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
331527 A. BUILDING __________
B. WING ______________ 		03/15/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE OF ORANGE & SULLIVAN COUNTIES INC 800 STONY BROOK COURT, NEWBURGH, NY, 12550
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)
L0500      
43029 Based on Agency's Internal Incident Report review, record review and staff interview, the hospice failed to ensure all patients were protected from neglect, mental, or physical abuse; and promote the rights of all patients. The Hospice failed to: Ensure that all patients are protected from neglect, mental, or physical abuse; and promote the Patients Rights. (L 517). The hospice's failure to ensure all patients' rights are respected, has the liklihood to cause serious harm, injury or death to the patients under the care of the hospice.
L0517      
43029 Based on Agency's Internal Incident Report review, record review, and staff interview the Hospice failed to ensure that all patient's are protected and free from neglect, mental, and physical abuse. This was evident for one (1) of one (1) clinical record review patient #1. Failure to ensure that all patients are protected from neglect, mental, and physical abuse has the likelihood for negative patients outcome. The Findings Are: Patient #1 has start of care date of 3/4/22 and expiration date of 3/9/22, with diagnoses of Malignant Neoplasm of Bronchus or Lung unspecified, Malignant unspecified Kidney, except Renal Pelvis, Localized swelling, Mass and Lump, Bilateral Lower Limb, End Stage Renal Disease, Diabetes Mellitus Type II, Chronic Obstructive Pulmonary Disease unspecified, and Melanoma in situ of unspecified part of face documented on the Hospice Plan of Care for the certification period 3/4/22 to 6/1/22. The Hospice Plan of Care for the certification period 3/4/22 to 6/1/22 documents "DNR (Do Not Resustate) in place, Skilled Nursing (SN) Routine Hospice Care: 2 visits/week x 13 weeks (2 visits per week x 13 weeks), 5 PRN visits (5 visits as needed) for exacerbation of disease process; HCA (Hospice Certified Aide): Routine Hospice Care: 7 visits/week for 13 weeks (7 visits per week x 13 weeks), notify SN for variations of normal BM (bowel movement) or no BM in 2-3 days". The "Incident/Occurrence Report and Assessment" dated 3/8/22 with an occurrence date of 3/7/22 documents, "LPN (Licensed Practical Nurse) reported to (Name of Clinical Nurse Manager) at 8:30 PM that during cares administered on 3/7/22 prior to 7 PM that HHA (Home Health Aide) appeared to be disimpacting patient; on Tuesday morning Human Resources and Director of Quality was notified; investigation initiated". The Internal Investigation dated 3/8/22 documents: "9:35- 9:50 AM received initial phone call from Nurse Practitioner/Director of Patient Services who reported, LPN (Licensed Practical Nurse) had called (Name of Clinical Nurse Manager) at night on 3/7/22 to report an incident that bothered her while working with the Hospice aide; that the aide had stuck his finger in a patient's rectum because the patient was impacted" "9:50 AM - LPN recounted the event of 3/7/22; at approximately 5:00 PM on 3/7/22, LPN and aide walked into room 106 together to perform cares; LPN left the room because other bells were going off and pharmacy was at the front door; at about 5:20 PM - 5:30 PM LPN return to room and noticed the aide was still performing cares; LPN stood on the opposite side of the aide with full view of the patient's face; as the aide was cleaning the patient's backside, the patient yelled Ow Ow; LPN looked at the patient's face and noticed that the patient appeared to be in a great deal of pain; LPN reports that she said stop, stop to the aide; the aide told the LPN the patient was impacted and he was "moving the process along"; LPN believes the aide digitally penetrated the patient's rectum in order to disimpact the patient because she (the LPN) saw the aide's hand motions and then the aide's fingers were covered in feces". The LPN's written statement dated 3/9/22 documents: "I left the facility and had an hour drive home in which I was processing the events of the day. As soon as I got home I called my supervisor (name of supervisor) to let her know what had happened". During the interview on 3/14/22 at 11:25 AM with the Director of Quality, Nurse Practitioner/Director of Patient Services, and Clinical Nurse Manager, they stated that "the aide works the 3:00 PM to 11:00 PM shift and was allowed to work the entire shift on 3/7/22". The report lacks documented evidence that the LPN immediately reported the incident of the aide working out of the scope of practice and causing injury to the patient, to the Registered Nurse (RN) on duty. There is no documented evidence that the Supervisor called the unit to inform the RN on duty of the incident / occurrence. The LPN and the Supervisor neglected to report the incident/occurence to the RN(s) on duty that was responsible for the care of the patient. There is no documented evidence that the Hospice took immediately action to protect the patient from mental and physical abuse. There is no documented evidence the patient was assessed by the RN after the incident. On 3/15/22 at 12:00 PM the Director of Quality was interviewed. The Director of Quality did not provide an explanation for the findings.