Every finding on record at Nursing and Therapy Services of Colorado Inc

A recertification survey was completed on 12/10/25. One deficiency was cited.

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide the physical therapist assistant (PTA) supervision per the HHA policy in 1 of 1 PTA record reviewed (Employee #5) . Findings include: AGENCY POLICY According to the agency policy titled "Therapy Services- Therapy Assistants" dated May 3, 2024 read in pertinent parts: "Supervision; the qualified therapist will supervise the assistant on duty with the cline in their assigned setting (home or clinic) every 14 days to ensure compliance with the written 485/Plan of Care and that the client's needs are being met." 1. On 12/10/25 a review of the PTA's personnel file revealed a hire date of 8/1/22. a. The agency failed to supervise the PTA according to the HHA policy. Review of the agency's policies revealed the following; "Supervision; the qualified therapist will supervise the assistant on duty with the client in their assigned setting (home or clinic) every 14 days to ensure compliance with the written 485/Plan of Care and that the client's needs are being met." Per the agency policy the PTA was to be supervised every 14 days. Review of PTA's personnel record failed to reveal a supervisory visit. There was no documentation revealed regarding a completed supervisory visit on the PTA including patient's response to the PTA's treatments. During an interview on 12/9/25 at 4:30 p.m., the PTA stated he had never had a formal supervisory visit, instead just speaking to the director of rehabilitation at the office. The PTA also stated he did not believe these conversations were documented or recorded. The PTA also stated there was no regular supervisory schedule. During an interview on 12/9/25 at 12:47 p.m., the director of rehabilitation stated PTA supervision was not being completed as per the home health agencies HHA policy which stated it needed to be completed every 14 days. The director of rehabilitation also stated he did not know who created the policy and he was not aware it existed.

A survey, prompted by #CO94403 and #CO94406, was completed on 12/7/22. Deficiencies were cited.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide home health services pursuant to the physician ordered individualized plans of care for 1 of 3 patient records reviewed (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 12/5/22. The plan of care (POC) for the certification period dated 7/5/22 to 9/2/22, revealed a start of care date of 7/5/22; diagnoses included weakness, bed confinement, chronic pain and osteoarthritis. POC orders included skilled nurse (SN) visits once every 60 days for recertification comprehensive assessment and certified nurse aide (CNA) supervision, as well as CNA visits, 6.5 hours per day, 7 days per week with tasks that included skilled patient transfers utilizing a mechanical hoyer lift, assistance with mobility exercises, activities of daily living (ADLs), personal hygiene and elimination needs. Review of Patient #1’s subsequent POCs for the certification periods dated 9/3/22 to 11/1/22 and 11/2/22 to 12/31/22 also showed orders for SN visits once every 60 days for recertification comprehensive assessments and CNA supervision, as well as CNA visits, 6.5 hours per day, 7 days per week with tasks that included assistance with mobility exercises, ADLs, personal hygiene and elimination needs, however the use of the mechanical hoyer lift had been discontinued. a) The agency failed to ensure Patient #1 received 6.5 hours per day, seven days per week of CNA services as ordered by the physician per the POC. Review revealed the agency failed to have the staffing availability to provide the ordered services and in doing so, the agency failed to meet Patient #1's individualized needs. Record review revealed Patient #1 was a patient with the agency for a period of four months beginning at the start of care on 7/5/22 and was discharged from the agency on 11/7/22. During the four months, the agency failed to provide the 6.5 hours per day of CNA services on 30 separate occasions, as ordered per the POC, with dates that included, 7/9/22, 7/10/22, 7/16/22, 7/17/22, 7/23/22, 7/24/22, 8/31/22, 9/1/22, 9/3/22, 9/4/22, 9/10/22, 9/11/22, 9/12/22, 9/15/22, 9/16/22, 9/24/22, 9/25/22, 10/1/22, 10/2/22, 10/8/22, 10/9/22, 10/15/22, 10/16/22, 10/22/22, 10/23/22, 10/29/22, 10/30/22, 11/1/22, 11/5/22 and 11/6/22. Review of missed visit documentation completed by agency staff for each of the 30 days that had been missed, showed the agency was unable to provide the CNA services because CNA coverage was unavailable due to a staffing shortage. During an interview on 12/5/22 at 8:00 a.m., Patient #1 stated the agency always had a difficult time maintaining consistent CNA coverage and had always been told the agency did not have any other staff available to provide the CNA services. Patient #1 further stated she had been confined to her bed for the past several months and would have never declined any additional agency staff assigned to assist the patient because she had minimal access to any other caregivers outside of agency staff that could provide any additional assistance. During an interview on 12/5/22 at 11:25 a.m., the agency administrator and alternate administrator both stated in the event a CNA was unavailable to complete their assigned shift, it was agency standard operating procedure to utilize their as needed CNA employees to complete the assigned shift. If a CNA was unavailable, agency leadership would assign a SN to complete the assigned CNA tasks. During an interview on 12/6/22 at 10:40 a.m., the Director of Clinical Services (DCS) stated it was her overall responsibility to ensure CNA coverage in the event a CNA was unavailable to complete their