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
261638 A. BUILDING __________
B. WING ______________ 		03/17/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
GOOD SHEPHERD HOSPICE OF SPRINGFIELD, LLC 3250 SOUTH NATIONAL AVENUE, 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)
L0509      
29559 Based on policy review, record review, and interview, the hospice provider failed to ensure investigations and/or documentation of all complaints were conducted in accordance with established practice. The agency did not follow-up with a complete investigation and written resolution to a family complaint in one of one complaint record reviewed (Patient/Record #3). The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the agency policy titled " Policy Number: AD.G20 GRIEVANCE" , last revised 08/2011, showed in part the following: " It is the policy of Good Shepherd Hospice not to discriminate on the basis of disability. Good Shepherd Hospice has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 504 of the Rehabilitation Act of 1973. The law and regulations may be examined in the office of the Executive Director who has been designated to coordinate the efforts of Good Shepherd Hospice to comply with section 504. Any person who believes that they have been subjected to discrimination on the basis of disability may file a grievance under this procedure. It is against the law for Good Shepherd Hospice to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance." PROCEDURES: 1 Grievances must be submitted to the Section 504 Coordinator within 10 days of the date the person filing the grievance becomes aware of the alleged discriminatory action. 2. A complaint must be in writing containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought. 3. The Section 504 coordinator or designee shall conduct an investigation of the complaint. The investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 504 Coordinator will maintain the files and records of Good Shepherd Hospice relating to such grievances. 4. The Section 504 Coordinator will issue a written decision on the grievance no later than 30 days after its filing. 5. The person filing the grievance may appeal the decision in writing to the President within 15 days of receiving the decision. 6. The President shall issue a written decision in response to the appeal within 30 days of its filing. 7. The availability and use of this grievance procedure does not prevent a person from filing a complaint of discrimination on the basis of disability with the US Department of Health and Human Services, Office for Civil Rights. 8. Good Shepherd Hospice will make appropriate arrangements to ensure that disabled persons are provided other accommodations if needed to participate in the grievance process. Such arrangements may include but not limited to providing interpreters for the deaf, providing taped materials for the blind, or assuring a barrier free location for the proceedings. The Section 504 Coordinator will be responsible for such accommodations. PATIENT/RECORD #3: Review of the agency complaint log showed a complaint, dated 02/22/2018, that was received from a patient's family member. The complaint was entered into the complaint log by the patient's RN case manager. The family stated that there was no follow-up on an abnormal urine laboratory test result that he/she had provided to the hospice nurse on 02/20/2018. The hospice administrator documented that the result was faxed to the hospice physician but "need to place call to confirm fax was received". The "resolution" section of the "complaint/Grievance Report" was left blank. The section titled "resolution" in the document has a place for the administrator to sign and date, this section was also left blank. There is no written evidence that the hospice provider followed-up with the physician or documented a resolution to the reporter regarding the complaint. During an interview with the administrator on 03/12/2020 at 3:05 PM, he/she stated that the agency should document and perform an investigation of any complaint and resolution to the complainant.