Every finding on record at Brighton Hospice Colorado, LLC

It is required that the hospice designates a registered nurse member of the IDG to: ensure continuous assessment of each patient’s and family’s needs. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that continuous assessment of the patient's needs occurred. CLINICAL RECORD 17: The patient elected the hospice benefit on 01/06/2025. On 11/12/2025, an Interdisciplinary Group (IDG) Meeting was conducted, during which it was determined that the patient had not had a bowel movement in four (4) days and was experiencing irregular bowel patterns. As a result, the patient was started on Senna-S to address constipation. Review of skilled nursing visit documentation dated 11/11/2025, 11/14/2025, and 11/18/2025 revealed no further assessment, monitoring, or follow-up documentation related to the patient’s constipation, bowel status, or response to the newly initiated bowel regimen. On 04/17/2026, during a joint clinical record review and interview, the Director of Clinical Quality confirmed that although the newly initiated medication was documented by the nurse, there was no evidence of documented follow-up after initiation. The Director acknowledged the absence of nursing documentation addressing the patient’s response, outcome, or effectiveness of the medication and agreed that additional follow-up documentation was expected and should have been completed to reflect appropriate monitoring and evaluation of the intervention.

It is required that each patient’s individualized written plan of care reflect the patient and family goals and identify planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, observation, and document review. 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that the patients' plans of care reflected identified problems based on assessment data, with planned interventions and patient-specific measurable goals. The hospice's policy "The Plan of Care" (No. 9-017) last revised 11/2024 read in part that "...The written plan of care will contain, but will not be limited to, the following...Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling...Individualized interventions to assist with end-of-life care...Statement of treatment goals and documentation of the progress of outcomes...Measurable outcomes anticipated from implementing and coordinating the plan of care...." The hospice's policy, "FACILITATING COMMUNICATION" (Policy No. 9-006; last reviewed 11/2024) read in part, "To assure that patients, visitors, and personnel with speech, vision, or hearing impairments, as well as those who have a limited command of the English language, have access to appropriate interpretive assistance and other aids at no cost to patient(s) being served, (agency name) will facilitate communication by using special devices, interpreters or other communication aides. The initial assessment will determine the patient's communication ability. If there is any question regarding the patient's ability to communicate properly, the assessment should stop and an interpreter should be secured. For hearing impaired patients: A. The admitting clinician ascertains the patient's preferred methods of communication, i.e., paper and pencil, lip reading, or sign language." The agency's policy "Care of the Dying Patient (No. 2-033)," dated 06/2022 and adopted 07/01/2024, reads in part that the "...Hospice interdisciplinary group members recognize the importance of each patient and family/caregiver’s unique and individual needs within the hospice setting." Within this framework, responsive and respectful care for the dying patient will be planned, implemented, and monitored in order to...identify secondary symptoms, determine the patient's response to treatment, and take action to limit them...An individualized plan of care will be developed in cooperation with the patient and family/caregiver, attending physician, and interdisciplinary group members, which facilitates: Prevention of secondary symptoms, including, but not limited to, nausea, vomiting, diarrhea, stomatitis, alopecia, GI disturbances, blood dyscrasia, etc... Monitoring of the response of secondary symptoms to treatment. With each patient visit, the hospice nurse will follow the plan of care and assess the need for changes/updates, and will document accordingly. Aspects of care that must be reflected in the clinical record, when applicable, include: Preventative and treatment/measures provided for secondary symptoms and/or pain/discomfort, and the response to treatment...." CLINICAL RECORD 3/HOME VISIT 3: The patient elected