Every finding on record at New St. Barnabas Medical Center, Inc.

Based on the findings of an onsite unannounced Medicare recertification survey completed October 25, 2021, New St. Barnabas Medical Center was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an onsite unannounced Medicare recertification survey completed October 25, 2021, New St. Barnabas Medical Center was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on the review of clinical records (CR), review of agency policies, and interview with agency staff, the agency failed to coordinate services and inform the physician and/or other personnel of changes in the patient's condition/needs and/or initiate plan of treatment revisions for two (2) of six (6) of active clinical records reviewed (CR1, CR2). Findings included: Review on 10/25/2021 of agency policies revealed "...Professional…Care Plans…An individualized plan of care…may be developed and implemented by each professional discipline providing service…The care plan shall be based on a systemic process of assessment, problem and need identification…and development of action steps…Care plans will be reviewed and updated on an ongoing basis and within five (5) days of identification of a change…” Additional review of agency policies revealed “…Professional…Services…Skilled Nursing Services…shall include but not limited to:..Notification of the physician and other member of the care team of client’s progress and needs…” CR1 Start of Care 9/18/2021, reviewed on 10/20/2021 at approximately 12:45 PM revealed "...Certification Period 9/18/2021 to 11/16/2021...Allergies, Substance, NKA (no known allergies)…(Food/Drug/Latex/Environmental)…Orders and Treatments...Frequencies...SN (Skilled Nursing) 1W (week)1...2W2…1W4…" CR1 documented “Transfer Summary” dated 10/18/2021, “…Transfer date 10/17/2021…Summary Of Care…Sent to ED (emergency Department) for allergic reaction where she found unresponsive, was treated and discharged back to ALF (assisted living facility)…” CR1 Review of SN visit conducted 10/19/2021 revealed: “…Medication change since last visit? No…Comments: Prednisone 20mg PO (by mouth) 2 Tabs BID (twice a day) X 5 Days D/C (discontinue) 10/22/2021, Cefdinir 300mg PO Q (every)12 Hrs (hours) X 7 Days 10/24/2021, EPIPEN .3mg Injectable, Seen in ED Sunday 17th for allergic reaction and UTI (urinary tract infection…” Review of CR1 “Patient Medication Record” dated 10/20/2021 revealed: “…Allergy Profile NKA (Food/Drug/Latex/Environment)…Current Medications…10/17/2021...EpiPen 2-Pak Injection 0.3mg/0.3mL 1 as needed for allergic reaction…” CR1 did not contain documentation of the SN coordinating care delivery with the patient physician and/or other personnel to revise/update the patient POC to meet the needs of the patient based on a change in condition. CR2 Start of Care 10/2/2021, reviewed on 10/20/2021 at approximately 1:45 PM revealed "...Certification Period 10/2/2021 to 11/30/2021.” CR2 Review of initial SN comprehensive assessment conducted 10/2/2021 revealed: “…Integumentary Status…Comments: Patient with skin tear to r (right) shin and left elbow…Wound 1-Location: R (right) shin, Status: Open…Type: Skin tear…Wound 2-Location L (left) elbow, Status: Open…Type: Skin Tear…” CR2 Review of Patient Plan of Care revealed: “…Primary Diagnosis, Unspecified open wound, right lower leg…Secondary/Other Diagnosis, Unspecified open wound left elbow...Orders and Treatments...SN (Skilled Nursing) Interventions…SN to instruct the patient, caregiver on wound care as follows: Cleanse skin tears to LLE (left lower extremity) and RUE (right upper extremity) with NSS (normal saline solution) or soap and water, pat dry, apply tefla and wrap with kerlix, tape to secure daily and PRN (as needed) for soiling…” During CR2 review, EMP3 (Clinical supervisor) confirmed location of patient wounds (right shin, left elbow) were documented correctly in the initial comprehensive assessment and incorrectly documented in the POC SN interventions. CR2 did not contain documentation of the SN coordinating care delivery with the patient physician and/or other personnel to revise/update the patient POC SN intervention for patient wound locations accuracy. An exit conference was conducted at approximately 12:00 PM on 10/25/2021 with agency administrator (EMP1), Director (EMP2), and nursing supervisor (EMP3). Above findings were reviewed.