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 ______________ 		12/03/2020
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)
L0557      
37615 Based on policy review, clinical record review, and staff interview, the agency failed to update the physician with changes in wounds for 1 of 1 patient with wounds (#3); and failed to notify the physician of non-compliance with wound orders for 1 of 1 patient with wounds (#3). Finding include: A policy, "Provision of Care and Record Management", was provided by the Regional Director of Clinical Operations on 12/2/20 at 4:40 p.m. The policy stated, "The hospice nurse will ...Assure communication and integration between the hospice and other non-hospice health care providers involved in the patient's care, documenting such in the medical record." 1A. Patient #3 was admitted on 11/27/19 with a diagnosis of Alzheimer's disease. The initial assessment was conducted on 11/27/20 by RN #1. The RN identified a stage 2 pressure ulcer (an open shallow ulcer with a red/pink wound bed) on the sacral area measuring 3 cm x3.5 cm x1 cm. The documentation also stated there was 75-100% yellow necrosis (dead tissue) on the wound. The Plan of Care for 11/27/19-1/20/20 included orders for skilled nursing visits weekly for 9 weeks and 4 as needed for change in status. Weekly visits were continued for the entire time Patient # 3 received home health services. On 12/9/19, RN #1 conducted a visit and the wound measured 4 X 4 X 1.5 cm with soft black eschar (dead tissue, usually black, brown, or tan in color). There was no evidence that the physician was notified of the increase in wound size or eschar. On 1/2/20, the physician visited the patient with the nurse. The wound measured 5x5x4.cm No undermining noted. On 1/7/20, RN #1 visited the patient. The sacral wound measured 5 X 6 X 4 with 2 cm undermining (tissue under the wound edges erode) at 12:00-3:00, 3:00-6:00, 6:00-9:00, and 9:00-12:00 positions. There was no evidence the physician was notified of the newly documented undermining. A nurse visit was conducted on 1/14/20. The wound was not assessed on this visit because the caregiver had already performed the wound care. On 1/20/20, RN #1 visit note revealed wound measured 7x7x5 with no undermining. The wound was not assessed on the 1/28/20 skilled nurse visit. RN #1 visited on 2/3/20 and wound measurements were 7.5x5x6 with undermining as follows: 6 cm from 12:00-3:00 position 3 cm from 3:00-6:00, 8 cm from 6:00-9:00, and 2 cm from 9:00-12:00. There was no evidence the physician was notified of the increased undermining of the wound. On 3/4/20, RN #1 documented "SACRAL DUCUB [decubitus] INCREASING IN SIZE [sic]." On 3/25/20, RN #1 visited. The wound measured 11x8x8. There was no evidence the physician was notified of the increase in depth. The physician made a visit on 4/1/20 and assessed the wound. An interview was conducted with RN #1 on 12/3/20 at 11:10 a.m. The RN confirmed there was no documentation the physician was updated on the changes in the wound. . 1B. Patient #3 was admitted on 11/27/19 with a diagnosis of Alzheimer's disease. The initial assessment was conducted on 11/27/20 by RN #1. The RN identified a stage 2 pressure ulcer on the sacral area measuring 3x3.5x1. The documentation also stated there was 75-100% yellow necrosis on the wound. The Plan of Care for 11/27/19-1/20/20 included orders for skilled nursing visits weekly for 9 weeks and 4 as needed for change in status. Weekly visits were continued for the entire time Patient #3 received home health services. The coordination note on 12/18/20 by LPN #2 stated, "PT [patient] CONT [continues] WITH SACRAL WOUND. DRSG [dressing] CHANGES PROVIDED BY PT DAUGHTER IN LAW OR GRANDSON ON DAYS HOSPICE DOES NOT PERFORM ...NONCOMPLIANT WITH CURRENT TX [treatment] ORDER." On 12/24/20, RN #1 documented, "FAMILY CONTINUES TO ASK FOR WOUND SUPPLIES DAILY DESPITE EDUCATION THAT ONLY A CERTAIN AMOUMT CAN BE ORDERED EACH TIME." On 1/2/20, LPN #2 documented, "PT CONT WITH SACRAL WOUND. WET TO DRY DRSG CHANGES PROVIDED BY PT DAUGHTER IN LAW OR GRANDSON, __________ (name), ON DAYS HOSPICE DOES NOT PERFORM. WOUND CARE PROVIDED; NONCOMPLIANT WITH CURRENT WOUND TX." An interview was conducted with RN #1 on 12/3/20 at 11:10 a.m. The RN stated the grandson would order wound care supplies online and apply what he wanted, not necessarily what was ordered. RN #1 stated this was discussed in IDT but confirmed there was no evidence this was discussed with the physician.