assigned shift and was unaware of the agency's standard operating procedure to assign a SN to complete the assigned CNAs tasks if agency CNAs were unavailable. The DCS further stated the agency had secured the appropriate CNA coverage for Patient #1 at the patient's start of care on 7/5/22, however shortly after the start of care, Patient #1s assigned CNA staff had reported environmental safety concerns and inappropriate verbal comments made by Patient #1 to the assigned CNA staff during their assigned shift and had asked to be removed from Patient #1s home as a result. Due to the expressed concerns, the DCS was unable to assign any additional CNA coverage to Patient #1 and that the patient’s needs were being met by a roommate and daughter that lived nearby when a CNA was unavailable. The DCS further confirmed Patient #1’s physician was never contacted to obtain orders to decrease the frequency and duration of CNA services due to the CNA staffing difficulties. b) The agency failed to ensure the CNA was providing skilled patient transfers having utilized the mechanical hoyer lift as ordered by Patient #1s physician per the POC. Further review of the POC dated 7/5/22 to 9/2/22, under the treatments and orders section, the CNA was to utilize the hoyer lift three times per day to assist with patient transfers. Review of agency documentation completed by RN #5 showed the RN had reported to the home of Patient #1 to conduct assigned CNA training and competency utilizing the patient's hoyer lift that was present in the home at the start of care. Upon RN #5’s inspection of the mechanical hoyer lift equipment, the RN determined the hoyer lift was not safe to use and had presented a safety risk to both Patient #1 as well as agency staff. RN #5 advised Patient #1 and agency staff that the hoyer lift was not to be used due to safety concerns. Review of documentation completed by CNA #6 between 7/5/22 and 8/30/22 showed the CNA was not utilizing the hoyer lift because the client had refused for the CNA to complete the assigned task. Review of documentation completed by CNA #7 between 7/29/22 and 9/2/22 showed the CNA was not utilizing the hoyer lift because she was told not to use it. Continued review showed the agency's CNAs failed to utilize a hoyer lift for patient transfers for the entire eight weeks during the POC certification period. During interview on 12/6/22 at 10:00 a.m., RN #5 confirmed she went to Patient #1’s home shortly after the patient was admitted to the agency to ensure the agency CNA’s assigned to provide care for the patient were competent to utilize the hoyer lift that was already in Patient #1’s home when she was admitted. RN #5 stated she observed Patient #1 to be confined to her bed and was unable to sit up on the side of the bed, stand or ambulate. RN #5 stated upon inspection of the hoyer lift in the patient’s home, she inspected the sling which was to be placed under the patient to securely cradle the patient during transfers, and found the sling to have several large rips and holes in it and deemed unsafe for use. RN #5 instructed the CNAs that were present during the competency training to not use the hoyer lift or transfer the patient out of her bed because the hoyer lift was not safe for use. The RN also educated Patient #1 about the unsafe sling and that the CNA’s had been instructed not to use the hoyer lift equipment. During continued interview, RN #5 stated after the home visit with Patient #1, she updated the agency DCS on the faulty hoyer lift equipment and sent a letter to Patient #1 to confirm the CNAs were instructed not to use the hoyer lift equipment. RN #5 stated she did not contact the patient's physician to obtain updated orders to discontinue the use of the hoyer lift and was unsure if any other agency RN’s had contacted the patient's physician because her primary role at the agency was as an educator and infection control coordinator. During interview on 12/6/22 at 10:40 a.m., the DCS stated Patient #1 had reported the hoyer lift had been purchased as used equipment off of Facebook marketplace and that the patient was unaware of how old the equipment was or if it had ever been serviced or inspected by a medical equipment company. The DCS confirmed agency staff were instructed not to use the hoyer lift that was provided by the patient. The DCS also confirmed the order to utilize the hoyer lift was removed from POC for the next certification period dated 9/3/22 to 11/1/22, however an agency RN failed to contact the patient's physician immediately after the equipment was deemed unsafe for use to obtain orders to discontinue the use of the hoyer lift equipment.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to have evidence of communication with the physician to discuss non functional medical equipment and obtain orders for new medical equipment in 1 of 3 patient’s record reviewed (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 12/5/22. The plan of care (POC) for the certification period dated 7/5/22 to 9/2/22, revealed a start of care date of 7/5/22; diagnoses included weakness, bed confinement, chronic pain and osteoarthritis. POC orders included skilled nurse (SN) visits once every 60 days for recertification comprehensive assessment and certified nurse aide (CNA) supervision, as well as CNA visits, 6.5 hours per day, 7 days per week with tasks that included skilled patient transfers utilizing a mechanical hoyer lift, assistance with mobility exercises, activities of daily living (ADLs), personal hygiene and elimination needs. Review of Patient #1’s subsequent POCs for the certification periods dated 9/3/22 to 11/1/22 and 11/2/22 to 12/31/22 also showed orders for SN visits once every 60 days for recertification comprehensive assessments and CNA supervision, as well as CNA visits, 6.5 hours