Every finding on record at St Barnabas Medical Center Inc.

Based on review of facility policy, clinical records (CR), and staff (EMP) interview, the facility failed to ensure the plan of care specified hospice care and services necessary to meet the patient's specific needs identified in the comprehensive assessment for one (1) of nine (9) active clinical records reviewed (CR1). Findings included: Facility policy review on 2/11/2022 revealed:: "...Policy # 3...Plan of Care Establishment...Policy...A plan of care will be established for each patient...Procedure...An individualized plan of care shall be developed and implemented by each professional discipline providing service...care plan shall be based on a systemic process of assessment, problem, and needs identification for goals and development of action steps. Each plan will include:..Specific, individualized, measurable goals and interventions..." CR1 review 2/8/2022 at approximately 12:30 PM. Start of Care 12/30/2021. Reviewed Plan of Care (POC) Certification period 12/30/2021 to 3/29/2022. Skilled nursing initial assessment assessment on 12/30/2022 revealed "...Wound...L (left forearm)...Size 5cm (centimeters)...Stage 2...Comments: [Patient] has large open area on L forearm, No redness or s/s (signs/symptoms) of infection noted. [Patient] is received (sic) NG (nursing-patient resides in nursing facility) daily dressing changes and wound care..." CR1 POC did not contain documentation of specific wound care interventions related to patient left forearm wound identified on the skilled nursing initial visit 12/30/2021. Exit conference was conducted with facility director of nursing (EMP6) on 2/11/2022 at approximately 1:00 PM. Above findings were reviewed.

Based on review of facility policy, clinical records (CR), and staff (EMP) interview, the facility failed to review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days for two (2) of nine (9) active clinical records reviewed (CR3, CR4). Findings Included: Facility policy review on 2/11/2022 revealed:: "...Policy #9...Interdisciplinary Group...Policy...will have an established Interdisciplinary Group to develop an individualized plan of care for each patient...Procedure...The IDG (Interdisciplinary Group) is responsible for meeting and reviewing the hospice patients at least every 15 days..." CR3 review 2/10/2022 at approximately 9:15 AM. Start of Care 8/12/2021. Period reviewed 12/3/2021 to 2/10/2022. IDG meetings were documented on 12/3/2021, 12/30/2021, and 1/28/2022, exceeding the IDG requirements to review, revise and document the individualized plan as frequently as the patient's condition requires, but no less than every 15 days. CR4 review 2/10/2022 at approximately 9:40 AM. Start of Care 1/18/2022. Period reviewed 1/18/2022 to 2/10/2022. IDG meeting was documented on 1/21/2022. There were no further IDG meetings documented, exceeding the IDG requirements to review, revise and document the individualized plan as frequently as the patient's condition requires, but no less than every 15 days. Exit conference was conducted with facility director of nursing (EMP6) on 2/11/2022 at approximately 1:00 PM. Above findings were reviewed.

Based on review of facility policy, clinical records (CR), and staff (EMP) interview, the facility failed to ensure a system of integration, specifically, visit documentation with all disciplines providing care and services in all settings for for one (1) of nine (9) active clinical records reviewed (CR4). Findings included: Facility policy review on 2/11/2022 revealed:: "...Policy # 3...Plan of Care Establishment...Policy...A plan of care will be established for each patient...Procedure...An individualized plan of care shall be developed and implemented by each professional discipline providing service...care plan shall be based on a systemic process of assessment, problem, and needs identification for goals and development of action steps. Each plan will include:..Specific, individualized, measurable goals and interventions...Care plans will be reviewed and updated at least every fourteen days and as needed on an ongoing basis...Care plans should be updated with...a plan of care order...Care planning shall be coordinated among all disciplines providing services..." CR4 review 2/10/2022 at approximately 9:40 AM. Start of Care 1/18/2022. Certification period reviewed 1/18/2022 to 4/17/2022. Patient resides in skilled nursing facility. CR4 documented the following physician orders : "...1/25/2022...Consult PT (Physical Therapy) for evaluation and up to 3 visits for family education, safety, and restorative care...1/26/2022...Consult SLP (Speech language Pathologist) to evaluate and follow for 3 visits..." CR4 did not contain documentation of physical therapy or speech therapy evaluations/visits completed. Exit conference was conducted with facility director of nursing (EMP6) on 2/11/2022 at approximately 1:00 PM. Above findings were reviewed. EMP6 reported [PT/SLP] documented in the [skilled nursing facility clinical record]...should have documented in [hospice clinical record].