Every finding on record at Personal Assistance Services of Colorado LLC

A recertification survey was completed on 2/2/26. One deficiency was cited.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure continuity of care upon discharge. Specifically, for 1 of 4 sample discharged patients, the agency failed to send the plan of care requested by the new home health agency (Patient #13). Findings include: The clinical record for Patient #13 was reviewed on 1/21/26. Plan of care orders for the certification period dated 10/8/25 to 12/6/25 revealed a start of care date of 7/1/14; diagnoses included Duchenne muscular dystrophy, idiopathic scoliosis, and abnormalities of breathing. Plan of care orders included skilled nursing services for seventy hours per week to provide assistance and monitoring for ventilator equipment, feeding tube, and activities of daily living. a) The agency failed to send the plan of care to the new home health agency. Review of the clinical record revealed Patient #13 was discharged from the agency on 11/25/25 due to a family request for transfer to a different home health agency. Further review revealed a nurse case manager communication note on 11/21/25 documented a request for the plan of care to be sent to the home health agency where Patient #13 would be transferred. The clinical record did not include documentation of the agency sending the plan of care During an interview with the agency administrator at 4:47 p.m. on 1/21/26, the administrator stated there was no documentation of the plan of care being sent. During an interview with the skilled care nurse manager (SCNM) at 12:02 p.m. on 1/22/26, the SCNM stated the plan of care had not been sent due an incomplete communication process between the family and the agency nurse case manager. The SCNM stated the plan of care should have been sent to the agency Patient #13 transferred to. During an interview with the agency administrator at 12:20 p.m. on 1/22/26, the administrator confirmed the agency policy was to send all necessary medical information to ensure transition of care and acknowledged the plan of care should have been sent to the new home health agency.

A complaint survey, prompted by #CO96944 was completed on 5/3/23. One deficiency was 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 interviews and record review, the agency failed to ensure care was provided according to each patient's individualized written plan of care, in conformance with physician orders, for 1 of 2 discharged patients reviewed who received certified nursing assistant (CNA) services (Patient #3). Findings include: 1. During an interview on 5/1/23 at 10:22 a.m., the administrator stated the agency had two categories of patients who received CNA services. One group of patients brought their own CNAs with them and/or the agency helped train the patient's family/friend(s) to become CNAs to be able to assist the patient with their CNA needs. The other group of patients, referred to as the community care patients by the agency, were patients who relied on the agency to hire CNAs to assist the patient with his/her CNA needs. The administrator stated the agency was struggling with staffing CNA visits for the community care patients. During continued interview, the administrator stated the agency had a few CNAs hired as "runners" and the runner CNA's role at the agency was to be available to fill any visits a patient's regularly scheduled CNA could not provide due to illness, vacation, resignation, or termination. The DON stated sometimes the agency had to prioritize which patients the runners went to each day to cover all of the community care patient shifts. The director of nursing (DON) stated the agency schedulers were aware of which community care patients had "natural support", which she defined as family or friends the community care patient could reach out to provide the physician ordered CNA visit if the agency was unable to staff the CNA visit. The administrator stated she did not believe the agency had documentation of which community care patients had "natural support" or who had agreed to rely on natural support if the agency was unable to staff their visit. During continued interview, the DON stated if the agency noticed a pattern of missed visits with a community care patient, the agency would immediately seek a conversation with the patient to attempt to solve the staffing issue to ensure the agency was meeting the patient's needs. The administrator stated the agency did their best to support people living in the community and to her knowledge the agency did not have an issue with missed visits. 