Cape Fear Valley Hospice and Palliative Care

“Based on agency policy, clinical record review, and staff interviews, the Medical Social Worker (MSW) failed to notify the registered nurse of a patients report of pain for 1 of 16 patients receiving MSW visits (#8).Findings included: A policy, Pain Assessment (revised 11/1/17) received on 7/6/26 at 12:23 PM from the volunteer coordinator stated, “All patients have the right to have their pain assessed and measures taken to reduce pain.”Findings included:Patient #8 was admitted on 6/4/26 with a diagnosis of atherosclerotic heart disease of the native coronary artery without angina pectoris (plaque build up in arteries without pain). The plan of care for 6/14/26-9/1/26 included orders for medical social worker (MSW) visits 1 time a month for 3 months with 3 PRN (as needed). Review of the clinical record revealed that on 6/5/26 MSW #13 documented, “PT [patient] reports that she can not sleep through the night due to pain…” Further review revealed that there was no documentation of the registered nurse being notified of the patients report of pain.An interview conducted on 7/8/26 at 11:40 AM with MSW #13 revealed that the registered nurse was not notified.An interview conducted on 7/8/26 at approximately 12:00 PM with the Executive Director revealed that the expectation is for unmanaged symptoms to be reported to the nurse.”

“Based on agency policy, clinical record review, and staff interviews, the registered nurse failed to document if the home hospice aide (HHA) was following the plan of care, if the patient/family was satisfied with the care provided by the HHA, if the aide was following infection control guidelines, or if the aide was reporting changes of condition during supervisory visits for 4 of 11 patients with orders for HHA visits (#4, 6, 9, & 14).Findings included: A policy, Hospice Aide Supervision (revised 11/1/22). Received on 7/8/26 at 10:05 from the Executive Director stated, “The Registered Nurse will supervise the Hospice Aides according to specific State guidelines and Federal Regulations Conditions of Participation… At least every 14 days…”Federal Condition of Participation §418.76(h)(3) stated, “The supervising nurse must assess an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to– i. Following the patient’s plan of care for completion of tasks assigned to the hospice aide by the registered nurse; ii. Creating successful interpersonal relationships with the patient and family; iii. Demonstrating competency with assigned tasks; iv. Complying with infection control policies and procedures; v. Reporting changes in the patient’s condition…”1. Patient #4 was admitted 6/1/26 with a diagnosis of malignant neoplasm (cancer) of the prostate. The plan of care for 6/1/26-8/5/26 included orders for SN visits 2 times a week for 10 weeks with 3 PRN (as needed) and HHA visits 2 times a week for 9 weeks and 1 time a week for 1 week. Review of the clinical record revealed that RN #6 documented HHA supervisory visits on 6/10/26, 6/15/26, 6/18/26, 6/15/26,6/18/26, 6/22/26, and 6/29/26 that stated, “NOT OBSERVED” for the following: “DOES THE HOSPICE AIDE REPORT ABNORMAL FINDINGS TO APPREATE STAFF” “DOES THE HOSPICE AIDE OBSERVED STANDARD PRECAUTIONS…?” “IS THE PATIENT/FAMILY PLEASE WITH CARE PROVIDED?” 2. Patient #6 was admitted on 5/26/26 with a diagnosis of Pick’s Disease (abnormal buildup of protein in the brain). The plan of care for 6/9/26-8/7/26 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 8 weeks with 6 PRN (as needed) and home hospice aide (HHA) visits 2 times a week for 1 week and 3 times a week for 8 weeks. Review of the clinical record revealed that registered nurse (RN) #6 documented weekly supervisory visits on 6/11/26, 6/17/26, 6/25/26, and 7/2/26 that stated, “NOT OBSERVED” for the following: “DOES THE HOSPICE AIDE REPORT ABNORMAL FINDINGS TO APPREATE STAFF” “DOES THE HOSPICE AIDE OBSERVED STANDARD PRECAUTIONS…?” “IS THE PATIENT/FAMILY PLEASE WITH CARE PROVIDED?”3. Patient #9 was admitted on 8/1/25 with a diagnosis of senile degeneration of the brain. The plan of care for 6/17/26-8/15/26 included orders for skilled nurse visits 1 every other week for 2 weeks, 1 time a week for 7 weeks with 3 PRN (as needed) and home hospice aide (HHA) visits 2 times a week for 1 week and 3 times a week for 8 weeks. Review of the clinical record revealed that registered nurse (RN) #6 documented supervisory visits on 6/17/26 and 6/23/26 that stated, “NOT OBSERVED” for the following: “DOES