Homeside Hospice LLC

“Based on observation, staff interview, and facility policy review, it was determined the facility failed to ensure proper infection prevention practices in two of the four home visits observed (Patient (P)1 and P2). Findings include:Facility policy titled, “Infection Control- Bag Technique,” dated 07/10/25, stated, “… Procedures: … 5. … hand hygiene is performed before removing … items from the bag … 8. All items that may be used with other patients … are to be cleaned with 70% alcohol …” On 11/19/25 at 1:27 PM, Staff (S)10 was observed providing care for P1.At 1:31 PM, S10 was observed touching P1 without gloves on and obtaining P1’s temperature and heart rate. S10 was then observed accessing his/her bag, without performing hand hygiene, and removing a stethoscope. At 1:33 PM, S10 was observed touching P1 without gloves on and obtaining P1’s blood pressure utilizing a manual blood pressure cuff. S10 was observed placing the contaminated blood pressure cuff on a barrier pad. S10 was then observed accessing his/her bag, without performing hand hygiene, and removing disposable alcohol pads.At 1:37 PM, S10 was observed placing the contaminated blood pressure cuff in his/her bag without being cleaned. At 1:41 PM, S10 was observed exiting P1’s room with the contaminated blood pressure cuff in his/her bag. At 1:46 PM, an interview was conducted with S10. While reviewing the home visit, S10 confirmed he/she did not clean the blood pressure cuff and accessed his/her bag multiple times without performing hand hygiene.On 11/21/2025 at 12:21 PM, an interview was conducted with S1. S1 stated, staff are to perform hand hygiene prior to accessing their bags. While reviewing the “Infection Control- Bag Technique” policy, S1 confirmed that all reusable patient care equipment, which includes a blood pressure cuff, is to be cleaned with a disposable alcohol pad.Cross reference:NJAC 8:42C – 10.2(b) On 11/19/2025 at 1:42 PM, Staff (S)4 conducted a home visit in the presence of S5 for Patient (P)2.At 1:46 PM, S4 was observed sanitizing his/her hands prior to entering his/her nursing bag. S4 removed an automatic wrist BP (Blood Pressure) Cuff from nursing bag and attempted to obtain a BP reading on P2’s right wrist using the automatic wrist BP monitor. After two error readings while using the automatic BP monitor, S4 unzipped the nursing bag and re-entered the bag without sanitizing his/her hands prior to grabbing a manual BP cuff.On 11/21/25 at 12:20 PM, an interview was conducted with S1. S1 stated that if a clinician started with the patient, clinicians are to sanitize their hands prior to re-entering their nursing bag. Findings include:Facility policy titled, “Infection Control- Bag Technique,” dated 07/10/25, stated, “… Procedures: … 5. … hand hygiene is performed before removing … items from the bag … 8. All items that may be used with other patients … are to be cleaned with 70% alcohol …” On 11/19/25 at 1:27 PM, Staff (S)10 conducted a home visit for Patient (P)1.At 1:31 PM, S10 was observed touching P1 without gloves on and obtaining P1’s temperature and heart rate. S10 was then observed accessing his/her bag, without performing hand hygiene, and removing a stethoscope.At 1:33 PM, S10 was observed touching P1 without gloves on and obtaining P1’s blood pressure utilizing a manual blood pressure cuff. S10 was observed placing the contaminated blood pressure cuff on a barrier pad. S10 was then observed accessing his/her bag, without performing hand hygiene, and removing disposable alcohol pads.At 1:37 PM, S10 was observed placing the contaminated blood pressure cuff in his/her bag without being cleaned.At 1:46 PM, an interview was conducted with S10. While reviewing the home visit, S10 confirmed he/she did not clean the blood pressure cuff and accessed his/her bag multiple times without performing hand hygiene.On 11/19/2025 at 1:42 PM, S4 conducted a home visit for P2 in the presence of S5.At 1:46 PM, S4 was observed sanitizing his/her hands prior to entering his/her nursing bag. S4 removed an automatic wrist BP (Blood Pressure) Cuff from nursing bag and attempted to obtain a BP reading on P2’s right wrist using the automatic wrist BP monitor. After two error readings while using the automatic BP monitor, S4 unzipped the nursing bag and re-entered the bag without sanitizing his/her hands prior to grabbing a manual BP cuff.On 11/21/2025 at 12:21 PM, an interview was conducted with S1. S1 stated, staff are to perform hand hygiene prior to accessing their bags. While reviewing the “Infection Control- Bag Technique” policy, S1 confirmed that all reusable patient care equipment, which includes a blood pressure cuff, is to be cleaned with a disposable alcohol pad.Cross reference:NJAC 8:42C – 10.2(b)”

