Every finding on record at Ahc Home Health of Colorado, LLC

Upon patient record review, 2 of 14 (Patient #6, 12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6 - POC dated 09/27/24 wound care to coccyx did not contain frequency. Patient #12 - POC dated 09/30/24 Morphine 20mg/ml give 5-10mg every 2 hours PRN severe pain did not include how many "mg/ml's" to give every 2 hours. No modifier for PRN wound care ordered on 10/14/24.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #10 - Patient was treated for a toe infection on 09/25/24 with antibiotics and physician ordered warm Epson Salt soaks TID and was treated for UTI with antibiotic on10/28/24 but record did not have evidence the POC was updated.

Upon client record review, 2 of 14 (Patient #9, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9 - POC dated 09/06/24 - Initial MSW visit missed on 09/09/24 - and no evidence of further attempts or that visit was made. Patient #11 - POC dated 09/23/24 - Initial MSW visit missed on 09/26/24 -and no evidence of further attempts or that visit was made.

Upon patient record review 2 of 14 (Patient #9, 14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #9 - Aide visit note on 10/14/24 aide documented that bed bath was not performed due to patient "decline in condition". Aide is not qualified to decide if patient is unable to perform or participate in care - RN must make decision to change care plan. Patient #14 - Aide visit note on 10/25/24 aide documented that bed to chair transfer was not performed due to patient "decline in condition". Aide is not qualified to decide if patient is unable to perform or participate in care - RN must make decision to change care plan.

Upon patient client record review, 3 of 14 (Patient #6, 9, 12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #6 - SN visit note on 10/04/24 and 10/18/24 - SN documented "wound care per orders"and did not include clear, complete documentation of care provided. Patient #9 - SN visit not on 10/04/24 SN documented "wound care per orders"and did not include clear, complete documentation of care provided. Patient #12 - SN visit note on 10/18/24 and 10/28/24 SN documented "wound care per orders"and did not include clear, complete documentation of care provided.

Upon patient record review, 2 of 11 (Patient #2, 4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #2, 4 - Record contained information that the patient was on oxygen. The medication profile did not list oxygen.

Upon patient record review, 2 of 11 (Patient #2, 4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2 - The record contained evidence that the patient was on oxygen. POC dated 10/16/2021 did not contain Oxygen. Patient #4 - The record contained evidence that the patient was on oxygen. POC dated 10/14/2021 did not contain Oxygen.

Upon patient record review, 1 of 11 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4 - SN visit note 11/10/2021 and 11/11/2021 documented "wound care performed" did not document specific wound care. SN provided wound care 10/28/2021 and 11/05/2021 R leg but order for wound care not added until 11/10/2021.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1- Upon home visit with the Aide - placed computer bag on the floor without a barrier. During the personal care she dropped the adult brief on the floor along with perineal wipes. After she completed care and put on new brief she picked up the dirty brief and placed in garbage.

Upon patient record review 7 of 10 applicable (Patient #1, 2, 3, 4, 6, 7, 8) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #1 - Aide visit 10/19/2021, 10/20/2021 and 10/21/2021 did not provide skin care, incontinence care, brush hair, cleaning bathroom which were assigned every visit on care plan. Aide provided bed bath on 11/09/2021 and 11/16/2021 but shower was on care plan every visit. Patient #2 - Aide did not provide shower or ROM on 11/04/2021 or 11/11/2021 as ordered every visit - did not provide shampoo on 10/28/2021, 11/04/2021 or 11/10/2021 as ordered every visit. Patient #3 - Aide provided shower on 09/06/2021, 09/14/2021, 10/19/2021, 11/04/2021 or 11/11/2021 but bed bath on care plan. Patient #4 - Aide care plan included ROM, oral care, shower and shampoo every visit. None of the tasks were documented as completed 10/19/2021. Visits dated 10/21/2021, 10/26/2021, 10/28/2021, 11/09/2021 and 11/11/2021 did not include ROM, oral care, or shampoo. Patient #6 - Aide provided bed bath on 11/10/2021 but shower was assigned on care plan. Aide did not provide cleaning to living area, incontinence care, dressing, shower, shampoo or skin care on 10/27/2021 or 11/03/2021. Patient #7 - Aide provided bed bath 2 x week on week 5 and week 6 but ordered only 1 x week. Aide provided shower on 10/19/2021, 10/21/2021 and 10/26/2021 but bed bath ordered. Patient #8 - Aide care plan included ROM, clean living area, assist dressing, shower, oral care, shampoo and shower. None of these tasks were documented as provided 09/13/2021, 10/26/2021, 11/03/2021 and 11/11/2021.

Conditions of Participation - Volunteers. L641

Upon personnel record review, 1 of 1 applicable (Personnel #11) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. The agency did not have a volunteer coordinator at the time of survey.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. At time of survey the agency has no volunteers or a volunteer coordinator

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. At time of survey the agency has no volunteers or a volunteer coordinator

Upon patient record review, 2 of 11 (Patient #1, 5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1 - SN visit note 09/04/2021 and 09/06/2021 documented "wound care performed" did not document specific wound care. Patient #5 - SN visit note 11/02/2021 did not contain foley catheter or balloon size RN inserted.