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 ______________ 		11/17/2021
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)
L0671      
42078 Based on clinical record review and interview, the agency failed to assure that documents in the clinical record were accurate in one (Record/Patient #2) of three clinical records reviewed. This deficient practice has the potential to affect the clinical documentation for all of the agency patients. Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/29/21 with a terminal diagnosis of worsening Alzheimer's disease, and secondary diagnoses of constipation, unspecified respiratory disorder, and nutritional deficiency. The patient resided in a skilled nursing facility. Review of skilled nursing visit dated 06/30/21 showed documentation that the patient, "had 90 CC's (cubic centimeters) drained from the foley catheter (a tube inserted into the bladder through the urethra to facilitate urinary drainage) since last night." During an interview on 11/17/21 the facility nurse stated that the patient did not have a foley catheter in place. He/she also reported that the nursing notes dated 06/30/21 addressed the patients lack of control of his/her bowel and bladder. During an interview on 11/17/21 at 4:30 PM the administrator stated that there were no records of the patient having a foley catheter, and that the documentation in the client's record was in error.
L0774      
42078 Based on clinical record review, and interview, the agency failed to assure that the patient's plan of care identified the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care in one (Patient/Record #1) of three records reviewed. This deficient practice has the potential to affect the care and services of all the agency patients. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 10/23/21 with a terminal diagnosis of multiple sclerosis (a disabling disease of the brain and spinal cord where the immune system attacks the protective sheath that covers nerve fibers). And secondary diagnoses of congestive heart failure (a condition in which the hearts doesn't pump a sufficient amount of blood to meet the body's metabolic needs), small bowel obstruction (a blockage in the upper section of the bowel), and neurogenic bladder (a condition in which problems with the nervous system affect the bladder and ability to urinate). The patient lived in a skilled nursing facility. Review of the initial nursing assessment, performed on 10/25/21, showed the patient: - Had a suprapubic catheter (a tube inserted through a surgical opening in the area just above the pubic bone to create an access the bladder and facilitate urinary drainage); - Had a colostomy (a surgical opening on the abdomen that allows fecal matter to collect in a bag) for bowel evacuation; - Wore Unna boots to keep the heels off the bed; - Had a wound on the right foot just below the fourth and fifth toes; and - Had a wound on the left upper inner thigh. Review of the interdisciplinary group meeting, dated November 4, 2021, showed: - The colostomy had been identified as a problem for the patient, and: * The plan failed to contain individualized goals and interventions for the patient's care, stating, "Patient will have adequate care of catheter/ostomy/nephrostomy tube;" and * Failed to identify which provider would be responsible for provision of care to the colostomy. - A Foley (a urinary catheter inserted through the urethra to access the bladder to collect urine) was incorrectly identified as a problem for the patient, when the patient had a suprapubic catheter, and: * The plan failed to contain individualized goals and interventions for the patient's care, stating, "Patient will have adequate care of catheter/ostomy/nephrostomy tube;" and * Failed to identify which provider would be responsible for provision of care to the catheter. - The plan of care/IDG documentation did not contain interventions or goals for the Unna boot and wounds to right foot and left thigh. During an interview on November 17, 2021 at 2:31 PM the administrator stated that the nursing facility staff provided the Unna boot wound care for the right foot and left thigh, and catheter care. The administrator showed this surveyor the coordinated task plan and nursing facility orders. The administrator stated that they were unable to provide documentation that the coordinated task plan was discussed during the IDG meeting or included in the hospice plan of care.