“Based on medical record review and staff interview, it was determined the facility failed to ensure supervision of hospice aides every 14 days in three of 10 records reviewed (Patient (P)1, P2, and P11). Findings Include:On 11/25/25, a medical record review was conducted on Patient (P)2. The following information was revealed:According to P2’s “Plan of Care,” an order for a Hospice Aid with a frequency of 3-7 visits per week was ordered for benefit period starting on 10/24/2025. Documented evidence revealed that the medical record lacked evidence of a Supervisory Aid visit on 11/07/25.On 11/20/25 at 1:53 PM, an interview was conducted with S15. S15 stated that P2 should have had a Supervisory Aid Visit on 11/07/25. Findings include:A review of P1’s medical record was conducted and revealed the following: S10 completed an Aide Supervisory Visit on 09/23/25. The next Aide Supervisory Visit was conducted by S10 on 10/08/25, 15 days after the previous Aide Supervisory Visit.A review of P11’s medical record was conducted and revealed the following: S16 completed an Aide Supervisory Visit on 10/16/25. The next Aide Supervisory Visit was conducted by S16 on 10/31/25, 15 days after the previous Aide Supervisory Visit.On 11/21/2025 at 12:54 PM, an interview was conducted with S1. S1 stated, hospice aide supervisory visits are to be conducted every 14 days. S1 confirmed the above findings for P1 and P11. Cross reference:NJAC 8:42C – 7.5(a)”

“Based on review of medical records and staff interview, it was determined the facility failed to ensure all patients receive a face-to-face encounter with a hospice physician or hospice nurse practitioner prior to the start of the third recertification period, and each benefit recertification period thereafter, in two of six medical records reviewed who required face-to-face encounters (Patient (P)2 and P14). Findings include:Reference: Title 42 Public Health, Chapter IV, Subchapter B, 418.22(4)(i) Certification of terminal illness, states, “... As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care. ...”On 11/21/25, a review of P2’s medical record was conducted and revealed the following:On 10/29/24, P2 elected hospice services.P1’s medical record lacked evidence of a face-to-face encounter with a hospice physician or hospice nurse practitioner for P2’s fifth benefit recertification period of 08/25/25-10/23/25.On 11/21/25 at 12:20 PM, Staff (S)1 confirmed that P2’s medical record lacked evidence of a face-to-face encounter with a hospice physician or a hospice nurse practitioner for his/her fifth benefit recertification period. S1 stated that there should have been a face-to-face encounter for this benefit recertification period. On11/21/25, a review of P14’s medical record was conducted and revealed the following:On 03/24/23, P14 elected hospice services. P14’s medical record lacked evidence of a face-to-face encounter with a hospice physician or hospice nurse practitioner for P14’s fourth benefit recertification period of 11/19/23 - 01/17/24, twelfth benefit recertification period of 03/13/25 - 05/11/25, and fourteenth benefit recertification period of 07/11/25 – 09/08/25.0n/11/21/25 at 1:59 PM, S1 confirmed that P14’s medical record lacked evidence of a face-to face encounter with a hospice physician or a hospice nurse practitioner for his/her fourth, twelfth and fourteenth benefit recertification periods. S1 reported that there should have been face-to-face encounters for these three benefit recertification periods.”