 12/09/25 at 1:05 PM, S3 was observed providing care for P3. At 1:07 PM, placed his/her tablet on a barrier pad on the living room table with his/her nursing bag. At 1:14 PM, P3’s family member picked up the tablet while searching for medications on the table. At 1:19 PM, S3 used scissors to remove dressings for the wound on P3’s left foot. At 1:21 PM, S3 placed the contaminated scissors next to the tablet on the barrier pad. At 1:42 PM, S3 began assessing P3’s vital signs. At 1:45 PM, S3 placed the contaminated vital signs equipment (blood pressure cuff, sphygmomanometer, stethoscope, pulse oximeter, thermometer) on top of the tablet on the barrier pad. At 1:52 PM, S3 cleaned the vital signs equipment with alcohol wipes and placed the equipment in his/her nursing bag. S3 did not clean the tablet. At 1:57 PM, S3 discarded the barrier pads and placed the contaminated tablet on P3’s table. At 2:05 PM, S3 exited P3’s home carrying the contaminated tablet in his/her hands. At 2:10 PM, an interview was conducted with S3. When questioned about the process for cleaning the tablet, S3 stated, he/she forgot to clean the tablet. S3 stated, the tablet should be cleaned after each patient visit. On 12/11/25 at 10:00 AM, S7 was observed providing care for P7. At 10:06 AM, S7 donned gloves and began assessing P7’s vital signs. At 10:10 AM, S7 completed vital signs. At 10:13 AM, S7 began conducting patient education on discharge with same gloves on from vital signs assessment. At 10:21 AM, S7 completed patient education and began conducting physical therapy exercises with P7 in his/her kitchen with same gloves on from vital signs assessment. At 10:29 AM, S7 doffed gloves and entered the central compartment of his/her nursing bag without hand sanitizing. At 10:41 AM, an interview was conducted with S7. When questioned about the facility policy for bag technique, S7 stated, staff must doff gloves and hand sanitize before entering the nursing bag. S7 confirmed that he/she did not hand sanitize prior to entering the bag at 10:29 AM. At 12:40 PM, an interview was conducted with S1 and S9. When questioned about bag technique, S1 stated, staff are taught to hand sanitize prior to accessing the bag and after every glove change. Findings include: Facility policy titled “Cleaning of Re-Useable Equipment,” dated 06/01/25, stated, “… Definitions: 1. Low-Level Disinfection … Examples include at least 70% isopropyl alcohol/ethyl alcohol … 3. Non-Critical Items – Equipment that is only meant to come in contact with intact patient skin … (e.g., stethoscope, blood pressure cuffs, pulse-oximeters … tablet) … Non-critical items also include … (e.g., staff bags,) … Procedure: 1. Non-critical items which will come in contact with intact patient skin will undergo a low-level disinfection between each patient use … 7. … tablet … should be wiped down with a low-level disinfectant at the … end of each visit …” On 12/09/25 at 1:17 PM, Staff (S)4 was observed providing care for P1. At 1:18 PM, S4 was observed setting up two barrier pads. S4 placed his/her bag on a barrier pad and removed a sphygmomanometer (blood pressure cuff), stethoscope, thermometer, and pulse oximeter from his/her bag placing them on the same barrier pad next to the bag. The second barrier pad remained empty. At 1:21 PM, P1 was observed touching both barrier pads with bare hands while searching for his/her admission packet, contaminating both barrier pads. At 1:22 PM, S4 took P1’s blood pressure and heart rate and then placed the contaminated equipment (sphygmomanometer, pulse oximeter, and stethoscope) on the empty barrier pad. At 1:27 PM, S4 took P1’s temporal (forehead) temperature and then placed the contaminated thermometer on the barrier pad with the sphygmomanometer, pulse oximeter, and stethoscope. At 1:37 PM, S4 cleaned the contaminated vital signs equipment (thermometer, pulse oximeter, sphygmomanometer, and stethoscope) with a disposable alcohol wipe and then placed the equipment back on the previously contaminated barrier pad next to his/her bag, re-contaminating the vital signs equipment. At 1:44 PM, P1 was observed touching the vital signs equipment and S4’s bag with bare hands while searching for his/her medication list, further contaminating the vital signs equipment and contaminating S4’s bag. At 1:45 PM, S4 placed the contaminated vital signs equipment back in his/her bag. At 2:00 