Atlantic Visiting Nurse

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on observations, patient and staff interviews, and review of facility documents, it was determined that the facility failed to ensure an individualized emergency preparedness plan is completed on admission in four of seven patient homes visited (Patient (P) 1, P3, P6, and P7). Findings include: On 8/7/24 at 12:18 PM, S20, a Home Health Aide (HHA), was observed providing care for P3. At 12:40 PM, P3’s admission packet was reviewed with P3’s wife. Surveyors were unable to locate a completed, individualized emergency preparedness plan within the admission packet. On 8/8/24 At 12:30 PM, a review of P3’s medical record revealed the following: the RN who completed the Start of Care documented that the EPP was completed on P3’s admission on 7/24/24 at 4:52 PM and a copy of the EPP was left in P6’s home. On 8/8/24 at 9:31 AM, S7, a Registered Nurse (RN), was observed providing care for P6. At 10:24 AM, when questioned about the admission packet S7 stated that he/she would be filling out the individualized emergency preparedness plan with P6 during the visit on 8/8/24 (26 days after P6 was admitted). At 1:30 PM, a review of P6’s medical record revealed the following: the RN who completed the Start of Care record documented that the EPP was completed on P6’s admission on 7/13/24 at 7:49 PM and a copy of the EPP was left in P6’s home. On 8/8/24 at 10:44 AM, S8, an Occupational Therapist (OT), was observed providing care for P7. At 11:15 AM, P7’s admission packet was reviewed with P7’s wife. Surveyors were unable to locate a completed, individualized emergency preparedness plan within the admission packet. On 8/8/24 At 1:30 PM, a review of P7’s medical record revealed the following: the RN who completed the Start of Care documented that the EPP was completed on P6’s admission on 7/10/24 at 3:50 PM and a copy of the EPP was left in P7’s home. Facility policy titled “Emergency Preparedness Plan” last revised 6/24 states “Purpose: The Emergency Preparedness Plan (EPP) describes the Agency’s approach to managing emergencies… Policy: Agency employees are oriented to the Emergency Preparedness Plan, including their responsibilities in carrying out the Plan, upon hire, annually, and when changes in staff responsibilities or roles occur… Patients receiving services from the Agency will, upon admission, be informed of the Agency’s emergency process and their personal responsibilities in the event of an emergency, as outlined in the Agency’s Patient Information Booklet. The clinical staff caring for the patient collaborate with the patient and caregiver to develop and individual EPP.” 1. On 8/7/2024 at 12:18 PM, during a home care visit with P3, a Home Health Aide (HHA) (S20), was observed providing care. At 12:40 PM, P3’s Patient Information Booklet was reviewed with P3’s family and revealed that P3’s Emergency Preparedness Plan (EPP) was left blank. 2. On 8/8/24 at 9:31AM, during a home care visit with P6, a Registered Nurse (RN) (S7), was observed providing care. At 10:24 AM, when questioned about the Agency’s Patient Information Booklet for P6, S7 stated that he/she would be filling out the individualized EPP with P6 during the visit (on 8/8/2024). At 10:24 AM, prior to the conclusion of the visit, S7 was observed reviewing and completing the EPP with P6 and his/her family, (26 days after P6’s admission), and a copy was left in P6’s home. At 1:30 PM, P6’s medical record was reviewed. The nurse who completed the Start of Care record documented that the EPP was completed on P6’s admission on 7/13/24 at 7:49 PM and a copy of the EPP was left in P6’s home. 3. On 8/8/24 at 10:44 AM, during a home care visit with P7, an Occupational Therapist (OT) (S8), was observed providing care. At 11:15 AM, P7’s Patient Information Booklet was reviewed with P7’s family and revealed that P7’s Emergency Preparedness Plan (EPP) was left blank. Facility Policy titled, “Emergency Preparedness Plan [EPP]” revised on 6/24, states “…Policy:…Patients receiving services from the Agency will, upon admission, be informed of the Agency’s emergency process and their personal responsibilities in the event of an emergency, as outlined in the Agency’s Patient Information Booklet. The clinical staff caring for the patient collaborate with the patient and caregiver to develop and individual EPP…” An in-home nursing care visit for Patient (P) 1 was observed on 8/7/24 at 1:16 PM. P1 was admitted to homecare services on 7/10/24 at 9:33 AM for wound care after surgery. On 8/7/24 at 2:15 PM, P1’s admission packet was reviewed. The admission packet revealed that P1’s Emergency Preparedness Plan was left blank. Staff (S) 5 confirmed that the EPP was incomplete and should have been completed during admission. Prior to conclusion of the nursing visit on 8/7/24, S5 reviewed and completed the EPP with P1 and his/her family. The EPP was left in P1’s home. On 8/8/24 at 12:30 PM, S1 confirmed that all patients should have the EPP documented in the medical record and a copy left in the home. On 8/9/24 at 12:00 PM, P1’s medical record was reviewed. The nurse who completed the Start of Care record documented that the EPP was completed on P1’s admission on 7/10/24 at 7:31 PM and a copy of the EPP was left in P1’s home.”

