Visiting Health Services of New Jersey

“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 observation, medical record review, staff interview, and facility document review, it was determined the facility failed to ensure, all patients with limited or no English language proficiency, received a qualified interpreter in four of four patients who requested the use of language interpreter services (Patient (P)7, P18, P19, P20). A review of P19’s medical record was conducted with S2 and S6 and revealed the following: A “SN [Skilled Nurse] OASIS Start of Care” note by S8, dated 07/12/26, stated, “… Ethnicity, Race, and Language: … What is your preferred language? Gujarati … Do you need or want an interpreter to communicate with a doctor or healthcare staff? 1. Yes.” The note lacked evidence that a qualified interpreter was offered to P19 and refused. A “SLP [Speech Language Pathology] Initial Evaluation” note by S28, dated 07/13/26, stated, “… Encounter Notes: … Note: pt [patient] is able to respond verbally in Gujarat (family translates). pt is able to follow one step level directions with assistance for mobility.” The note lacked evidence that a qualified interpreter was offered to P19 and refused. A “OT [Occupational Therapy] Initial Evaluation” note by S29, dated 07/20/26, stated, “… Problem: Patient-Stated Goal: … Intervention: Patient Care Preferences: “… have an interpreter attend each visit and plan visits when caregiver is available. Visit Notes: DIL [Daughter-in-law] present for interpretor [sic] as per preference.” The note lacked evidence that a qualified interpreter was offered to P19 and refused. A review of P20’s medical record was conducted with S2 and S6 and revealed the following: A “SN OASIS Start of Care” note by S16, dated 07/22/26, stated, “… Encounter Notes: … Patient alert and oriented, Spanish speaking, granddaughter [name], present and translated at patient request … Ethnicity, Race, and Language: … What is your preferred language? Spanish … Do you need or want an interpreter to communicate with a doctor or healthcare staff? 1. Yes.” The note lacked evidence that a qualified interpreter was offered to P20 and refused. A “SN OASIS Resumption of Care” note by S30, dated 08/07/26, lacked evidence that a qualified interpreter was offered to P20 and refused. A “PT [Physical Therapy] Initial Evaluation” note by S31, dated 08/19/26, lacked evidence that a qualified interpreter was offered to P20 and refused. Findings include: Facility policy titled, “Foreign Language Interpreter,” dated 10/2024, stated, “… Procedure. Needs Assessment … During the admission assessment process the nursing team will verify the patient’s communication needs and ensure that the appropriate services are provided … Should the patient refuse the services of a foreign language interpreter, staff will document the refusal in Epic [electronical medical record system] and complete the Foreign Language Interpreter Waiver Form … Interpreter Services … The following resources may be utilized to facilitate adequate communications for patients with Limited English Proficiency: VRI (video remote interpreting), Over the telephone, Face to face qualified interpreters … Team Member Competency. Bilingual team members that provides patient care, including medical staff, must be assessed and deemed competent to communicate in their target language. Staff must demonstrate proficiency and ability to communicate clinical and non-clinical information … Procurement of Interpreters. Offer the services of an interpreter to every patient with Limited English Proficiency … Document in Epic which form of interpreting was used with interpreter name, number and/or agency …” Findings include: Facility policy titled, “Foreign Language Interpreter,” dated 10/2024, stated, “… Procedure. Needs Assessment … During the admission assessment process the nursing team will verify the patient’s communication needs and ensure that the appropriate services are provided … Should the patient refuse the services of a foreign language interpreter, staff will document the refusal in Epic [electronical medical record system] and complete the Foreign Language Interpreter Waiver Form … Interpreter Services … The following resources may be utilized to facilitate adequate communications for patients with Limited English Proficiency: VRI (video remote interpreting), Over the telephone, Face to face qualified interpreters … Team Member Competency. Bilingual team members that provides patient care, including medical staff, must be assessed and deemed competent to communicate in their target language. Staff must demonstrate proficiency and ability to communicate clinical and non-clinical information … Procurement of Interpreters. Offer the services of an interpreter to every patient with Limited English Proficiency … Document in Epic which form of interpreting was used with interpreter name, number