Survey Report for 331535

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	331535	A. BUILDING __________ B. WING ______________	07/30/2020
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)
L0674
L0674	25230 Based on clinical record review, the Hospice failed to ensure the content of Hospice clinical record includes patient's response to medications and treatments. This was evident in review of one (1) of three (3) clinical records reviewed. Patient #1. Failure to ensure the clinical record includes patient's response to medications has the potential for negative outcome. The findings include: Patient #1 has a start of care date of 06/24/20 at the Hospice House with admitting diagnoses of " Covid 19 and Metastatic Lung Cancer". The Hospice Physician Initial patient report dated 06/24/20 documents medication treatment plan includes " Lorazepam 1 mg (IVP) Intra Venous Push) every 4 hours as needed for anxiety/agitation". The " Inpatient Initial Assessment " dated 06/24/20, the Skilled Nurse (SN) documents the " patient was medicated upon arrival with Lorazepam 1 mg IV (Intravenous) " . The Medication Administration Record dated 6/24/20 documents the administration of Lorazepam 1mg at 15:00H (3:00PM). The Skilled Nurse note dated 06/24/20 documents at 22:00H (10:00PM) that the patient appears to be resting comfortably, no signs of agitation. The clinical record lacks documented evidence that the Hospice conducted timely clinical assessment of the patient's response to the administration of the Lorazepam at 3:00 PM. The Hospice failed to ensure therapeutic symptom management of the patient from 3:00 PM until 10:00 PM. The survey was reviewed with the agency's Nurse Practitioner and Director of Patient Services on 07/30/20.