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
331535 A. BUILDING __________
B. WING ______________ 		01/08/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VNS AND HOSPICE OF SUFFOLK, INC 101 LAUREL ROAD, EAST NORTHPORT, NY, 11731
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)
L0555      
16362 Based on Clinical Record review and staff interview, the Hospice failed to ensure that Hospice Care and Services were provided in accordance with the established written Plan of Care (POC). This was evident in one (1) of three (3) Clinical Records reviewed (Patient #1). Failure to provide Hospice Care and Services in accordance with the written POC places terminally ill patients at risk for unmet needs. The finding is: Patient #1 has a start of care date of 07/23/19 with diagnoses Senile degeneration of the brain not elsewhere classified, Dementia, Pressure Ulcer or Right and Left heel, Long term use of antibiotics personal history of Urinary Tract Infections, and Type 2 diabetes mellitus without complications as documented on the "Hospice Plan of Care" dated from 11/14/20 to 1/12/21. The "Hospice Plan of Care" from 11/14/20 to 01/12/21 documents "Aide; 2 d 8 wk (two visits a day for eight weeks) Beginning on 11/15/2020 - Ending 1/9/2021" and "Aide; 2 d 3 d (two x a day x three days); Beginning 1/10/2021 - Ending on 1/12/2021". The Clinical Record documents patient was receiving aide services five (5) days a week/two x per day up until 12/11/20, with the exception on 12/8/20 once a day. The Hospice failed to provide aide services as per the Plan of Care. The hospice Director of Patient Services (DPS) was informed of the survey findings on 01/08/21 at 2:30 PM and again at exit conference at 4:15 PM. The DPS acknowledged the findings.
L0671      
16362 Based on clinical record review and staff interview, the hospice failed to ensure in one (1) out of three (3) records that professional staff maintained an accurate, current, complete and clearly documented record related to the provision of the patient's care. (Patient #1) Failure to maintain an accurate, current, complete and clearly documented record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Findings include: Patient #1 has a start of care date of 07/23/19 with diagnoses Senile degeneration of the brain not elsewhere classified, Dementia, Pressure Ulcer or Right and Left heel, Long term use of antibiotics personal history of Urinary Tract Infections, and Type 2 diabetes mellitus without complications as documented on the "Hospice Plan of Care" dated from 11/14/20 to 1/12/21. The "Hospice Plan of Care" from 11/14/20 to 01/12/21 documents "Skilled Nursing (SN); 1 wk 1 wk PRN (as needed): (two visits a day for eight weeks) Beginning during week of 11/14/2020 - Ending on 11/14/2020"; SN; "5 wk 8 wk 3 PRN; (five x a week for eight weeks); Beginning 11/15/2020 - Ending on 1/9/2021"; SN; 2 wk 1 wk 1 PRN: (two x a week for one week, and one as needed); Beginning during week of 1/10/2021 - Ending on 1/12/2021" to perform wound care, assessment, Foley Catheter change. The clinical record contains a physician's Verbal Order dated 12/18/20 that orders for patient to take: nitrofurantoin macrocrystals-monohydrate 100 mg oral capsule; take 1 cap(s) orally 2 x a day for 10 days for infection. The SN visit notes from 12/22/20, 12/24/20 and 12/28/20 continues to document under the Narrative Notes "Antibiotics continue as ordered" for UTI (urinary tract infection). The record lacks documented evidence the caregiver was educated on the administering of antibiotics to his mother and SN followed up with the caregiver until 1/4/21. Interview with the RN (Registered Nurse, Employee #3) on 1/8/21 at 11:00 AM - RN stated: he was not aware that the caregiver was not giving the antibiotics to the patient. The RN stated: "I discussed antibiotic use which had been ordered for patient and" caregiver "told me that he never gave it to his mother in fear of patient getting diarrhea from the medication." The stated: RN was not aware that the patient's caregiver was not administering the antibiotics that was ordered because the urine was clearing up, and the caregiver never reported to RN that he was holding the antibiotics. The findings were reviewed with the Director of Patient Services (DPS) on 01/08/21 at 2:30 PM and again at exit conference with the DPS, CEO (Chief Executive Officer) and Supervisor of Home Health Aide Department. at 4:15 PM. Findings are acknowledged.