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 ______________ 		04/20/2020
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)
L0501      
28783 Based on clinical record review, policy review, caregiver and staff interviews the agency failed to implement the patient's right to receive effective pain management in accordance with agency policy for 1 of 3 patient records reviewed [#1]. Findings include: "PATIENT BILL OF RIGHTS ... Policy No. 2-002 ... PURPOSE ... To encourage awareness of patient rights ... POLICY ... The rights contained within this policy include the basic rights of the patient ... PROCEDURE ... 1 ... E. Patients have the right to receive effective pain management ... J. Have the right to have the patient's person and property treated with consideration, respect, and full recognition of the patient's individuality and personal needs ..." Review of the clinical record for Patient #1 revealed the Election of Hospice Benefit/Consent was signed on 11/7/19. The consent revealed, "PHILOSOPHY: HOSPICE IS A PHILOSOPHY OF CARE THAT FOCUSES ON THE PHYSICAL, EMOTIONAL, PSYCHOSOCIAL AND SPIRITUAL NEEDS OF PERSONS FACING A LIFE THREATENING ILLNESS. THE GOAL OF CARE IS THE PALLIATION OR LESSENING OF PAIN, DISCOMFORT AND OTHER SYMPTOMS ASSOCIATED WITH THE ILLNESS WHEN A CURE IS NO LONGER CONSIDERED AN OPTION ... HOSPICE WILL WORK WITH YOU TO MAKE SURE THAT YOU ARE COMFORTABLE AND FREE OF DISTRESSING SYMPTOMS ... I HAVE BEEN INFORMED OF MY PATIENT RIGHTS AND RESPONSIBILITIES AS PROVIDED TO ME BY THE HOMECARE AND HOSPICE REPRESENTATIVE AND CONTAINED IN MY COPY OF THIS AGENCY'S PATIENT HANDBOOK." The Hospice Certification and Plan of Care [POC] for the Certification Period 11/7/19 to 2/4/20 revealed a start of care date of 11/7/19. Diagnoses on the POC included Unspecified Sequelae of Unspecified Cerebrovascular Disease, Dysphagia, Type 2 Diabetes, Chest Pain, and Malignant Neoplasm of Colon. SN [skilled nursing] services were ordered on this POC. SN visit frequency was 1 time per week for 1 week, 2 time per week for 2 weeks 1 time per week for 10 weeks and 4 prn [as needed] for symptom management. SN orders included "HOSPICE NURSE TO MONITOR PAIN LEVEL USING PAIN SCALE EACH VISIT AND REPORT CHANGES IN PAIN LEVEL TO PHYSICIAN ... Goals ... A NURSING PLAN OF CARE WILL BE ESTABLISHED THAT MEETS THE PATIENT'S NEEDS ..." Medications on the POC for the Certification Period 11/7/19 to 2/4/20 included Acetaminophen-Codeine 300-60 mg [milligrams] 1 tablet 3 times daily for pain with a start date of 10/28/19 and Morphine Concentrate 100 mg/5 ml [milliliters] (20 mg/ml) place 0.25 ml every 2 hours mouth/under tongue as needed for pain/shortness of breath with a start date of 11/7/19. Review of the "Client Medication Report" revealed on 11/29/19 Patient #1 started Fentanyl Transdermal 25 micrograms/hour apply to skin every 3 days [Narcotic patch used for severe pain]. Review of SN visit notes revealed the start of care visit [11/7/19] was conducted by the Case Manager, a RN [registered nurse/RN#1]. The Case Manager [RN#1] documented on 11/7/19, "WAS THE PATIENT SCREENED FOR PAIN ... YES ... THE PATIENT'S PAIN SEVERITY WAS ... SEVERE ... TOTAL SCORE (PAIN) ... 