Every finding on record at Abode Healthcare Colorado, Inc

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview and observation. 1 of 19 (5%) clinical records reviewed and 1 of 4 (25%) home visit observations revealed that the hospice did not ensure the comprehensive assessment included an updated medication profile that contained the patient's current medications. HOME VISIT 1/CLINICAL RECORD 4: The patient elected the hospice benefit on 01/14/2026 with a diagnosis of Malignant neoplasm of bladder, co-morbidity of Type 2 Diabetes Mellitus. During the observed home visit with the Registered Nurse (RN - Personnel Record 7) on 05/20/2026, the patient's medications were reviewed with the son and compared to the hospice medication profile (printed on 05/19/2026). The son reported that the patient was receiving insulin via Insulin Pen twice a day, "for the last two decades." The RN (Personnel Record 7) was interviewed after the visit and stated, "I knew he was taking insulin, but it looks like I missed adding it to the medication list." There was no documented evidence that the hospice medication profile included the Insulin Pen, thus no evidence that the comprehensive assessment included a complete drug profile of the patient's current medications. During a joint record review and interview on 05/22/2026, the Clinical Manager agreed there was no documented evidence that the Insulin Pen was added to the hospice medication profile.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 2 of 19 (11%) clinical records reviewed revealed that the hospice did not ensure the plans of care included planned interventions with goals for the problems identified in the comprehensive assessments. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/14/2026 with a diagnosis of Malignant neoplasm of bladder, co-morbidity of Type 2 Diabetes Mellitus (DM). During Home Visit 1 with the Registered Nurse (Personnel Record 7) on 05/20/2026, the patient's medications were reviewed with the son and compared to the hospice medication profile (printed on 05/19/2026). The son reported that the patient was receiving Insulin via Insulin Pen twice a day, "for the last two decades." The Registered Nurse (Personnel Record 7) was interviewed after the visit and stated, "I knew he was taking insulin, but it looks like I missed adding it to the medication list." The wound documentation by the Registered Nurse revealed a coccyx wound with an onset date of 02/04/2026 and a restaged date of 05/20/2026. The plans of care dated 01/14/2026-04/13/2026 and 04/14/2026-07/12/2026 reviewed on 05/22/2026 did not identify Type 2 DM or the coccyx wound as problems with planned interventions and goals. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/13/2026 with a diagnosis of Malignant neoplasm of lower lobe, left bronchus or lung. The Registered Nurse (RN) assessment on 01/13/2026 documented, "dressing on pleurx drain site." The RN visit on 01/25/2026 documented, "Drained pleurovac, output 550ml of sanguineous pleural fluid." The RN visit on 01/28/2026 documented, "RN drained 250ml of sanguineous fluid from her left lung." The RN visit on 01/30/2026 documented, "RN drained 400ml sanguineous fluid." A review of the plan of care dated 01/13/2026-02/06/2026 revealed that the PleurX drain was not identified as a problem with the intervention to drain the site and goals. During a joint record review and interview on 05/22/2026, the Clinical Manager agreed there was no documented evidence that the plans of care included the problems identified with planned interventions and goals.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. 2 of 4 (50%) home visit observations revealed that the hospice did not ensure staff followed the agency's hand hygiene policy. DOCUMENT 3: Agency Policy, "Hand Hygiene", Policy No. 7-009.1-7.009.2, stated in part, "Hand decontamination using an alcohol-based hand rub should be performed: Before having direct contact with patients, after contact with a patient's intact skin, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient." HOME VISIT 3: During the observed home visit with the Social Worker (Personnel Record 9) in an Assisted Living Facility on 05/21/2026, the Social Worker was observed signing in at the front table, reviewing the patient's binder at the facility, and touching the patient's hand and lifting the patient's spoon to queue the patient to eat. The Social Worker was not observed washing her hands prior to or during the visit. The Social Worker was interviewed and agreed that she did not wash her hands. HOME VISIT 4: During the observed home visit with the Chaplain (Personnel Record 10) in a long-term care facility on 05/21/2026, the Chaplain was observed entering the facility, reviewing the patient's binder at the facility, entering the patient's room, touching the patient's bed remote, pillows, and hand during the visit. The Chaplain exited the building to retrieve an item from her car then reentered the facility and patient's room. The Chaplain was not observed washing her hands prior to or during the visit. The Chaplain was interviewed and agreed that she did not wash her hands. During a review of the observed home visits and agency policy, the Clinical Manager agreed that the staff did not adhere to the agency's hand hygiene policy.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the Volunteer Requirement/Cost Savings Report revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. DOCUMENT 1: A review of the Volunteer Requirement/Cost Savings Report for 01/01/2025-12/31/2025 revealed volunteer hours at 2.57% of the total patient care hours of all paid hospice employees and contract staff. A review of the Volunteer Requirement/Cost Savings Report for 01/01/2026-05/21/2026 revealed volunteer hours at 3.47% of the total patient care hours of all paid hospice employees and contract staff. A review of the Volunteer Requirement/Cost Savings Report for 05/01/2025-05/01/2026 revealed volunteer hours at 3.45% of the total patient care hours of all paid hospice employees and contract staff. During a joint review of the documentation and interview on 05/22/2026, the Executive Director agreed there was no documented evidence that the volunteer hours equaled at least 5% of the total patient care hours. Additionally, the Executive Director stated, "We need to increase our recruitment efforts in outlying areas of our territory. We are also struggling with short length of stays affecting the numbers. We have a PIP (Performance Improvement Project) in place for this." During a joint review of the documentation and interview on 05/22/2026, the Volunteer Coordinator agreed there was no documented evidence that the volunteer hours equaled at least 5% of the total patient care hours. Additionally, the Volunteer Coordinator stated, "We have volunteers, but we have a large territory and need to get volunteers in the outside areas." A review of the Volunteer Requirement/Cost Savings Report revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, interview and observation. 