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
261500 A. BUILDING __________
B. WING ______________ 		01/13/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE COMPASSUS-SOUTHWEST MISSOURI 1341 W BATTLEFIELD STREET, SUITE 120, SPRINGFIELD, MO, 65807
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      
17006 Based on policy review, record review and interview the agency failed to conduct/document timely grievance investigations and resolution in two (Record/Patient #1 and #2) of three grievances reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Procedures: Complaints and Grievances," revised 03/01/2020 showed: - The purpose is to provide prompt investigation and resolution to patient and/or family complaints or grievances; - A complaint or grievance is a concern expressed by anyone about the quality of care, care delivery, services, colleagues, or any area under the influence or responsibility of the agency's program; if from a patient or family member, this may include issues of discrimination, access, or violation of rights; - The area executive of clinical services (AECS) or designee is responsible to educate general and supervisory colleagues regarding the complaint procedure, and insure that the procedure is followed; - The AECS or designee will also be responsible to oversee the investigation, findings, and resolution of the complaint for compliance with the agency's policy and procedures; - If a patient or family member voices a complaint regarding hospice services or provides of hospice services to a hospice colleague, the colleague will be responsible to notify the supervisor regarding the complaint voiced by the patient or family member; - The supervisor will be responsible for the following actions: *Complete the top portion of the written complaint report detailing the complaint as related by colleagues and/or complainant; * Submit the report to the AECS or designee within 24 hours of receiving the complaint; - The AECS or designee will be responsible for the following actions: *Investigate the complaint within five working days and determine appropriate corrective actions; *The investigation may include review of documentation, interview of complainant, colleagues, witnesses, and/or others pertinent to the occurrence, review of state and/or federal regulations, review of corporate policies and procedures and review of pertinent legal issues; - Should the investigation reveal actions that violate agency policy and/or local, state, or federal laws/regulations consult with regional vice president, regional clinical director, vice president of human resources and/or compliance officer for further decision making; - Within 30 days, contact the complainant either via telephone or with a letter detailing the steps toward resolution; - Within 14 working days after the initial resolution communication provide follow up contact with the complainant to determine satisfaction with the resolution; - Document investigative actions, corrective actions and follow up contacts on the bottom portion of the complaint report; and - If the corrective action includes any kind of colleague disciplinary action, place a copy of the complaint report, investigative data, and resolution information in the colleague's personnel file. Review of the agency's policy titled, "Patients' Rights," revised 07/05/2019 showed reports of grievances, violation of patients' rights or other concerns raised to an agency colleague will be fully investigated and documented in accordance with state statute or agency compliance policies. Complaint #1: Review of a complaint report dated 11/30/2020 showed: - Under the section to describe the occurrence/complaint, the director of clinical services (DCS) A received a call from licensed practical nurse (LPN) B who was in the patient's home at the time; - The nurse and spouse talked about how the wound increased in size during the transfer from bed to chair when the lift (mechanical) was not working; - The spouse was angry during the call and stated he/she did not want registered nurse (RN) C to come back; - The spouse spoke through the nurse that was in the home during the call; - DCS A spoke with the nurse and spouse about what they could do (different dressing changes, staff education) and he/she seemed appeased with the conversation; - DCS A asked the spouse if he/she could call later and was informed, not to bother because LPN B had it handled; - DCS A signed and dated the form on 01/06/2021 (over a month later); - The section for complaint investigation and resolution (which showed to include interviews conducted, records reviewed, and regulatory or legal issues identified) showed to see included documentation (complaint resurfaced on 12/30/2020); - The section for corrective action was blank; - The section for communication showed an X was placed in the box beside phone call to complainant and dated 12/31/2020; - The area executive of clinical operations (ACO) signed the form on 