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
331529 A. BUILDING __________
B. WING ______________ 		05/14/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
M J H S HOSPICE AND PALLIATIVE CARE, INC 39 BROADWAY, SUITE 200, NEW YORK, NY, 10006
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      
41671 Based on clinical record review and staff interview the Hospice failed to ensure all patients have the right to exercise their rights regarding treatment or care and all complaints are investigated with a resolution. This was evident for one (1) of twenty (20) clinical records reviewed. (Patient #2). Failure to ensure all patients has the right to exercise their rights regarding treatment or care and all complaints are documented, investigated and resolved has the potential for negative patient outcome. The finding is: 36311 1. Patient #2 has a Start of Care date of 8/8/2020 with the following diagnosis "Malignant Neoplasm of Colon, Malignant Neoplasm Metastatic to Liver, Malignant Neoplasm Metastatic to Lung" documented in the Physician's Order/ Plan of Care from 8/8/2020 to 11/5/2020. The Charts/Clinical Notes dated 8/13/2020 documents: "(Name) states that she feels that hospice has not provided anything, and she expected patient's supplies to be there." The clinical record lacks documented evidence of a complaint investigation and resolution. On 5/13/21 at 12:56 pm, the Director of Quality and Management was interviewed and did not provide an explanation for the findings.
L0543      
41671 Based on clinical record review and staff interview the hospice failed to ensure that care and services are provided in accordance with the established written Plan of Care. This was evident for three (3) of twenty (20) clinical records reviewed (Patient #2 #3 and #12). Failure to ensure that care and services provided to all patients are in accordance with the established written Plan of Care has the potential for negative patient outcomes. The Findings are: 36311 1. Patient #2 has a Start of Care date of 8/8/2020 with the following diagnosis "Malignant Neoplasm of Colon, Malignant Neoplasm Metastatic to Liver, Malignant Neoplasm Metastatic to Lung" documented in the Physician's Order/ Plan of Care from 8/8/2020 to 11/5/2020. The Duty Sheet documents Aide services were provided on 8/25/20 and 8/26/20 for five hours. The Physician's Order/Plan of Care lacks documented evidence of an order for the Hospice Aide services that were provided. On 5/13/21 at 12:56 pm, the Director of Quality and Management was interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 3/15/21 with the following diagnosis "Alzheimer's Disease with Late Onset, Dementia, Failure to Thrive, Agitation" documented in the Physician's Orders/Plan of Care from 3/15/21 to 6/12/21. The Physician's Orders/Plan of Care from 3/15/21 to 6/12/21 documents: PC (Pastoral Care) 6 PRN (six as needed). The Supplemental Orders from 3/22/21 to 4/1/21 documents: 4/1/21 PT (Physical Therapy) 1-4 x week x 2 weeks (one to four times a week for two weeks). The Clinical Record documents: PC visits on 3/19/21, 3/26/21, 4/1/21, 4/9/21, 4/16/21, 4/22/21, 5/4/21, and 5/10/21, total of 8 visit, excess of 2 visits from the 6 PRN. PT visits on 4/5/21 and 4/9/21, 2 visits for week one and no visit for week 2. The clinical record documents PC conducting more than the six as needed visits order as per the Plan of Care. The Hospice failed to provide PT services as per the Plan of Care. The clinical record lacks documented evidence of the patient receiving PC and PT services in accordance to the Plan of Care. On 5/13/21 at 12:56 pm, the Director of Quality and Management was interviewed and did not provide an explanation for the findings. 19902 3.Patient #12 has a Start of Care date of 3/29/2021 with the diagnosis "Senile Degeneration of Brain" documented in the Physician's Orders/ Plan of Care dated 3/29/2021 to 6/26/2021. The Supplemental Orders dated 4/8/2021 document: "4/8/21 AID (Hospice Aide/Home Health Aide(HHA)) 1-5 x week x 13 weeks, 2-5h duration (one to five visit a week, two to five hours each visit)." The Initial "HHA Plan of Care" dated 3/31/2021 documents: "Frequency: 5 days; Duration: 4 hrs (hours)." The Skilled Nurse Clinical Notes dated 4/12/2021 document: "Phone call to patient's (family); to provide clarity and confirm patient needs re: hha services. At this time arrangements were made to staff the case, M-W-F from 9-2 and Tuesday and Wednesday afternoon from 1-5. (Patient's family) stated that he had never agreed to have an aide during the afternoon hours; (Family) could not understand why two weeks into the case we were unable to provide 5 days/week of hha services during the morning hours." The clinical record lacked documented evidence that the patient received Hospice Aide service during the week 4/11/2021 to 4/17/2021. The Hospice failed to provide aide services as per the Plan of Care. On 5/14/2021 at 12:00PM, the Vice President of Clinical Services, Director of Clinical Services, Quality Management Director, and Vice President Business Development were interviewed, and did not provide an explanation for the findings.
