Valley Home Care Inc.

“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)”

“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)”

“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)”