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
261612 A. BUILDING __________
B. WING ______________ 		07/29/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PREFERRED HOSPICE OF MISSOURI (CENTRAL) 1900 NORTH PROVIDENCE ROAD SUITE 311, COLUMBIA, MO, 65202
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      
42078 Based on agency policy, record review, and interview, the agency failed to immediately investigate a complaint related to care that was not provided in one (Record/Patient #6) of six records reviewed. This deficient practice has the potential to affect the care of all agency patients. Findings included: Review of agency policy dated 08/11/2020 and titled, "Nursing Services," showed: - In the event of a service failure or complaint from a client or family, the clinical manager should be immediately notified of the incident. A formal investigation is expected to begin immediately. In cases of patient care and failures to complete task, the immediate resolution of the complaint should be communicated to the staff and the failure should be addressed during the investigation; and - Service failures should result in a formal and written grievance with investigation and resolution present to the QAPI team members and to the Governing Body for review. RECORD/PATIENT #6: Review of the clinical record showed that the patient was admitted on 01/28/2021 with a terminal diagnosis of heart failure (a condition where the heart is unable to pump sufficient blood to meet the body's metabolic needs). The patient had a nursing visit frequency of two times per week identified on the 07/15/2021 interdisciplinary group (IDG) meeting notes. Review of the nursing visit frequency showed the patient received one nursing the week of 07/23/2021. During an interview on 07/28/2021 at 10:13 AM, the caregiver of Record/Patient #6 stated that: - There seems to be some scheduling issues; - On 07/20/2021 a visit was scheduled, the staff did not call the patient/caregiver, and no visit was made, - He/she waited until 07/22/2021 to call the office because he/she had not heard anything from the nurses, and: * He/she spoke with employee 4 to verify that a visit would be made on 07/23/2021; and * He/she reported that the visit scheduled for 07/20/2021 had not been made. During an interview on 07/28/2021 at 01:20 PM, employee 4 stated that he/she: - Did receive a call from the patient's family member stating that the patient had not received a visit that week; - Was unable to immediately notify the administrator of the missed visit because the administrator was out of the office for the remainder of the week; - Was unsure of who to contact, so he/she spoke with nursing staff members who were in the office at the time; - Offered to send a nurse to visit the patient that day, the family member declined the same day visit, and the family member asked that the routine visit schedule for the next day be kept; - Received assurance from complainant #2 that a visit would be made the next day; and - Notified the administrator of the missed visit. During an interview on 07/27/2021 at 01:20 PM the administrator stated that there was no investigation into the missed visits reported by the family member.
L0536      
42078 Based on policy review, record review, and interview, the agency failed to meet the requirements for the Condition of Participation: §418.56 Interdisciplinary group (IDG), care planning, and coordination of services when the hospice failed to: - Designate a registered nurse that is a member of the IDG to provide coordination of care and to ensure continuous assessment of each patient's and family's needs, and implementation of the interdisciplinary plan of care (L540). The cumulative effect of this deficient practice resulted in the failure of the agency to provide care planning, coordination, and IDG oversight to meet the needs of all hospice patients.