01/07/2021; -There was no documentation of an investigation being conducted until 12/30/2020. During an interview on 01/12/2021 at 12:55 PM, RN C stated that: - The patient's air mattress went flat; - He/she met the durable medical equipment (DME) representative to assist with transferring the patient so they could put a new mattress on the bed; - The DME representative brought a Hoyer (mechanical) lift because the patient's lift was not working; - The patient was not able to tolerate being lifted with the Hoyer lift; - He/she could not leave the patient laying on a flat mattress; - He/she told the patient he/she could transfer him/her to the wheelchair; - The patient said that would work; - He/she explained to the patient how they would transfer, and the patient agreed; - He/she did not squeeze or bear hug the patient; - He/she squatted down by the patient so the patient's elbows rested on his/her shoulders; - He/she held the patient in the "love handle" area and tried to keep the patient close. They stood, pivoted around and sat in the wheelchair. The patient immediately said I bear hugged him/her when he/she was transferred to the chair. They thanked me for coming out. Nothing happened to make me think there was an issue. RN C said from now on, if in a situation like that, he/she would call EMS (emergency medical services) to assist. He/she would not transfer a patient on his/her own. The DCS A had not talked to him/her about the incident. He/she did not learn there was an issue until 12/31/2020 when the administrator talked to him/her. During an interview on 01/12/2020 at 4:07 PM DCS A stated that: - When a complaint is made, he/she fills out a complaint form and contacts the family or patient and discusses the complaint; - He/she then sends the form to the administrator; - He/she would talk with the staff, patient and family regarding their concerns; - On 11/30/2020 the licensed practical nurse (LPN) called him/her from the patient's home; - They talked about how the wound had increased in size and that the lift was not working properly; - The spouse did not want RN C to come back; - The spouse spoke through the nurse and did not want to speak to him/her directly. They talked about what they could do as an action plan. He/she seemed appeased at that time. The patient's spouse did not want him/her to call back. He/she said the LPN had it handled. They did not mention that they felt the transfer caused the wound to increase in size or cause pain in the chest or ribs; - If there was anything he/she felt that needed to be reported he/she would have; and - They did say the patient was pivot transferred but did not report about a bear hug transfer. During an interview on 01/13/2020 at 11:45 AM, the ACO stated that: - The complaint process is a team process; - The team reports to their director, the director contacts the patient or family regarding the complaint so they can hopefully resolve the issue, then the director informs me so I can follow up within 14 days to make sure their complaint is resolved; - On 11/30/2020 he/she was notified the patient did not want RN C back in the home; - The administrator had been off for a couple of weeks and he/she had asked DCS A to follow up; - On 12/30/2020 the bereavement coordinator brought the situation to his/her attention. He/she found out the family had been talking about the situation for a month; - An investigation had not been conducted before 12/30/2020; - The DCS thought he/she had resolved the situation and an investigation didn't need to be done; - He/she expected staff to notify him/her about issues that were not resolved; - He/she has started education with the staff regarding the complaint process and has made it very clear to the team that if they feel something is not resolved, it needs to be reported to him/her; - He/she went to visit the patient and the patient did not feel RN C did anything abusive; - The patient said he/she felt it was never abusive and he/she knew the nurse had no intention of hurting him/her; - At the conclusion of his/her investigation he/she felt the nurse did not do anything intentional or hurtful and knew if RN C thought he/she did anything wrong or hurtful he/she would have notified him/her. Complaint #2: Review of a complaint report dated 12/18/2020 showed: - Under the section to describe the occurrence/complaint showed the family member requested a different aide. This section was signed by DCS A and dated 12/18/2020; and - The section for investigation and resolution was blank. During an interview on 01/13/2021 at 11:45 AM the ACO stated that: - The complaint came from the patient's family member; - He/she talked with the patient and the patient was very satisfied with his/her aide; - The patient was incontinent at times and the caregiver blamed the aide for the incontinence and odor; - We are providing many supplies and clean blankets for the patient to use; and - He/she had told DCS A last week to write up more detail about the complaint.