PM, S4 was observed exiting P1’s home without re-cleaning the contaminated vital signs equipment and cleaning the contaminated bag. At 2:04 PM, an interview was conducted with S4. While reviewing the home visit, S4 confirmed the findings. On 12/09/25 at 2:31 PM, S5 was observed providing care for P2. At 2:33 PM, S5 took P2’s blood pressure and heart rate, with bare hands, and then placed the contaminated equipment (sphygmomanometer, pulse oximeter, and stethoscope) on a barrier pad. S5 then, with bare hands, accessed his/her tablet, contaminating the tablet. At 2:35 PM, S5 measured P2’s ankles, with bare hands, and then accessed his/her tablet, contaminating the tablet. At 3:24 PM, S5 cleaned the vital signs equipment (pulse oximeter, sphygmomanometer, and stethoscope) with a disposable alcohol wipe and then placed the equipment on a barrier pad. S5 then placed the contaminated tablet on the vital signs equipment, re-contaminating the vital signs equipment. At 3:28 PM, P2 was observed signing the tablet with his/her bare hands. S5 was then observed exiting P2’s home without re-cleaning the contaminated vital signs equipment and cleaning the contaminated tablet. At 3:29 PM, an interview was conducted with S5. While reviewing the home visit, S5 confirmed the findings. On 12/11/2025 at 12:40 PM, an interview was conducted with S1 and S9. While reviewing the findings for the home visits for P1 and P2, S1 and S9 stated, the vital signs equipment should have been cleaned again following re-contamination. S1 stated, staff tablets should be cleaned after every patient visit. NJAC 8:42-12.2(b) NJAC 8:42 – 12.3”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure a Governing Body was established for the Home Health Agency. On 12/12/25 at 10:01 AM, S1 provided surveyors with facility document titled “OPERATIONAL BYLAWS AND RULES of Bayonne Visiting Nurse Association, INC./LLC”, Adopted: “December 11, 2025”. The document was signed by S9, Executive Director, on 12/11/25. While providing the document, S1 stated, “now we understand that this is necessary.” At 11:30 AM, surveyors requested an interview with S8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave today. At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. When questioned about governing body documentation, S9 confirmed that the facility was unable to provide documentation of governing body meeting minutes or bylaws prior to December 11, 2025. Findings include: On 12/09/25 at 9:51 AM, during entrance conference, Governing Body Bylaws and meeting minutes were requested. Staff (S)1 asked the surveyor to explain what was meant by “Governing Body.” Governing Body was explained to S1. On12/10/25 at 12:14 PM, Governing Body Bylaws and meeting minutes were requested again of S1. The Governing Body regulation was reviewed with S1. S1 stated that he/she would check to see what they have. On 12/11/25 at 1:01 PM, Governing Body Bylaws and meeting minutes were requested again of S1 and S9. The Governing Body regulation was reviewed with both S1 and S9. S1 reported that the annual agency evaluation is part of the “executive summary” that is discussed at QAPI (Quality Assurance and Performance Improvement-Ongoing, data-driven program that identifies, monitors, and corrects systemic problems in care and operations to improve quality and patient safety) meeting. At 2:10 PM, S1 presented the facility’s QAPI minutes again, which included a one page document titled, “Annual Agency Report.” Upon review of these documents, there is no evidence of Governing Body duties discussed at these meetings. On 12/12/25 at 10:01 AM, S1 provided surveyors with a facility document titled, “OPERATIONAL BYLAWS AND RULES of Bayonne Visiting Nurse Association, INC./LLC”, Adopted: “December 11, 2025”. This document was signed by S9, the Executive Director, on 12/11/25. While providing the document, S1 stated, “now we understand that this is necessary.” This document did not exist when the surveyors started the survey on 12/9/25. On 12/12/25 At 11:30 AM, the surveyors requested an interview with S8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave today. At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. When questioned about governing body documentation, S9 confirmed that the facility was unable to provide documentation of governing body meeting minutes or bylaws prior to December 11, 2025.”