and/or agency …” On 08/25/26 at 2:15 PM, a home visit for P7 was observed, completed by Staff (S)14. Prior to the start of the visit, S14 explained that P7 only spoke Spanish and P7’s spouse (Family (F)7) spoke limited English. S14 stated that he/she was Spanish speaking and could communicate with the patient and family. At the start of the visit, F7 reported that he/she preferred to communicate in Spanish. S14 was observed communicating with P7 and F7 in Spanish. S14 was not observed using the language line during the visit. At 2:38 PM, an interview was conducted with F7 using a telephonic interpretation provider. F7 stated that the home health aides (HHA) speak Spanish, the nurse speaks a little Spanish, and he/she speaks a little English. F7 stated that “maybe sometimes” he/she feels like he/she doesn’t understand what is being communicated. According to F7, the nurse communicates with his/her son and he/she relays the information to F7. On 08/27/26 at 12:50 PM, an interview was conducted with S1 and S2. S2 stated that the agency is in the process of scheduling bilingual HHAs for completion of a conversational certification. This would certify that staff could have non-clinical conversations with patients. S1 stated that until certified, staff should use the language line when working with patients. A review of P7’s medical record was conducted with S13 and S15 and revealed the following: A “SN [Skilled Nursing] OASIS Start of Care” note completed by S27, dated 09/07/25, stated, “… Encounter Notes … Patient is Spanish speaking, SN is fluent in Spanish, if visiting nurse is not fluent in Spanish, language line wound [sic] have to be contacted for translation … Ethnicity, Race, and Language … Language – What is your preferred language? Spanish … Interpreter – Do you need or want an interpreter to communicate with a doctor or health care staff? 1. Yes …” S27 was identified as a facility Certified Interpreter on a list provided by S3. A “MSW [Master of Social Work] Home Visit” note completed by S20, dated 09/12/25, stated, “... Encounter Notes ... [F7] provides all of [his/her] care taking, asked [F7] if [he/she] needs help with [P7’s] care...Educated [F7] about Senior Services. We discussed their care taker programs...” The medical record lacked evidence that a qualified interpreter was offered to P7 and lacked evidence that P7 refused interpreter services. A “PTA [Physical Therapy Assistant] Home Visit” note completed by S24, dated 02/04/26, stated, “ ... Encounter Notes ...Skilled Need: PT [Physical Therapy] for LE [lower extremity] strengthning [sic], bed mobility, caregiver education...” The medical record lacked evidence that a qualified interpreter was offered to P7 and lacked evidence that P7 refused interpreter services. A “PT Home Visit” note completed by S22, dated 02/18/26, stated, “... Encounter Notes...Assessment Revisit Note - Skilled Need: PT for heel cord stretch, ROM [range of motion] and fall prevention...Caregiver Involvement: [Spouse/Name], present and supportive. The medical record lacked evidence that a qualified interpreter was offered to P7 and lacked evidence that P7 refused interpreter services. A “SN Home Visit” note completed by S23, dated 03/09/26, stated, “... Encounter Notes...Skilled Need: Foley Catheter changed-well tolerated, clear yellow urine returned to bedside drainage bag. Medication review and instruction, Skin Integrity, Safety/Fall/Infection precautions, MD f/up [follow up]... The medical record lacked evidence that a qualified interpreter was offered to P7 and lacked evidence that P7 refused interpreter services. A “SN Home Visit” note completed by S21, dated 08/10/26, stated, “...Encounter Notes ... Skilled Need: HHA supervision pain assessment...” The medical record lacked evidence that a qualified interpreter was offered to P7 and lacked evidence that P7 refused interpreter services. A review of P18’s medical record was conducted with S13 and S15 and revealed the following: A “SN OASIS Start of Care” note completed by S8, dated 08/11/26, stated, “… Encounter Note … Issues Identified: Spanish interpreter [name/ID#]. Will need language interpreter if clinician does not speak Spanish/family member not present to interpret … Language – What is your preferred language? Spanish … Interpreter – Do you need or want an interpreter to communicate with a doctor or health care staff? 