L0540      
42078 Based on policy review, record review, direct observation, and interview the hospice failed to ensure that the designated nurse/Director of Clinical Services (DCS) was an active member of the interdisciplinary group (IDG) that provides coordination of care and ensures continuous assessment of each patient's and family's needs, and implementation of the interdisciplinary plan of care in five (Records/Patients #1, #2, #3, #4, and #6) of five applicable records reviewed. The cumulative effect of this deficient practice has the potential to affect the care planning, coordination, and IDG oversight to meet the needs of all hospice patients. Findings included: Review of agency policy dated 08/11/2020 and titled, "Interdisciplinary Team," showed that: - The primary members of the Interdisciplinary Team (IDG) include the physician, director of clinical services, registered nurse, pastoral/counselor, and social worker; and - Responsibilities of the IDG team include * Establish the plan of care; * Review, assess, and recommend changes in the plan of care; * Initiate recommendations of the IDG; * Establish the scope and frequency of services and revise changes when appropriate; * Monitor and provide supervision of hospice care and services; * Maintain and monitor records of services provided; and * Provide and facilitate the exchange of information to the IDG team, resident, or attending physician, and family/caregiver. Review of agency job description dated 01/19/2020 and titled, "Preferred Hospice Job Description: Director of Clinical Services," showed that the DCS responsibilities include, but not limited to: - Will create schedules for clinical staff and sitters; and - Supervises the running of and documenting of IDT meetings, monitoring clinical staff documentation for accuracy and timeliness via the electronic medical record. RECORD/PATIENT #1: Review of the IDG attendance log, within the clinical record, failed to list the DCS to be present during the IDG meeting on 06/03/2021, 06/17/2021, 07/01/2021, 07/15/2021, and 07/29/2021. RECORD/PATIENT #2: Review of the IDG attendance log, within the clinical record, failed to list the DCS to be present during the IDG meeting on 06/03/2021, 06/17/2021, and 07/01/2021. RECORD/PATIENT #3: Review of the IDG attendance log, within the clinical record, failed to list the DCS to be present during the IDG meeting on 07/01/2021, and 07/15/2021. RECORD/PATIENT #4: Review of the IDG attendance log, within the clinical record, failed to list the DCS to be present during the IDG meeting on 07/15/2021. RECORD/PATIENT #6: Review of the IDG attendance log, within the clinical record, failed to list the DCS to be present during the IDG meeting on 07/01/2021, 07/15/2021, and 07/29/2021. During an observation of the IDG meeting on 07/29/2021 at 09:30 AM this surveyor noted that the DCS was not present in the meeting (either in person or by phone). During an interview on 07/28/2021 at 08:14 AM employee 3 stated that there are many near misses with the schedule and that the administrator is doing the scheduling. During an interview on 07/28/2021 at 08:58 AM, employee 1 stated that the DCS is the administrator. During an interview on 07/29/2021 at 11:05 AM, employee 5 stated: - That the DCS was not present in IDG today; - The DCS is usually not present during IDG; and - The DCS is a corporate employee over all of the nurses of all of the agencies owned by the company.
L0653      
42078 Based on agency policy, record review, and interview, the agency failed to ensure that a staff member was was fully oriented and knowledgeable of the agency's clinical / nursing policies prior to him / her being assigned to on-call duty. This deficient practice has the potential to affect the care and treatment of all the agency patients. Findings included: Review of agency policy dated 08/11/2020 and titled, "On-Call Services," showed that: - Every after-hours patient, family/caregiver call will be returned within 15 minutes and a team member will make a home visit within three hours or within 1 hour if emergent, if: * The patient, family/caregiver requests a visit; * The family/caregiver sounds distressed and cannot be quieted by phone; * The patient has experienced a change in level of consciousness; * The patient has died; and * The patient is in crisis; - The on-call nurse will report any concerns to the director of clinical services to ensure appropriate continuity of care; and - The on-call nurse will make a personal visit to the patient/family when receiving a call about an imminent death or a death that has just occurred. Review of the on call log provided by the answering service showed that: - The answering service gave a message to employee 1, on 07/26/2021 at 01:17 AM, that a patient had passed away; and - The answering service gave a second message, on 07/26/2021 at 2:20 AM, to employee 1 that the patient had passed away and the family had not yet received a call back from the agency. During an interview on 07/28/2021 at 08:58 AM, employee 1 stated that: - He/she was assigned to take the calls from the answering service on the weekend of 07/23/2021, and then forward the messages to employee 2; - He/she had not performed this task in the past; - He/she had not received training on what to do, or what processes were involved; - He/she was told that two people needed to be on call; and - A call that was missed on 07/26/2021: * The answering service put a message through that a patient had passed away; * He/she thought it was simply a message to be passed along to the office the next business day; * He/she did not notify anyone after taking the first message from the answering service; * He/she received a second page from the answering services; and * He/she returned the call to the answering service when he/she received the second call:, and * Then he/she notified the nurse on call. During an interview on 07/29/2021 at 12:00 PM the administrator stated that there was no documentation that employee 1 had received orientation to on-call duties.