“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, staff interviews, and a review of facility policies, it was determined that the facility failed to follow accepted standards of practice to prevent transmission of infections and communicable diseases in five out of seven patients (Patient (P) 1, P2, P4, P5 and P7). Findings include: Facility Policy titled, “Hand Hygiene” last revised 6/22, states “Procedure: … Handwashing with water: … 5. Rub hands together for at least 20 seconds, covering all surfaces of the hands…” Super Sani-wipe General Guidelines For Use states, “…DIRECTIONS FOR USE …TO DISINFECT AND DEODORIZE: To disinfect nonfood contact surfaces only: …Unfold a clean wipe and thoroughly wet surface. All treated surface to remain wet for a full two (2) minutes. Let air dry. …” On 8/7/24 at 1:02 PM, S10, a Physical Therapist (PT), was observed providing care for P2. At 1:03 PM, after entering P2’s home, S10 entered the patient’s bathroom to perform hand hygiene. S10 washed hands with soap and water for only ten seconds before donning gloves and starting patient care. At 1:07 PM, S10 was observed to use a stethoscope to assess P2. At 1:37 PM, S10 was observed to use a blood pressure cuff on P2. S10 was then observed to clean the stethoscope and blood pressure cuff with a Super Sani-Cloth wipe and placed items immediately into nursing bag without allowing time to dry. On 8/8/24 at 9:31 AM, S7, a Registered Nurse (RN), was observed providing care for P6. At 9:33 AM, S7 placed three barrier pads on P6’s dining room table. S7 placed nursing bag on the first pad, the laptop on the second pad, and began removing vital signs equipment from the nursing bag and placing them on the third pad. The three barrier pads were placed in close proximity to one another, and each pad was overlapping another pad. At 9:46 AM, S7 placed a fourth barrier pad on the table for placing vital signs equipment after cleaning. At 9:47 AM, S7 cleaned the blood pressure cuff and sphygmomanometer with Sani Cloth wipes and placed them on the fourth barrier pad. The cuff and sphygmomanometer were observed over the edge of the barrier pad and touching the table surface and the outer surface of the nursing bag after being placed on the barrier pad. S7 did not clean or disinfect the table surface prior to placing the barrier pad. At 9:48 AM, surveyors observed all four barrier pads on the table were overlapping and cleaned vital signs equipment were observed touching dirty vital signs equipment and dirty supplies. On 8/7/24 at 1:35 PM, during a home visit of P1, Staff (S) 5, Registered Nurse (RN), was observed using blood pressure cuff. After removal of the blood pressure cuff, S5 cleaned the blood pressure cuff with the facility approved cleansing wipe and placed the cuff on a clean barrier pad. S5 then placed used cleansing wipe onto the same clean barrier pad. On 8/8/24 at 11:15 AM, during a home visit of P5, S9, RN, was observed using stethoscope and blood pressure cuff. The “dirty” blood pressure cuff was placed on a disposable barrier. S9 cleaned the stethoscope with facility approved cleansing wipes and placed the “clean” stethoscope next to the “dirty” blood pressure cuff on the disposable barrier pad. After completing his/her assessment of P5’s incision, S9 was observed removing used gloves and placing them on the same barrier as the “dirty” blood pressure cuff and the “clean” stethoscope. S9 was then observed leaning on this barrier to clean the blood pressure cuff. On 8/12/24 at 10:45 AM, S1, Quality and Education Manager, confirmed that there is not a separate policy for the separation of “clean” and “dirty” items. He/she explained that this information is found in the facility’s “Clinical Bag Technique” policy. A discussion with S1 revealed that this policy lacks guidance for placement of reusable equipment after it is cleaned while it is drying. S1 reported that after equipment is cleaned, staff are taught to place equipment on a clean barrier to dry before returning items to the clinical bag. On 8/8/24 at 9:33 AM, during a home visit of