Every finding on record at Interim Healthcare of Southeastern Colorado Inc

A complaint survey, based on complaint #CO2689778 was completed on 12/12/25. Three deficiencies were cited.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included all required services and supplies. Specifically, the agency did not include the patient’s feeding tube in the plan of care for 1 of 5 sample patients (Patient #4). Findings include: The clinical record for Patient #4 was reviewed on 12/11/25. Plan of care orders for the certification period dated 12/2/25 to 1/30/26 revealed a start of care date of 12/2/25; diagnoses included pressure ulcer of the left buttock, weakness, anemia, and heart failure. Plan of care orders included home health aide once per week for eight weeks for bathing and grooming, occupational therapy once per month for one month for evaluation, physical therapy twice a week for four weeks for balance and gait training, and skilled nursing three times a week for eight weeks for wound care and to assess nutrition measures. a) The agency failed to ensure Patient #4’s feeding tube, including maintenance, precautions, and feeding tube site care, was included in the plan of care. 1. The comprehensive assessment, dated 12/2/25, completed by a registered nurse upon start of care for Patient #4, stated the patient had a feeding tube. However, the plan of care, dated 12/2/25, created for Patient #4 based on the comprehensive assessment, did not include the feeding tube or any information regarding the maintenance, precautions, and site care for the feeding tube. 2. During an interview with the director of nursing (DON) at 9:29 a.m. on 12/12/25, the DON stated it had been an oversight to not include the feeding tube in Patient #4’s plan of care. The DON stated the information from the assessment regarding the feeding tube should have been transferred from the comprehensive assessment to the plan of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and record reviews, the agency failed to provide services and treatments only as ordered by a physician or allowed practitioner for 2 of 5 records reviewed (Patients #1 and #2). Findings Include 1. The clinical record for Patient #1 was reviewed on 12/11/25. The Plan of Care certification period dated 10/13/25 to 12/11/25 revealed a start of care date of 10/18/24; diagnosis included Alzheimer’s disease, Down syndrome, artificial openings of the gastrointestinal tract, and orders for a G-tube. The Plan of Care orders included skilled nurse (SN) visits five times a week for 24 hour supervision, aspiration precautions, equipment safety, fall precautions, and use of assistive devices. a) The agency failed to provide 24 hour supervision as ordered by the physician. Record review for Patient #1 revealed SN visits scheduled 12 hours five days a week, Monday through Friday. Record review failed to reveal documentation of 24 hour supervision per the plan of care orders signed by Patient #1’s primary physician on 10/15/25. During an interview conducted on 12/11/25 at 1:21 p.m., the Registered Nurse (RN) case manager stated Patient #1 was watched by care givers at a day program. Record review failed to reveal documentation of who provided supervision to Patient #1 while at the day program. b) The agency failed to obtain orders for protective mittens which were applied by SN to Patient #1. During a home visit conducted on 12/11/25, the state surveyor observed LPN #3 apply protective mittens to Patient #1. During an interview conducted at the home visit LPN #3 revealed Patient #1 would have mittens applied daily. LPN #3 stated the previous care plan included orders for mittens. At an interview completed at the home visit, Patient #1’s primary care giver stated SN applied mittens to Patient #1 daily. Record review failed to reveal orders for protective mittens for Patient #1. During an interview on 12/11/25 at 1:21 p.m., the RN case manager admitted SN applied mittens to Patient #1. Further interview revealed the RN case manager failed to ensure a physician’s order for the mittens was in Patient #1’s record. 2. The clinical record for Patient #2 was reviewed on 12/10/25. The Plan of Care certification period dated 10/13/25 to 12/11/25 revealed a start of care date of 10/18/24; diagnosis included cerebral palsy, gastro-esophageal reflux disease, and orders for a G-tube. The plan of care orders included SN visits five times a week for 23 hours of supervision per day, G/J-tube removal prevention at all hours of the day and night, and mandatory nursing accompaniment and monitoring during daily weekday program outings per terms of program enrollment. a) The agency failed to provide 23 hours of supervision as ordered by the physician. Record review for Patient #2 revealed SN visits scheduled 12 hours five days a week, Monday through Friday. Review of nursing notes failed to reveal who provided 23 hours of supervision outside of SN visits. During an interview on 12/11/25 at 11:29 a.m., the RN case manager stated Patients #1 and #2 had their allotted home health hours reduced. The RN case manager admitted current orders did not reflect the care provided for Patients #1 and #2.