Federal Inspection Issues Report on Andover Subacute Long-Term Care Facility

Recent CMS Inspection Finds Andover Facility Not in Compliance with Federal Requirements, Cites Multitude of Issues & Failures

Facility and residents were in “immediate jeopardy” health and safety at risk for serious injury, serious harm … or death”

CMS Issues Massive Fines, Orders Ongoing Penalties, Oversight

Gottheimer had asked for CMS and state to investigate

On May 7, 2020, U.S. Congressman Josh Gottheimer (NJ-5) announced that the Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS), has issued its inspection report for the Andover Subacute and Rehabilitation II facility in Sussex County, NJ. 

The CMS inspection report found that the Andover Subacute II facility was not in substantial compliance with federal requirements.

CMS has imposed a Civil Money Penalty accruing a total of $220,235 for the fifteen days of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), beginning April 6th and ending on April 20th — or more than $14,000 per day, in addition to other fines. CMS has stated that the monetary penalties to the Andover facility will continue to accrue until substantial compliance is achieved or termination occurs. 

CMS defines a situation in which a long-term care facility is non-compliant when the facility has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.

The Andover Subacute II facility must now submit a Plan of Correction (PoC) for the deficiencies cited by CMS within ten calendar days.

“I am absolutely disgusted and heartbroken for the residents, staff, and families about the conditions this CMS inspection has uncovered from the facility in Andover. The loss of life and the circumstances that so many of the residents faced are a complete tragedy. This is why I’ve been working with NJDOH, the Governor, and FEMA to get the National Guard and the VA into facilities like Andover Subacute to assist staff and help keep residents safe. It’s also why I demanded that CMS and the State investigate. I’ve also been working with Sussex County Sheriff Michael Strada, Andover Township Mayor Michael Lensak, and local law enforcement to get more PPE to the personnel at these facilities. We will not beat this virus and flatten the curve if the coronavirus is able to continue to spread like wildfire in our long-term care facilities,” said Congressman Josh Gottheimer (NJ-5). 

Within the inspection report, CMS noted, “These failures in proper infection control practices had the potential to affect all residents in the facility through the development and transmission of COVID-19 and other communicable diseases. It was determined that the provider’s non-compliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm impairment or death to residents.” 

According to County data received this week, the Andover Subacute II facility currently has 133 residents and 54 staff members who have tested positive for COVID-19. In total, 94 residents and 1 staff member have died.

When first contacted about issues at the Andover facility in mid-April, Gottheimer continued to request coordination, action, and resources from the State of New Jersey, FEMA, and the federal government to address COVID-19 outbreaks in long-term care facilities in North Jersey. Since learning of the crisis at the facility, Gottheimer has been in regular touch with New Jersey Department of Health (NJDOH) Commissioner Judith Persichilli and with the Governor’s office. Gottheimer also asked the State and CMS to investigate the facility.

Gottheimer has also asked the Federal Emergency Management Agency (FEMA) to deploy National Guard and Reserves to assist North Jersey long-term care facilities in need, and he requested that the U.S. Department of Health and Human Services (HHS) deploy U.S. Public Health Service front-line health care workers.

This week, Gottheimer introduced new bipartisan with Congressman Chris Smith (NJ-4) — the Nursing Home Pandemic Protection Act of 2020 — to codify into federal law new requirements that nursing homes report communicable diseases, infections, and potential outbreaks to the Centers for Disease Control and Prevention (CDC) and that residents and their families be kept informed of infections inside the facilities; as well as requiring facilities have both a crisis plan in place to manage an outbreak and a stockpile of personal protect equipment (PPE) on hand.

Within the inspection report on Andover Subacute II, CMS cited a variety of serious and alarming concerns, including:

• On 4/10, a resident was found on the floor by the bed, had fallen on the wet floor and obtained a small abrasion on the head. The resident was pronounced dead the morning of 4/11. The following is an excerpt from hand written notes from the resident’s physician: “Found dead this am…not performed Physical-COVID-19 test was done?…High fever for the last few days – that was not brought to my attention. Flu like illness, likely COVID-19.” 

• Multiple patients with elevated temperatures and no documented clinical assessment or follow-up from medical staff;

• Documented incidences of a patient under investigation (PUI) for COVID-19 being placed in a room with a resident who was asymptomatic. In one case, the PUI’s test came back positive and only then was the resident moved to a different room; 

• Review of facility documentation found several missing elements including missing temperature logs for residents and a lack of documentation of resident symptoms;

• A resident was documented to have a temperature of 104.9 on 4/6. The following day, the resident’s temperature was not documented at all. The resident was found unresponsive and pronounced dead on 4/8. “No documentation of coronavirus monitoring was found regarding the respiratory symptoms which included coughing or shortness of breath assessment” for this resident; 

• On 4/16, a resident was admitted to the hospital with respiratory failure and possible COVID-19. There were no documented notes in the resident’s temperature log regarding their condition for the previous five shifts and no test had been ordered for the resident. The resident was subsequently intubated at the hospital; 

• Multiple instances of insufficient PPE usage and protection for staff in the facility.

Read the CMS letter to Andover Subacute And Rehab II HERE. 

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