Every finding on record at Cape Fear Valley Homecare and Hospice, LLC

Based on agency policy, clinical record review, and staff interviews, the agency failed to document coordination of care for 2 of 3 patients. (Patient’s #1 and 2.)Findings included: --- A policy, Hospice Medical Record (revised 10/01/2024) received on 04/08/2025 at 2:20 PM from the executive director stated, “The hospice medical record shall contain the following information: … Documentation and communication with the patient, caregiver, and physicians.”A policy, Plan of Care (revised 10/01/2024) received on 04/08/2025 at 2:20 PM stated, “The plan of care must include… Coordination of Care.”Patient #1 was admitted on 09/27/2022 with a diagnosis of Alzheimer’s Disease (progressive disorder that affects memory and behavior). The plan of care (POC) for 03/15/2025-05/13/2025 included orders for skilled nurse (SN) visits 2 every 2 weeks for 2 weeks, 2 times a week for 7 weeks, and 3 PRN (as needed). Review of the clinical record revealed that on 03/28/2025 RN #6 documented, “Urine smelly with lots of SEDK,ENT [sic], low grade fever [98.2]. 5 day antibiotic ordered…” Further review revealed that there was no documentation of RN #6 contacting the physician.During an interview conducted on 04/08/2025 at 1:28 PM RN #6 stated, “I usually say [in the clinical record] that I reached out and got approval [from a physician].” Patient #2 was admitted on 02/26/2025 with a diagnosis of Malignant Neoplasm of Head of Pancreas (pancreatic cancer). The plan of care for 02/26/2025-05/26/2025 included orders for skilled nurse (SN) visits 2 times a week for 13 weeks with 3 PRN (as needed), MSW visits 1 time a month for 4 months, and volunteer visits 1 time a month for 1 month. Review of the clinical record revealed that on 03/13/2025 the volunteer coordinator documented, “Patient was experiencing an increase in pain during visit. Writer called the patients [sic] case manager [registered nurse (RN) #5’s name] and asked that [RN #5’s name] direct her [caregiver] in interventions to try.” Further review revealed no documentation of RN #5 educating the patient/caregiver on pain management. Further review revealed that on 04/03/2025 Medical Social Worker (MSW) #7 documented, “Not a good day for patient as patient was experiencing dizziness… Patient reports ealier [sic] that morning he thought he saw spiders in the bed…” There was no documentation in the clinical record of the nurse case manager being notified of a change of condition.An interview conducted on 04/08/2025 at 1:24 PM with the volunteer coordinator revealed that RN#5 was notified by telephone during the visit and RN #5 spoke with the caregiver during the call.During an interview conducted on 04/08/2025 at 2:17 PM RN #5 stated, “I did speak with the family about pain and normally I would document it.”During an interview conducted on 04/08/2025 at 1:45 PM MSW #7 stated, “I don’t think that I did notify the case manager.”An interview on 04/08/2025 at 1:31 PM with the executive director revealed that care coordination should be documented in the clinical record.During an interview conducted on 04/08/2025 at 1:52 PM the patient care manager stated, “I would recommend them [MSW] to call the case manager or the patient care manager.”An interview on 04/08/2025 at approximately 2:20 PM revealed that the expectation is to document all communications.