2 of 19 (11%) clinical records reviewed revealed that the hospice did not ensure physician's orders were obtained. CLINICAL RECORD 4/HOME VISIT 1: The patient elected the hospice benefit on 01/14/2026 with a diagnosis of Malignant neoplasm of bladder, co-morbidity of Type 2 Diabetes Mellitus. During the observed home visit with the Registered Nurse (RN - Personnel Record 7) on 05/20/2026, the patient's medications were reviewed with the son and compared to the hospice medication profile (printed on 05/19/2026). The son reported that the patient was receiving insulin via Insulin Pen twice a day, "for the last two decades." Insulin was not listed on the medication profile. The RN (Personnel Record 7) was interviewed after the visit and stated, "I knew he was taking insulin, but it looks like I missed adding it to the medication list." There was no documented evidence that the hospice obtained a physician's order for the insulin. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/13/2026 with a diagnosis of Malignant neoplasm of lower lobe, left bronchus or lung. The RN comprehensive assessment on 01/13/2026 documented, "dressing on PleurX drain site." The RN visit on 01/25/2026 documented, "Drained pleurovac, output 550ml of sanguineous pleural fluid." The RN visit on 01/28/2026 documented, "RN drained 250ml of sanguineous fluid from her left lung." The RN visit on 01/30/2026 documented, "RN drained 400ml sanguineous fluid." There was no documented evidence of a physician's order to drain the PleurX. During a joint record review and interview on 05/22/2026, the Clinical Manager agreed there was no documented evidence that physician orders were obtained for the insulin or to drain the PleurX.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 10 (40%) records reviewed it was revealed that the agency did not ensure that an interdisciplinary comprehensive assessment was completed within five days after the patients' election of the hospice benefit. Clinical Record 5: The patient was admitted to hospice on 7/21/23 and the spiritual care assessment was documented as completed by the Chaplain on 8/25/2023, which was beyond the 5-day timeframe for completing the comprehensive assessment. Clinical Record 6: The patient was admitted to hospice on 8/18/2023, and at the time of the site visit review, there was no documented evidence that the Chaplain had completed a spiritual assessment. The Social Worker completed an assessment on 8/22/2023 and included a statement that the patient reported, "She would love some additional support and wanted visits as often as possible". Clinical Record 7: The patient was admitted to hospice on 8/9/2023 and there was no documented evidence that Social Work and Spiritual Care assessments were completed within 5 days following the patient's admission to hospice. The plan of care included orders for visits to be made by the Chaplain and Social Worker (MSW), and the record contained evidence of a Missed Visit note written by the MSW dated 8/24/23. At the time of the site visit review on 8/28/23, there was no documentation that the Chaplain and MSW services were refused. Clinical Record 8: The patient was admitted to hospice on 8/7/23 and the spiritual care assessment was documented as completed by the Chaplain on 8/25/23, which was 18 days after the date of the patient's hospice admission. The clinical record did not include any documentation to reveal a reason for the delay. The Executive Director stated in interview on 8/28/23 that the primary Chaplain was out on medical leave and two "PRN" Chaplains have been providing services. The Executive Director confirmed that the Chaplains had not completed spiritual care assessments within 5 days. 6 of 10 (60%) of records reviewed revealed that the agency did not ensure that an interdisciplinary comprehensive assessment was completed within five days after the election of the hospice benefit.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 10 (20%) clinical records reviewed it was revealed that the agency did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 10: The patient was admitted to hospice services on 8/8/2023 and the nursing assessment dated 8/8/23 did not include documented evidence of the completion of an initial bereavement assessment. Documentation in response to assessment prompts stated: "Was the Bereavement Risk Assessed? NO"; and "Indicate the reason bereavement risk not assessed: Not appropriate at time of evaluation". The social work assessment dated 8/11/2023 included the following documentation in response to assessment prompts: "Was the bereavement risk assessed? NO"; and "Indicate reason bereavement risk was not assessed: Not appropriate at time of evaluation". At the time of review on 8/28/23, the clinical record did not contain any further documentation that described the completion of an initial bereavement assessment. Clinical Record 9: The patient was admitted to hospice services on 8/1/2023 and the nursing assessment dated 8/1/23 did not include documented evidence of the completion of an initial bereavement assessment. Documentation in response to assessment prompts stated: "Was the Bereavement Risk Assessed? NO"; and "Indicate the reason bereavement risk not assessed: Not appropriate at time of evaluation". The social work assessment dated 8/4/2023 included the following documentation in response to assessment prompts: "Was the bereavement risk assessed? NO"; and "Indicate reason bereavement risk was not assessed: Not appropriate at time of evaluation". At the time of review on 8/28/23, the clinical record did not contain any further documentation that described the completion of an initial bereavement assessment. The Executive Director confirmed in interview on 8/28/2023 that the identified clinical records did not contain evidence of the completion of an initial bereavement assessment. THIS IS A CONTINUED REQUIRED ACTION: 2 of 10 (20%) of clinical records reviewed revealed that the agency did not ensure that the initial bereavement assessment was completed within 5 days after the election of hospice benefits.