Andover Subacute and its failures

Editor’s note: U.S. Rep. Josh Gottheimer (D-NJ 5th District) sent the following letter, dated Jan. 6, 2022, to The Honorable Xavier Becerra, Secretary, and The Honorable Chiquita Brooks-LaSure, Administrator, U.S. Department Health and Human Services Centers for Medicare & Medicaid Services.

Dear Secretary Becerra and Administrator Brooks-LaSure:

In April 2020, North Jersey residents learned about the crisis of care at the Andover Subacute and Rehabilitation II facility in Sussex County, N.J. The substandard quality of care at the facility led to hundreds of residents testing positive for Covid-19, with nearly one hundred ultimately succumbing to the disease. Most jarringly, during the height of the crisis, a police inspection of the facility found 17 bodies piled in a makeshift morgue.

Following these developments, the Centers for Medicare & Medicaid Services (CMS) completed an Immediate Jeopardy complaint survey at the facility. That survey revealed that the facility was not in compliance with federal requirements and required the facility to correct the identified deficiencies. Now, nearly two years removed from the initial crisis, I am requesting an update on the facility’s compliance with its Plan of Correction (PoC) that CMS required it to submit under the May 2020 CMS inspection report.

Following my April 2020 requests for the federal government to address Covid-19 outbreaks in long-term care facilities in New Jersey, CMS released on May 6, 2020, an extensive inspection report for the Andover Subacute and Rehabilitation II facility. The CMS inspection report found that the Andover Subacute II facility was not in substantial compliance with federal care requirements. In the report, CMS imposed a Civil Money Penalty accruing a total of $220,235 and required the facility to submit a PoC for the deficiencies cited by CMS.

CMS identified several alarming and widespread concerns, including missing temperature logs for residents and lack of documentation of resident symptoms; incidences of residents under investigation for Covid-19 being placed in rooms with residents who were asymptomatic; and, multiple instances of insufficient PPE usage and protection for staff in the facility. CMS also identified several unacceptable episodes impacting specific residents, including one in which facility staff did not inform a resident’s physician of a resident’s high fever, and another in which facility staff did not document a resident’s temperature at all the day after experiencing a fever. Both residents were later pronounced dead.

As stated, CMS required the Andover Subacute and Rehabilitation II facility to submit a PoC within ten calendar days of May 6, 2020, detailing corrective actions to bring the facility into compliance with federal care requirements. To be acceptable, the facility had to submit a list of the specific corrective actions; institute systemic changes to ensure that the deficient practices did not occur again; detail a quality assurance system; and, submit dates by which the corrective actions were to be completed within “acceptable time frames.” CMS was set to review corrective actions to determine compliance.*

Now, more than a year removed from these initial findings, the facility owes the public and the families of those impacted their compliance with federal care requirements. This is particularly important given the news that emerged just this week that the same facility is now the site of New Jersey’s worst current Covid-19 outbreak, with 192 residents and 108 employees having tested positive amid the omicron wave. According to state data, as of this week, only 52.4 percent of the facility’s residents had received their booster shots, and none of the facility’s staff were boosted. New Jersey taxpayers — who indirectly support the facility each year via the millions in Medicare and Medicaid payments that it receives — are owed transparency and full disclosure. North Jersey families should have confidence that elderly relatives and veterans will be well cared for in their later years, whether residing in private or state-run long-term care facilities.

For these reasons, within 30 days, please update me on the progress Andover Subacute and Rehabilitation II facility, now known as Woodland Behavioral and Nursing Center, has made toward compliance with its PoC. Please include information on progress in correcting the shortcomings that led to the Covid-19 outbreak and resulting deaths in 2020. Thank you for your ongoing work on this pressing matter and your responsiveness to this request.

Josh Gottheimer

Member of Congress