P4, S6, Physical Therapist, was observed placing his/her clinical bag on a disposable barrier on P’s couch. A second disposable barrier was placed on the opposite end of the couch. While S6 was documenting, he/she sat on the couch in between the clinical bag and computer. At 9:47AM, the clinical bag was observed pressing against the fabric of the couch on two sides after being displaced by S6 when he/she sat on the couch. On 8/11/24 at 11:07 AM, S1 confirmed that clinical bags should be placed on a clean, hard, non-porous surface. Facility Policy titled, “Clinical Bag Technique” revised on 6/24, states “…Procedure: 1. Upon entrance to a patient’s home, the clinical bag is placed on a solid surface. For questionable surfaces a barrier, (e.g. newspaper or paper towel) is recommended. …3. Hand Hygiene is performed prior to administering care. Hand hygiene must be performed before removing any supplies or equipment from the clinical bag. 4. After hand hygiene, the clinician enters the bag and takes out all equipment that will be needed for the visit. Equipment is placed on a paper towel or designated barrier….7. Reusable equipment is cleaned/disinfected, hand hygiene is performed with an alcohol-based antiseptic agent and equipment and supplies are returned to the bag…” On 8/7/2024 at 1:49 PM, during a home care visit with Patient (P) 1, a Registered Nurse (Staff (S) 5) was observed rendering wound care to P1 per physician’s orders. On arrival, P1 was noted to have a V.A.C. (Vacuum Assisted Closure) dressing in place. After removing the old dressing, P1 was noted to have two wounds (Wound #1 and Wound #2). S5 then removed a gauze pad and cleansing solution from his/her clean area and began irrigating Wound #2. S5 was then observed wiping the skin between both wounds, with the same gauze pad, and proceeded to then cleanse Wound #1. S5 was observed using the same soaked saline gauze to clean both Wound #2 and Wound #1, as well as the skin between both wounds. S5 then disposed of the gauze pad, removed his/her gloves, performed hand hygiene, and began reapplying a new V.A.C. dressing per physician’s order. At 1:56 PM, S5 stated, “when they [the clinician’s] change this dressing, make sure they treat it as two separate wounds and use different supplies.” On 8/8/2024 at 10:04 AM, medical record review for P1 revealed “SN [Skilled Nursing] Routine Visit” from visit date 8/7/2024, documentation by S5 states, “…Visit Summation[:] … Visit Summary[:] Wound care rendered per orders using wound vac, both wounds noted no longer tunneling together. …” These findings were reviewed with S1 (Manager of Clinical Education) and S21 (Wound Team Manager) on 8/8/2024 at 10:24 AM. S1 and S21 confirmed that separate supplies should have been used to cleanse each wound individually. On 8/8/24 at 11:15 AM, during a home visit of P5, S9, a Registered Nurse (RN), was observed using stethoscope and blood pressure cuff. The “dirty” blood pressure cuff was placed on a disposable barrier. S9 cleaned the stethoscope with facility approved cleansing wipes and placed the “clean” stethoscope on the same “dirty” disposable barrier pad. After completing his/her assessment of P5’s incision, S9 was observed removing used gloves and placing them on the same barrier as the “dirty” blood pressure cuff and the “clean” stethoscope. S9 was then observed placing the “dirty” blood pressure cuff on top of the previously cleaned stethoscope and began to clean the blood pressure cuff with facility approved cleansing wipes. The used/dirty gloves were observed to be touching the blood pressure cuff and previously “cleaned” stethoscope during this process. S9 then returned the stethoscope and blood pressure cuff to his/her bag, without disinfecting on a clean surface, after contact with the dirty gloves and disposable barrier. On 8/12/24 at 10:45 AM, S1, Quality and Education Manager, confirmed that there is not a separate policy for the separation of “clean” and “dirty” items. He/she explained that this information would be found in the facility’s “Clinical Bag Technique” policy and revealed