THE HOSPICE AIDE REPORT ABNORMAL FINDINGS TO APPREATE STAFF” “DOES THE HOSPICE AIDE OBSERVED STANDARD PRECAUTIONS…?” “IS THE PATIENT/FAMILY PLEASE WITH CARE PROVIDED?”4. Patient #14 was admitted on 3/3/26 with a diagnosis of amyotrophic lateral sclerosis (progressive degenerative disease affecting the brain and spinal cord). The plan of care for 6/1/26-8/29/26 included orders for skilled nurse visits 2 times a week for 13 weeks with 3 PRN (as needed) and home hospice aide (HHA) visits 2 times a week for 13 weeks. Review of the clinical record revealed that registered nurse (RN) #6 documented supervisory visits on 6/1/26, 6/4/26, 6/10/26, and 6/12/26 that stated, “NOT OBSERVED” for the following: “DOES THE HOSPICE AIDE REPORT ABNORMAL FINDINGS TO APPREATE STAFF” “DOES THE HOSPICE AIDE OBSERVED STANDARD PRECAUTIONS…?” “IS THE PATIENT/FAMILY PLEASE WITH CARE PROVIDED?”During an interview conducted on 7/8/26 at 12:00 PM RN #6 stated, “I thought that the aide had to physically be there during my visits to document it. On Monday of this week, I educated on supervisory visits.”An interview conducted on 7/8/26 at approximately 12:15 AM with the Executive Director revealed that the expectation is for the registered nurses to interview the patient/family to document the assigned supervisory task.”

“Based on agency policy, clinical record review, and staff interviews, the registered nurses failed to include a discharge summary for 2 of 2 patients with live discharges (#16 & 17).Findings included: A policy, Hospice Medical Record (revised 10/01/24) received on 7/6/26 at 12:23 PM from the volunteer manager stated, “The hospice medical record shall contain the following clinical information… Transfer/Discharge summaries.”1. Patient #16 was admitted on 5/12/26 with a diagnosis of hypertensive heart disease without heart failure (heart damage from long term unmanaged high blood pressure), The plan of care for 5/12/26-8/9/26 included orders for skilled nurse visits 2 times a week for 13 weeks with 3 PRN (as needed). Review of the clinical record revealed that on 5/15/26 registered nurse #6 documented a live discharge due to a patient revocation (patient voluntary discharge from hospice). Further review revealed that there was no discharge summary documented.2. Patient #17 admitted on 8/25/25 with a diagnosis of cerebral infarction (lack of oxygen in the brain from a blood clot). The plan of care for 4/11/26-6/9/26 included orders for skilled nurse visit 1 every other week for 2 weeks, 1 time a week for 7 weeks, with 3 PRN and discharge for extended prognosis. Review of the clinical record revealed that on 6/10/26 registered nurse #1 documented a live discharge due to the patient no longer qualifying for hospice. Further review revealed that there was no discharge summary documented.During an interview conducted on 7/8/26 at 10:19 AM the Executive Director stated, “The discharging nurse needs to put in a discharge summary the day of the discharge.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to document coordination of care for 2 of 3 patients. (Patient’s #1 and 2.)Findings included: A policy, Hospice Medical Record (revised 10/01/2024) received on 04/08/2025 at 2:20 PM from the executive director stated, “The hospice medical record shall contain the following information: … Documentation and communication with the patient, caregiver, and physicians.”A policy, Plan of Care (revised 10/01/2024) received on 04/08/2025 at 2:20 PM stated, “The plan of care must include… Coordination of Care.”Patient #1 was admitted on 09/27/2022 with a diagnosis of Alzheimer’s Disease (progressive disorder that affects memory and behavior). The plan of care (POC) for 03/15/2025-05/13/2025 included orders for skilled nurse (SN) visits 2 every 2 weeks for 2 weeks, 2 times a week for 7 weeks, and 3 PRN (as needed). Review of the clinical record revealed that on 03/28/2025 RN #6 documented, “Urine smelly with lots of SEDK,ENT [sic], low grade fever [98.2]. 