DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
331519 A. BUILDING __________
B. WING ______________ 		12/11/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VNSNY HOSPICE AND PALLIATIVE CARE 220 E 42ND STREET, 7TH FLOOR, NEW YORK, NY, 10017
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0505      
19902 Based on review of complaint log, clinical record, and interview, the Hospice did not ensure ensure that all patient/caregiver complaints are resolved as per hospice policy and procedures. This was evident for one (1) of four (4) clinical record reviewed (Patient #3). Failure to ensure that patient/caregivers complaints are investigated and resolved has the potential for negative patient outcomes. The findings are: The agency's "Complaints" Policy documents: "The complaint process includes intake, investigation, resolution, corrective action and documentation, including written reports. Complaint resolution is achieved in accordance with established timeframes. The patient or their designee will receive a written response to any written complaint, and an oral complaint (where a written response is specifically requested), within 15 days of the VNSNY Hospice's receipt to the complaint." Patient #3 has a Start of Care date of 5/30/2020, a Discharge Charge date of 6/01/2020, with the following diagnoses "Malignant Neoplasm of Unspecified Part of Bronchus or Lung, Secondary Malignant Neoplasm of Right Lung, Secondary Malignant Neoplasm of Left Lung, Secondary Malignant Neoplasm of Pleura, and Secondary Malignant Neoplasm of Retroperiton and Peritoneum" documented on the Hospice Certification and Plan of Care dated 5/30/2020 to 8/27/2020. The Complaint report dated 8/25/2020 documents the following telephone complaint: "Complaint: Hospice did not follow up timely when (patient's spouse) called about PCA (Patient Controlled Analgesia) morphine port needle dislodging when patient went to bathroom; (spouse) called at 7:44pm on 6/1 to report needle was out. Spouse was in a panicked." The Complaint report dated 8/25/2020 (receipt date) documents the following investigation: "7:33pm Initial call triaged and a request for a visit was made due to dislodged port. Patient is comfortable and no bleeding at the time of call; 7:44pm Urgent visit requested by AHS (After Hour Supervisor) for scheduling; 8:08pm (Spouse) called again to see if the RN (Registered Nurse) is nearby; still waiting for a call for ETA (Estimated Time of Arrival) and is very anxious and angry; 8:10pm AHS coordinated with scheduler needed ETA from nurse; 8:30pm (Spouse) called again for nurse ETA stating the matter is urgent. AHS coordinated with scheduler and confirmed a nurse is scheduled and waiting on a response for ETA. AHS reviewed medications that can be given for comfort and sublingual if needed. Patient was comfortable at time of call; 9:14pm (Spouse) called stated still waiting for nurse to come and wants ETA. Apology was given by AHS and the visit was confirmed as scheduled. Pt was comfortable at this time no bleeding. (Spouse) asked AHS not to call (spouse) back, but instead (spouse) wants the visiting nurse to call; 9:20pm Continued coordination with scheduler for ETA; 10:35pm Nurse made a visit and CPR was initiated by EMS to patient was a full code." The Coordination Note dated 6/1/20 9:20 documents: "(AHS Manager) is going to call the nurse to give instruction to call (patient's spouse) for ETA. Addem: (nurse's name) will be visiting now and I asked (nurse) to call with ETA." The Complaint report dated 8/25/2020 documents the following resolution and outcomes: "Issue Status: Resolved - Unsubstantiated; Issue Resolution Date: 10/30/2020 (greater than 15 days of receipt of complaint); Resolution Summary: Apology/Acknowledgement; Change in Process/Procedure; Clarified Concerns/Explanation Provided; Educate Staff; AHS Director implemented new process of providing an ETA to families for all expected visits." The hospice complaint resolution of "unsubstantiated" is not consistent with the investigation and Resolution summary describing corrective actions taken for failure to communicate the ETA. The Complaint dated 8/25/2020 lacks documented evidence of a complaint resolution within the 15-day timeframe. The Complaint investigation lack documentation of the complete investigation that includes an interview with the visiting nurse regarding lack of communication of the ETA. On 12/11/2020 at 11:00am, the Director of Quality was interviewed, and stated "no" the visiting nurse did not call the patient's spouse to inform of the ETA. The Director of Quality stated that the nurse was taking care of another patient. The Director of Quality stated the complaint should be "substantiated" for not providing the nurse's ETA.