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an accurate and complete clinical record for 2 of 5 sample patients (Patient #1, #2). Findings include: 1. The clinical record for Patient #1 was reviewed on 12/11/25. Plan of care orders for the certification periods dated 8/14/25 to 10/12/25, 10/13/25 to 12/11/25, and 12/12/25 to 2/9/26 revealed a start of care date of 10/18/24; diagnoses included Alzheimer's disease, dementia, chronic obstructive pulmonary disease, and down syndrome. Plan of care orders included skilled nursing five times per week for 12 hours per day for 10 weeks to provide medication management, nutrition management, care of oxygen equipment, and safety measures. a) The agency failed to ensure Patient #1’s clinical record contained documentation of safety mitts applied for Patient #1. i) Review of Patient #1’s safety measures for the current certification period, dated 12/12/25, and the previous certification period, dated 10/13/25 revealed safety mitts were to be applied to prevent Patient #1 from removing his feeding tube. However, the clinical record did not contain documentation that the mitts were being applied for Patient #1 within the nursing visit notes. ii) During a home visit interview at 3:00 p.m. on 12/11/25, the consumer's caregiver and licensed practical nurse (Employee #5) stated although the mitts were being applied, they had not documented the application of the mitts in Patient #1’s record. b) The agency failed to ensure Patient #1’s clinical record contained documentation of rights modification for Patient #1. i) Review of Patient #1’s plan of care for the current certification period, dated 12/12/25, and the previous certification period, dated 10/13/25 revealed the agency had not placed the Rights Modification form for safety mitt use in Patient #1’s clinical record. ii) During an interview with the Director of Nursing (DON) and Registered Nurse (RN) Case Manager at 1:21 p.m. on 12/11/25, the RN Case Manager stated the Rights Modification form had been requested by the caregivers. The DON stated the agency would get the form from the caregivers and put the form in the file. When asked why they did not have the form, the RN Case Manager stated that they did not know they needed it or that it was a required document that needed to be in the consumers record. iii) The Rights Modification form was provided by the agency and reviewed at approximately 4:00 p.m. on 12/11/25. 2. The clinical record for Patient #2 was reviewed on 12/11/25. Plan of care orders for the certification periods dated 10/13/25 to 12/11/25, and 12/12/25 to 2/9/26, revealed a start of care date of 10/18/24; diagnoses included cerebral palsy, obstructive sleep apnea, and gastro-esophageal reflux. Plan of care orders included skilled nursing five times per week for 12 hours per day for 10 weeks to provide medication management, nutrition management, care of oxygen equipment, and safety measures. a) The agency failed to ensure Patient #2’s clinical record contained documentation of the safety mitts applied for Patient #2. i) Review of Patient #2’s plan of care for the current certification period, dated 12/12/25, and the previous certification period, dated 10/8/25 revealed safety mitts were to be applied to prevent Patient #2 from removing his feeding tube. However, the clinical record did not contain documentation that the mitts were being applied for Patient #2. ii) During a home visit interview at 3:00 p.m. on 12/11/25, the patient's caregiver and licensed practical nurse (Employee #5) stated although the mitts were being applied, they had not documented the application of the mitts in Patient #2’s record. b) The agency failed to ensure Patient #2’s clinical record contained documentation of rights modification for Patient #2. i) Review of Patient #2’s plan of care for the current certification period, dated 12/12/25, and the previous certification period, dated 10/8/25 revealed the agency had not placed the Rights Modification form for safety mitt use in Patient #2’s clinical record. ii) During an interview with the administrator at 9:40 a.m. on 12/12/25, the administrator stated the Rights Modification form had been obtained by the caregivers/family but the agency had not placed it into the clinical record. The administrator stated the agency would get the form from the caregivers. iii) The Rights Modification form was provided by the agency and reviewed at approximately 10:10 a.m. on 12/12/25.