“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 staff communicate with the physician when there is a delay in services when a missed visit occurs, in seven of the 12 active medical records reviewed (Patient (P)1, P2, P3, P9, P10, P11, and P12). A review of P12’s medical record was conducted and revealed the following: P12’s Plan of Care Orders for the certification period beginning 11/10/25 showed visit orders for the SN as “effective 11/16/25 1 WK1 [one visit a week for one week] and…PT as “2WK1[two visits a week for one week], 1WK5 [one visit a week for five weeks]…” During the week of 11/10/25 to 11/15/25, the medical record showed that P12 only received one visit from the PT. P12 did not receive a second PT visit or a visit from the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. An updated order placed on 11/21/25 states, “Move RN01 [registered nurse] to next Medicare Week…SN EFFECTIVE 11/23/25 1WK1 [one visit a week for one week]” During the week of 11/23/25-11/29/25, the medical record showed that P12 did not receive any visits from the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. Findings include: Facility policy titled “Coordination of Care, From Admit Through Discharge,” dated 12/01/25, stated, “… Procedure: … 4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: … c. When a missed visit occurs altering the Plan of Care …” Facility policy titled “Home Care Record,” dated 10/01/25, stated, “… Procedure: … 2. The patient home care record shall contain the following clinical information: … p. Documentation and communication with the … physicians …” A review of P1’s medical record was conducted and revealed the following: P1’s Plan of Care Orders for the certification period beginning 11/19/25 showed visit orders for the Physical Therapist (PT) as “… 1WK7 [one visit a week for seven weeks] …” beginning on 11/19/25. During the week of 11/23/25 to 11/29/25, the medical record showed that P1 did not receive any visits by the PT. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. A review of P2’s medical record was conducted and revealed the following: P2’s Plan of Care Orders for the certification period beginning 10/29/25 showed visit orders for the PT as “… 3WK1 [three visits a week for one week], 2WK7 [two visits a week for seven weeks] …” beginning on 10/29/25. During the week of 10/26/25 to 11/01/25, the medical record showed that P2 received one visit by the PT on 10/29/25 and had one Missed Visit Notification Note by the PT for 10/31/25. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician for the third visit ordered for the week. During the week of 11/16/25 to 11/22/25, the medical record showed that P2 received only one visit by the PT on 11/18/25. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. A review of P3’s medical record was conducted and revealed the following: P3’s Plan of Care Orders for the certification period beginning 09/13/25 showed visit orders for the Skilled Nurse (SN) as “… 1WK8 [one visit a week for eight weeks] …” beginning on 11/16/25. During the week of 11/23/25 to 11/29/25, the medical record showed that P3 did not receive any visits by the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. A review of P9’s medical record was conducted and revealed the following: P9’s Plan of Care Orders for the certification period beginning 11/11/25 showed visit orders for the SN as “… 2WK7 [two visits a week for seven weeks] …” beginning on 11/23/25. During the week of 11/30/25 to 12/06/25, the medical record showed that P9 received only one visit by the SN on 12/03/25. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. A review of P10’s medical record was conducted and revealed the following: P10’s Plan of Care Orders for the certification period beginning 11/10/25 showed visit orders for the Occupational Therapist (OT) as “… 1WK1 [one visit a week for one week] …” beginning on 11/10/25, for the SN as “… 1WK1 [one visit a week for one week], 2WK1 [two visits a week for one week], 1WK3 [one visit a week for three weeks] …” beginning on 11/10/25, and for the PT as “… 3WK2 [three visits a week for two weeks], 2WK1 [two visits a week for one week], 1WK3 [one visit a week for three weeks] …” beginning on 11/10/25. During the week of 11/09/25 to 11/15/25, the medical record showed that P10 did not receive any visits by the OT. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. During the week of 11/16/25 to 11/22/25, the medical record showed that P10 did not receive any visits by the PT and the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. During the week of 11/23/25 to 11/29/25, the medical record showed that P10 did not receive any visits by the PT and the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. During the week of 11/30/25 to 12/06/25, the medical record showed that P10 did not receive any visits by the PT and the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. A review of P11’s medical record was conducted and revealed the following: P11’s Plan of Care Orders for the certification period beginning 10/16/25 showed visit orders for the OT as “… 1WK5 [one visit a week for five weeks] …” beginning on 10/26/25, for the SN as “… 3WK1 [three visits a week for one week], 2WK2 [two visits a week for two weeks], 1WK3 [one visit a week for three weeks] …” beginning on 10/26/25, and for the PT as “… 2WK2 [two visits a week for two weeks], 1WK5 [one visit a week for five weeks] …” beginning on 10/19/25. During the week of 10/26/25 to 11/01/25, the medical record showed that P11 received only two visits by the SN on 10/28/25 and 10/31/25. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. During the week of 11/23/25 to 11/29/25, the medical record showed that P11 did not receive any visits by the OT and the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. During the week of 11/30/25 to 12/06/25, the medical record showed that P11 did not receive any visits by the PT. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. All findings were confirmed by Staff (S)1. On 12/11/25 at 12:40 PM, an interview was conducted with S1 and S9. When questioned about missed visits, S1 stated that a Missed Visit Notification Note is to be entered into Homecare Homebase and the medical provider must be notified when a missed visit occurs. S1 stated that the Missed Visit Notification Note should include the staff members discipline, the date of the missed visit, and information on the notification of the medical provider. Cross reference: NJAC 8:42-6.1(a)(6)”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure the administrator was appointed by the facility’s governing body. On 12/12/25 at 11:30 AM, surveyors requested an interview with Staff (S)8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave. S1 stated, “You can speak to S9. He/she is the Alternate Administrator.” A review of the organizational chart provided by the facility lacked evidence of S9 as Alternate Administrator. At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. S9 stated, he/she was hired in June 2025. When questioned about who appointed him/her as Alternate Administrator, S9 stated that he/she was appointed by the Regional Vice President of Operations. S9 stated that his/her name should appear on the facility organizational chart as Alternate Administrator. When questioned if there was any documentation from governing body meeting minutes that would provide evidence of the appointment of S8 or S9 as Administrator for the facility, S9 stated “No.” At 02:40 PM, S1 provided surveyors with facility document titled “Administrative Appointments.” The document stated, “The governing body appoints [S8] to serve as the agency Executive Director (Administrator and Supervising Nurse) … In his/her absence, [S9] is given the administrative authority and responsibility to carry out these same position responsibilities...” The document was dated “6/24/2025” and lacked a signature from S8. S1 confirmed that facility was unable to provide governing body meeting minutes documenting the appointments of S8 as Administrator. Findings include: On 12/09/25 at 9:51 AM, during entrance conference, Staff (S) 8 was identified as administrator for the facility. On 12/12/25 at 11:30 AM, surveyors requested an interview with 8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave. S1 stated, “You can speak to S9. [He/she] is the Alternate Administrator.” At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. When questioned if there was any documentation from governing body meeting minutes that would provide evidence of the appointment of S8 or S9 as Administrator for the facility, S9 stated “No.” At 2:40 PM, S1 provided surveyors with facility document titled “Administrative Appointments.” The document stated, “The governing body appoints [S8] to serve as the agency Executive Director (Administrator and Supervising Nurse) … In [his/her] absence, [S9] is given the administrative authority and responsibility to carry out these same position responsibilities...” The document was dated “6/24/2025” and lacked a signature from S8. S1 confirmed that facility was unable to provide governing body meeting minutes documenting the appointments of S8 as Administrator.