Every finding on record at Duke Homecare & Hospice

Observed in Record Review. In 1 of 3 patient records reviewed, for discharged patients, it was noted by the surveyor that for HOSRRDC#1 a copy of the Notice of Medicare Non-coverage (NOMNC) was not provided to or signed as required by the patient when it was determined that the patient was going to be discharged for extended prognosis. Finding was discussed and verified with the Clinical Nurse Managers.

Observed in Record Review. In 3 of 20 patient records reviewed, it was noted by the hospice nurse surveyor that the comprehensive assessment was not completed within five calendar days of the election of the hospice benefit. For HOSRRNHV#7, the MSW assessment was not completed within 5 days with no explanation in the record as to why. The assessment was 13 days late. For HOSRRNHV#8, the chaplain assessment was not conducted within 5 days with no explanation documented with why late. Chaplain assessment not documented as being completed. The MSW assessment was not completed within 5 days with no documented explanation. Assessment was 5 days late. In HOSRRNHV#14, the MSW assessment was not conducted within 5 days with no documented explanation and was completed 16 days late. Findings were discussed and verified with the hospice clinical nurse managers.

Observed in Record Review. In 2 of 20 patient records reviewed, it was noted by the hospice nurse surveyor that the bereavement risk assessment was not completed as part of the comprehensive assessment. For HOSRRNHV#3 and HOSRRNHV#10, there was no documented Bereavement Risk Assessment by any member of the Interdisciplinary Team. Finding was discussed and verified with the hospice clinical nurse managers.

Observed in Record Review. In 2 of 20 patient records reviewed, for active patients, it was noted by the nurse surveyor that the plan of care was not updated based on changes in the patient condition. For HOSRRHV#3, Skilled nursing notes and IDG notes reflect that the patient was having increased anxiety, however the Care Plan was not updated to reflect anxiety or the noted interventions. HOSRRNHV#4, the patient had a change of condition resulting in daily nursing visits. The plan of care had not been updated to reflect the change of condition or that for the patient death was imminent. Findings were discussed and verified with the Clinical Nurse Managers.

Observed in Record Review. In 20 of 20 patient records reviewed, for active patients, the nurse surveyor noted that the goals were not measurable. For example, Patient cognitive care needs met without s/s of complications, and “Patient and/or family verbalizes understanding of nutritional needs. Most goals did not have a timeframe for completion or were to end of certification period or at death. Those goals with short term completion dates were not updated to reflect an on-going problem. All findings were discussed and verified with the Hospice Clinical Nurse Managers.

Observed in Patient Home. In 1 of 3 home visits conducted, for patients with a hospice aide, it was noted by the nurse surveyor that the hospice aide care plans did not include the information necessary for the hospice aide to effectively care for the patients. For RRHV#4, the patient had a foley catheter inserted and required catheter care and for the foley bag to be emptied at each hospice aide visit. The Hospice Aide Care Plan had not been updated to reflect this change. Findings were discussed and verified with the Hospice Nurse Manager present on the home visit.

Observed in Patient Home. In 2 of 3 home visits conducted, patients with the hospice aide, the nurse surveyor noted that care was not provided according to the hospice aide plan of care. RRHV#2, the Home Health Aide Care Plan indicated that the hospice aide was to provide the patient with a bed bath. During the home health aide visit the aide stated that she gave the patient a shower anytime there was help available at the facility to help her transfer the patient to the shower chair even though it was not on the care plan for her to do so. For RRHV#4, the Home Health Aide Care Plan indicated the hospice aide was to assist the patient with bowel/bladder elimination. The patient had had a foley catheter inserted and the hospice aide emptied the foley bag and performed catheter care at each visit. Findings were verified by the nurse managers who were present on the patient visits.

Observed in Record Review. In 1 of 20 patient records reviewed, for active patients, it was noted by the nurse surveyor that hospice aide supervisory visits were not documented no less frequently than every fourteen days. For HOSRRHV#6, hospice aide supervisory visits were two days late (sixteen days between supervisory visits) and five days late (nineteen days between supervisory visits). Findings were verified with the Hospice Clinical Nurse Manager.

Observed in HR File Review. In 1 of 2 hospice aide competency records reviewed, the organization had not documented an annual on-site visit by a registered nurse. There was no documentation that validated that a RN made an on-site visit to the location where a patient was receiving care in order to observe and assess the hospice aide at any time during a 12 month period. The last signed evaluation was done two years prior to the date of the survey. This was discussed with hospice leadership.

Observed in Patient Home. In 3 of 3 home visits conducted, in a skilled facility, it was noted by the nurse surveyor that for RRHV#1, RRHV#2, and RRHV#6, the Skilled Nursing Facility had not been provided the physician certification and recertification of the patient’s terminal illness. Findings were verified by the Hospice Nurse Managers.

Observed in Document Review. The organization's contract for a Skilled Nursing Facility (SNF), Carver Living Center, did not contain all of the required elements. This was evidenced by the lack of a stipulation stating that the SNF would complete criminal background checks on employees who provide direct patient care or have access to patient records. This was discussed with the leadership of the organization.

Observed in Document Review. There was no documentation provided to demonstrate that the In-patient Hospice conducted quarterly sprinkler testing during the fourth quarter of 2025. This included no testing of high and low Air Pressure Supervisory Signals. This was confirmed by the Facilities Team.