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 5 of 10 (50%) clinical records it was revealed that the agency did not ensure that the written plans of care included orders for all drugs and treatment needed to meet patients' needs. Clinical Record 3: The nursing assessment completed at the time of admission on 8/5/2023 stated that the patient was using "continuous oxygen" at a rate of "4L". The plan of care dated 8/4/2023 included documentation of interventions for the "Hospice nurse to instruct and monitor use of oxygen", and "skilled nurse to provide instructions for performing inhalation therapy and care for equipment". Oxygen equipment was listed on the plan of care, however there were no orders present that described the oxygen rate, route, and frequency of use on the care plan. Clinical Record 8: The nursing assessment completed at the time of admission on 8/7/23 stated that the patient was using "continuous oxygen". There were no orders present on the plan of care that described the oxygen rate, route, and frequency of use. Clinical Record 9: The nursing assessment completed at the time of admission on 8/1/2023 stated that the patient was using oxygen at "4L per nasal cannula continuously". The plan of care included documentation of an intervention to instruct and monitor use of oxygen but there were no orders present on the plan of care that described the oxygen rate, route, and frequency of use. Clinical Record 10: The nursing assessment dated 8/8/2023 stated that the patient using oxygen "per nasal cannula 3L continuous". The plan of care dated 8/8/23 included documentation of an intervention to instruct and monitor use of oxygen but there were no orders present on the plan of care that described the oxygen rate, route, and frequency of use. Clinical Record 6: The nursing assessment completed at the time of admission on 8/18/2023 stated that the patient was using "continuous oxygen". Documentation in the narrative of the nursing assessment stated that orders were received for "O2 2L per NC continuous". There were no orders present on the plan of care that described the oxygen rate, route, and frequency of use. In interview on 8/28/2023 Executive Director confirmed that the plans of care did not include orders for the administration of oxygen. THIS IS A CONTINUED REQUIRED ACTION 5 of 5 (100%) of clinical records reviewed with patients utilizing Oxygen revealed that the agency did not ensure that the written plan of care did included the administratition of oxygen.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. The Agency policy, “Bereavement Assessment,” stated in part, “On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment. At a minimum, it will include: patient and family/caregiver loss issues, survivor needs, social, spiritual, and cultural factors, services to be provided including individual counseling, support groups, and letters and cards, referrals to be made, grief risk factors and potential for pathological grief reactions.” In 8 of 19 (42%) clinical records reviewed, the hospice did not ensure an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election to hospice care. Clinical Record 1: The patient elected hospice care on 1/26/2023. The initial bereavement assessment was completed on 3/21/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 2: The patient elected hospice care on 3/27/2023. The initial bereavement assessment was completed on 4/6/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 3: The patient elected hospice care on 2/24/2023. The initial bereavement assessment was completed on 3/21/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 4: The patient elected hospice care on 6/12/2023. The initial bereavement assessment was completed on 6/22/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 7: The patient elected hospice care on 3/7/2023. The initial bereavement assessment was completed on 3/14/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 8: The patient elected hospice care on 6/6/2022. The initial bereavement assessment was completed on 7/7/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 10: The patient elected hospice care on 6/5/2023. The initial bereavement assessment was completed on 6/19/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 17: The patient elected hospice care on 8/25/2021. The initial bereavement assessment was completed on 9/22/2021. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. During the joint record review on 7/13/2023, the Executive Director was interviewed and agreed, there was no documented evidence the initial bereavement assessments were completed no later than five days after the election of hospice care. Agency policy, “Bereavement Assessment,” stated in part, “On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment. At a minimum it will include: patient and family/caregiver loss issues, survivor needs, social, spiritual and cultural factors, services to be provided including individual counseling, support groups, and letters and cards, referrals to be made, grief risk factors and potential for pathological grief reactions.” Record 1: The patient elected hospice care on 1/26/2023. The initial bereavement assessment was completed on 3/21/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Record 2: The patient elected hospice care on 3/27/2023. The initial bereavement assessment was completed on 4/6/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Record 3: The patient elected hospice care on 2/24/2023. The initial bereavement assessment was completed on 3/21/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Record 4: The patient elected hospice care on 6/12/2023. The initial bereavement assessment was completed on 6/22/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Record 7: The patient elected hospice care on 3/7/2023. The initial bereavement assessment was completed on 3/14/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Record 8: The patient elected hospice care on 6/6/2022. The initial bereavement assessment was completed on 7/7/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Record 10: The patient elected hospice care on 6/5/2023. The initial bereavement assessment was completed on 6/19/2023. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Record 17: The patient elected hospice care on 8/25/2021. The initial bereavement assessment was completed on 9/22/2021. There was no documented evidence that an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. During the joint record review on 7/13/2023, the Executive Director was interviewed and agreed, there was no documented evidence the initial bereavement assessments were completed no later than five days after the election of hospice care.

