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

Upon patient record review, 4 of 14 (Patient #5, 9, 10, 11) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #5 - Medication profile contained Oxygen 1-4 L/M nasal cannula as needed for hypoxia, no modifier for range 1-4 L/M. Patient #9 - Mupirocin 2% topical cream 1 application daily did not specify site. Patient #10 - Medication profile contained Oxygen 1-4 L/M nasal cannula as needed for hypoxia, no modifier for range 1-4 L/M. Diclofenac 1% gel apply 2mg 1 x day as need for pain - did not specify site. Patient #11 - Medication profile contained Oxygen 1-4 L/M nasal cannula as needed for hypoxia, no modifier for range 1-4 L/M. BenGay ultra strength topical cream 1 application 3 times as needed for pain did not specify site.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patient #6 - Patient admitted 04/28/25 and the initial bereavement assessment was not completed until 07/24/25.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #6 - POC did not include the scope of services for the home health aide.

Upon patient record review, 4 of 14 (Patient #5, 9, 10, 11) 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 #5 - POC contained Oxygen 1-4 L/M nasal cannula as needed for hypoxia, no modifier for range 1-4 L/M. Patient #9 - Mupirocin 2% topical cream 1 application daily did not specify site. Patient #10 - POC contained Oxygen 1-4 L/M nasal cannula as needed for hypoxia, no modifier for range 1-4 L/M. Diclofenac 1% gel apply 2mg 1 x day as need for pain - did not specify site. POC had Premier protein drink for nutrition but did not specify amount or frequency. Patient #11 - POC contained Oxygen 1-4 L/M nasal cannula as needed for hypoxia, no modifier for range 1-4 L/M. BenGay ultra strength topical cream 1 application 3 times as needed for pain did not specify site.

Upon patient record review, 3 of 14 (Patient #5,7,9) 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 equipment and supply needs. Patient #5 -Patient has a hospital bed and bedside table but not on the POC. Patient #7 - Patient has a hospital bed and bedside table but not on the POC. Patient #9 - Patient has a wheel chair, hospital bed and bedside table but not on the POC.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #7 - There was no evidence for the frequency for the task "shower" on the aide plan of care.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency did not utilize at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was 2.4%.

Upon patient record review, 2 of 14 (Patient #6, 9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #6 - Patient/caregiver requested the Patient Notification of Hospice Non-Covered Addendum, but no documentation that this was provided. Patient #9 - Patient/caregiver requested the Patient Notification of Hospice Non-Covered Addendum on admission 12/20/24, sent on 12/31/24.

Upon patient record review, 1 of 14 (Patient #11) 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 #11 - SN documented on visit note 07/09/25 blood sugar of 72 - did not include how obtained or site.

Upon patient record review, 2 of 6 applicable (Patients #3, 9) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient #3 Aide care plan contained both bed bath and shower every visit but did not contain that patient was cognitively and functionally able to make decision. Patient #9 Aide care plan contained "changed linen and up in wheelchair if patient requests".

Upon patient client record review, 1 of 9 (Patient #9) 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. Patient #9 - SN visit note 06/24/2022 "foley catheter inserted per MD order" and did not include details of the procedure or how the patient tolerated.