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
331525 A. BUILDING __________
B. WING ______________ 		09/17/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
JANSEN HOSPICE AND PALLIATIVE CARE 670 WHITE PLAINS ROAD, SUITE 213, SCARSDALE, NY, 10583
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)
L0552      
43029 Based on clinical record review and staff interview the hospice's Interdisciplinary Group (IDG) failed to review, and document the individualized plan of care and/or determine the need to revise the plan of care in three (3) of three (3) records reviewed (Patient #1, #2, and #3). Failure to ensure the IDG reviews, revises, and documents the plan of care has the potential to result in inaccurate care planning decisions, unmet patient needs, and possible negative patient outcomes. Findings: 1. Patient # 1 has a start of care date of 8/10/2021 with diagnosis End Stage Renal Disease, Urinary Tract Infection, and Malignant Neoplasm Skin/Unspecified Lower Limb, Including Hip documented on the Hospice certification and Plan of Care for certification period dated 8/10/2021 to 11/7/2021. The Hospice certification and Plan of Care for certification period dated 8/10/2021 to 11/7/2021 documents, "hha 4x/week x1 week, 5x/week x12 weeks" The Client Coordination Note dated 8/30/21 by Case Coordinator documents "patient's daughter is in desperate need of an aide, she's been waiting several weeks" The IDG Case Conference Notes lack documented evidence the Interdisciplinary Group reviewed and/or revised the patients plan of care to reflect the lack of home health aide services to individualize the patients plan of care. 2. Patient #2 has a start of care date of 4/12/2021 with diagnosis Alzheimer's Disease documented on the Hospice certification and Plan of Care for certification period dated 4/12/21 to 7/10/2021. The Hospice certification and Plan of Care for certification period dated 4/12/21 to 7/10/2021 documents "hha 4x/week x1week, 5x/week x12 weeks". On 9/23/21 at 12:00 PM the aide duty sheets were requested for the month of July 2021. There is no documented evidence hha services were provided for the weeks of July 5th and 12th. The IDG Case Conference Notes lack documented evidence the Interdisciplinary Group reviewed and/or revised the patients plan of care to reflect the lack of home health aide services to individualize the patients plan of care. There is no documented evidence of a current Plan of care. 3. Patient #3 has a start of care date of 7/21/2021 with diagnosis Acute Myeloblastic Leukemia, in relapse, Neoplasm of Trachea, Bronchus and Lung, Malignant Neoplasm of Pancreas, and Dementia documented on the Hospice certification and Plan of Care for certification period dated 7/21/2021 to 10/18/2021. The Hospice certification and Plan of Care for certification period dated 7/21/2021 to 10/18/2021 documents "hha effective 7/25//2021 5x/week x12 weeks, 1x/week x 1 week" The Client Coordination Note documents the following missed hha visits " 8/10/21, 8/11/21, 8/12/21, 8/13/21, 8/16/21; 8/18/21, 8/19/21, and 8/2021". The IDG Case Conference Notes lack documented evidence the Interdisciplinary Group reviewed and/or revised the patients plan of care to reflect the lack of home health aide services to individualize the patients plan of care. During an interview on 9/17/2021 at 3:00 PM at with the Director of Patient Services and Hospice Administrator they did not provide an explanation for the above findings.
L0650      
43029 Based on clinical record review and staff interview, the agency failed to ensure Hospice care provided is consistent with the patient and/or family needs and goals to optimize care. This was evident for three (3) of three (3) clinical records reviewed (Patient #1, #2 and #3). Failure to ensure Hospice care is consistent with patient and family needs and goals as priority places the patient at risk for negative outcomes. The finding are: 1. Patient # 1 has a start of care date of 8/10/2021 with diagnosis End Stage Renal Disease, Urinary Tract Infection, and Malignant Neoplasm Skin/Unspecified Lower Limb, Including Hip documented on the Hospice certification and Plan of Care for certification period dated 8/10/2021 to 11/7/2021. The Hospice certification and Plan of Care for certification period dated 8/10/2021 to 11/7/2021 documents, "hha 4x/week x1 week, 5x/week x12 weeks" The Client Coordination Note dated 8/30/21 by Case Coordinator documents "patient's daughter is in desperate need of an aide, she's been waiting several weeks" The record lack documented evidence of consistent aide services 2. Patient #2 has a start of care date of 4/12/2021 with diagnosis Alzheimer's Disease documented on the Hospice certification and Plan of Care for certification period dated 4/12/21 to 7/10/2021. The Hospice certification and Plan of Care for certification period dated 4/12/21 to 7/10/2021 documents " hha 4x/week x1week, 5x/week x12 weeks" On 9/23/21 at 12:00 PM the aide duty sheets were requested for the month of July 2021. There is no documented evidence hha services were provided for the weeks of July 5th and 12th. The record lack documented evidence of consistent aide services. 3, Patient #3 has a start of care date of 7/21/2021 with diagnosis Acute Myeloblastic Leukemia, in relapse, Neoplasm of Trachea, Bronchus and Lung, Malignant Neoplasm of Pancreas, and Dementia documented on the Hospice certification and Plan of Care for certification period dated 7/21/2021 to 10/18/2021. The Hospice certification and Plan of Care for certification period dated 7/21/2021 to 10/18/2021 documents "hha effective 7/25//2021 5x/week x12 weeks, 1x/week x 1 week" The Client Coordination Note documents the following missed hha visits " 8/10/21, 8/11/21, 8/12/21, 8/13/21, 8/16/21; 8/18/21, 8/19/21, and 8/2021" The record lack documented evidence of consistent aide services During an interview on 9/17/2021 at 3:00 PM at with the Director of Patient Services and Hospice Administrator they did not provide an explanation for the above findings.