L0547      
41671 Based on clinical record review and staff interview the hospice failed to ensure that the content of each patient's Plan of Care includes the scope and frequency of services to be provided to meet each patient's individualized needs. This was evident for four (4) of twenty (20) clinical records reviewed. (Patients #2, #3, #11 and #12). Failure to ensure that each patient's Plan of Care includes the frequency and scope of services necessary to meet their specific needs has the potential for negative outcomes. The findings are: 36311 1. Patient #2 has a Start of Care date of 8/8/2020 with the following diagnosis "Malignant neoplasm of Colon, Malignant Neoplasm Metastatic to Liver, Malignant Neoplasm Metastatic to Lung" documented in the Physician's Order/ Plan of Care from 8/8/2020 to 11/5/2020. The Duty Sheet documents Aide services were provided on 8/25/20 and 8/26/20 for five hours. There is no documented evidence that the plan of care included orders for the frequency of Hospice Aide service to meet the patient's needs. On 5/13/21 at 12:56 pm, the Director of Quality and Management was interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 3/15/21 with the following diagnosis "Alzheimer's Disease with Late Onset, Dementia, Failure to Thrive, Agitation" documented in the Physician's Orders/Plan of Care from 3/15/21 to 6/12/21. The Physician's Orders/Plan of Care from 3/15/21 to 6/12/21 documents: PC (Pastoral Care) 6 PRN (six as needed). The Supplemental Orders from 3/22/21 to 4/1/21 documents: 4/1/21 PT (Physical Therapy) 1-4 x week x 2 weeks (one to four times a week for two weeks). The Clinical Record documents: PC visits on 3/19/21, 3/26/21, 4/1/21, 4/9/21, 4/16/21, 4/22/21, 5/4/21, and 5/10/21, total of 8 visit, excess of 2 visits from the 6 PRN. PT visits on 4/5/21 and 4/9/21, 2 visits for week one and no visit for week 2. The clinical record documents PC conducting more than the six as needed visits and the PT missing 2 visits order in the plan of care. There is no documented evidence of the Plan of Care being updated to include the need for additional PC visits and discontinuing PT visits to meet the specific needs of the patient and family. On 5/13/21 at 12:56 pm, the Director of Quality and Management was interviewed and did not provide an explanation for the findings. 19902 3. Patient #11 has a Start of Care date of 3/10/2021 with the diagnosis "Senile Degeneration of Brain" documented in the Physician's Orders/ Plan of Care dated 3/10/2021 to 6/7/2021. The Physician's Orders/Plan of Care dated 3/10/2021 to 6/7/2021 documents: "PC (Pastoral Counseling) 6 PRN (as needed visits): status (in) change." The PC "Initial Visit" Note dated 3/15/2021 and "Routine Visit" Notes dated 4/2/2021, 4/5/2021, 4/13/2021, 4/19/2021, 4/26/2021, 5/4/2021 and 5/10/2021 are documenting the PC conducting eight visits. The clinical record documents the PC conducting more than the six as needed visits order that is in the plan of care. There is no documented evidence that the Plan of Care was updated to include the need of additional PC visits to meet the specific needs of the patient and family. On 5/12/2021 at 3:00PM, the Vice President of Clinical Services, Director of Clinical Services, Quality Management Director, and Vice President Business Development were interviewed, and did not provide an explanation for the findings. 4. Patient #12 has a Start of Care date of 3/29/2021 with the diagnosis "Senile Degeneration of Brain" documented in the Physician's Orders/ Plan of Care dated 3/29/2021 to 6/26/2021. The Supplemental Orders dated 4/8/2021 document: "4/8/21 AID (Hospice Aide) 1-5 x week x 13 weeks, 2-5 h duration (one to five visit a week, two to five hours each visit)." The Hospice Aide "Duty Sheet" dated 4/7/2021 documents aide service being provided on 4/7/2021. There is no documented evidence of the plan of care including orders for Hospice Aide service on 4/7/2021 to meet the patient's needs. On 5/14/2021 at 12:00PM, the Vice President of Clinical Services, Director of Clinical Services, Quality Management Director, and Vice President Business Development were interviewed, and did not provide an explanation for the findings.