2. The clinical record for Patient #3 was reviewed on 5/2/23. The plan of care for the certification periods dated 11/13/22 to 1/11/23 and 1/12/23 to 3/12/23 revealed a start of care date of 12/4/18; diagnoses included neuromuscular dysfunction, unspecified injury at C4 level of cervical spine, neuromuscular dysfunction of bladder, neurogenic bowel, peritoneal abscess and non-pressure chronic ulcer of buttocks. Plan of care orders included skilled nursing (SN) once every 60 days for supervision of the CNAs and CNA visits three times a day for personal care and assistance with activities of daily living (ADLs). a) The agency failed to ensure CNA care was provided as ordered by the physician. Review of the plan of care for the certification periods dated 11/13/23 to 1/11/23 and 1/12/23 to 3/12/23 showed Patient #3 was unable to balance or bear weight, required assistance with transfers, had a colostomy (an opening in large intestine that has a bag attached to allow a person to defecate), a suprapubic catheter (a tube inserted into a person's bladder to drain urine) and required assistance with ADLs. Review of the care plans revealed the patient required the assistance of the CNA to provide bathing, use of equipment, emptying her colostomy and suprapubic bags, change her colostomy bag as needed, clean the tubing and bag for her suprapubic catheter, care of the skin around her colostomy as long as there was no skin issues, transfers, standing with the use of a mechanical device, hair care, mouth care, nail care, range of motion exercises, apply lotion, monitor Patient #3's skin and report any observed issues to the SN, assist Patient #3 with repositioning, and encourage Patient #3 to drink fluids. However, clinical record review showed CNA services were not provided as ordered. Specifically: Review of the plan of care for the period dated 11/13/22 to 1/11/23 showed Patient #3 should have received 180 CNA visits and review of the plan of care for the period dated 1/12/23 to her discharge on 3/8/23 showed Patient #3 should have received 168 CNA visits. Review of CNA visit notes and/or electronic visit verification (EVV) from 11/13/22 to 1/11/23 showed Patient #3 received a total of 66 of the 180 physician ordered CNA visits as follows: 38 of 60 morning visits; 28 of 60 midday visits; and zero of 60 evening visits. Review of CNA visit notes and/or electronic visit verification (EVV) from 1/12/23 to Patient #3's discharge date of 3/8/23 showed Patient #3 received a total of 37 of the 168 physician ordered CNA visits as follows: 25 of 56 morning visits; 12 of 56 midday visits; and zero of 56 evening visits. Review of a missed visit notification log faxed on 12/2/22 showed the physician who ordered services for Patient #3 was notified of the deviations to the plan of care for CNA visits not provided from 11/11/22 to 11/20/22 as follows: - alternate caregiver available and provided necessary care on 11/20/22 for the midday visit; - patient canceled her appointment and declined a substitute CNA for two of Patient #3's physician ordered CNA morning visits (11/12/22 and 11/19/22); three of Patient #3's physician ordered CNA midday visits (11/12/22, 11/17/22, and 11/19/22); and 8 of Patient #3's physician ordered evening visits (11/13 - 11/20/22). Review of a missed visit notification log faxed on 1/23/23 showed the physician who ordered services for Patient #3 was notified of the deviations to the plan of care for CNA visits not provided from 11/21/22 to 1/8/23 as follows: - alternate caregiver available and provided necessary care on 11/21/22 and 1/4/23 for the morning visit; - regularly scheduled CNA unavailable and client declined a substitute for: three of Patient #3's physician ordered CNA morning visits (12/4/22, 12/22/22 and 12/29/22, but there was EVV and a visit note for the 12/29/22 visit) and Patient #3's physician ordered CNA midday visit on 12/4/22; -patient canceled her appointment and declined a substitute CNA for 18 of Patient #3's physician ordered CNA morning visits (11/24/22, 11/26/22, 11/28/22, 12/1/22, 12/3/22 - 12/6/22, 12/8/22 - 12/10/22, 12/12/22, 12/13/22, 12/15/22, 12/17/22, 12/24/22, 12/31/22, and 1/7/23); 26 of Patient #3's physician ordered CNA midday visits (11/24/22, 11/26/22, 12/1/22, 12/3/22 - 12/10/22, 12/12/22 - 12/15/22, 12/17/22, 12/22/22, 12/24/22, 12/29/22, 12/31/22, 1/1/23, 1/3/23, 1/5/23 - 1/8/23) 49 of Patient #3's physician ordered evening visits (11/21/22 - 1/8/23). Review of a missed visit notification log faxed on 2/10/23 showed the physician who ordered services for Patient #3 was notified of the deviations to the plan of care for CNA visits not provided from 1/9/23 to 1/29/23 as follows: - alternate caregiver available and provided necessary care on two of Patient #3's physician ordered CNA morning visits (1/22/23 and 1/26/23) and two of Patient #3's physician ordered CNA midday visits (1/30/23 and 