per day, 7 days per week with tasks that included assistance with mobility exercises, ADLs, personal hygiene and elimination needs, however the use of the mechanical hoyer lift had been discontinued. a) The agency failed to communicate with Patient #1’s physician to discuss the patient’s malfunctioning hoyer lift and obtain orders for a new hoyer lift for patient transfers due to the patient’s bed bound status, after it had been determined the mechanical hoyer lift provided by the patient at the time of admission to the agency was malfunctioning and could not be utilized. Review of the start of care (SOC) comprehensive assessment completed by RN #8 on 7/5/22, showed Patient #1 was bedfast, unable to transfer, unable to turn and position, unable to ambulate or be up in a chair, and that the patient was dependent upon a mechanical [hoyer] lift device for transfers in and out of bed. Review of agency documentation completed by RN #5 showed the RN had reported to the home of Patient #1 to conduct assigned CNA training and competency utilizing the patient's hoyer lift that was present in the home at the start of care. Upon RN #5’s inspection of the mechanical hoyer lift equipment, the RN determined the hoyer lift was not safe to use and had presented a safety risk to both Patient #1 as well as agency staff. RN #5 advised Patient #1 and agency staff that the hoyer lift was not to be used due to safety concerns. However, there was no further documentation to show RN #5 had contacted Patient #1’s physician to discuss the faulty hoyer lift equipment or make arrangements for replacement equipment. Review of a recertification comprehensive assessment completed by RN #4 on 8/30/22, eight weeks after the patient’s start of care, continued to show Patient #1 remained bed bound and that the client used to utilize a hoyer lift for transfers in and out of bed but it was broken. RN #5 also documented Patient #1’s daughter had purchased the hoyer lift from eBay. Review of a discharge comprehensive assessment completed by RN #9 on 11/7/22, showed Patient #1 was being discharged from the agency, four months after her admission, and that the patient remained bedfast and was unable to transfer, turn or reposition. Further record review failed to reveal the agency had contacted Patient #1’s physician and notified them, the patient’s mechanical hoyer lift was non functional or made arrangements to secure a new functional hoyer lift due to the patient’s bed bound status, during the entire four months the patient was with the agency. At the time of survey, RN #8 was unavailable for interview because she was no longer employed by the agency. During interview on 12/6/22 at 10:00 a.m., RN #5 confirmed she went to Patient #1’s home shortly after the patient was admitted to the agency to ensure the agency CNA’s assigned to provide care for the patient were competent to utilize the hoyer lift that was already in Patient #1’s home when she was admitted. RN #5 stated she observed Patient #1 to be confined to her bed and was unable to sit up on the side of the bed, stand or ambulate. RN #5 stated upon inspection of the hoyer lift in the patient's home, she inspected the sling which was to be placed under the patient to securely cradle the patient during transfers, and found the sling to have several large rips and holes in it. RN #5 deemed the hoyer lift unsafe for use and instructed the CNAs that were present during the competency training to not use the hoyer lift or transfer the patient out of her bed because the hoyer lift was not safe for use. The RN also educated Patient #1 about the unsafe sling and that the CNA’s had been instructed not to use the hoyer lift equipment. During continued interview, RN #5 stated after the home visit with Patient #1, she updated the agency Director of Clinical Services (DCS) on the faulty hoyer lift equipment and sent a letter to Patient #1 to confirm the CNAs were instructed not to use the hoyer lift equipment. RN #5 stated she did not contact the patient’s physician to discuss the faulty medical equipment or obtain orders for a replacement hoyer lift and was unsure if any other agency RN’s had contacted the patient’s physician because her primary role at the agency was as an educator and infection control coordinator. During an interview on 12/5/22 at 2:57 p.m., RN #4 confirmed she had completed the recertification comprehensive assessment via a virtual telehealth visit on 8/30/22 and was not physically present in the patient’s home for the comprehensive assessment. RN #4 stated she had briefly been assigned as Patient #1’s RN Case Manager and had only completed the one virtual visit on 8/30/22. RN #4 stated the patient was lying in her bed for the virtual visit and had reported she had not been out of bed for a long while because the hoyer lift was not working. RN #4 went on to state she had contacted the DCS after the comprehensive assessment to let her know the broken hoyer lift the daughter had purchased off of eBay remained in the home, however RN #4 did not contact Patient #1’s provider to discuss the broken mechanical hoyer lift equipment or obtain orders to secure a new functional hoyer lift. During an interview on 12/5/22 at 12:46 p.m., the DCS confirmed she was made aware of the non functional mechanical hoyer lift by RN #5 after the RN was unable to provide the CNA competency training in Patient #1’s home due to the rips and holes in the hoyer sling and had instructed the CNAs not to use the hoyer lift equipment. The DCS stated she was unsure if any other agency licensed clinicians had contacted the patient’s physician to discuss the faulty medical equipment purchased from eBay or obtain orders for a new hoyer lift through an authorized medical equipment provider. The DCS acknowledged the physician should have been contacted.