Every finding on record at Community Home Care and Hospice of Vance County,Inc.

Based on agency policy, clinical record review, and staff interviews, the agency failed to notify a patient’s legal representative before making changes to the plan of care for 1 of 3 discharged patients (patient #2).Findings included: --- A policy, Patient Bill of Rights (revised 11/17/2025) received on 12/09/2025 at 2:20 PM from the executive director stated, “A patient may designate someone to act as his/her representative. The representative, on behalf of the patient, may exercise any of the rights provided by the hospice… Be advised in advance of the rights to participate in planning the care or service and in the planning changes in the care and service; have the right to refuse care or treatment… The family or guardian may exercise the patient’s rights when a patient is incompetent…”A policy, The Plan of Care (revised 11/05/2025) received on 12/09/2025 at 2:21 PM from the executive director stated, “The plan of care will be reviewed and revised as frequently as deemed necessary… by the interdisciplinary group with input from the attending physician, the patient and family/caregiver…”Patient #2 was admitted on 09/09/2025 with diagnoses of chronic obstructive pulmonary disorder (progressive lung condition causing an airflow blockage) and dementia (progressive loss of brain function). Patient #2 resided at a facility. The plan of care for 09/09/2025-11/15/2025 included orders for Chaplain visits 1 time a month and skilled nurse visits (SN) 2 times a week, medical social work visits 2 times a month, and “SN to develop and maintain a hospice patient plan of care in collaboration with facility staff, any applicable surrogate, caregiver, and physicians.”A review of the clinical record revealed that patient #2’s son completed the admission documentation on 09/09/2025 due to the patient having “confusion”. Further review revealed the following:During the spiritual evaluation on 09/17/2025 the Chaplain initiated a plan of care that included Chaplain visits 1 time a month. There was no documentation of the legal representative being notified of the changes to the plan of care.During the registered nurse (RN) visit on 09/19/2025 RN #5 documented, “Verbalized his anxiety increases with his SOB [shortness of breath]. Discussed with Med Tech [facility staff] administering Ativan [anti-anxiety medication].” There was no documentation of the legal representative being notified.During the medical social workers (MSW) visit on 09/23/2025 MSW #3 documented, “POC [plan of care] reviewed with Med Tech.” There was no documentation of the plan of care being reviewed with the legal representative. During the RN visit on 10/02/2025 RN #2 documented, “Reports increased anxiety… states he feels “air hunger [shortness of breath]’ all day… New orders received from MD [physician]…” There was no documentation of the legal representative being notified of the change to the plan of care.During the RN visit on 10/13/2025 RN #2 documented, “Increased confusion… increased anxiety… new orders received from MD…” There was no documentation of the legal representative being notified of new orders.During the RN visit on 11/09/2025 RN #7 documented, “Orders please [sic] for stool softener laxative [induces bowel movement]. Orders change for lorazepam [anti-anxiety medication] scheduled and PRN [as needed] …” There was no documentation of the legal representative being notified of the medication changes.An interview conducted with the Chaplain on 12/09/2025 at 2:03 PM revealed that they were not aware that they needed to contact the legal representative when implementing a plan of care.An interview conducted on 12/09/2025 at 2:08 PM with RN#2 revealed that they were not contacting the legal representative when changes where made to the plan of care.During an interview conducted on 12/09/2025 at 2:43 PM MSW #3 stated, “I did call him [legal representative] … I always call at admission.”During an interview on 12/09/2025 at 3:04 PM RN #7 stated, “He never answers his phone…”During an interview on 12/09/2025 at 2:27 PM the agency director stated, “They should call [the legal representative] after each visit.

Upon patient record review 1 of 19 (Patient #11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 11: The medical record contained an initial comprehensive spiritual assessment completed 4/18/23 with a start of care 3/31/23.

Upon patient record review 1 of 19 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 4: There was no evidence of a comprehensive spiritual assessment. Corrected on site.

Upon patient record review, 4 of 19 (Patient #3,#5,#8,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 3: The medical record contained nursing documentation since admission identifying patient utilizes oxygen at 4 LPM. The medication profile inaccurately stated the administration rate as 2 LPM. Corrected on site. Patient 5: The medication profile contained a lidocaine topical patch with no area identified for administration. Corrected on site. Patient 8: The medical record contained nursing documentation since 9/6/23 identifying patient use of oxygen. There was no evidence of oxygen on the medication profile. Corrected on site. Patient 13: The medication profile contained clotrimazole topical medication with no area defined for administration. Corrected on site.

Upon patient record review, 1 of 19 (Patient #8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 8: The medical record contained an initial bereavement assessment completed 9/15/23. Patient start of care was 9/1/23.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 2: The medical record contained nursing documentation since admission identifying patient has a decubitus ulcer to the right iliac crest. There was no evidence the RN measured and assessed the wound from 9/15/23 to 10/3/23.

Upon patient record review, 2 of 19 (Patients #8,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 8: The medical record contained nursing documentation upon admission identifying patient had dyspnea with minimal exertion and oxygen was later in use starting 9/6/23. There was no evidence of problems, goals, and interventions related to respiratory dysfunction and oxygen use. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient had dysphagia requiring pureed diet. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site.