It is required that the hospice designates a Registered Nurse member of the IDG to: provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the hospice did not ensure hospice care and services were provided to patients and families as ordered. Record 6: The patient elected hospice care on 8/26/2022. The physician’s order on 9/26/2022 ordered skilled nursing visits twice weekly, effective 9/25/2022. During the week of 9/25/2022-10/1/2022, a nursing visit was documented on 9/29/2022. There was no documented evidence of a second nursing visit or reason for the missed visit. Record 7: The patient elected hospice care on 3/7/2023. The plan of care recertification update order on 5/21/2023 ordered social worker visits effective 6/5/2023, two visits monthly for one month. During June 2023, there were no documented social worker visits or reasons for the missed visits. Record 8: The patient elected hospice care on 6/6/2022. The plan of care recertification update order on 12/1/2022 ordered skilled nursing visits once weekly, effective 12/4/2022. During the week of 12/25/2022-12/31/2022, there were no documented skilled nursing visits or reasons for the missed visit. During the joint record review on 7/14/2023, the Executive Director was interviewed and agreed there was no documented evidence that the hospice care and services were provided as ordered. Record 6: The patient elected hospice care on 8/26/2022. The physician’s order on 9/26/2022 ordered skilled nursing visits twice weekly effective 9/25/2022. During the week 9/25/2022-10/1/2022, a nursing visit was documented on 9/29/2022. There was no documented evidence of a second nursing visit or reason for the missed visit. Record 7: The patient elected hospice care on 3/7/2023. The plan of care recertification update order on 5/21/2023 ordered social worker visits effective 6/5/2023 two visits monthly for one month. During the month of June 2023, there were no documented social worker visits or reasons for the missed visits. Record 8: The patient elected hospice care on 6/6/2022. The plan of care recertification update order 12/1/2022 ordered skilled nursing visits once weekly effective 12/4/2022. During the week 12/25/2022-12/31/2022, there were no documented skilled nursing visits or reasons for the missed visit. During the joint record review on 7/14/2023, the Executive Director was interviewed and agreed, there was no documented evidence that the hospice care and services were provided as ordered.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the hospice did not ensure that the plan of care included interventions and goals based on problems identified in the comprehensive assessments. Clinical Record 4: The patient elected hospice care on 6/12/2023. The Registered Nurse assessment on 6/13/2023 documented intermittent confusion, 3 or more falls in the past month, total fall risk score (MAHC-10 fall risk assessment tool) 20, high risk for falls. The plan of care was reviewed for 6/13/2023- 7/13/2023 and did not include any documented evidence of interventions and goals for the risk of falls. Clinical Record 9: The patient elected hospice care on 12/16/2022. The Registered Nurse assessment on 4/18/2023 documented intermittent confusion, 1-2 falls in the past month, total fall risk score (MAHC-10 fall risk assessment tool) 24, high risk for falls. The plan of care was reviewed for 4/18/2023- 7/13/2023 and did not include any documented evidence of interventions and goals for the risk of falls. Clinical Record 18: The patient elected hospice care on 6/16/2022. The Registered Nurse assessment on 6/19/2022 documented patient seen for a visit following a fall and hitting his head, 1-2 falls in the past month, disoriented x 3 at all times, total fall risk score (MAHC-10 fall risk assessment tool) 20, high risk for falls. The Registered Nurse assessment on 8/20/2022 documented the patient visit for an unwitnessed fall, total fall risk score (MAHC-10 fall risk assessment tool) 18, and high risk for the risk of falls. The plan of care was reviewed for 6/19/2022-8/26/2022 and did not include any documented evidence of interventions and goals for the risk of falls. During the joint record review on 7/14/2023, the Executive Director was interviewed and agreed, there was no documented evidence that the plans of care included interventions and goals for the risk of falls. Record 4: The patient elected hospice care on 6/12/2023. The registered nurse assessment on 6/13/2023 documented intermittent confusion, 3 or more falls in the past month, total fall risk score (MAHC-10 fall risk assessment tool) 20, high risk for falls. The plan of care was reviewed for 6/13/2023- 7/13/2023 and did not include any documented evidence of interventions and goals for the risk of falls. Record 9: The patient elected hospice care on 12/16/2022. The registered nurse assessment on 