1/31/23); - regularly scheduled CNA unavailable and patient declined a substitute on Patient #3's physician ordered morning and midday visits on 1/17/23; - patient canceled her appointment and declined a substitute CNA for five of Patient #3's physician ordered CNA morning visits (1/14/23, 1/21/23, 1/24/23, 1/28/23 and 1/29/23); 13 of Patient #3's physician ordered CNA midday visits (1/11/23, 1/12/23, 1/14/23 - 1/16/23, 1/19/23 - 1/22/23, 1/24/23, 1/27/23 - 1/29/23); and 21 of Patient #3's physician ordered evening visits (1/9/23 - 1/29/23). Review of a missed visit notification log faxed on 3/17/23 showed the physician who ordered services for Patient #3 was notified of the deviations to the plan of care for CNA visits not provided from 1/30/23 to 3/5/23 as follows: - alternate caregiver available and provided necessary care for six of Patient #3's physician ordered CNA morning visits (2/1/23; 2/15/23, 2/22/23 - 2/24/23, 3/1/23) and one of Patient #3's physician CNA ordered midday visits (2/3/23); - regularly scheduled CNA unavailable and patient declined a substitute for three of Patient #3's physician ordered CNA morning visit (2/10/23, 2/13/23, and 2/27/23) and one of Patient #3's physician ordered CNA midday visits (2/10/23); - patient canceled her appointment and declined a substitute CNA for eight of Patient #3's physician ordered CNA morning visits (2/11/23, 2/14/23, 2/15/23, 2/17/23, 2/18/23, 2/21/23, 2/25/23, 3/3/23); 24 of Patient #3's physician ordered CNA midday visits (2/2/23, 2/4/23 - 2/6/23, 2/8/23, 2/9/23, 2/11/23, 2/12/23, 2/14/23, 2/15/23 - 2/19/23, 2/21/23, 2/23/23 - 2/28/23, 3/2/23 - 3/5/23); and 35 of Patient #3's physician ordered evening visits (1/30/23 to 3/5/23). Review of a missed visit notification log faxed on 4/17/23 showed the physician who ordered services for Patient #3 was notified of the deviations to the plan of care for CNA visits not provided from 3/6/23 to 3/8/23 as follows: - alternate caregiver available and provided necessary care for Patient #3's physician ordered CNA morning and midday visits on 3/7/23; - regularly scheduled CNA unavailable and patient declined a substitute for Patient #3's physician ordered CNA morning visit on 3/6/23; and - patient canceled her visit and declined a substitute CNA for Patient #3's physician ordered CNA morning and midday visits on 3/8/23 and physician ordered CNA evening visits for 3/6/23 - 3/8/23. Review of typed written explanation for missing documentation in Patient #3's record completed by the community care manager on 5/2/23 showed Patient #3 was scheduled to receive care by CNA #10 on 1/15/23 for her morning visit from 9:30 a.m. to 11:30 a.m., and by CNA #9 on 1/13/23 for her midday visit from 1:00 p.m. to 2:00 p.m. and 1/19/23 for her morning visit from 8:30 a.m. to 12:00 p.m. However, there was no EVV that CNAs #9 or #10 completed these visits; no documented evidence that a visit note was completed by CNAs #9 or #10 for these visits; and no evidence a missed visit notification was sent to Patient #3's ordering physician for these visits. Review of Patient #3's schedule documentation showed Scheduler #5 assigned CNA #8 to complete Patient #3's 1/9/23 midday visit beginning at 2:00 p.m. However, there was no EVV that CNA #8 completed this visit; no documented evidence that a visit note was completed by CNA #8 for this visit; and no evidence a missed visit notification was sent to Patient #3's ordering physician. Review of a text message sent to Patient #3 on 12/20/22 at 12:55 p.m. by former Scheduler #6 stated: "Hi. It's [staff name] from Pasco [Personal Assistance Services of Colorado]. I'm sorry but We have to cancel your visit on Thursday 12/22/22[.] [w]e have a lot of staff out sick this week." The text message failed to state how former Scheduler #6 ensured Patient #3 would have her needs met during that time period. Review of scheduling notes for Patient #3's CNA visit scheduled 12/22/22 from 8:30 a.m. until 12:00 p.m. showed Scheduler #7 documented the scheduled CNA visit did not occur as the agency did not have enough staff to complete the visit. The schedule note failed to state how the agency ensured Patient #3 would have her needs met during this time period. Review of a text message sent to Patient #3 by Scheduler #5 on 1/29/23 at 7:35 a.m. stated, "Good morning, we are going to cancel today[s] runner visit. We had a call out today and need to adjust the schedule." The text message failed to state how Scheduler #5 ensured Patient #3's needs were met. Review of scheduling notes for Patient #3's CNA visit scheduled 1/29/23 from 10:00 a.m. until 12:00 p.m. showed Scheduler #5 documented the scheduled CNA visit did not occur due to staff not being available to complete the visit. The schedule note failed