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
341589 A. BUILDING __________
B. WING ______________ 		07/25/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
COMMUNITY HOME CARE OF VANCE COUNTY 946 W ANDREWS AVE SUITE S, HENDERSON, NC, 27536
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)
L0543      
41345 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".