Based on agency policy review, clinical record review, staff and caregiver interview, failed to coordinate the discharge plan of care with the patient/caregiver for 1 of 3 live discharge records reviewed. (Patient #2) Findings included: --- Patient Rights and Responsibilities were received from the agency director on 10/21/24 at 3:42 PM and revealed, ";A patient has the right to...be advised of the agencys procedures for discharge... receive information about the scope of services that hospice will provide and specific limitation on those services..." Policy 2.007, titled ";Live Discharge/Transfer of the Hospice Patient" was received from the agency director on 10/21/24 at 11:35 AM. This policy revealed, ";If a patient has elected to enter a non-contracted facility a discharge from hospice services is not automatically required. The hospice agency must consider the amount of time that the patient is anticipated to remain in the facility as well as the effect on the hospice plan of care. If there is little impact on the hospice plan of care, discharge from hospice service could be deemed inappropriate and a violation of the patient rights." Patient #2 was admitted to the agency on 06/03/24 with a principal hospice diagnosis of Alzheimers disease. The Plan of Care from 06/03/24 to 08/31/24 revealed orders for skilled nursing three times per week for 13 weeks, medical social work one time per month for one month, home health aide two times per week for 13 weeks, chaplain one time per month for one month, and volunteer one time per month for one month. Patient #2 was treated with antibiotics, steroids and antihistamines (allergy medicine) for low grade fever and respiratory symptoms intermittently throughout the 44 days that she received hospice services and on 07/16/24 her daughter/responsible party took her to the hospital because of the ongoing symptoms. The agency discharged Patient #2 on 07/16/24 due to the patient going to a hospital where the agency was not contracted to provide services. There was no documented evidence that the patient/responsible party were educated about options for hospitalization and treatment at non-contracted facilities or evidence that the agency attempted any alternative methods to avoid discharging the patient. In an interview on 10/21/24 at 3:12 PM, Employee #1, agency director, stated that Patient #2s responsible party ";kept taking her to different hospitals and went to [name of the non-contracted hospital] without contacting us...I asked the nurses to [educate the responsible party about options for hospitalization and treatment at non-contracted facilities] but Im not sure if that was followed up on..." The agency nurses who visited Patient #2 were not available for interview at the time of survey.

Based on policy review, clinical record review, and staff interview, the allegation that the agency omitted documentation of a wound in the clinical record for 1 of 3 records reviewed is substantiated (Patient #1). Findings included: Policy Number 2.002 Initial & Comprehensive Admission Assessment & Plan of Care effective 07/12/96 and last revised on 03/01/21 was received from Employee #1, the agency director, on 11/22/21 at 11:56 AM. This policy revealed, "The purpose of the initial assessment visit will be to evaluate the patient's physical, psychosocial, and emotional states related to the terminal illness and related conditions and to determine the patient's immediate care and support needs" and "The initial assessment performed by the RN (registered nurse) ...will include assessment of ...Integumentary (skin) system ..." Policy Number 3.029 Wound Assessment, Documentation and Photography effective 12/31/08 and last revised 03/01/21 was received from Employee #1, the agency director, on 11/22/21 at 11:56 AM. This policy revealed, "Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation within the medical record." Patient #1 was admitted to the agency on 11/20/20 with a principle hospice diagnosis of emphysema (a type of chronic lung disease). Plan of Care of certification period 11/20/20 to 02/17/21 revealed orders for skilled nursing services 2 times per week for 1 week. Clinical record review revealed a skilled nursing visit note report of 11/20/20 which revealed an integumentary (skin) assessment documented as, "bruising ...poor turgor" and a wound assessment that identified a right buttock wound. A handwritten admission SBARR (acronym for situation, background, assessment, recommendations, response) scanned document dated 11/20/20 revealed, "nose 2.3 x 2.1 cm (centimeters) unstageable (a wound that has full thickness tissue loss where the base of the wound is not visible))" There is no evidence of documentation regarding a nasal wound in the clinical record from the 11/20/20 admission visit. In an interview on 11/22/21 at approximately 3:00 PM, Employee #1, the agency director, stated that the Admission SBARR document is one that the admitting nurse completes as an aid to give report regarding newly admitted patients. Employee #1 stated that this document is not intended to be part of the patient's clinical record. In an interview on 11/22/21 at approximately 3:20 PM, Employee #2, the admitting registered nurse, was unable to explain why she documented a nose wound as "unstageable" on the Admission SBARR document and stated, "I had to think real deep to remember the patient because I do so many admissions. If there was an opening, I would have put open, but it was closed ...there was no open area on her nose." When questioned about the buttock wound, Employee #2 stated, "That one I do not recall at all." In a follow up interview on 11/22/21 at approximately 3:50 PM, Employee #1 agreed that it would be unlikely for a nurse to write the word "unstageable" in notes to describe an area with closed skin.