5 day antibiotic ordered…” Further review revealed that there was no documentation of RN #6 contacting the physician.During an interview conducted on 04/08/2025 at 1:28 PM RN #6 stated, “I usually say [in the clinical record] that I reached out and got approval [from a physician].” Patient #2 was admitted on 02/26/2025 with a diagnosis of Malignant Neoplasm of Head of Pancreas (pancreatic cancer). The plan of care for 02/26/2025-05/26/2025 included orders for skilled nurse (SN) visits 2 times a week for 13 weeks with 3 PRN (as needed), MSW visits 1 time a month for 4 months, and volunteer visits 1 time a month for 1 month. Review of the clinical record revealed that on 03/13/2025 the volunteer coordinator documented, “Patient was experiencing an increase in pain during visit. Writer called the patients [sic] case manager [registered nurse (RN) #5’s name] and asked that [RN #5’s name] direct her [caregiver] in interventions to try.” Further review revealed no documentation of RN #5 educating the patient/caregiver on pain management. Further review revealed that on 04/03/2025 Medical Social Worker (MSW) #7 documented, “Not a good day for patient as patient was experiencing dizziness… Patient reports ealier [sic] that morning he thought he saw spiders in the bed…” There was no documentation in the clinical record of the nurse case manager being notified of a change of condition.An interview conducted on 04/08/2025 at 1:24 PM with the volunteer coordinator revealed that RN#5 was notified by telephone during the visit and RN #5 spoke with the caregiver during the call.During an interview conducted on 04/08/2025 at 2:17 PM RN #5 stated, “I did speak with the family about pain and normally I would document it.”During an interview conducted on 04/08/2025 at 1:45 PM MSW #7 stated, “I don’t think that I did notify the case manager.”An interview on 04/08/2025 at 1:31 PM with the executive director revealed that care coordination should be documented in the clinical record.During an interview conducted on 04/08/2025 at 1:52 PM the patient care manager stated, “I would recommend them [MSW] to call the case manager or the patient care manager.”An interview on 04/08/2025 at approximately 2:20 PM revealed that the expectation is to document all communications.”

“Based on agency policy review, clinical record review, staff and caregiver interview, failed to coordinate the discharge plan of care with the patient/caregiver for 1 of 3 live discharge records reviewed. (Patient #2) Findings included: Patient Rights and Responsibilities were received from the agency director on 10/21/24 at 3:42 PM and revealed, “;A patient has the right to...be advised of the agencys procedures for discharge... receive information about the scope of services that hospice will provide and specific limitation on those services...” Policy 2.007, titled “;Live Discharge/Transfer of the Hospice Patient” was received from the agency director on 10/21/24 at 11:35 AM. This policy revealed, “;If a patient has elected to enter a non-contracted facility a discharge from hospice services is not automatically required. The hospice agency must consider the amount of time that the patient is anticipated to remain in the facility as well as the effect on the hospice plan of care. If there is little impact on the hospice plan of care, discharge from hospice service could be deemed inappropriate and a violation of the patient rights.” Patient #2 was admitted to the agency on 06/03/24 with a principal hospice diagnosis of Alzheimers disease. The Plan of Care from 06/03/24 to 08/31/24 revealed orders for skilled nursing three times per week for 13 weeks, medical social work one time per month for one month, home health aide two times per week for 13 weeks, chaplain one time per month for one month, and volunteer one time per month for one month. Patient #2 was treated with antibiotics, steroids and antihistamines (allergy medicine) for low grade fever and respiratory symptoms intermittently throughout the 44 days that she received hospice services and on 07/16/24 her daughter/responsible party took her to the hospital because of the ongoing symptoms. The agency discharged Patient #2 on 07/16/24 due to the patient going to a hospital where the agency was not contracted to provide services. There was no documented evidence that the patient/responsible party were educated about options for hospitalization and treatment at non-contracted facilities or evidence that the agency attempted any alternative methods to avoid discharging the patient. In an interview on 10/21/24 at 3:12 PM, Employee #1, agency director, stated that Patient #2s responsible party “;kept taking her to different hospitals and went to [name of the non-contracted hospital] without contacting us...I asked the nurses to [educate the responsible party about options for hospitalization and treatment at non-contracted facilities] but Im not sure if that was followed up on...” The agency nurses who visited Patient #2 were not available for interview at the time of survey.”