to state how the agency ensured Patient #3's needs were met. Review of a text message sent to Patient #3 by Scheduler #7 on 2/10/23 at 8:31 a.m. stated, "Hey [Patient #3], [CNA #9] is out again today and won't be able to make it and my runner is booked so I'm going to have to cancel. I'm really sorry." The text message failed to state how Scheduler #7 ensured Patient #3's needs were met. Review of scheduling notes for Patient #3's CNA visits scheduled on 2/10/23 from 8:30 a.m. to 12:00 p.m. and 1:00 p.m. to 2:00 p.m. showed the comment section stated "CNA called off from visit" for both scheduled visits. The scheduled notes failed to state how the agency ensured Patient #3's needs were met. Review of a text message sent to Patient #3 by Scheduler #5 on 2/21/23 at 12:07 p.m. stated "Due to a call out, we are canceling your next three visits in the morning. I apologize we are extremely short staffed." The text message failed to state how Scheduler #5 ensured Patient #3's needs were met. Review of scheduling notes for Patient #3's CNA visits scheduled on 2/22/23 from 6:30 a.m. to 10:00 a.m., 2/23/23 from 7:00 a.m. to 10:30 a.m., and 2/24/23 from 8:30 a.m. to 12:00 p.m. showed Scheduler #7 documented "Client has natural support." The scheduled note failed to show the reason the three visits were canceled was due to the agency not having staff available to provide the visit. During an interview on 5/3/23 at 8:55 a.m., Patient #3 stated the times she preferred to have her three CNA visits start were 8:30 a.m. for her morning visit, 1:00 p.m. for her midday visit, and 8:00 p.m. for her evening visit. During an interview on 5/2/23 at 3:11 p.m., Patient #3 stated she was supposed to receive three CNA visits a day, a morning visit, a midday visit and an evening visit. Patient #3 stated she informed the agency to stop trying to schedule her evening visit sometime in 2020 as the agency would only offer CNA assistance for those visits either at 4:30 p.m. or 11:00 p.m. and she did not want to get back into bed that early or late. Patient #3 stated the agency provided CNA visits during her midday visit regularly until January of 2023 when her regular CNA resigned and the agency relied on runner CNAs to provide her midday CNA visits. Patient #3 stated she had several missed visits as the agency had no CNA staff to provide her care for her scheduled visits. Patient #3 stated many times the agency would call or text her to inform Patient #3 they did not have a CNA to cover her CNA visits at the times she preferred (and the agency agreed to when they accepted her as a patient), but they could send a CNA to cover her visit at another time. Patient #3 stated the agency often offered her her morning visit at 5 a.m. instead of 8:30 a.m. which was her preferred time so she would say no to cancel the visit as that was too early for her to get up and sit in her wheelchair for the entire day. Patient #3 stated sometimes the agency schedulers would call or text her and inform her the agency did not have a runner available to come assist her as they were short staffed and asked Patient #3 if her mom could assist her with her needs. Patient #3 stated other times the schedulers would call or text her to inform her the agency had no CNAs to cover her visit. During an interview on 5/3/23 at 10:28 a.m., Scheduler #5 stated if a patient did not have a regularly scheduled CNA the agency would use a runner CNA to fill shifts for the patient. Scheduler #5 stated if the agency had more patient visits to cover than runner CNAs to provide those shifts, the scheduling team was instructed to ask patients if they could have their care provided by a family member or friend - natural support. Scheduler #5 stated members of the scheduling team were aware of which patients had natural support and Patient #3 was stated one of those patients. Scheduler #5 acknowledged he sent Patient #3 text messages stating he was canceling her CNA visit, including the one on 2/21/23 where he informed Patient #3 that her visits for the next three mornings would be canceled as the agency did not have a runner available to cover her shifts. Scheduler #5 acknowledged he did not ask Patient #5 if her mom would be able to cover that care, he just assumed Patient #3's mom would cover her CNA needs for those three mornings. During an interview on 5/3/23 at 10:06 a.m. the community care manager acknowledged the agency did not have EVV or visit notes for the following CNA visits for Patient #3: 1/13/23 midday visit, 1/15/23 and 1/19/23 morning visits. The community care manager stated the agency's electronic medical record system which included their EVV was not always functioning correctly at the time of those visits and the documentation and EVV for those visits did not