Patient Care

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of facility documents and staff interview, it was determined the facility failed to electronically submit completed OASIS assessments to the CMS system within 30 days of completing the assessment of the beneficiary. Findings include: On 8/22/24 at 11:09 AM, the OASIS report, “HHA [Home Health Agency] Error Summary by Agency Report” was electronically run in the presence of Staff (S) 4 (Executive Director) and was found to have 1,956 records with errors, 3330, “Record Submitted Late: The submission date is more than 30 days after M0090 (Date Assessment Completed) on this new record.” On 8/22/24 at 11:15 AM, an interview with S4 (Executive Director) indicated that they [the facility] is aware and track every late upload from a quality standpoint. On 8/23/24 at 11:09 AM, during an interview with S4 and S1 (Patient Care Manager), S4 stated there are quality reviewers (QR’s) who monitor this and the information is found on the electronic dashboard. Facility Document titled, “Patient Care - W. [West] Orange, NJ Special Project,” provided by S4 outlines the process the facility used to address the significant backlog of OASIS states, “...10/16/23[:] Clean Up Project initiated to address remaining backlog of OASIS assessments...” A line graph [graphical display of information that changes continuously over time], was attached to this document which includes the numerical percentage of “Late Locks” (late uploads) to the left monthly from April 2023-July 2024. Although this graph shows a fluctuating and overall decrease in trend, 8.17% late uploads were recorded in July 2024. S4 stated, “we are aware and take this very seriously.” N.J.A.C. 8.42-3.1(d)”

“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.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This Standard is not met as evidenced by: Based on observation, staff interviews, medical record review, and review of facility policy and procedure, it was determined that the facility failed to provide language translation services to a non-English speaking patient according to facility policy in one of four medical records reviewed (Patient (P) 7). Findings inlcude: On 8/22/24 at 10:34 AM, P7’s initial Physical Therapy home visit was observed. During the evaluation, Staff (S) 10, Physical Therapist, communicated with P7 through his/her spouse. In the middle of the visit, at 11:00 AM, S10 asked P7’s spouse what language the patient speaks. S10 was informed that P7 spoke Russian. On 8/22/24 at 11:25 AM, an interview was conducted with S10 after the home visit was completed. S10 reported that all staff have access to interpreter services on their tablets. S10 explained that he/she typically uses family members for translation if they are present during the treatment. According to S10, they usually only need the interpreter services on the tablet if the patient is alone. On 8/23/24 at 11:30 AM, P7’s medical record was reviewed. The admission assessment was completed on 8/20/24 at 2:17 PM. P7’s response to “What is your preferred language?” was “Russian.” P7’s response to “Do you need or want an interpreter to communicate with a doctor or health care staff?” was “Yes.” On 8/23/24 at 11:45 AM, S1, Patient Care Manager, reported that typically family is used to interpret for the patient. According to S1, patients are informed during the admission process that interpreters are available and the facility is usually made aware that an interpreter is needed during the referral process. S1 explained that staff would document use of an interpreter or offering of an interpreter in the narrative section of the clinician’s documentation. On 8/23/24 at 12:20 PM, S1 and S4, Executive Director, explained that the question asked on admission, “Do you need or want an interpreter to communicate with a doctor or health care staff,” does not imply the patient wants to use interpreter services. S1 and S4 stated that a “yes” answer to this question means that the patient just wants someone to interpret for them, and this could be family. S4 was unable to provide evidence in the medical record that P7 was offered interpreter services. The medical record lacked evidence that P7 was offered and/or declined the use of