the hospice benefit on 02/12/2025 and resided in an Assisted Living Facility. On 04/14/2026, a skilled nursing visit note documented that the patient had severe hearing loss. During the observed home visit, conducted with the Social Worker (Personnel Record 7) on 04/16/2026, the use of a whiteboard was required to effectively communicate with the patient, confirming that the patient’s hearing deficit significantly impacted her ability to communicate verbally and necessitated assistive communication methods to participate in care discussions. Despite the documented severity of the patient’s hearing loss and the demonstrated need for alternative communication strategies, review of the patient’s plans of care for the benefit periods 02/07/2026 to 04/07/2026 and 04/08/2026 to 06/06/2026 revealed that the interdisciplinary care plans failed to identify severe hearing loss as a patient problem, did not include interventions to address the need for assistive communication such as use of a whiteboard and/or hearing aids, and did not establish any goals related to improving or accommodating effective communication. CLINICAL RECORD 15: The patient resided at home and elected the hospice benefit on 02/24/2026 with a terminal diagnosis of malignant neoplasm of the colon and secondary diagnoses of malignant ascites, thrombocytosis, and chronic pain, indicating a complex and high risk clinical profile. The patient revoked the hospice benefit on 03/03/2026 due to seeking aggresive treatment (total parenteral nutrition). During the Registered Nurse's admission visit on 02/24/2026, the following was documented: the patient was alert and oriented, with an Edmonton Symptom Assessment System (ESAS) score of 3/10 for nausea necessitating the initiation of Ondansetron, and the patient was prescribed multiple medications for pain, nausea, gastrointestinal management, fluid balance, and electrolyte replacement. The Interdisciplinary Group (IDG) meeting notes on 02/27/2026, nursing documented identified admission goals of comfort, absence of pain, and avoidance of hospitalization. The nurse further documented frequent nausea and vomiting, daily large volume drainage of malignant ascites ranging from 300–500 cc and resulting fluid shifts with electrolyte imbalances such as hypokalemia (3.2), which the nurse noted increased the patient’s risk for arrhythmias, falls related to muscle weakness, and bowel obstruction. The patient was further described as experiencing severe weight loss secondary to poor nutritional intake from persistent nausea and vomiting, decreasing mobility in the context of malignancy and thrombocytosis (476K), and a significantly elevated risk for blood clots without anticoagulation therapy. A review of the patient’s plan of care for the benefit period dated 02/24/2026 to 05/24/2026 revealed that despite these clinical findings and risks identified during both the admission assessment and IDG review, the patient’s plan of care did not clearly reflect the full scope of identified problems, coordinated and planned interventions to address persistent nausea and vomiting, nutritional decline, and the potential thrombotic risk or goals to measure progress for treatment.

It is required that each patient’s individualized written plan of care include all services necessary for the palliation and management of the terminal illness, including the following medical supplies and appliances to meet the patient's needs. This standard was not met as evidenced by clinical record review, and interview. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure documentation of all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances to meet the patient's needs. CLINICAL RECORD 12: The patient resided at an assisted living facility and elected the hospice benefit on 02/20/2026. On review of the clinical record, it was noted that the Registered Nurse visit on 04/08/2026, documented a 16Fr Foley catheter with a 30cc balloon was placed. There was no physician's order for the catheter, and the Foley catheter was not included in the plan of care for the initial benefit period dated 02/20/2026 to 05/20/2026. On 04/17/2026, during a joint clinical record review and interview, the Director of Clinical Quality acknowledged that the patient’s Foley catheter was not listed on the plan of care and that the corresponding physician order documentation was missing from the medical record. The Director confirmed that the Foley catheter should have been included on the patient’s plan of care and that the omission did not meet care planning and documentation requirements.