come through the system. The community care manager stated CNA #9 and #10 should have filled out a paper visit note and documented the times they provided Patient #3 care, but failed to do so and the agency was unable to get this task completed as neither CNA worked for the agency anymore. The community care manager stated a missed visit was not sent to Patient #3's physician for these three visits as she was positive the three visits occurred, but acknowledged she had no documentation evidence these three visits occurred. During an interview on 5/2/23 at 2:12 p.m., the community care manager stated she started her position with the agency in April of 2022. The community care manager stated she noticed many of Patient #3's visits were not provided as scheduled and she worked on trying to rectify the situation with Patient #3. The community care manager stated Patient #3 informed her that she canceled many of the CNA visits the agency offered as Patient #3 preferred to have visits by a regularly scheduled CNA not a runner CNA. Patient #3 also canceled her visits often as she did not like the times CNA visits were offered to her or the length of the visit that was offered to her. The community care manager stated she hired several regularly scheduled CNAs to provide Patient #3's care with the focus on hiring CNAs to cover Patient #3's morning and midday visits as those were the two shifts Patient #3 told the community care manager those visits were the two visits a day Patient #3 wanted the agency to provide. The community care manager stated Patient #3 informed the community care manager that Patient #3 did not want the agency to find coverage for her evening visits as Patient #3 preferred her mom to assist her with that visit. The community care manager stated the agency struggled to keep Patient #3's CNA visits filled by a consistent CNA. The community care manager stated some of the CNA's assigned to care for Patient #3 resigned and one of the CNAs assigned Patient #3 requested not return as she stated Patient #3 was rude to her. During continued interview, the community care manager stated she attempted to help Patient #3 switch her Medicaid waiver to the In Home Support Services program at the agency as this program would allow Patient #3's mom to be paid to be Patient #3's caregiver in August of 2022, but Patient #3 declined this offer. In December of 2022, the community care manager stated she provided Patient #3 with a list of other agencies Patient #3 could look into to see if one of those agencies would be better able to meet Patient #3's CNA needs. The community care manager stated she did not reach out to Patient #3's Medicaid single entry point case manager (SEP) to inform the SEP that the agency was struggling to provide Patient #3 her CNA visits as ordered. The community care manager also stated to her knowledge no one at the agency reached out to Patient #3's physician to inform the physician Patient #3 no longer wanted an evening CNA visit. During continued interview, the administrator stated the agency typically would not reach out to a patient's physician to inform him/her if the agency was struggling to cover visits as ordered by the physician (other than via a missed visit notification) as the agency's goal was always to work toward finding staff to cover all visits as ordered by the physician. During an interview on 5/3/23 at 11:10 a.m., the community care manager, administrator, DON, alternate administrator and chief operations officer (COO) all reviewed the text messages sent to Patient #3 on 12/20/22, 2/10/23, 2/21/23 and acknowledged the text messages canceled her visit and did not show how Schedulers #5, #6 or #7 ensured Patient #3's needs were met. The community care manager stated she trained her scheduling staff to always offer a runner CNA when possible which could include the scheduler or a member of the administrative team who had his/her CNA license to cover a visit. The community care manager stated she trained her scheduling team with community care patients who had no natural support available, if no runner CNA was available to ask the patient if it was ok to cancel their shift and if the patient agreed the scheduler was to ensure the patient could get his/her needs met by their natural support (family or friends). The community care manager acknowledged Schedulers #5, #6, and #7 did not document either in the text or Patient #3's chart that they ensured Patient #3's needs would be met by her mom when they the schedulers text Patient #3 on 12/20/22, 2/10/23, and 2/21/23 to cancel Patient 3's visits. The community care manager was not aware schedulers were just canceling visits and stated she would immediately reeducate her scheduling staff on the correct process.