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
331560 A. BUILDING __________
B. WING ______________ 		06/13/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE OF NEW YORK, LLC 30-30 47TH AVENUE, SUITE 635, LONG ISLAND CITY, NY, 11101
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      
36311 Based on review of the clinical records, complaint log, and interviews with staff, the hospice failed to ensure that patient/caregiver complaints are fully investigated, documents a resolution, and the complainants are informed of the results of the investigation. This was evident for two (2) of three (3) clinical records reviewed (Patient's #1 and #2). Failure to ensure that patient/caregivers complaints/concerns are investigated and resolved has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 1/20/2022 with the following diagnoses "Senile Degeneration of Brain, Hemiplegia and Hemiparesis, Unspecified Dementia" documented in the Physician's Orders/Plan of Care as of 3/21/2022. The Charts/Clinical Notes dated 5/13/2022 documents: "5/12 through today received several phone calls from NYSDOH complaint division inquiring about the administration of IVABT (intravenous antibiotic) and IVF (intravenous fluid)." "There is miscommunication resulting because there are numerous agencies, family members passing information that is causing confusion and misinformation." The clinical record lacks documented evidence of a complaint investigation and resolution. On 06/13/2022 at 1:30pm, the Deputy Director of Quality and Regulations Affairs was interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 6/13/2022 with the following diagnoses "Dementia with Lewy Bodies, Chronic Kidney Disease Stage 4, Essential Hypertension" documented in the Physician's Orders/Plan of Care as of 6/13/2021. The Complaint Investigation Form dated 1/31/2022 documents: "1. Contacted the 24-hour line when patient had an unexpected fever, and it took 4 hours for someone to report they will send someone. 2 hours later after an RN was scheduled to come, they cancelled." "2. A priest was promised to come to the home to pray with patient, but no one ever came, and patient passed without last rights." "Complaint Resolution: An email regarding issues was sent to patient care coordinator and Clinical Director, Father (name) has also contacted regarding patient and is looking into previous emails.' The clinical record lacks documented evidence of a complaint investigation, resolution, and notification of the results of the investigation to the complainant. On 06/13/2022 at 1:30pm, the Deputy Director of Quality and Regulations Affairs was interviewed and did not provide an explanation for the findings.
L0512      
36311 Based on clinical care record review and staff interviews, the hospice failed to ensure that the patient receive timely and effective symptom control. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that all patients receive timely and effective symptom control has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 1/20/2022 with the following diagnoses "Senile Degeneration of Brain, Hemiplegia and Hemiparesis, Unspecified Dementia" documented in the Physician's Orders/Plan of Care as of 3/21/2022. The Charts/Clinical Notes dated 4/24/2022 documents: "9:00pm telephone call from daughter reporting that client is refusing food/fluids, and congestive respirations noted, this writer instructed caller to administer Hyoscyamine 1 tablet sublingual, emotional support provided, caller is requesting a nursing visit, (name of nurse) schedule to visit." There is no documented evidence of the nurse conducting a home visit or notification to the family of visit cancellation. and there is no documented evidence of a timely follow-up to the report of respiratory distress to determine the status of the patient after the initial call and the effectivity of treatment. On 06/13/2022 at 1:30pm, the Deputy Director of Quality and Regulations Affairs was interviewed and did not provide an explanation for the findings.