DEPARTMENT OF HEALTH AND HUMAN SERVICES | FORM APPROVED | ||
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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 ______________ |
09/03/2020 | |
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 |
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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) |
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L0543 | |||
42560 Based on clinical record reviews and interviews the agency failed to ensure all care and services provided followed an individualized written Plan of Care. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1) Failure to ensure that care and services provided follows an individualized written Plan of Care, has the potential risk for negative patient outcomes. The findings are: Patient #1 has a Start of Care Date of 04/22/20 with the following diagnoses documented on the Hospice Certification and Plan of Care for Certification Period 04/22/20 to 07/20/20 "Amyotrophic Lateral Sclerosis, Chronic Obstructive pulmonary Disease, unspecified." The Hospice Physician Order (supplemental) dated 05/04/20 documents: "Change SN(Skilled Nurse) visits to in person visits Q 2(every two) weeks and PRN(per needed). SN Effective 05/03/20 1WK1(one visit a week for one week), 1EVERY2WK10(one visit every two weeks for ten weeks)". The clinical record lacks documented evidence of the patient receiving SN(Skilled Nurse) visits during the week of 05/17/20. The clinical record lacks documented evidence of the patient receiving SN services in accordance to the Plan of Care. On 09/03/20 at 3:15PM, the Director of Quality was interviewed, and did not provide an explanation. | |||
L0544 | |||
42560 Based on clinical record reviews and interview the agency failed to ensure that the patient or the primary care giver receive education and training identified in the plan of care (POC). This was evident in one (1) of three (3) clinical records reviewed (Patient #2). Failure to ensure that each patient and the primary care giver(s) receive education and training identified in the plan of care has the potential risk for negative patient outcomes. The findings are: 1.Patient #2 has a Start of Care Date of 04/09/20 with the following diagnoses documented on the Hospice Certification and Plan of Care for Certification Period 04/09/20 to 07/07/20 "Unspecified Severe Protein-Calorie Malnutrition, Unspecified Osteoarthritis, Essential(primary) Hypertension, Cardiomegaly." The Hospice Certification and Plan of Care with Start of Care date 04/09/20 documents: "Orders of Discipline: Hospice Nurse to instruct to perform wound care to stage 2 right hip. Utilizing technique- cleanse with wound cleanser, apply triad, cover with foam, DSG and change TIW(for three times a week) and PRN(as needed) Instruct Caregiver in wound Care. The Visit Note Report dated 04/09/20(RN Home visit) documents:" Wound assessed. State of the wound: chronic. Wound care not provided: Caregiver completed care." There is no documented evidence of the caregiver being instructed in wound care. On 09/02/20 at 4:45PM, the Director of Quality was interviewed, and did not provide an explanation. |