4/18/2023 documented intermittent confusion, 1-2 falls in the past month, total fall risk score (MAHC-10 fall risk assessment tool) 24, high risk for falls. The plan of care was reviewed for 4/18/2023- 7/13/2023 and did not include any documented evidence of interventions and goals for the risk of falls.. Record 18: The patient elected hospice care on 6/16/2022. The registered nurse assessment on 6/19/2022 documented pt seen for visit following a fall and hitting his head, 1-2 falls in the past month, disoriented x 3 at all times, total fall risk score (MAHC-10 fall risk assessment tool) 20, high risk for falls. The registered nurse assessment on 8/20/2022 documented pt visit for unwitnessed fall, total fall risk score (MAHC-10 fall risk assessment tool) 18, high risk for the risk of falls. The plan of care was reviewed for 6/19/2022-8/26/2022 and did not include any documented evidence of interventions and goals for the risk of falls. During the joint record review on 7/14/2023, the Executive Director was interviewed and agreed, there was no documented evidence that the plans of care included interventions and goals for the risk of falls.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed revealed the hospice did not ensure the DME and supplies were in the patient’s plan of care. Clinical Record 3: The patient elected hospice care on 2/24/2023. The Registered Nurse assessment on 2/24/2023 revealed durable medical equipment (DME) to be provided by the hospice: hospital bed, over-bed table, oxygen concentrator, and oxygen cylinder. The plan of care dated 2/24/2023 documented DME and supplies: none. The plan of care was reviewed between 2/24/2023 - 3/24/2023 and did not include any documented evidence the DME was updated to the plan of care. Clinical Record 6: The patient elected hospice care on 8/26/2022. The Registered Nurse assessment on 8/26/2022 revealed durable medical equipment (DME) to be provided by the hospice: over bed table, walker (wheeled), and wheelchair. Additionally, the registered nurse assessment on 8/26/2022 revealed the patient would need a hospital bed with full rails, FWW, over-the-bed table, and fall mats; supplies: large pullups and briefs, wipes, rinse-free foam soap, and medium gloves. The plan of care dated 8/26/2022 documented DME and supplies: none. The plan of care was reviewed between 8/26/2022- 9/26/2022 and did not include any documented evidence the DME and supplies were updated to the plan of care. Clinical Record 12: The patient elected hospice care on 4/13/2023. The Registered Nurse assessment on 4/13/2023 revealed durable medical equipment (DME) in the home: alternating pad/pump, over-bed table, oxygen concentrator, and walker (standard). The plan of care dated 4/13/2023 documented DME and supplies: none. The plan of care was reviewed between 4/13/2023- 5/13/2023 and did not include any documented evidence the DME was updated to the plan of care. During the joint record review on 7/14/2023, the Executive Director was interviewed and agreed there was no documented evidence the DME and supplies were listed on the plan of care. Record 3: The patient elected hospice care on 2/24/2023. The registered nurse assessment on 2/24/2023 revealed durable medical equipment (DME) to be provided by the hospice: hospital bed, over bed table, oxygen concentrator, oxygen cylinder. The plan of care dated 2/24/2023 documented DME and supplies: none. The plan of care was reviewed between 2/24/2023- 3/24/2023 and did not include any documented evidence the DME was updated to the plan of care. Record 6: The patient elected hospice care on 8/26/2022. The registered nurse assessment on 8/26/2022 revealed durable medical equipment (DME) to be provided by the hospice: over bed table, walker (wheeled), wheelchair. Additionally, the registered nurse assessment on 8/26/2022 revealed the patient will need hospital bed with full rails, FWW, over the bed table and fall mats; supplies: large pullups and briefs, wipes, rinse free foam soap and medium gloves. The plan of care dated 8/26/2022 documented DME and supplies: none. The plan of care was reviewed between 8/26/2022- 9/26/2022 and did not include any documented evidence the DME and supplies were updated to the plan of care. Record 12: The patient elected hospice care on 4/13/2023. The registered nurse assessment on 4/13/2023 revealed durable medical equipment (DME) in the home: alternating pad/pump, over bed table, oxygen concentrator, walker (standard). The plan of care dated 4/13/2023 documented DME and supplies: none. The plan of care was reviewed between 4/13/2023- 5/13/2023 and did not include any documented evidence the DME was updated to the plan of care. During the joint record review on 7/14/2023, the Executive Director was interviewed and agreed, there was no documented evidence the DME and supplies were listed on the plan of care.

