Survey Report for 361678

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	361678	A. BUILDING __________ B. WING ______________	07/16/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HOSPICE OF THE WESTERN RESERVE AT UNIVERSITY HOSP	17876 ST. CLAIR AVENUE, SUITE 102, CLEVELAND, OH, 44110
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)
L0515
L0515	31597 Based on medical record review, policy review and interview, the agency failed to ensure one patient (Patient #1) had the right to choose the attending physician. This had the potential to affect all the facility's 301 active patients. Findings include: The agency's Patient and Family Bill of Rights policy (Policy #003, Revision Date: 09/19) was reviewed. The policy stated: 4. The patient has the right to choose his/her attending physician. The medical record of Patient #1 was reviewed. The record contained a Notice of Election form signed by Patient #1's family member on 11/01/19. The signed form read: I acknowledge that the attending physician of my choice may provide care for me by the facility if credentialing requirements are met and my attending agrees. I designate ________ , located at________ to be my attending physician effective _______. I understand that I may change who I designate as my attending physician at any time. Staff X was interviewed on 07/20/20 at 9:08 AM. Staff X interviewed Staff Y on Saturday, 07/18/20, regarding Patient #1. Staff Y reported the family of Patient #1 was informed that Staff Z could not be the attending physician for Patient #1 while Patient #1 remained in the intensive care unit, per the contracted hospital's policies.