Upon patient record review, 4 of 19 (Patients #3,#5,#8,#13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3: The medical record contained nursing documentation since admission identifying patient utilizes oxygen at 4 LPM. The order for oxygen entered into the medical record was inaccurate stating 2 LPM. Corrected on site. Patient 5: The medical record contained an order for a lidocaine topical patch with no area identified for administration. Corrected on site. Patient 8: The medical record contained nursing documentation since 9/6/23 identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 13: The medical record contained an order for clotrimazole topical medication with no area defined for administration. Corrected on site.

Upon patient record review, 6 of 19 (Patients #1,#3,#6,#8,#9,#13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bed rails, shower chair, and APP mattress. There was no evidence of the bed, rails, shower chair and mattress included as DME in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed and geri-chair. There was no evidence of the bed and chair included as DME in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon recertification visit 9/13/23 identifying patient use of a hospital bed, over the bed table, scoop mattress, chair alarm, and fall mat. There was no evidence of the bed, table, mattress, alarm, and mat included as DME in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a walker, 9/5/23 identifying use of oxygen concentrator, and 9/21/23 identifying use of a shower chair. There was no evidence of the walker, oxygen, and shower chair included a DME in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation 9/11/23 identifying patient use of a walker and electric scooter. There was no evidence of the walker and scooter included as DME in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, over the bed table, and wheelchair. There was no evidence of the bed, table, and wheelchair included as DME in the plan of care. Corrected on site.

Upon client record review, 2 of 19 (Patient #9 and #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 9: The medical record contained orders for social work frequency of once monthly effective 5/5/23 and 8/3/23. There was no evidence of social work visits completed. Missed visit 5/30/23 stated no answer when call made, 6/22/23 stated no SW available to meet frequency, 7/30/23 and 8/31/23 stated not available for visit, and 9/29/23 stated other support will be provided by telephone. Patient 11: The medical record contained an ordered social work frequency of 2M2,1M2 effective 8/7/23. There was no evidence of social work visits completed in August and September.

Upon patient record review, 1 of 19 (Patients #10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 10: The medical record contained nursing documentation upon admission identifying patient is non-ambulatory. There was no evidence of transfer instructions included on the aide care plan. Corrected on site.

Upon patient record review 2 of 19 (Patients #10,#11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 10: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 9/17/23. Patient 11: The medical record contained an ordered aide frequency of three times a week. There was no evidence of a third visit completed the week of 9/3/23.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 7: The Certification of Terminal Illness for benefit period starting 9/6/22 did not contain a narrative from the medical record to support eligibility for recertification. The medical record statement was there was no need for a CTI.

Upon patient client record review, 1 of 19 (Patient #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 3: The medical record contained nursing documentation since admission identifying patient resided in a nursing home. The medical record patient profile stated the patient was in a personal residence. Corrected on site.

Based on policy and procedure, record review and staff interview the agency failed to follow the plan of care for aide services for 1 of 3 patients receiving a home health aide (#1) performing dressing changes without an order for 1 of 1 patients with a PleurX catheter (drain for the chest) (#2) nursing services for 1 of 3 patients receiving skilled nursing (#2). Review of a policy "Provision of Care and Record Management", 4-027 was received from the agency director on 07/25/22 at 4:27 p.m. The policy stated," ....care provided to the patient will be in accordance with the plan of care ...every effort should be made to adhere to the ordered visit frequency ..." 1. Patient#1 was admitted on 06/04/22 with diagnoses of alzheimer's, gerd (gastroesophageal reflux disease), hyperlipidemia (high cholesterol), and hypertension. The Plan of Care for 06/04/22-06/16/22 included orders for skilled nursing 1 time a week for 1 week, 3 times a week for 1 week, and 2 times a week for 10 weeks; home health aide effective 06/05/22 2 times a week for 1 week, and 3 times a week for 10 weeks. Review of the record revealed no home health aide visits were made from 06/05/22 until the patient discharged on 06/16/22. An interview with Employee #2 on 7/25/22 at 3:43 p.m. revealed, "the agency didn't have any aides on staff at that time and we were supposed to have contract aides, but they weren't able to start". We thought we were going to have aides on Monday 6/7, but we found out on Monday 6/7 that we were not going to have any aides" we should have wrote an order to cancel services". 2a. Patient #2 was admitted on 02/23/22 with diagnose of chronic hepatic failure without coma (liver), and portal hypertension (liver). The Plan of Care for 02/23/22-05/23/22 included orders for skilled nursing 2 times a week for 13 weeks and 4 as needed visits. An order for skilled nursing to drain PleurX to abdomen once every 3 days was in the record starting 04/30/22 with description to not drain if systolic blood pressure is 90 or below. No orders were in the record for a dressing change to the PleurX. Review of skilled nursing note on 05/27/22 revealed dressing to insertion site completed as well. Further record review revealed skilled nursing note on 06/08/22 changed dressing using sterile technique. An interview with Employee #2 on 07/25/22 at 3:58 p.m. revealed, " I don't see any dressing change orders in the record". " I would expect an order to be in the record to change the dressing around the PleurX". 2b. Patient #2 was admitted on 02/23/22 with diagnose of chronic hepatic failure without coma (liver), and portal hypertension (liver). The Plan of Care for 02/23/22-05/23/22 included orders for skilled nursing 2 times a week for 13 weeks and 4 as needed visits. Review of skilled nursing visits revealed only 1 visit was in the record for the week of 5/1/22. An interview with Employee #2 on 07/25/22 at 3:49 p.m. revealed, "I do see a missed visit for that week and that is all" The other employee left without notice and I can't answer that regarding the frequency".