professional interpreter services as per facility policy. Facility Policy titled, “Limited English Proficiency Persons (LEP)” last reviewed on July 1, 2024, stated, “…Procedure: 1. On admission the patient/family/caregiver will be informed that interpreter services including American Sign Language (ASL) are available. If an individual is identified as a LEP person during the admission process, the agency will make formal arrangements with individuals or organizations to obtain the services of a qualified interpreter when needed….5. Family and friends may not be used to interpret or translate unless client/LEP person is made aware of the availability of interpreters at no charge, and then without coercion, chooses family or friends…When it is expressed by the patient that this service is not wanted (including remote interpreter services), the agency will oblige the patient’s request to allow a family member in order to meet patient’s Rights and Responsibilities in accordance with the agency official policies and procedures. Such an offer and the response will be documented in the patient’s medical record.” N.J.A.C. 8:42-13.2(a)5”

“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, facility policy review and staff interviews, it was determined the facility failed to provide a sanitary environment by ensuring equipment that is used for more than one patient is disinfected between each patient use. On 8/21/24 at 1:42 PM, during a home visit with Patient (P) 2, Staff (S) 3 (Registered Nurse), was observed taking a tablet out of his/her bag and using it to document during the patient’s home visit. At 2:38 PM, at the conclusion of the visit, S3 provided the tablet to P2, and the patient used his/her finger to sign the tablet. S3 then carried the tablet out of the patient’s home. The tablet was not cleaned following contact with the patient. On 8/23/24 at 12:10 PM, S4 (Executive Director), confirmed “the tablet has to be wiped down with a low-level disinfectant after the patient signs.” The facility policy titled, “Cleaning of Re-Usable Equipment” revised date 6/1/22, states, “…Policy: Equipment used for more than one patient is cleaned between each patient use. …Procedure 1. Non-critical items which will come in contact with intact patient skin will undergo a low-level disinfection between each patient use. …” N.J.A.C. 8:42-12.3 (a)4 Findings include: On 8/21/24 at 1:08 PM, Staff (S) 7, an Occupational Therapist (OT) was observed providing care for P4. At 1:29 PM, S7 began taking P4’s vital signs with gloves on. At 1:31 PM, S7 began entering the vital signs into his/her tablet without doffing gloves and performing hand hygiene. At 1:37 PM, S7 began cleaning vital signs equipment (stethoscope, oximeter, blood pressure cuff and sphygmomanometer) with disinfectant wipes but failed to clean the tablet. At 1:41 PM, P4 signed the tablet using his/her finger. At 1:53 PM, the visit was completed and S7 exited P4’s home without cleaning the tablet. When questioned about the tablet, S7 stated that he/she should have cleaned the tablet before leaving P4’s home. On 8/22/24 at 11:05 AM, an interview was conducted with S8, a Physical Therapist (PT). When questioned about tablets, he/she stated that the facility policy is to clean the tablet before leaving the patient’s house once patient care is completed.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on medical record review and staff interview, it was determined the facility failed to ensure one out of five medical records reviewed (Patient (P) 17) received written notice of non-covered care, prior to discharge. Findings include: On 8/23/24, a review of P17’s medical record indicated he/she was discharged from homecare services on 10/31/23. Review of P17’s medical record lacked evidence that he/she received a Notice of Medicare Non-Coverage (NOMNC); a notice that indicates when care is set to end from a home health agency. On 8/23/24 at 12:20 PM, Staff (S)4 (Executive Director) confirmed this finding. N.J.A.C. 8.42-3.1(d)”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on medical record review, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure that patient’s medical records are completed within 24 hours, as per facility policy in eight out of 12 medical