L0549      
41671 Based on clinical record review and staff interview the hospice failed to ensure the Plan of Care documents all treatments and drugs necessary to meet the need of the patient. This was evident for one (1) of twenty (20) clinical records reviewed. (Patient #13). Failure to ensure the Plan of Care documents all treatments and drugs necessary to meet the need of the patient, has the potential for negative patient outcomes. The Finding is: 19902 1.Patient #13 has a Start of Care date of 10/7/2020 with the diagnosis "Encephalocele" documented in the Physician's Orders/ Plan of Care dated 4/5/2021 to 6/3/2021. The electronic Prescription dated 2/16/2021 documents: "Hydrocortisone 1% Tropical Cream; apply 1 (one) small amount to affected area twice a day." The SN "Routine Visit" notes dated 4/23/2021 and 4/28/2021 document: "Informed to moisturized skin daily as instructed in the past. Informed to apply hydrocortisone as prescribed to patchy areas on (patient) skin." The clinical record lacks documented evidence of the Hospice Plan of Care being updated to include Hydrocortisone. On 5/14/2021 at 12:00PM, the Vice President of Clinical Services, Director of Clinical Services, Quality Management Director, and Vice President Business Development were interviewed, and did not provide an explanation for the findings.
L0550      
41671 Based on clinical record review and staff interview the hospice failed to ensure the Plan of Care included the necessary medical supplies and equipment to manage the patient's terminal illness and related conditions. This was evident in for one (1) of twenty (20) clinical records reviewed. (Patient #2). Failure to ensure the Plan of Care includes all necessary medical supplies and equipment to manage the patient's terminal illness and related condition has the potential for negative patient outcome. The finding is: 36311 1. Patient #2 has a Start of Care date of 8/8/2020 with the following diagnosis "Malignant neoplasm of Colon, Malignant Neoplasm Metastatic to Liver, Malignant Neoplasm Metastatic to Lung" documented in the Physician's Order/ Plan of Care from 8/8/2020 to 11/5/2020. The Charts/Clinical Notes documents: 8/14/20- Patient refuses hospital bed but agrees to have oxygen delivered. 8/19/20- No Oxygen at home, oxygen ordered for delivery today. 8/20/20- patient is now using pullups. 8/24/20 -Use of protective barrier after each incontinent change as he is now incontinent bowel and bladder. The Order Number: 723561493 documents supplies for Paste protectant ZGuard, Hydraguard cream, Glove, Clothlike Brief, and oral swab were ordered on 8/25/20 and delivered on 8/26/2020 There is no documented evidence the Plan of Care was updated to include the need of Oxygen, Pullups, and protective barrier to meet the specific needs of the patient and family. On 5/13/21 at 12:56 pm, the Director of Quality and Management was interviewed and did not provide an explanation for the findings.
L0625      
41671 Based on clinical record review and staff interview the hospice failed to ensure all Hospice Aides receive complete written patient care instructions prepared by a Registered Nurse (RN). This is evident for three (3) of twenty (20) clinical records reviewed (Patient # 4, #8 and #18). Failure to ensure all Hospice Aides receive complete written patient care instructions prepared by a Registered Nurse (RN) has the potential for negative patient outcome. The findings are: 36311 1. Patient #4 has a Start of Care date of 11/25/20 with the following diagnosis "Diffuse Large B Cell Lymphoma, Brain Metastasis, Decreased Oral Intake, Weight Loss" documented in the Physician's Orders/Plan of Care from 2/23/21 to 5/23/21. The Supplemental Orders from 4/12/21 to 5/23/21 documents: "4/12/21 Aid 1-5 x week x 13 weeks (one to five times a week for thirteen weeks), 1-4 (one to four hours) duration discontinue on 5/23/21; 4/12/21 Aid 1-4 duration, 2 PRN (two as needed): status change." The Home health aide Plan of Care dated 11/27/20 lacks documented evidence of the frequency of the Toileting, Assisted ROM (range of motion) Exercises, Oral Hygiene, Skin Care, and Nail Care. There is no documented evidence that the Aide received complete written patient care instructions. On 5/13/21 at 12:56 pm, the Director of Quality and Management was interviewed and did not provide an explanation for the findings. 33127 2. Patient #8 has a Start of Care date of 02/21/21 with the following diagnosis Systolic CHF (Congestive Heart Failure) documented in the Physician's Orders / Plan of Care dated 02/21/21 to 05/21/21. The Physician's Orders / Plan of Care dated 02/21/21 to 05/21/21 documents: "AID 1-4 h duration, 2 PRN: support, 1-5 x week x13 weeks, 1-4 hours duration." The HHA(home health aide) Plan Of Care dated 02/23/21 documents: " Bathing: Bed (check mark), Frequency (blank); Toileting: Incontinent Care (check mark), Frequency (blank); Oral Hygiene, Frequency (blank); Skin Care: Frequency (blank), Nail Care; Frequency (blank)." There is no documented evidence that the Aide received complete written patient care instructions. On 5/14/2021 at 12:00PM, the Vice President of Clinical Services, Director of Clinical Services, Quality Management Director, Vice President Business Development were interviewed, and did not provide an explanation for the findings. 42560 3. Patient #18 has a Start of Care date of 08/29/2020 with the following diagnoses "Malignant Neoplasm of Cervix, Malignant Neoplasm Metastatic to Brain, Pulmonary Embolism, Fatigue, Hypertension and Seizure Disorder" documented on the Home Health Certification and Plan of Care dated 02/21/2021 to 04/21/2021 and 04/09/2021 to 06/07/2021. The Physician's Orders/Plan of Care/Team Care Plan documents:"The certification period beginning 02/21/2021 documents: "AID 02/25/2021 1-5 x week x 8 weeks (one to five times a week for eight weeks) , 1-4h (one to four hours) duration ended on 04/21/2021 and for certification period beginning 04/09/2021: AID 04/09/2021 1-5 x week x 8 weeks (one to five times a week for eight weeks) , 1-4h (one to four hours) duration." The Physician's Orders/Plan of Care/Team Care Plan for Certification Period beginning 02/21/2021 and 04/09/2021 documents: "Seizure Precautions." The Aide Care of Plan lacks documented evidence of safety precautions for seizures. There is no documented evidence of the aide's written patient care instructions being complete. On 5/14/2021 at 12:40 pm, the Vice President of Clinical Services, Director of Clinical Services, Quality Management Director, and Vice President Business Development were interviewed, and did not provide an explanation for the findings.
