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
341587 A. BUILDING __________
B. WING ______________ 		02/28/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PROMEDICA HOSPICE (RALEIGH) 4505 FALLS OF NEUSE ROAD, SUITE 650, RALEIGH, NC, 27609
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)
L0505      
44098 Based on policy review, clinical record review, and staff interview, the agency failed to document and follow-up on a complaint for 1 of 1 clinical record (Patient #1) reviewed with a documented concern. Findings included: Policy 260, Patient Concerns, was received from Director of Professional Services on 03/03/22 at 7:43 AM. This policy revealed, "The employee ...receiving the concern initiates the patient concern report ..." and "Concerns are evaluated by the agency's Quality Assessment and Performance Improvement Committee ...resolution/outcome information is documented on the concern report and communicated to the complainant within 30 days." Patient #1 was admitted to the agency on 11/05/20 with a principle hospice diagnosis of malignant neoplasm (cancer) of the rectum. For the hospice benefit period beginning 01/19/22 through the time of discharge on 02/22/22, discipline visits were ordered as follows: skilled nursing 2 times per week for 8 weeks and 3 PRN (as needed), home health aide 1 time per week for 9 weeks, medical social worker 1 time every 30 days effective 02/06/22, spiritual care 1 time every 30 days effective 02/06/22, and music therapy services 1 time every 30 days effective 01/30/22. A care coordination note of 02/21/22 at 5:48 PM, was written by Employee #3, Assistant Director of Professional Services. This note revealed, "GOT EMAIL MESSAGE THAT DAUGHTER WANTED TO TRANSFER PATIENT TO [name of transfer hospice agency]. CALLED HER TO FIND REASONS WHY ...SHE STATED THAT THERE HAD BEEN SOME PROBLEMS WITH COMMUNICATION WITH THE FACILITY AND HHA (home health aide) SERVICES. SHE STATED SHE HAD CALLED LAST WEEK WITH REGARDS TO A WOUND AND HE (Patient #1) DID NOT GET A NURSE VISIT UNTIL SATURDAY. (ON RESEARCH THE CALL CAME IN WEDNESDAY, EMAIL WAS SENT AND THE VISIT - AFTER A SECOND CALL - NURSE VISIT ON SUNDAY) ...I APOLOGISED AND ASKED IF THERE WAS ANYTHING ELSE WE COULD DO. SHE SAID NO ..." There was no evidence of a documented concern or follow-up related to this reported concern. In an interview on 02/28/22 at approximately 4:15 PM, Employee #2, Director of Professional Services, confirmed that there was not a patient concern report related to this reported concern and stated, "We probably should have done one ..." Employee #3 was not available for interview at the time of survey.
L0554      
44098 Based on agency "guidebook" review, clinical record review, and staff interview, the agency failed to coordinate nursing services with the facility/caregiver for 1 of 3 patients (Patient #1). Findings included: Individualizing the Hospice Plan of Care Guidebook was received from the Director of Professional Services on 02/28/22 at approximately 12:00 PM. This guidebook revealed the following regarding facility patients: "The hospice team and facility staff communicate, establish, and agree upon a coordinated POC (Plan of Care) for both providers which reflects the hospice philosophy, and is based on an assessment of the patient's needs and unique living situation in the facility." Patient #1 was admitted to the agency on 11/05/20 with a principle hospice diagnosis of malignant neoplasm (cancer) of the rectum. For the hospice benefit period beginning 01/19/22 through the time of discharge on 02/22/22, discipline visits were ordered as follows: skilled nursing 2 times per week for 8 weeks and 3 PRN (as needed), home health aide 1 time per week for 9 weeks, medical social worker 1 time every 30 days effective 02/06/22, spiritual care 1 time every 30 days effective 02/06/22, and music therapy services 1 time every 30 days effective 01/30/22. Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report from 01/19/22 to 02/22/22 revealed a current problem list that included the need for facility staff care coordination, observation and assessment of skin, and pressure ulcer care. This Plan of Care Update Report also included a hospice order dated 02/05/22, "COVER TO PROTECT BLISTER". A care coordination note of 02/05/22 at 10:47 AM was written by Employee #4, On-Call Triage Nurse. This note revealed, " ...PATCHED CALL FROM [name of caller and facility]. CALLER FRUSTRATED AND STATED SHE HAS BEEN REQUESTING F/U (follow-up) CALL FROM RNCM (registered nurse case manager) X 3 DAYS. FACILITY RN (registered nurse) ASSESSED PT (patient) AND PT HAS NEW LARGE PRESSURE SORE/BLISTER TO RIGHT HEEL. RIGHT TOES ALSO RED. FOOT TENDER TO TOUCH. BLISTER STILL INTACT AT THIS TIME. INSTRUCTED TO FLOAT HEELS AT ALL TIMES TO PREVENT PRESSURE ON AREA. ASSURED HER THAT TRIAGE WILL UPDATE RNOC TO F/U AFTER PREVIOUS OBLIGATIONS. VISIT ASSIGNED TO [name of on-call nurse]". A care coordination note of 02/20/22 at 9:55 AM was written by Employee #6, On-Call Triage Nurse. This note revealed, " ...PATCHED CALLER [name of caller and facility] WHO STATES THAT THE WOUND TO THE RIGHT HEEL HAS OPENED UP AND IS BLEEDING. CALLER STATES THEY HAVE NO SUPPLIES OR ORDERS TO DO WOUND CARE. REVIEWED COORDINATION NOTES. ORDERS WERE PLACED ON THE 15TH AFTER VISIT REGARDING SAME WOUND. CALLER STATES THEY HAVE NOT ARRIVED. INSTRUCTED TO CLEAN WITH SOAP AND WATER AND PAT DRY AND TO KEEP HEEL OFF BED. RNOC (registered nurse on call) NOTIFIED. VISIT ASSIGNED." A care coordination note of 02/21/22 at 5:48 PM, was written by Employee #3, Assistant Director of Professional Services. This note revealed, "GOT EMAIL MESSAGE THAT DAUGHTER WANTED TO TRANSFER PATIENT TO [name of transfer hospice agency]. CALLED HER TO FIND REASONS WHY ...SHE STATED THAT THERE HAD BEEN SOME PROBLEMS WITH COMMUNICATION WITH THE FACILITY AND HHA (home health aide) SERVICES. SHE STATED SHE HAD CALLED LAST WEEK WITH REGARDS TO A WOUND AND HE (Patient #1) DID NOT GET A NURSE VISIT UNTIL SATURDAY. (ON RESEARCH THE CALL CAME IN WEDNESDAY, EMAIL WAS SENT AND THE VISIT - AFTER A SECOND CALL - NURSE VISIT ON SUNDAY) ...I APOLOGISED AND ASKED IF THERE WAS ANYTHING ELSE WE COULD DO. SHE SAID NO ..." In an interview on 02/28/22 at approximately 4:15 PM, Employee #2, Director of Professional Services, confirmed that the registered nurse case manager, Employee #5, should have ensured that the wound care supplies should have been available for facility use and that the nurse should have visited the patient when the caregiver requested an additional visit. Employee #5 was not available for interview at the time of survey.