Survey Report for 331529

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	331529	A. BUILDING __________ B. WING ______________	12/22/2020
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)
L0671
L0671	41671 Based on clinical record review and staff interview the agency failed to ensure that the patient care and clinical information in the clinical record is correct. This was evident in one (1) of six (6) clinical records reviewed. (Patient #2). Failure to ensure that the information in the clinical record is correct has the potential for negative patient outcome. The Findings are: Patient #2 has a Start of Care Date of 10/19/18 and the following diagnosis, "Malignant Neoplasm of Esophagus" documented on the Home Health Certification and Plan of Care for the Certification Period 10/19/18 to 01/16/19. The MJHS Hospice and Palliative Care: Routine Visit - on 10/23/2018 documents: Physical / Clinical Monitoring: Vital Signs: Time: 10:40 PM Temperature: 97.6 F Method (Axillary) Pulse: 60bpm Location (Radial) Rhythm/quality (Irregular): Respiration 32 bpm Rhythm/ Quality (Shallow) (Nurse:D.E.Mc.). The MJHS Hospice and Palliative Care Chart/Clinical Notes: Effective Date: 10/23/2018 documents: SN - Skilled Nursing: "Note: 9:15 PM -Triage. Call received from patient's daughter reporting patient's death. 9:17 PM Report to On - call field Nurse. 10:22 PM Report from On-call field nurse (TOD) Time of Death 10:00 PM10/23/2018. (Nurse: D.M.C.) The MJHS Hospice and Palliative Care Chart/Clinical Notes: Effective Date: 10/23/2018: On-Call Pronouncement Note documents: "Patient's death was pronounced at 10:00PM on 10/23/2018 at home. (Nurse M.B)." There is a discrepancy in the time of Nurse (D.E.Mc.) documented visit on 10/23/18. The Clinical record failed to accurately document the time Nurse (D.E.Mc.) visited and provided services to Patient #2 on 10/23/2018. On 12/16/2020 at approximately 11:00AM the Vice President of Clinical Services and the Vice President Business Development was interviewed and did not provide an explanation. On 12/22/2020 at approximately 3:21PM during the exit conference the Surveyor received a print screen of Patient #2 schedule October 2018 documents: "Tuesday,10/23/18 11:45 AM SN: D.E.Mc." The Vice President of Clinical Services stated the patient received care from the nurse on the morning of 10/23/2018.