L0629      
41671 Based on clinical record review and staff interview the hospice failed to ensure onsite visits are conducted every 14 days to all patient's home that are receiving home health aide services. This is evident for two (2) of twenty (20) clinical record reviewed. (Patient #5 and #8). Failure to ensure that onsite visits are conducted every 14 days to all patient's home that are receiving home health aide services, has the potential for negative patient outcome. The Findings are: 36311 1. Patient #5 has a Start of Care date of 1/2/21 with the following diagnosis "Gastric Adenocarcinoma, Gastroesophageal Reflux Disease, Hypertension, Depression" documented in the Physician's Orders/Plan of Care from 1/2/21 to 4/1/21. The Supplemental Orders from 1/7/21 to 1/7/21 documents:" 1/7/21 Aid 1-5 x week x 13 weeks (one to five times a week for thirteen weeks), 1-3 (one to three hours) duration." The Duty Sheet documents aide services being provided on: 3/1/21 to 3/4/21, 3/8/21 to 3/12/21, 3/15/21 to 3/19/21, 3/22/21 to 3/26/21, and 3/29/21 to 4/2/21. There is no documented evidence of hospice aide supervision from 3/4/21 to 3/25/21 (22 days). There is no documented evidence of the Registered Nurse supervising the hospice aide at least every 14 days to assess the quality of care and services provided. On 5/13/21 at 12:56 pm, the Director of Quality and Management was interviewed and did not provide an explanation for the findings. 33127 2 .Patient #8 has a Start of Care date of 02/21/21 with the following diagnosis Systolic CHF (Congestive Heart Failure) documented on the Physician's Orders / Plan of Care dated 02/21/21 to 05/21/21. The Physician's Orders / Plan of Care dated 02/21/21 to 05/21/21 documents: "AID 1-4 h duration, 2 PRN: support, 1-5 x week x13 weeks, 1-4 hours duration." There is no documented evidence of hospice aide supervision from 03/19/21 to 04/12/21 (24 days). There is no documented evidence of the Registered Nurse supervising the hospice aide at least every 14 days to assess the quality of care and services provided. On 5/14/2021 at 12:00PM, the Vice President of Clinical Services, Director of Clinical Services, Quality Management Director, Vice President Business Development were interviewed, and did not provide an explanation for the findings.
L0672      
41671 Based on clinical record review and staff interview the hospice failed to ensure that clinical records contain all pertinent information. This is evident for one (1) of twenty (20) clinical records reviewed. (Patient #12). The finding is: 19902 1.Patient #12 has a Start of Care date of 3/29/2021 with the diagnosis "Senile Degeneration of Brain" documented in the Physician's Orders/ Plan of Care dated 3/29/2021 to 6/26/2021. The Physician's Orders/Plan of Care dated 3/29/2021 to 6/26/2021 documents: "SN (Skilled Nurse) Assess need for HHA (home health aide/Hospice Aide) hours." The SN "Initial Visit" dated 3/29/2021 and "Routine Visit" dated 3/30/2021 document: "Type of Visit: Comprehensive." The MSW(Medical Social Worker) Initial Visit notes dated 3/30/2021 document: "Concrete service status & needs: Pt (Patient) will have a hha." The Initial "HHA Plan of Care" dated 3/31/2021 and signed SN documents: "Frequency: 5 days; Duration: 4 hrs (hours)." The clinical record lacks documented evidence that the SN included the patient's need for Hospice Aide service in the comprehensive assessment. The clinical record lacks documentation of complete and pertinent information related to patient care. On 5/14/2021 at 12:00PM, the Vice President of Clinical Services, Director of Clinical Services, Quality Management Director, Vice President Business Development. The Director of Clinical Services stated, the "determination for hha service was made on 3/30/21; the nurse did not document."