It is required that care and services are provided according to the established care/service plan. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record review, personnel record review, observation and interview with the Executive Director, which revealed the following issues regarding Hospice Aide services: The hospice aide failed to provide services as ordered on the plan of care [HCDT.16.I/L626]; and the hospice aide failed to report changes in the patient's nursing needs to the Registered Nurse [HCDT.18.I/ L628]. The cumulative effect of this deficiency has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.76, Hospice Aide and Homemaker Services. This deficient practice illustrated a systemic process failure that had the potential to affect all patients receiving hospice care services from the agency.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, interview, observation, and personnel record review. In 3 of 8 (38%) clinical records reviewed with a hospice aide ordered, the hospice did not ensure that the hospice aide provided services per the plan of care. Clinical Record 1: The patient elected hospice care on 1/26/2023, with a primary diagnosis of infection/inflammatory reaction due to an internal left knee prosthetic. A review of the clinical record revealed four wounds, three currently active as follows: Wound #1 – Ant-patellar, lt, nonhealing surgical, onset 11/24/2021, Wound #2-Ant-pretibial, dist, lt, chronic infection, onset 1/1/2023, Wound #3-Dist, lt-patellar, lt, seroma, onset 2/24/2023, Wound #4-Ant, lat, lt, patellar, lt, seroma, onset 4/21/2023-5/8/2023 inactivated. A physician order dated 5/29/2023 revealed wound orders for Wounds #1, 2, and 3 as follows: Cleanse daily then apply silvasorb to wound bed & cover with non-stick gauze, then protect with abd pad, and secure with paper tape. A physician order dated 7/12/2023 revealed wound orders for Wounds #1, 2, and 3 as follows: Cleanse with wound cleanser, apply silvasorb to the wound bed, cover with non-stick gauze, then abd pad, then secure with paper tape. Patient or hospice nurse to provide wound care. The medication profile reviewed on 7/11/2023 revealed patient was taking Penicillin 1/31/2023-3/13/2023 for infection to left knee; Penicillin 3/13/2023-3/29/2023 prophylaxis, Penicillin 3/28/2023-6/19/2023 infection; Doxycycline 3/13/2023-3/28/2023 infection, Doxycycline 6/19/2023-7/3/2023 infection; Penicillin 500mg tablet, 250mg twice daily for infection. During a home visit (Record #1) observation with Registered Nurse (RN) (Staff #8) on 7/12/2023 at 9:35 am, the patient reported the hospice aide (Staff #12) does the wound care on Mondays and Fridays after showering. The hospice aide care plan dated 2/17/2023 did not include wound care as an assigned task. Hospice aide visits were documented on 5/29/2023, 6/2/2023, 6/5/2023, 6/9/2023, 6/12/2023, 6/16/2023, 6/19/2023, 6/23/2023, 6/26/2023, 6/30/2023, 7/3/2023, 7/7/2023, 7/10/2023. During an interview with the patient (Record #1) on 7/12/2023, the patient reported the hospice aide (Staff #12) does wound care on her leg wounds after her showers on Mondays and Fridays. The patient explained the wound care provided by the hospice aide included putting silvasorb on the wounds and covering them with gauze, pad, and tape. During an interview with the Registered Nurse (RN) (Staff #8) on 7/12/2023, the RN reported the patient has had chronic infections in the left leg that started prior to hospice and continue, doxycycline and penicillin are used to try and keep the infection from worsening. During a joint record review with Human Resources on 7/13/2023, the Human Resources partner confirmed the hospice aide clinical competency completed on 2/10/2023 did not include wound care. During an interview with the hospice aide (Staff#12) and Executive Director on 7/13/2023, the hospice aide confirmed she has been providing wound care on Mondays and Fridays after showering the patient. The hospice aide confirmed she uses the dressings and silvasorb gel every Monday and Friday for “at least a month.” The hospice aide agreed that wound care was not ordered on the hospice aide's care plan. The hospice aide stated, “I’ve been helping her because it’s hard for her (patient) to bend down and do it.” During an interview with the Executive Director on 7/13/2023, the Executive Director agreed the hospice aide did not follow the plan of care as ordered. The Executive Director stated, “It is against our policy for the hospice aide to provide wound care.” Clinical Record 5: The patient elected hospice care on 6/21/2021. The hospice aide care plan dated 5/26/2023 assigned instructions for the aide to complete every visit: bathing shower. The hospice aide visits documentation on 6/5/2023 and 6/9/2023 revealed shower was not completed, and “bed bath given.” Clinical Record 10: The patient elected hospice care on 6/5/2023. The hospice aide care plan dated 6/5/2023 and 6/9/2023 assigned instructions for the aide to complete every visit: bathing chair/bath. The hospice aide visit documentation on 6/7/2023 revealed bathing chair/bath was not completed, “not care planned for today.” During the joint record review on 7/13/2023, the Executive Director was interviewed and agreed there was no documented evidence hospice aides followed the plan of care as ordered. Record 1: The patient elected hospice care on 1/26/2023, with a primary diagnosis of infection/inflammatory reaction due to internal left knee prosthetic. A review of the clinical record revealed 4 wounds, 3 currently active as follows: Wound #1 – Ant-patellar, lt, nonhealing surgical, onset 11/24/2021, Wound #2-Ant-pretibial, dist, lt, chronic infection, onset 1/1/2023, Wound #3-Dist, lt-patellar, lt, seroma, onset 2/24/2023, Wound #4-Ant, lat, lt, patellar, lt, seroma, onset 4/21/2023-5/8/2023 inactivated. A physician order dated 5/29/2023, revealed wound orders for Wound #1, 2 and 3 as follows: Cleanse daily then apply silvasorb to wound bed & cover with non-stick gauze, then cover with abd pad and secure with paper tape. A physician order dated 7/12/2023, revealed wound orders for Wound #1, 2 and 3 as follows: Cleanse with wound cleanser, apply silvasorb to wound bed, cover with non-stick gauze, then abd pad, then secure with paper tape. Patient or hospice nurse to provide wound care. The medication profile reviewed on 