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. On 04/17/2026, during a review of the hospice’s Volunteer Program documentation and an interview with the Volunteer Coordinator (VC - Personnel Record 5), it was determined that the hospice did not ensure volunteers contributed at least 5% of the total patient care hours provided by paid hospice employees and contract staff, as required. Analysis of volunteer contribution data showed an average of 5.84% from January 1, 2024, through December 31, 2024, which declined to 4.46% from January 1, 2025, through December 31, 2025, and remained below the minimum requirement of 4.48% year-to-date for 2026. The Volunteer Coordinator confirmed that a QAPI Performance Improvement Project (PIP) was initiated on 07/01/2025 in response to declining volunteer hours, with interventions including monthly accountability meetings, incorporation of Social Work and Spiritual Care interns, and reallocation of staff duties to allow additional time for volunteer recruitment activities. Documented recruitment efforts included advertisements on volunteer recruitment and employment websites, participation in local health career fairs, outreach to a local university photography program to assess student interest in volunteering to photograph patients and families, partnership with a local pet therapy organization, and increased outreach to public health colleges. Planned retention initiatives included Volunteer Appreciation Week activities such as gift bags with hospice merchandise (T-shirts, cups, and treat bags), efforts to keep volunteers informed through regular care updates for patients they support, recognition of significant volunteer milestones or events, and individualized one-on-one “coffee talks” between the Volunteer Coordinator and volunteers. Despite these actions, the hospice has yet to meet the required percentage of volunteer service hours. On 04/17/2026, during a review of the hospice’s Volunteer Program documentation and an interview with the Volunteer Coordinator (VC) (Personnel Record 5), it was determined that the hospice did not ensure volunteers contributed at least 5% of the total patient care hours provided by paid hospice employees and contract staff, as required. Analysis of volunteer contribution data showed an average of 5.84% from January 1, 2024, through December 31, 2024, which declined to 4.46% from January 1, 2025, through December 31, 2025, and remained below the minimum requirement of 4.48% year-to-date for 2026. The Volunteer Coordinator confirmed that a QAPI Performance Improvement Project (PIP) was initiated on 07/01/2025 in response to declining volunteer hours, with interventions including monthly accountability meetings, incorporation of Social Work and Spiritual Care interns, and reallocation of staff duties to allow additional time for volunteer recruitment activities. Documented recruitment efforts included advertisements on volunteer recruitment and employment websites, participation in local health career fairs, outreach to a local university photography program to assess student interest in volunteering to photograph patients and families, partnership with a local pet therapy organization, and increased outreach to public health colleges. Planned retention initiatives included Volunteer Appreciation Week activities such as gift bags with hospice merchandise (T-shirts, cups, and treat bags), efforts to keep volunteers informed through regular care updates for patients they support, recognition of significant volunteer milestones or events, and individualized one-on-one “coffee talks” between the Volunteer Coordinator and volunteers. Despite these actions, the hospice has yet to meet the required percentage of volunteer service hours.

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. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the clinical record included physician orders. CLINICAL RECORD 17: The patient elected the hospice benefit on 01/06/2025. On 11/12/2025, an Interdisciplinary Group (IDG) Meeting was conducted, during which it was determined that the patient had not had a bowel movement in four (4) days and was experiencing irregular bowel patterns. As a result, the patient was started on Senna-S to address constipation. However, no physician order was entered to support the initiation of this medication. On 04/17/2026, during a joint clinical record review and interview, the Director of Clinical Quality confirmed that no physician order was present in the clinical record to authorize or support initiation of the medication.

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. In 2 of 19 (11%) clinical records reviewed it was revealed that the agency did not ensure that the patient's individualized written plans of care were updated based on new problems identified in the updated comprehensive assessments. The agency's policy, "Plan of Care", (PC:22) with the revision date of 10/1/2019 read in part: "The hospice plan of care is a document that describes both the palliative and supportive care to be provided by the hospice to the patient... as well as the manner by which the hospice will provide care. The care provided to the patient... shall be in accordance with the plan of care... The contents of the plan of care includes... objectives, interventions, and goals of treatment, based upon needs identified in a comprehensive patient assessment... Interventions are directed toward achieving the desired goals or outcomes in the plan of care and the responses of the patient... to the interventions... documentation related to the patient's plan of care identifies new problems." Clinical Record 14: The patient elected the hospice benefit