10.0 ... TOTAL SCORE (PATIENTS WITH A TOTAL SCORE OF 1-3 IS CONSIDERED TO BE MILD PAIN, 4-6 MODERATE PAIN AND 7-10 SEVERE PAIN) ... SEVERE PAIN ... WHAT RELIEVES PAIN (MARK ALL) ... MEDICATIONS ... INDICATE WHAT MAKES PAIN WORSE (MARK ALL THAT APPLY) ... ACTIVITY MOVEMENT, EXERCISE ... PROCEDURES OR TREATMENTS ... CERTAIN POSITIONS ... INDICATE EFFECTS OF THE PAIN ON QUALITY OF LIFE INDICATORS (MARK ALL THAT APPLY) ... ABILITY TO ENJOY ACTIVITIES/HOBBIES ... APPETITE ... EMOTIONS ... FUNCTIONAL STATUS ... MOBILITY. SN visits were conducted by the case manager [RN#1] for 6 of 7 visits between 11/7/19 to 11/29/19. Patient #1 reported the following pain levels: Pain level 8 on 11/12, Pain level 10 on 11/14, Pain level 9 on 11/18, Pain level 8 on 11/21, and Pain level 4 on 11/23/19. The patient's pain level was rated as a 10 on 11/29/19 at which time Fentanyl 25 mcg was initiated; and Acetaminophen-Codeine 300-60 mg 1 tablet 3 times daily was changed to Tylenol [same as Acetaminophen]-Codeine 300-30 mg every 4 hours as needed for pain. After Fentanyl was started on 11/29/19 Patient #1 continued with complaints of "Severe" pain from 12/2/19 to 1/27/20. The pain was rated "10" for 13 of 19 visits [12/2/19, 12/5, 12/11, 12/13, 12/16, 12/19, 12/23, 12/26, 12/31, 1/6, 1/15, 1/16, 1/20/20], rated "9" for 4 of 19 visits [12/9/19, 1/2, 1/13, 1/27/20] and rated "8" for 2 of 19 visits [1/9/20 and 1/22]. There was no evidence in the visit notes that the physician was notified of the patient's complaints of severe breakthrough pain and the possible need to adjust Fentanyl to better manage the patient's pain. The case manager [RN#1] conducted 17 of the 19 visits conducted between 12/2/19 to 2/3/20 and the licensed practical nurse [LPN#1] conducted 2 of the 19 visits [1/20 and 1/22/20]. LPN#1 documented on 1/20/20 "HOW WOULD YOU RATE YOUR PAIN AT PRESENT ... 10 ... HOW WOULD YOU RATE YOUR PAIN IN THE LAST 24 HOURS ... 8 ... WHAT IS YOUR ACCEPTABLE LEVEL OF PAIN ... 5 ... INDICATE FACTORS THAT ALLEVIATE THE ABDOMINAL PAIN (MARK ALL THAT APPLY) ... PRESCRIPTION PAIN MEDICATION ... INDICATE EFFECTS OF THE ABDOMINAL PAIN ON QUALITY OF LIFE INDICATORS (MARK ALL THAT APPLY) ... ABILITY TO ENJOY ACTIVITIES/HOBBIES ... SLEEP/REST DISTURBANCE ... INDICATE HOW OFTEN BREAKTHROUGH PAIN MEDICATION IS NEEDED FOR ABDOMINAL PAIN ... GREATER THAN 3 TIMES / DAY ... INDICATE GOAL RELATIVE TO PAIN (MARK ALL THAT APPLY) ... REDUCTION OF PAIN TO IMPROVE FUNCTIONAL ABILITY ... REDUCTION OF PAIN WHILE MAINTAINING MAXIMUM LEVEL OF CONSCIOUSNESS ... REDUCTION OF PAIN TO PROMOTE MAXIMUM COMFORT ... Narrative ... PT [patient] REPORTS PAIN 8/10 ABDOMINAL AND CHEST FROM RECENT INJURY WITH TRAPEZE ... PT REPORTS LITTLE EFFECT FROM FENTANYL PATCH ... PT USING MORPHINE CONCENTRATE Q2HRS [every 2 hours] AND TYLENOL 3 [Tylenol with Codeine] ... COMMUNICATED WITH ______ [Name of Director of Operation] REGARDING PT CONDITION ..." LPN#1 documented on the prn visit dated 1/22/20 "HOW WOULD YOU RATE YOUR PAIN AT PRESENT ... 8 ... HOW WOULD YOU RATE YOUR PAIN IN THE LAST 24 HOURS ... 8 ... WHAT IS YOUR ACCEPTABLE LEVEL OF PAIN ... 5 ... INDICATE FACTORS THAT ALLEVIATE THE ABDOMINAL PAIN (MARK ALL THAT APPLY) ... PRESCRIPTION PAIN MEDICATION ... INDICATE EFFECTS OF THE ABDOMINAL PAIN ON QUALITY OF LIFE INDICATORS (MARK ALL THAT APPLY) ... ABILITY TO ENJOY ACTIVITIES/HOBBIES ... SLEEP/REST DISTURBANCE ... INDICATE HOW OFTEN BREAKTHROUGH PAIN MEDICATION IS NEEDED FOR ABDOMINAL PAIN ... GREATER THAN 3 TIMES / DAY ... INDICATE GOAL RELATIVE TO PAIN (MARK ALL THAT APPLY) ... REDUCTION OF PAIN TO IMPROVE FUNCTIONAL ABILITY ... REDUCTION OF PAIN WHILE MAINTAINING MAXIMUM LEVEL OF CONSCIOUSNESS ... REDUCTION OF PAIN TO PROMOTE MAXIMUM COMFORT ... Narrative ... TACHYCARDIC [RAPID HEART RATE] AT 102 ... POOR PO [by