7/11/2023 revealed patient was taking Penicillin 1/31/2023-3/13/2023 for infection to left knee; Penicillin 3/13/2023-3/29/2023 prophylaxis, Penicillin 3/28/2023-6/19/2023 infection; Doxycycline 3/13/2023-3/28/2023 infection, Doxycycline 6/19/2023-7/3/2023 infection; Penicillin 500mg tablet, 250mg twice daily for infection. During home visit (Record #1) observation with Registered Nurse (RN) (Staff #8) on 7/12/2023 at 9:35am, the patient reported the hospice aide (Staff #12) does the wound care on Monday and Fridays after showering. The hospice aide care plan dated 2/17/2023 did not include wound care as an assigned task. Hospice aide visits were documented on 5/29/2023, 6/2/2023, 6/5/2023, 6/9/2023, 6/12/2023, 6/16/2023, 6/19/2023, 6/23/2023, 6/26/2023, 6/30/2023, 7/3/2023, 7/7/2023, 7/10/2023. During an interview with the patient (Record #1) on 7/12/2023, the patient reported the hospice aide (Staff #12) does the wound care on her leg wounds after her showers on Monday and Fridays. The patient explained the wound care provided by the hospice aide included putting silvasorb on the wounds and covering them with gauze, pad and tape. During an interview with the registered nurse (RN) (Staff #8) on 7/12/2023, the RN reported the patient has had chronic infections in the left leg that started prior to hospice and continue, doxycycline and penicillin are used to try and keep the infection from worsening. During a joint record review with Human Resources on 7/13/2023, the Human Resources partner confirmed the hospice aide competency completed on 2/10/2023 did not include wound care. During an interview with the hospice aide (Staff#12) and Executive Director on 7/13/2023, the hospice aide confirmed she has been providing wound care on Mondays and Fridays after giving the patient a shower. The hospice aide confirmed she uses the dressings and silvasorb gel every Monday and Friday, for “at least a month.” The hospice aide agreed, wound care was not ordered on the hospice aide plan of care. The hospice aide stated, “I’ve been helping her because it’s hard for her (patient) to bend down and do it.” During an interview with the Executive Director on 7/13/2023, the Executive Director agreed the hospice aide did not follow the plan of care as ordered. The Executive Director stated, “it is against our policy for the hospice aide to provide wound care.” Record 5: The patient elected hospice care on 6/21/2021. The hospice aide care plan dated 5/26/2023 assigned instructions for the aide to complete every visit: bathing shower. The hospice aide visit documentation on 6/5/2023 and 6/9/2023 revealed shower not completed, “bed bath given.” Record 10: The patient elected hospice care on 6/5/2023. The hospice aide care plan dated 6/5/2023 and 6/9/2023 assigned instructions for the aide to complete every visit: bathing chair/bath. The hospice aide visit documentation on 6/7/2023 revealed bathing chair/bath not completed, “not careplanned for today.” During the joint record review on 7/13/2023, the Executive Director was interviewed and agreed, there was no documented evidence hospice aides followed the plan of care as ordered.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, interview and observation. In 3 of 8 (38%) clinical records reviewed with a hospice aide ordered, the hospice did not ensure the hospice aide reported changes in the patient’s nursing needs to the Registered Nurse. Clinical Record 1: The patient elected hospice care on 1/26/2023, with a primary diagnosis of infection/inflammatory reaction due to an internal left knee prosthetic. A review of the clinical record revealed four wounds, three currently active as follows: Wound #1 – Ant-patellar, lt, nonhealing surgical, onset 11/24/2021, Wound #2-Ant-pretibial, dist, lt, chronic infection, onset 1/1/2023, Wound #3-Dist, lt-patellar, lt, seroma, onset 2/24/2023, Wound #4-Ant, lat, lt, patellar, lt, seroma, onset 4/21/2023-5/8/2023 inactivated. A physician order dated 5/29/2023 revealed wound orders for Wounds #1, 2, and 3 as follows: Cleanse daily then apply silvasorb to wound bed & cover with non-stick gauze, then protect with abd pad, and secure with paper tape. A physician order dated 7/12/2023 revealed wound orders for Wounds #1, 2, and 3 as follows: Cleanse with wound cleanser, apply silvasorb to the wound bed, cover with non-stick gauze, then abd pad, then secure with paper tape. Patient or hospice nurse to provide wound care. The medication profile reviewed on 7/11/2023 revealed patient was taking Penicillin 1/31/2023-3/13/2023 for infection to left knee; Penicillin 3/13/2023-3/29/2023 prophylaxis, Penicillin 3/28/2023-6/19/2023 infection; Doxycycline 3/13/2023-3/28/2023 infection, Doxycycline 6/19/2023-7/3/2023 infection; Penicillin 500mg tablet, 250mg twice daily for infection. During a home visit (Record #1) observation with Registered Nurse (RN) (Staff #8) on 7/12/2023 at 9:35 am, the patient reported the hospice aide (Staff #12) does the wound care on Mondays and Fridays after showering. The hospice aide care plan dated 2/17/2023 did not include wound care as an assigned task. Hospice aide visits were documented on 5/29/2023, 6/2/2023, 6/5/2023, 6/9/2023, 6/12/2023, 6/16/2023, 6/19/2023, 6/23/2023, 6/26/2023, 6/30/2023, 7/3/2023, 7/7/2023, 7/10/2023. During an interview with the patient (Record #1) on 7/12/2023, the patient reported the hospice aide (Staff #12) does wound care on her leg wounds after her showers on Mondays and Fridays. The patient explained the wound care provided by the hospice aide included putting silvasorb on the wounds and covering them with gauze, pad, and tape. During an interview with the Registered Nurse (RN) (Staff #8) on 7/12/2023, the RN reported the patient has had chronic infections in the left leg that started prior to hospice and continue, doxycycline and penicillin are used to try and keep the infection from worsening. The RN stated she was not aware the hospice aide was providing wound care to the patient on Mondays and Fridays after the patient's shower. It had not been reported to her by the hospice aide. During an interview with the Executive Director on 7/13/2023, the Executive Director agreed the hospice aide should have reported the patient's need for assistance with wound care to the RN. The Executive Director stated, “It is against our policy for the hospice aide to provide wound care.”