A recertification survey was completed on 9/15/22. One deficiency was cited.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the registered nurse (RN) conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician ordered start of care date, for 5 of 12 active clinical records reviewed (Patients #4, #7, #9, #10 and #12). Findings include: AGENCY POLICY According to the policy, "Initial Comprehensive Assessment," dated 4/2/21, in part: "An initial comprehensive assessment of an individual is conducted within 48 HOURS of referral for home care/service(s), or within 48 HOURS of the individual's return home, or on the physician's pr practitioner's (e.g. [for example] NP [Nurse Practitioner], PA [Physician's Assistant], CNS [Clinical Nurse Specialist] ordered start of care date. 1. During an interview on 9/12/22 at 9:58 a.m., the administrator stated the agency typically received referrals for services from hospitals, skilled nursing facilities, physician offices and individual patients via an electronic portal. She stated once the referral was received, the appropriate clinicians would review the referral to determine if the patient was appropriate to receive services from the agency and then the agency would let the referral source know when the agency would be able to staff the patient and inquire if the date was acceptable to the referral source. 2. The clinical record for Patient #10 was reviewed on 9/14/22. The plan of care for the certification periods dated 6/3/22 to 8/1/22 and 8/2/22 to 9/30/22 revealed a start of care date of 6/3/22; diagnoses included type 2 diabetes, chronic respiratory failure, hyperlipidemia, malignant neoplasm of cecum, history of falling, dependence on supplemental oxygen, nicotine dependence and long term current use of hypoglycemic drugs and insulin. Plan of care orders included skilled nurse (SN) visits once weekly for medication box refill. a) The agency failed to start services for Patient #10 within 48 hours of the referral. Review of the referral received on 5/3/22 from a skilled nursing facility, revealed Patient #10 was ordered to have an evaluation for SN and certified nurse aide (CNA) services. The referral failed to reveal a frequency or specific needs. Review of a document titled "Client Order" showed the agency accepted Patient #10 for care and services on 5/2/22 for start of care (SOC) on 5/6/22 as the patient would be discharged from his current facility on 5/5/22. However, review of the SOC Assessment, dated 6/3/22, completed by registered nurse (RN) #8 revealed Patient #10 started services on 6/3/22, 29 days following Patient #10's expected discharge home and 31 days after acceptance of the referral. Further review of the record failed to show the patient's physician was aware of the delay in the initiation of services or that the physician had approved the delay. 3. The clinical record for Patient #7 was reviewed on 9/13/22. The plan of care for the certification period dated 9/7/22 to 11/5//22 revealed a start of care date of 9/7/22; diagnoses included streptococcal arthritis of left knee, weakness, unsteadiness on feet, hypertension, type 2 diabetes, history of falling, long term and current use of hypoglycemic drugs and insulin and presence of an insulin pump. Plan of care orders included physical therapy (PT) visits once weekly for one week then twice weekly for three weeks and occupational therapy (OT) once weekly for three weeks. a) The agency failed to start services for Patient #7 within 48 hours of the referral. Review of the referral received on 8/24/22 from a physician's office, revealed Patient #7 was ordered to have SN services. The referral failed to reveal a frequency or specific needs. Review of an untitled document showed the agency notified the referral source of the agency's acceptance of Patient #7 for care and services on 8/25/22. However, review of the SOC Assessment, dated 9/7/22, completed by physical therapist (PT) #9 revealed Patient #7 started services on 9/7/22, 13 days after acceptance of the referral. Further review of the record failed to show the patient's physician was aware of the delay in the initiation of services or that the physician had approved the delay. 4. The clinical record for Patient #12 was reviewed on 9/14/22. The plan of care for the certification period dated 6/29/22 to 8/27/22 revealed a start of care date of 6/29/22; diagnoses included encounter for adjustment and management of a vascular access device, Ehlers-Danlos syndrome, cardiac arrhythmia, gastroparesis, chronic pain, anxiety, migraines and history of falling. Plan of care orders included SN visits once weekly for peripherally inserted central catheter (PICC) line dressing changes. a) The agency failed to start services for Patient #12 within 48 hours of the referral. Review of the referral received on 8/17/22 from a physician's office, revealed Patient #12 was ordered to have weekly and as needed (PRN) dressing changes as the patient was having a port placed on 8/8/22. The order failed to show specific dressing change orders. Review of the "Client Order" showed the agency accepted Patient #12 for care and services on 8/17/22 for SOC on 8/26/22. Review of the SOC Assessment, dated 8/26/22, completed by RN #10 revealed Patient #12 started services on 8/26/22, nine days after acceptance of the referral. However, further review of the record failed to show the patient's physician was aware of the delay in the initiation of services or that the physician had approved the delay. 5. Similar findings of delayed initiation of care and services of four days following receipt and acceptance of the patient referral was found for Patient #4 and seven days following receipt and acceptance of the patient referral for Patient #9. 6. During an interview on 9/15/22 at 10:10 a.m., the administrator reviewed the referral information for Patient's #4, #7, #9, #10 and #12 and confirmed the initiation of services occurred later than 48 hours after the agency received the referral and accepted the patients for care and services. She stated she believed the process the agency was following to notify the referral sources of the anticipated SOC was acceptable, but acknowledged there was no evidence to show the patient's physician was aware of the delay in care. She further confirmed there were no physician orders approving the delay in the initiation of services for patients. The administrator stated going forward, the agency would be educating the clinicians to document the delayed SOC verbal order on the plan of care so that it could then be countersigned by the physician timely.

