Every finding on record at Colorado Family Caregivers Home Health LLC

A complaint survey, prompted by #CO2593027, was completed on 12/9/25. One deficiency was cited.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient's needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the home health nurse made an onsite, in person visit every 60 days to assess the quality of care and to ensure services met the patient’s needs. Specifically, the agency failed to ensure supervisory visits were completed onsite for 1 of 4 sample patients who received home health aide services as the only ordered home health service (Patient #2). Findings include: 1. The clinical record for Patient #2 was reviewed on 12/8/25. Plan of care orders for the certification period dated 10/15/2025 to 12/13/2025 revealed a start of care date of 8/21/24; diagnoses included cerebral palsy and localization-related symptomatic epilepsy. Plan of care orders included certified nurse aide services 12 hours per day for 60 days for bathing, feeding, and activities of daily living. Review of Patient #2’s comprehensive assessment completed for the most recent 60-day recertification period, dated 10/10/25, revealed the assessment and concurrent supervisory visit by a registered nurse had been completed in the community room of the apartment complex where Patient #2 resides instead of in the home of the patient. The Home Safety Evaluation portion of the assessment was marked “not applicable” because the registered nurse was not able to evaluate the home to assess home safety. Further review of the medical record revealed the supervisory visits completed at each 60-day recertification on 10/18/24, 12/16/24, 2/13/25, 4/14/25, 6/12/25, and 8/11/25 had also been completed in the community room of the apartment complex. During an interview with the director of nursing (DON) at 10:24 a.m. on 12/9/25, the DON stated she had regarded the supervisory visits as acceptable due to the visits having been completed in a private section of the apartment complex’s community room. Additionally, the DON stated she had regarded the supervisory visits as acceptable because each plan of care for Patient #2 (with information regarding the location of the visits) was signed by Patient #2’s primary care physician. During an interview with the administrator at 1:05 p.m. on 12/9/25, the administrator stated he had not known the regulations were as specific as they were and believed it would be an "easy fix" to ensure all supervisory visits were completed at the home of the patient.