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care, documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review, document review, and interview. The Agency policy, “Volunteer Services,” stated in part, “The Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care, as established in the IDG team meeting and in accordance with the patient’s wishes.” In 1 of 2 (50%) clinical records reviewed of patients receiving volunteer visits, the hospice did not ensure a plan of care was established for volunteer services. Clinical Record 3: The patient elected hospice care on 2/24/2023. The plan of care for episode 2/24/2023-7/13/2023 did not include any documented evidence of volunteer services to be provided. Volunteer visits were documented on paper for 4/6/2023, 4/19/2023, 4/26/2023, 5/11/2023, 5/24/2023, and 5/31/2023. The Volunteer Coordinator was interviewed on 7/13/2023 and stated there is no care plan for this patient, the volunteer just documents what she does on her note based on what the patient wants. Additionally, during an interview on 7/13/2023, the Volunteer Coordinator agreed, there is no documented evidence of a plan of care for volunteer services. The Executive Director was interviewed on 7/13/2023 and agreed with the finding. Agency policy, “Volunteer Services,” stated in part, “The Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care, as established in the IDG team meeting and in accordance with the patient’s wishes.” Record 3: The patient elected hospice care on 2/24/2023. The plan of care was reviewed between 2/24/2023- 7/13/2023 and did not include any documented evidence of volunteer services. Volunteer visits were documented on paper for 4/6/2023, 4/19/2023, 4/26/2023, 5/11/2023, 5/24/2023 and 5/31/2023. The Volunteer Coordinator was interviewed on 7/13/2023 and stated, there is no plan of care for this patient, the volunteer just documents what she does on her note based on what the patient wants. Additionally, during interview on 7/13/2023, the Volunteer Coordinator agreed, there is no documented evidence of a plan of care for volunteer services. The Executive Director was interviewed on 7/13/2023 and agreed with the finding.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. The Agency policy, “Transfer Information,” stated in part, “Within 48 hours of transfer, the transferring clinician will complete a transfer summary. Completed transfer summaries will be given to a clinical records clerk who will send a copy to the receiving organization within 72 hours of transfer.” In 1 of 1 (100%) clinical records reviewed of a patient transferred to another hospice revealed the hospice did not ensure the discharge summary was forwarded to the receiving hospice. Clinical Record 16: The patient elected hospice care on 6/21/2022. The discharge summary revealed the patient transferred to another hospice on 11/28/2022. There was no documented evidence that the discharge/transfer summary was forwarded to the receiving hospice. During the joint record review on 7/13/2023, the Executive Director was interviewed and agreed there was no documented evidence that the discharge/transfer summary was sent to the receiving hospice. Agency policy, “Transfer Information,” stated in part, “Within 48 hours of transfer, the transferring clinician will complete a transfer summary. Completed transfer summaries will be given to a clinical records clerk who will send a copy to the receiving organization within 72 hours of transfer.” Record 16: The patient elected hospice care on 6/21/2022. The discharge summary revealed the patient transferred to another hospice on 11/28/2022. There was no documented evidence that the discharge/transfer summary was forwarded to the receiving hospice. During the joint record review on 7/13/2023, the Executive Director was interviewed and agreed, there was no documented evidence that the discharge/transfer summary was sent to the receiving hospice.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary; the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with a discharge from hospice, the hospice did not ensure the discharge summary was sent to the patient’s attending physician. Clinical Record 14: The patient elected hospice care on 5/1/2020. The discharge documentation revealed the patient was discharged on 2/14/2023, no longer terminally ill. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. Clinical Record 15: The patient elected hospice care on 2/11/2023. The Registered Nurse documentation revealed the patient was discharged on 3/29/2023, heading to hospital for hip fracture and revoking hospice services to seek aggressive treatment for hip fracture. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. During the joint record review on 7/14/2023, the Executive Director was interviewed and agreed there was no documented evidence that the discharge summary was sent to the patient’s attending physician. Record 14: The patient elected hospice care on 5/1/2020. The discharge documentation revealed the patient was discharged on 2/14/2023, no longer terminally ill. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. Record 15: The patient elected hospice care on 2/11/2023. The registered nurse documentation revealed the patient was discharged on 3/29/2023, patient heading to hospital for hip fracture, pt revoking hospice services to seek aggressive treatment for hip fx. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. During the joint record review on 7/14/2023, the Executive Director was interviewed and agreed, there was no documented evidence that the discharge summary was sent to the patient’s attending physician.