A complaint survey, prompted by #CO27354, was completed on 7/7/21. Two deficiencies were cited.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure nursing staff promptly alerted the physician of changes in the patient's condition that suggested a need to alter the plan of care for 1 of 1 patients whose record was reviewed and who received intravenous (IV) therapy (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 7/6/21. The Plan of Care for the certification period dated 5/19/21 to 7/17/21 revealed a start of care date of 5/19/21; diagnosis included Diamond Blackfan anemia, Crohn's disease, epilepsy and hip dysplasia. a) Clinical record review revealed the agency nursing staff failed to notify patient #1's physician that medication infusion did not occur, thereby affording the physician the opportunity to alter the patient's plan of care. Review of physician orders revealed ferrlecit infusion and complete blood count (CBC) weekly for four weeks. Review of the initial assessment dated 5/19/21 and electronically signed by nurse #2 on 5/21/21 revealed no documentation of ferrlecit infusion as ordered by the physician. In an interview on 7/6/21 at approximately 8:45 a.m. the mother of patient #1 reported on 5/19/21 she observed nurse #2 unsuccessfully attempt IV access six times on patient #1. The mother of patient #1 reported the patient did not receive the ferrlecit infusion and there was no clear plan to provide infusion services for going forward. The mother of patient #1 reported that patient #1 hemoglobin and hematocrit drop to low levels without regular ferrlecit infusions. Low levels of hemoglobin and hematocrit result in fatigue and shortness of breath for patient #1. The mother of patient #1 reported that she requested discharge from the agency on 5/21/21 to resume infusions at the physician's office. In an interview on 7/6/21 at approximately 2:35 p.m., the agency Director of Healthcare Services (DHS) reported on 5/21/21 the physician's representative for patient #1 called the agency to report patient #1's mother reported the patient had not received the ferrlecit infusion. The DHS acknowledged there was no documentation nurse #2 contacted the physician to report the ferrlecit infusion was not completed. In addition, the DHS confirmed there was no documentation of attempted IV access on 5/19/21. In the same interview, the DHS acknowledged that nurse #2 confirmed IV access was not obtained during the 5/19/21 nursing visit and patient #1 did not receive the ordered medication infusion.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure all nursing interventions, treatments and services provided to patients were accurately documented and included within the clinical record for 1 of 1 patient records reviewed receiving intravenous (IV) therapy (Patient #1). Findings include: AGENCY POLICY According to the agency policy, "Contents of the Patient/Client Record", dated 4/2/21 (in pertinent part): " The following information is included in each patient/client record when applicable to the care/service the patient/client is receiving. 2.(l.) All interventions, including treatments, and services and responses to those interventions." 1. The clinical record for Patient #1 was reviewed on 7/6/21. The Plan of Care for the certification period dated 5/19/21 to 7/17/21 revealed a start of care date of 5/19/21; diagnosis included Diamond Blackfan anemia, Crohn's disease, epilepsy and hip dysplasia. a) The agency failed to ensure clinical interventions and treatments provided to patient #1 were accurately documented within the clinical record. Review of physician orders revealed ferrlecit infusion and complete blood count (CBC) lab draw weekly for four weeks. Review of the comprehensive assessment dated 5/19/21 and electronically signed by nurse #2 on 5/21/21 revealed no documentation of ferrlecit infusion as ordered by the physician. In an interview on 7/6/21 at approximately 8:45 a.m. the mother of patient #1 reported on 5/19/21 she observed nurse #2 unsuccessfully attempt IV access six times on patient #1. The mother of patient #1 reported the patient did not receive the ferrlecit infusion and there was no clear plan to provide IV infusion services going forward. The mother of patient #1 reported that patient #1 hemoglobin and hematocrit drop to low levels without regular ferrlecit infusions. Low levels of hemoglobin and hematocrit result in fatigue and shortness of breath for patient #1. The mother of patient #1 reported that she requested discharge from the agency on 5/21/21 to resume infusions at the physician's office. In an interview on 7/6/21 at approximately 2:35 p.m, the agency Director of Healthcare Services (DHS) reported on 5/21/21 the physician's representative for patient #1 called the agency to report patient #1's mother reported the patient had not received the ferrlecit infusion. The DHS acknowledged there was no documentation nurse #2 contacted the physician to report the ferrlecit infusion was not completed. In addition, the DHS confirmed there was no documentation of attempted IV access on 5/19/21. In the same interview, the DHS acknowledged that nurse #2 confirmed IV access was not obtained during the 5/19/21 nursing visit and patient #1 did not receive the ordered medication infusion.