that this policy lacks guidance for placement of reusable equipment after it is cleaned while it is drying. S1 reported that after equipment is cleaned, staff are taught to place equipment on a clean barrier to dry before returning items to the clinical bag. Facility Policy titled, “Clinical Bag Technique” revised on 6/24, states “…Procedure: ...4. After hand hygiene, the clinician enters the bag and takes out all equipment that will be needed for the visit. Equipment is placed on a paper towel or designated barrier….7. Reusable equipment is cleaned/disinfected, hand hygiene is performed with an alcohol-based antiseptic agent and equipment and supplies are returned to the bag…” On 8/7/24 at 1:02 PM, during a home visit with P2, S10, a Physical Therapist (PT), was observed providing care. At 1:03 PM, after entering P2’s home, S10 entered the patient’s bathroom to perform hand hygiene. S10 washed hands with soap and water for ten seconds before donning gloves and starting patient care. Facility Policy titled, “Hand Hygiene” last revised 6/22, states “Procedure: … Handwashing with water: … 5. Rub hands together for at least 20 seconds, covering all surfaces of the hands…” On 8/7/24 at 1:07 PM, during a home visit with P2, S10, a Physical Therapist (PT), was observed to use a stethoscope to assess P2. At 1:37 PM, S10 was observed to use a blood pressure cuff on P2. S10 was then observed to clean the stethoscope and blood pressure cuff with a Super Sani-Cloth wipe and placed items immediately into nursing bag without allowing time to dry, according to the manufacturers Guidelines for Use. Super Sani-wipe General Guidelines For Use states, “…DIRECTIONS FOR USE …TO DISINFECT AND DEODORIZE: To disinfect nonfood contact surfaces only: …Unfold a clean wipe and thoroughly wet surface. All treated surface to remain wet for a full two (2) minutes. Let air dry. … Facility Policy titled, “Cleaning of Non-Critical Equipment” last revised 12/23, states, “...Procedure: ...4”

“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 observation, medical record review, review of facility documents, and staff interviews, it was determined the facility failed to provide skilled services according to the Home Health Agencies (HHA’s) procedure for Bridging Two Wounds with Vacuum Assisted Closure (V.A.C.) Therapy in one out of seven patients observed (Patient (P) 1). Findings include: On 8/7/2024 at 1:56 PM, during a home care visit with Patient (P) 1, a Registered Nurse (Staff (S) 5) was observed rendering wound care to P1 per physician’s orders. S5 packed Wound #1 and Wound #2 separately with white foam and covered with black foam per order. S5 then cut a piece of black foam to create a “bridge” between both wounds. S5 was then observed bridging together both wounds by placing the black foam directly on the patient’s intact skin between the two wounds, without first protecting the intact skin with a piece of the V.A.C. Drape. On 8/9/24 at 10:20 AM, an interview was conducted with S1, Manager of Clinical Education. S1 stated that wound V.A.C. training is provided both on orientation and monthly and includes education to staff providing wound care to lay down a barrier or drape between wounds when bridging. S1 stated that the facility uses KCI’s (the company who provides the wound V.A.C.’s and supplies) guidance and follows their procedure on proper application of wound V.A.C.’s. At 11:36 AM, during an interview with S21, Wound Team Manager, when asked S21 if he/she would ever lay black foam directly onto patient’s intact skin in order to create a bridge between wounds S21 stated, “I would if it was narrow.” Inquiry was made for what policy/procedure is expected to be followed by clinicians for bridging together wounds with V.A.C. therapy. The following was provided by the facility: Document titled, “V.A.C.® Dressing Application Guide [for] Bridging Two Wounds” by KCI, states, “…10. Protect intact skin between the two wounds with a piece of the V.A.C.® Drape. …” These findings were confirmed with S1 and S21 on 8/12/24 at 11:25 AM. N.J.A.C. 8:42-7.3(c)4”