Every finding on record at Allelon Opco of Colorado LLC

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan includes contact information for the federal, state, tribal, regional, local emergency preparedness staff, and other sources of assistance. This standard was not met as evidenced by document review and interview. The hospice did not ensure the emergency preparedness communication plan included contact information for the federal, state, tribal, regional, local emergency preparedness staff. Review of the agency’s Emergency Preparedness (EP) binder and EP program revealed no documented evidence that the communication plan included contact information for the federal, state, tribal, regional, local emergency preparedness staff, and other sources of assistance. During a joint review of the Emergency Preparedness Plan and interview on 01/30/2025, the Executive Director agreed that the communication plan did not include the contact information required and stated, "We need to add the contact information to the emergency preparedness plan, we missed that." A review of the Emergency Preparedness Binder revealed the hospice did not ensure that the emergency preparedness communication plan included contact information for the federal, state, tribal, regional, local emergency preparedness staff.

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; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. 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, observation, and interview. In 2 of 13 (15%) clinical records reviewed, the hospice did not ensure the medication profile was updated when new medications were added, or changes are made to existing medication(s). Clinical Record 2/Home Visit 2: During the home visit observation with Hospice Aides (HHA) (Personnel Record 3 and Personnel Record 8) on 01/29/2025, a medication review was completed by comparing the hospice medication profile to the patient's current home medications. The caregiver/daughter assisted with the medication review. The patient’s home medications included Fentanyl 25mcg patch-apply one patch every 72 hours, dated 01/17/2025 and Dexamethasone 2mg-take one tablet every morning by mouth, dated 01/17/2025. The caregiver/daughter confirmed the patient was receiving the Fentanyl and Dexamethasone. Fentanyl and Dexamethasone were not listed on the hospice medication profile reviewed on 01/29/2025. Clinical Record 3/Home Visit 3: During the home visit with the Social Worker (SW) (Personnel Record 6) on 01/29/2025, a medication review was completed by comparing the hospice medication profile to the patient's current home medications. The patient and spouse assisted with the review. The hospice medication profile reviewed on 01/29/2025 included Trelegy Ellipta 100mcg/62.5mcg-25mcg powder inhalation and Breztri Aerosphere 160mcg/9mcg-4.8mcg/actuation. The patient stated, "The hospice wanted me to start those, but I refused so they never sent them." During a joint record review and interview on 01/29/2025, the Clinical Director agreed the hospice medication profiles were not updated when changes were made in the patient’s medications. When reviewing Home Visit 3, the Clinical Director stated, "Yes we never sent the Trelegy or Breztri to the patient because the patient refused to take them after the doctor ordered them, these should have been discontinued." The Clinical Director also stated, "We need to provide more education to the nurses on visualizing the medications and keeping the medication list updated."

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, measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 13 (31%) clinical records reviewed, the hospice did not ensure the individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 12/13/2024, with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care dated 12/13/2024 to 01/30/2025 included a patient problem related to bowel regimen the associated goal documented, "patient/caregiver will report no bowel movement within _ [left blank] days to hospice." The goal on the plan of care was not measurable when it did not include the number of days for the patient to report a bowel movement. Clinical Record 2: The patient elected the hospice benefit on 11/19/2024, with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung. The plan of care dated 11/19/2024 to 01/30/2025 included a patient problem related to respiratory status, the associated goal documented, "patient will achieve optimal breathing patterns, airway patency and comfort." The goal on the plan of care was not measurable when it did not define the patient's optimal breathing pattern and comfort. Clinical Record 4: The patient elected the hospice benefit on 11/13/2024, with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care dated 11/13/2024 to 01/30/2025 included a patient problem related to pain, the associated goal documented, "patient will receive optimal level of pain." The goal on the plan of care was not measurable when it did not identify what the patient's optimal level of pain would be. Clinical Record 5: The patient elected the hospice benefit on 09/05/2024, with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care dated 09/05/2024 to 01/30/2025 included a patient problem related to respiratory status, the associated goal documented, "patient will achieve optimal breathing patterns, airway patency and comfort." The goal on the plan of care was not measurable when it did not define the patient's optimal breathing pattern and comfort. During a joint record review and interview on 01/30/2025, the Clinical Director agreed that the goals were not defined and measurable and stated, "We need to provide more education to the nurses."

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: The most recent hospice plan of care, Hospice election form and any advance directives, Physician certification and recertification of the terminal illness, Names and contact information for hospice staff involved in the patient’s care, Instructions on how to access the hospice’s 24-hour on-call system, Hospice medication information, and Hospice physician and attending physician (if any) orders. This standard was not met as evidenced by observation and interview. In 1 of 1 (100%) home visit observation for a patient that resided in a SNF (skilled nursing facility), the hospice did not ensure the SNF was provided with the hospice plan of care and physician certification of terminal illness. Home Visit 1: During the home visit observation on 01/29/2025 with the Registered Nurse (RN) (Personnel Record 5), the hospice binder in the SNF was reviewed jointly with the RN. The SNF's electronic chart with hospice documents uploaded was reviewed with the facility social worker and hospice RN. There was no documented evidence in the hospice binder and the facility electronic chart that the hospice plan of care and physician certification were provided to the SNF. During an interview on 01/29/2025, the Clinical Director agreed the plan of care and physician certification should have been provided to the SNF and stated, "We do not have any documentation to show it was done."