1. Yes …” A “SN Home Visit” note completed by S8, dated 08/19/26, lacked evidence that a qualified interpreter was offered to P18 and lacked evidence that P18 refused interpreter services. A “PT Initial Evaluation” note completed by S11, dated 08/23/26, stated, “… Encounter Notes: … Pt [patient] able to converse in simple English and requested [his/her] [grandchild] to assist in translation …” The medical record lacked evidence that a qualified interpreter was offered to P18 and lacked evidence that P18 refused interpreter services. A “PT Home Visit” note completed by S11, dated 08/25/26, stated, “… Encounter Notes: … Caregiver involvement: Patient has a supportive family present during visit assisting with Spanish translation…” The medical record lacked evidence that a qualified interpreter was offered to P18 and lacked evidence that P18 refused interpreter services. A review of P19’s medical record was conducted with S2 and S6 and revealed the following: A “SN OASIS Start of Care” note completed by S8, dated 07/12/26, stated, “… Ethnicity, Race, and Language: … What is your preferred language? Gujarati … Do you need or want an interpreter to communicate with a doctor or healthcare staff? 1. Yes.” The medical record lacked evidence that a qualified interpreter was offered to P19 and lacked evidence that P19 refused interpreter services. A “SLP [Speech Language Pathology] Initial Evaluation” note completed by S28, dated 07/13/26, stated, “… Encounter Notes: … Note: pt [patient] is able to respond verbally in Gujarat (family translates). pt is able to follow one step level directions with assistance for mobility …” The medical record lacked evidence that a qualified interpreter was offered to P19 and lacked evidence that P19 refused interpreter services. A “OT [Occupational Therapy] Initial Evaluation” note completed by S29, dated 07/20/26, stated, “… Problem: Patient-Stated Goal: … Intervention: Patient Care Preferences: … have an interpreter attend each visit and plan visits when caregiver is available. Visit Notes: DIL [Daughter-in-law] present for interpretor [sic] as per preference …” The medical record lacked evidence that a qualified interpreter was offered to P19 and lacked evidence that P19 refused interpreter services. A review of P20’s medical record was conducted with S2 and S6 and revealed the following: A “SN OASIS Start of Care” note completed by S16, dated 07/22/26, stated, “… Encounter Notes: … Patient alert and oriented, Spanish speaking, granddaughter [name], present and translated at patient request … Ethnicity, Race, and Language: … What is your preferred language? Spanish … Do you need or want an interpreter to communicate with a doctor or healthcare staff? 1. Yes …” The medical record lacked evidence that a qualified interpreter was offered to P20 and lacked evidence that P20 refused interpreter services. A “SN OASIS Resumption of Care” note completed by S30, dated 08/07/26, lacked evidence that a qualified interpreter was offered to P20 and lacked evidence that P20 refused interpreter services. A “PT Initial Evaluation” note completed by S31, dated 08/19/26, lacked evidence that a qualified interpreter was offered to P20 and lacked evidence that P20 refused interpreter services. All medical record findings for P7, P18, P19, and P20 were confirmed during review. On 08/27/26 at 12:50 PM, an interview was conducted with S1, S2, S3, S6, S10, S13, and S15. S1 stated that the facility’s policy does not allow family members or friends to translate for patients unless the patient is offered and refuses the qualified interpreter services provided by the facility. S1 stated that if a patient refuses translation services, a waiver must be completed and placed in the patient’s electronic medical record. S13 confirmed that the electronic medical records for P7, P18, P19, and P20 did not contain waivers refusing interpreter services. S3 confirmed the list of certified interpreters as complete and accurate. S8, S11, S14, S16, S20, S21, S22, S23, S24, S28, S29, S30, and S31 were not identified as certified interpreters according to the list provided by S3. Cross reference: N.J.A.C. 8:42-13.2(a)5”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to ensure that services ordered by the physician are provided as indicated in the plan of care. Facility policy titled, “Verification of Physician Orders”, revised 3/22, states, “…NOTICES TO THE PHYSICIAN … 2. If fewer visits are provided during the week than ordered, the physician will be notified with documentation in the clinical record that the physician is aware of the missed visits unless the physician has authorized missed visits under specified circumstances (for example, the plan of care indicates that the office may skip nursing visits on the day of physician visits or that home health aide visits may be skipped when the patient’s daughter is in the home to provide personal care). …” Findings include: On 2/29/24 during a review of Patient (P) 8’s medical record the “Home Health Plan of Care” for P8 for the certification period of 1/21/24 - 3/20/24, revealed the following: The section labeled Visit Sets stated, “… Speech Language Pathology[SLP]: 1 visit every 6 days for 6 days from 1/29/2024 to 2/3/2024, Comments: ST [Speech Therapy] evaluation for cognition; 1 visit every week for one week from 2/4/24 to 2/9/24; 2 visits per week for three weeks from 2/11/24 to 3/1/24. …” The week of 