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
261577 A. BUILDING __________
B. WING ______________ 		08/26/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
BENTON COUNTY HOSPICE 1238 COMMERCIAL, WARSAW, MO, 65355
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)
L0798      
38507 Based on review of Missouri Revised Statute 192.2405, record review, and interview, the agency failed to operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of the patients when the agency failed, as a mandated reporter, to hotline possible misappropriation of the patient's property (medication) to the State in one (Record/Patient #1) of one record reviewed. This deficient practice has the potential to affect the safety of all the agency's patients. Findings included: Review of Missouri Revised Statute 192.2405 showed the following persons shall be required to immediately report or cause a report to be made to the department (Department of Health and Senior Services) under sections 192.2400 to 192.2470: (1) Any person having reasonable cause to suspect that an eligible adult presents a likelihood of suffering serious physical harm, or bullying as defined in subdivision (2) of section 192.2400, and is in need of protective services; (2) Any...home health agency, home health agency employee, ...in-home services owner or provider, ...nurse, nurse practitioner, ...other health practitioner, ...social worker, or other person with the responsibility for the care of an eligible adult who has reasonable cause to suspect that the eligible adult has been subjected to abuse or neglect or observes the eligible adult being subjected to conditions or circumstances which would reasonably result in abuse or neglect. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 07/01/2020 for a terminal diagnosis of metastatic (growing) lung cancer. The patient lived in the home with the spouse, daughter, and grandson. The daughter was the primary caregiver. On 07/27/2020, the patient's friend became the durable power of attorney (DPOA) and primary caregiver. The patient obtained an ex parte against the daughter so she could not be in contact with the patient. Review of the visit notes showed: - A skilled nurse visit on 07/06/2020 by LPN A. He/she documented, "Medications was assessed and counted. Patient received 90 tabs of hydrocodone on 7/1/20. Today patient had 48 tabs left. Patient and her daughter stated that patient grandson had taken pain medication. Now patient keeps her medications in locked gun safe. Informed patient and her daughter that this nurse will report stolen medications to Dr. (name) and to hospice. Informed patient that she will not get any refills at this time. Informed her that police will be notified if any more medication is missing. Patient and daughter stated that they understand. Patient grandson lives with patient at present time. Patient stated that she didn't want grandson going to jail, d/t she wanted him to come to her funeral." LPN A went on to explain to the patient and daughter, "If any more medication come up missing that police will be notified"; and - A skilled nurse visit on 07/28/2020 by LPN B. He/she documented, "Tom (caregiver and DPOA) opened the gun safe where narcotics were kept. 2009847 Fentanyl TD 50 mcg 2 patches, one patch missing. 4000228N Lorazepam tablets 0.5mg 4/40. 2009832 Hydrocodone 5/325mg tablets 16/90, 12 tabs missing out of med planner, filled 7/10/20. 209884 Hydrocodone 5/325mg 30/30 tabs, filled 7/22/20. 4009979 Lorazepam Intensol, in refrigerator 29.5/30 ml, filled 7/23/20. This nurse and Tom counted medications. Call placed to RN case manager and (medical director) notified of missing medications. ...PCP is out of town for two weeks." The patient stated to the nurse and caregiver, "he just showed up, didn't say anything, took some stuff out of other bedroom and then took stuff out of gun safe, I don't know what he took." The patient was not sure who this person was. During an interview on 08/26/2020 at 9:50 AM, the administrator stated that: - The agency did not call the State of Missouri hotline as far she knew for either incidents; and - The State contacted the agency by phone and that started the protective service worker involvement. Telephone call to the Department of Health and Senior Services Special Investigator on 08/25/2020 at 4:00 PM. The investigator stated that: - A report was received on Patient #1 on 07/29/2020 from the hotline call center for criminal prosecution due to law enforcement was involved with the case; - The complaint was called into the hotline by a family member against the agency; and - He/she was working with the agency on this case and had been in contact with the administrator. During an interview on 08/26/2020 at 9:30 AM, the registered nurse case manager (RN A) was interviewed. She stated that: - The first theft of narcotics was discovered by LPN A on 07/06/2020 during a narcotic count; - The second theft was discovered by LPN B on 07/28/2020 when the patient reported someone came in the house and opened the gun safe and removed something and a narcotic count was done; - He/she was sure that LPN A and B reported this to the agency supervisor and physicians; - The State of Missouri hotline for adult abuse was not called because the new DPOA did not want the hotline called; and - Since the new DPOA was appointed by the patient 07/27/2020, the safe combination is only known to the patient, husband, and DPOA.