mouth] INTAKE REPORTED BY PCG [patient caregiver] ... PRN FOR UNRESPONSIVENESS ... PT ALERT, RESPONSIVE, KNEW DATE ... PT LETHARGIC ... PT REPORTS PAIN ABDOMEN 8/10 ... PT REPORTS SOME NV [nausea and vomiting] LAST 24 HRS [hours] DIARRHEA EPISODE AS WELL ... INTERIM DOO [director of operations] ... TO CONTACT PCP [primary care provider] FOR NEW ANTIDIARRHEAL MEDICATION ... PATIENT LIVES WITH PARENTS ... THERE IS CONCERN PT PCG ABLE TO ADEQUATELY MANAGE PT CARE AND MEDICATIONS ... COMMUNICATED WITH ... DOO REGARDING PT CONDITION ..." Interview with the caregiver of Patient #1 conducted on 4/13/20 at 2:38 to 3:04 p.m. revealed, "They won't looking after her like they were supposed to ... She was in pain ... They were supposed to increase her morphine but they didn't ... _________ [Name of LPN#1] came in here one day [1/22/20] because we could not get her to respond ... when he got here ... he said she looked alright ... he called the company and said that she was alright ... He told my daughter she was putting on ... half the time they didn't come in here and look after her like they were supposed to." Interview with LPN#1 conducted 4/20/20 at 12:35 p.m. to 12:52 p.m. revealed, "No the doctor was not notified of the pain [1/20/20] ... The patient that I observed was not in distress ... Having not had seen her before I would have contacted the office and discussed it with the interim director [DOO] ... I sent an email at the end [end of visit 1/20/20] ... Based off her numerical numbers ... yes ... I should have contacted the doctor, but I must say that the patient I observed seemed to be very comfortable at a pain level of 10." The DOO was unavailable for interview. The Administrator from a different office was present during the interview with LPN#1. The Administrator searched the clinical record for evidence that the physician was notified of the patient's pain by the interim director on 1/20/20. The Administrator indicated during the interview "I don't see anything that she [interim director] notified the physician of the pain [pain reported by LPN#1 on 1/20/20] ..." The Administrator searched for evidence that the DOO notified the physician of need for change in antidiarrheal medication, tachycardia and complaints of severe abdominal pain of 8 [1/22/20]. The Administrator indicated, "There's not anything in the coordination notes that anyone contacted the physician on the 22nd [1/22/20] ... The next order I see is for the patient to be discharged on the 27th [1/27/20]." Interview with the case manager [RN#1] conducted on 4/20/20 at 1:20 p.m. revealed regarding visits conducted 1/2/20 and 1/27/20, "If I called, I would have called him [physician] from my car ... I don't take my phone in the house ... If I documented that Doctor ________ [Name of physician] was called, then I called ... I would have documented it ... if I didn't document it then I didn't call ... She always had the generalized pain ... Yes, I should have notified the physician of her pain, because pain is subjective not objective." Interview with LPN#1 conducted 4/20/20 at 3:32 p.m. revealed, "No I didn't [tell patient she was faking] ... I may have said to the DOO that I noted a discrepancy in what I was visualizing and what the patient had reported [1/22/20] ... the purpose of my visit was PRN for unresponsiveness." Interviews confirmed the agency failed to implement the patient's right to receive effective pain management in accordance with agency policy. Complaint Intake # NC00162957