2/18/24, P8’s medical record indicated that no SLP visits were made. An “Inconvenience Visit Note was documented on 2/20/24 that stated, “… All Conversations …2/20/24 Inconvenience Visit: approx. [approximately] 2 minutes from pt [patient] house. Spouse cancelled because family dog just passed away. Re-scheduled for Thursday. …” On 2/29/24 at 3:02 PM, S1 (RN Director) explained that an Inconvenience Visit note is completed when the patient cancels the visit when the clinician is en-route. S1 explained that the clinician should complete a missed visit note in addition to the inconvenience note. The medical record for P8 does not contain evidence that the physician was notified of the missed visit on 2/20/24. On 3/1/24, during a review of P9’s medical record, the “Home Health Plan of Care” for P9, for the certification period of 1/29/24- 3/28/24, revealed the following: The section labeled Visit Sets stated, “… Speech Language Pathology[SLP]: 1 visit every 6 days for 6 days from 1/29/2024 to 2/3/2024, Comments: Eval [evaluate] and treat; 1 visit every 6 days for 6 days 2/4/2024 to 2/9/2024, Comments: Extension of SLP Eval and treat; 1 visit every week for 1 week 2/11/2024 to 2/16/2024; 1 visit every week for 3 weeks 2/18/2024 …” The Week of 2/4/24, P9’s medical record indicated that a SLP visit was missed. The “2/6/2024 SLP Missed Visit Note” lacks documentation that a physician was notified of the missed visit scheduled for 2/6/24. The “2/6/2024 SLP Missed Visits Notes” states, “…All Conversations (Oldest Message First) February 29,2024 [name of clinician], SLP to [name] RN 2/6/24 called Dr. [name] office and spoke with [name] to report a MV [missed visit]. 2/29/24 23:08 [11:08 PM]. …” On 3/1/24 at 10:07 AM, during an interview with S1 (RN Director), he/she confirmed that documentation of notification of a missed visit is expected to occur within 24 hours and that this SLP did not meet that expectation. N.J.A.C. 8:42-6.2(a)(6)”

“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 review of facility policy and procedure, observations, and staff interview, it was determined the facility failed to implement its policy and procedures regarding cleaning and disinfecting of equipment, to prevent the transmission of infections and communicable diseases. Facility Policy titled, “Cleaning & Disinfecting Guidelines for Patient Care Equipment” last revised 03/2022, states, “…Procedure … 3. Separation must be maintained between clean and soiled equipment to prevent cross contamination. … 4. …Patient care equipment should be wiped to thoroughly wet the surface (contact time) and remain wet for the time frame specific to the product’s instructions, before drying and returning to the clinician’s bag. …6. Follow the manufacturer’s instructions for equipment use, transportation, storage, and cleaning/disinfection. …” Manufacturer instructions for use (IFU) the Sani-Cloth Germicidal Disposable Wipes, located on the package, states, “… use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry…” On 2/28/24 at 12:18 PM, during a home visit with P2, Staff (S) 6 (Physical Therapist), was observed opening two clean barriers and placing them near the patient’s side. S6 then placed an unused blood pressure cuff, pulse oximeter, and thermometer on one barrier (clean). After using the equipment on P2, S6 then placed the used equipment onto an unused barrier (dirty). S6 then individually disinfected each used item with Sani-Cloth Germicidal Disposable Wipes and was observed placing disinfected/clean items back onto the same (dirty) barrier to dry. There was no clear and distinct separation between clean and soiled/used equipment observed. Additionally, after disinfecting the blood pressure cuff, S6 immediately rolled up the blood pressure cuff, not allowing the disinfectant to dry on the surface, for the recommended time, as per the manufacturer’s instructions (two minutes). On 2/29/24 at 10:50 AM, during a home visit with P4, S9 (Registered Nurse), was observed cleaning/disinfecting the used blood pressure cuff with a Sani-Cloth Wipe and then immediately rolled up the cuff, not allowing the disinfectant to dry on the surface for the recommended time. On 3/1/2024 at 12:24 PM, an interview was conducted with S3 (Director of Quality) and S12 (Registered Nurse - Staff Development) in which the process of cleaning equipment was discussed. S3 explained the staff is educated to clean the blood pressure cuff and allow it to dry (according to manufacturer’s guidelines), prior to rolling them and placing them back in their bags for storage. S3 indicated the staff should not be rolling the blood pressure cuffs up immediately after cleaning them because it does not give the disinfectant time to dry properly. S12 confirmed this by stating “the blood pressure cuff should be left open so you can see the surface and ensure the disinfectant has dried.” N.J.A.C. 8:42-12.2(b)”