Observed in Document Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by not verifying compliance with manufacturer's guidelines for device use (COP 418.60) and policies related to required documentation (COP 418.102). This was confirmed with the Chief Nurse Officer.

Observed in Record Review. In 9 of 20 patient records reviewed, The hospice nurse surveyor noted on (HOSV#1) that the plan of care goals did not include any outcome measures and had not been updated to address the patient's symptom needs. The current plan of care did not include any outcomes for managing the patient's airway clearance on a Trilogy ventilation and cough vest. Also, the patient had a gastostomy tube; however, there were no goals to address the wound care or patency of the device. Some of the goals in the plan of care were the same and had not been updated since June. In (HOSV#3), there were no measurable outcomes defined on the plan of care to manage the patient's pain and in (HOSV#4), there were no outcome measures that addressed the patient's needs including pain and wound healing. The goals had blank spaces were the measured were required to be filled in. In (HOSV#5) the goals had not ben updated since August and the only measurable outcome for pain less than 3, did not have a time frame for achieving the goal. In (HORR#2) there were no measurable outcomes for managing the patient's respiratory needs, the Pleurex and fluid volume reduction, there were no pain goals. Also, in (HOSRR#3) there were no goals to address symptoms of nausea, vomiting, diarrhea and constipation or the colostomy needs. In (HOSRR#5) there were no goals to manage ascites. In (HOSRR#6) there were no expected outcome measures or goals for respiratory symptoms of dyspnea and oxygen safety. In (HOSRR#15) the plan of care was incomplete and did not include any outcome measures or expected timeframes for achievement. The surveyor noted in 15 records that all the care plan goals were the same for all patients and did not include goals that were individualized toe the patient's needs or symptom management. This was confirmed with the nurse manager.

Observed in Record Review. In 3 of 20 patient records reviewed, The hospice nurse surveyor noted (HOSV#2) that the current plan of care was not updated to include orders for Trilogy ventilation and settings. In (HOSRR#2), there were no diet orders, and in (HOSRR#7) there were no diet orders. This was confirmed with the nurse manager.

Observed in Medication Management Tracer. The hospice nurse surveyor noted in the inpatient unit that the organization was using a single use glucometer for multiple patients, for the past year and documentation confirmed the use on several patients. The devise was immediately removed while on site. This was confirmed with the Chief Nursing Officer.

Observed in Record Review. In 3 of 20 patient records reviewed, The hospice nurse surveyor noted (HOSRR#3) that there was no evidence in the record that the Medical Director reviewed clinical information or documented and signed the initial certificate of terminal illness since the patient was admitted over three weeks ago. Also, in (HOSRR#4), the initial certification was not completed until over six weeks after admission. In (HOSRR#7), the certification had not yet been completed since the patient was admitted over two weeks ago. This was confirmed with the nursing officer.

Observed in Individual Tracer. In 3 of 20 patient records reviewed, The hospice nurse surveyor noted on (HOSV#1) that the certification was not completed by the physician before the certification in September. It was not completed until November. also, the surveyor noted that there was no certification completed for the November certification period. On (HOSV#5), the surveyor noted that the physician's re-certification of terminal illness was not completed before the recertification period for October 2021 and was not signed until mid November and for the August 2022 certification it was not signed until October. In (HOSRR#8), the September re-certification was not completed until November. This was confirmed with the nurse manager.

Observed in Record Review. For Hospice RR # 11, the RN checked the incorrect box and documented the patient had a peripheral intravenous line , when the patient had a peripherally inserted central line.

Observed in Record Review. In 1 of 20 patient records reviewed, it was noted by the hospice surveyor during in hospice record review that the CTI was blank for the Certification period starting on 1/27/2023. So, no CTI was documented.

Observed in Building Tour. In 12 of 12 patient rooms, The hospice nurse surveyor noted that there was a patio door in the patient room that exited to an outdoor patio without means to an egress. The surveyor noted in discussion with the manager that twelve rooms had the same patio door and patio design and did not end in an egress. The patios were lined with bushes and metal frames. The surveyor noted that none of the doors were labeled NO EXIT as required. This was confirmed with the chief nursing officer and signs were affixed on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. In 2 of 2 patient corridors, The hospice nurse surveyor noted that both patient corridors contained equipment that blocked the means of egress to the exit doors. The surveyor confirmed that the four computer terminals, four chairs and four bedside tables resided in the corridor and were not removed when not in use. One of the set-up was within four feet of the exit door. This was corrected on site and the corridors were cleared. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. The hospice nurse surveyor noted that the ceiling of the telecom closet had three penetrations that were not sealed. The penetrations were sealed on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Individual Tracer. In 2 of 7 home visits conducted, The hospice nurse surveyor noted (HOSV#3) that the plan of care did not identify the care and services that were needed and identify which provider was responsible for performing the functions that had been agreed upon and included in the plan of care. Also, in (HOSV#5) the plan of care did not indicate the specific functions or roles for this patient in a skilled facility. this was confirmed with the nurse manager.

Observed in Individual Tracer. In 1 of 7 home visits conducted, The hospice nurse surveyor noted (HOSV#3) that the facility confirmed that they had not received a copy of the patient’s most recent hospice plan of care, the patient’s hospice election form and any advance directives , the physician certification of the patient’s terminal illness, information on the hospice medications for the patient and orders from the hospice physician and attending physician, if any, for the patient. The record did not include any documents since the patient was admitted three weeks ago. This was confirmed with the registered nurse.