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure an alternate administrator was designated, in writing, by the facility’s administrator and governing body. On 12/12/25 at 11:30 AM, surveyors requested an interview with Staff (S)8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave. S1 stated, “You can speak to S9. He/she is the Alternate Administrator.” A review of the organizational chart provided by the facility lacked evidence of S9 as Alternate Administrator. At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. S9 stated, he/she was hired in June 2025. When questioned about who appointed him/her as Alternate Administrator, S9 stated that he/she was appointed by the Regional Vice President of Operations. S9 stated that his/her name should appear on the facility organizational chart as Alternate Administrator. When questioned if there was any documentation from governing body meeting minutes that would provide evidence of the appointment of S8 or S9 as Administrator for the facility, S9 stated “No.” At 02:40 PM, S1 provided surveyors with facility document titled “Administrative Appointments.” The document stated, “The governing body appoints [S8] to serve as the agency Executive Director (Administrator and Supervising Nurse) … In his/her absence, [S9] is given the administrative authority and responsibility to carry out these same position responsibilities...” The document was dated “6/24/2025” and lacked a signature from S8. S1 confirmed that facility was unable to provide governing body meeting minutes documenting the appointment of S9 as Alternate Administrator. Findings include: On 12/09/25 at 9:51 AM, during entrance conference, Staff (1) identified him/herself as the alternate administrator for the facility. On 12/12/25 at 11:30 AM, surveyors requested an interview with S8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave. S1 stated, “You can speak to S9. [He/she] is the Alternate Administrator.” At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. S9 stated, he/she was hired in June 2025. When questioned about who appointed him/her as Alternate Administrator, S9 stated that he/she was appointed by the Regional Vice President of Operations. S9 stated that his/her name should appear on the facility organizational chart as Alternate Administrator. When questioned if there was any documentation from governing body meeting minutes that would provide evidence of the appointment of S8 or S9 as Administrator for the facility, S9 stated “No.” A review of the organizational chart provided by the facility lacked evidence of S9 as Alternate Administrator. At 2:40 PM, S1 provided surveyors with facility document titled “Administrative Appointments.” The document stated, “The governing body appoints [S8] to serve as the agency Executive Director (Administrator and Supervising Nurse) … In [his/her] absence, [S9] is given the administrative authority and responsibility to carry out these same position responsibilities...” The document was dated “6/24/2025” and lacked a signature from S8. S1 confirmed that facility was unable to provide governing body meeting minutes documenting the appointment of S9 as Alternate Administrator.”

“Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA’s patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This Element is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure written agreements for social work services, that were provided to the home health agency’s patients, by another home health agency. Findings include: On 12/09/25 at 9:51 AM, during entrance conference, Staff (S) 1 reported that the facility currently does not have social workers at this branch to provide services to the patients. At 10:15 AM, S1 reported that the parent company has eight branches, and if necessary, staff, social workers, can be borrowed from one of the other branches. When asked if any of these branches share the same license number with this facility, S1 reported that there are no other branches under their license. S1 reported that there are two social workers who cover patients at different branches. On 12/11/25 at 1:07 PM, S1 was asked to provide written agreements or contracts with other agencies/branches for use of their HHA or SW staff. On 12/12/25 at 10:32 AM, Staff (S)1 presented a document to surveyors titled “Shared Employee Form” for S15 and S16, the two social workers the facility uses from a separately licensed facility. The form for S15 stated “Effective Date: 04/20/25”. The form for S16 stated “Effective Date: 08/25/24”. The forms were only signed by the social worker and their supervisor at the other facility. At 4:00 PM, S1 presented a document to surveyors titled “Shared Employee Form” for S17, a home health aide the facility uses from a separately licensed facility. The form for S16 stated “Effective Date: 04/20/25”. The form was only signed by the home health aide and their supervisor at the other facility. S1 confirmed that the Shared Employee Forms were not signed by a representative from their agency, did not specify each party’s responsibilities, functions, and objectives, and did not contain a time during which the services were to be provided or the duration of the agreement.”