records reviewed (Patient (P) 1, P5, P8, P9, P13, P14, P16, and P17). Findings include: Patient (P) 1’s medical record was reviewed on 8/22/24 at 12:30 PM, the following was revealed: P1 was admitted to home care services on 7/27/24 for Physical Therapy (PT) for right hip pain. On 8/2/24, P1 was seen in-home by PT at 9:28 AM. The visit note was completed on 8/4/24 at 6:46 PM. On 8/6/24, P1 was seen in-home by PT at 12:00 PM. The visit note was completed on 8/8/24 at 11:04 AM. On 8/8/24, P1 was seen in-home by PT at 11:05 AM. The visit note was completed on 8/11/24 at 7:11 PM. On 8/14/24, P1 was seen in home by PT at 2:14 PM. The visit note was completed on 8/18/24 at 9:14 AM. P5’s medical record was reviewed on 8/22/24 at 12:30 PM, the following was revealed: On 7/2/24, P5 was seen in-home for a Skilled Nurse (SN) visit at 12:58 PM. The visit note was completed on 7/12/24 at 7:15 AM. On 7/9/24, P5 was seen in-home for a SN visit at 3:18 PM. The visit note was completed on 7/11/24 at 11:56 PM. On 7/12/24, P5 was seen in-home for a SN visit at 7:41 AM. The visit note was completed on 7/14/24 at 6:42 PM. P8’s medical record was reviewed on 8/22/24 at 10:30 AM, the following was revealed: P8 was admitted to home care services on 6/6/24 for a left lower leg wound. The benefit period reviewed was 8/5/24 to the date of the survey, 8/23/24. On 8/5/24, P8 was seen in-home for a skilled nursing visit at 10:47 AM. The visit note was completed on 8/7/24 at 2:26 AM. On 8/8/24, P8 was seen in-home for an Occupational Therapy (OT) visit at 2:51 PM. The visit note was completed on 8/12/24 at 6:26 AM. On 8/12/24, P8 was seen in-home for a PT visit at 10:54 AM. The visit note was completed on 8/14/24 at 7:01 AM. On 8/13/24, P8 was seen in-home for an OT visit at 1:16 PM. The visit note was completed on 8/19/24 at 6:40 AM. On 8/22/24 at 3:02 PM, an interview was conducted with Staff (S)4, Executive Director. S4 stated that clinicians are expected to have visit notes documented in the medical record within 24 hours. P9’s medical record was reviewed on 8/22/24 at 2:00 PM, the following was revealed: On 8/16/24, P9 was seen in-home for a SN visit at 3:10 PM. The visit note was completed on 8/18/24 at 12:27 AM. P13’s medical record was reviewed on 8/23/24 at 10:30 AM, the following was revealed. The Client Coordination Note Report stated, “…Note Date 2/27/24 Note Type MISSED VISIT NOTIFICATION…MISSED VISIT ON 01312024…DISCIPLINE SN…”. The Client Coordination Note Report stated, “…Note Date 2/29/2024 Note Type MISSED VISIT NOTIFICATION…MISSED VISIT ON 02092024…DISCIPLINE PT [Physical Therapist] …”. P14’s medical record was reviewed on 8/23/24 at 11:30 AM, the following was revealed: The Client Coordination Note Report stated, “…Note Date 11/21/2023 Note Type MISSED VISIT NOTIFICATION…MISSED VISIT ON 11012023…DISCIPLINE SN…”. P16’s medical record was reviewed on 8/23/24 at 11:50 AM, the following was revealed: The Client Coordination Note Report stated, “…Note Date 1/26/2024 Note Type MISSED VISIT NOTIFICATION…MISSED VISIT ON: 01/03/2024…DISCIPLINE OT [Occupational Therapist] …”. P17’s medical record was reviewed on 8/23/24 at 11:50 AM, the following was revealed: The Client Coordination Note Report stated, “…Note Date 10/30/2023 Note Type MISSED VISIT NOTIFICATION…MISSED VISIT ON: 10/26/2023…DISCIPLINE PT…”. On 8/23/24 at 11:33 AM, the above findings were confirmed with S4, Executive Director. S4 stated, “we want staff to document within 24 hours, that is the expectation.” The facility policy titled, “Coordination of Care, From Admit Through Discharge” revised date 6/1/24, states, “…PROCEDURE: …5. Coordination of care among disciplines: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge. This includes: …c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals, and care as well as changes in these. i. All clinicians will report within 1 business day to the Patient Care Manager or Clinical Director by fax, telephone, in person at the agency, or through coordination notes by synching point of care devices. Report will include: …Missed visits and changes to scheduled visits…d. Completed visit notes will be submitted to the agency via synchronization within 24 hours of visit for point of care agencies. …” N.J.A.C. 8.42-11.2(a)1”