on 2/25/2022. Documentation in the Face-to-Face visit note completed by the Nurse Practitioner on 4/18/2023, stated: "Pt has been struggling with recurrent symptomatic hypotension and often bradycardia- not uncommon for her systolic BPs to be in the 80-90 range and this still continues." A physician order dated 2/25/22 included orders for, "Midodrine HCl 5 MG Tab(s) Oral 1 tab Daily Hypotension", and the "Hospice Medication Profile" dated 4/7/23 listed Midodrine as an active medication for the patient. Also, in the "Hospice Nursing Clinical Notes" dated 4/28/2023 and 5/5/2023, the nurse identified "dizziness" in the cardiopulmonary section of the note. In the IDT Meeting notes dated 4/19/2023, 5/3/2023, 5/17/2023, and 5/31/2023, there was no documentation that described the patient's problem with hypotension and no goals and interventions identified to specifically address this symptom. Clinical Record 3: The patient elected the hospice benefit on 6/9/2022. In the 9/272022 "Hospice Clinical Nursing Note," the nurse documented: "...facility nurse alerted this RN the patients BLE were edematous. This RN assess pt, who was in bed, supine, and noted pt was tearful, and did not allow this RN to touch her bilateral lower extremities... Facility nurse and NP reported this is a new occurrence for this patient. RN notified 'NP'... stated she will see patient the following day. " In the Interdisciplinary Meeting Note (IDT) dated 9/28/22, it was documented: "IDT team including Physician, Pt, caregiver and IDG collaborated on POC. Updated Below. All agree with POC. Medications reviewed by MD.." There was no identification of the new symptom of edema and no interventions or goals documented to address the new symptom. Documentation in the 10/2/2022 "PRN Progress Note," stated: "RN asked by Triage nurse to visit pt to assess increased edema. RN checked in with facility nurse Christina who reports she noticed increased edema to le's and to left ue... Skin on upper extremity does appear to have some mild fluid accumulation. Le's are 2-3 + on ankles and tops of feet." In the "Hospice Clinical Nursing Note," dated 10/4/22, the RN documented: "...edema to BLE is unchanged - RN to contact NP again, because after 7 - 10 days of this edema, there has been no change, and pts L arm appears slightly edematous." In the IDT Meeting Note dated 10/12/2022, it was documented: "IDT team including Physician, Pt, caregiver and IDG collaborated on POC. Updated Below. All agree with POC. Medications reviewed by MD." A new medication entry, "Furosemide (Lasix) 20 MG Tab(s) Oral 1 tab Daily X 14 days X 14 days New Hospice Covers: Y Start Effective Date: 10/05/2022 Discontinued Date: 10/20/2022", was included on the medication list, however, there was documentation present that described the identified problem of the edema and no interventions or goals developed that were specific for this symptom. During an interview with the Director of Clinical Services on 6/7/2023 and joint review of the documentation, it was confirmed that the new onset issues of hypotension and edema were not specifically identified or addressed with interventions or desired goals for treatment for these patients.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 3 (33%) clinical records reviewed in which bereavement services were provided it was revealed that the agency did not ensure that the bereavement plan of care was initiated within the fifteen-day time period after a patient's death as set forth by the agency's policy. The agency's policy "Plan of Care" (PC:22), with the revision date of 10/1/2019, stated in part: "Bereavement Plan of Care... the hospice core team shall review and update the bereavement plan of care, at a minimum: fifteen calendar days following the patient's death." Clinical Record 3: The patient elected the hospice benefit on 6/29/2022 and passed on 10/30/2022. The nurse completed the death pronouncement visit on 10/30/2022, and the last care coordination note was dated 10/30/2022 and documented when the nurse was called for patient's death. The Bereavement Assessment/Initial Care Plan was dated as opened on 12/9/2022, which was the first documented contact made with the patient's family, 40 calendar days after the patient's death and included documentation of bereavement care plan interventions to be initiated at designated time points. During an interview with the Director of Clinical Services on 6/7/2023 and a joint review of the policy and the record in question, they confirmed that this Bereavement Plan of Care was initiated outside the agency's fifteen-day timeline outlined in their policy.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. In 5 of 16 (31%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure that the hospice aide care plans included documentation of the required instruction by the RN for how the hospice aide should handle the patient's oxygen or wound dressings during care. Clinical Record 14: The patient elected the hospice benefit on 2/25/2022. The nurse documented in the "Hospice Nursing Clinical Note" dated 5/2/2023 that the patient had dyspnea and was on oxygen at 2.5 liters per minute (LPM) per nasal cannula (NC). Documentation in the "Hospice Nursing Clinical Note" dated 5/22/2023 stated, "Pt is O2 dependent continuous 2L-3L. Pt noted to be dyspneic both at rest and upon minimal exertion. Pt is mostly bedbound". During the home visit observation (Home Visit 1) with the hospice aide (Staff 10) on 6/6/23, the aide verbalized that she removed the patient’s oxygen for the patient's shower, and the nurse is aware that the oxygen was removed for care. Documentation on the "Hospice Aide Assignment" dated 5/4/2023, included areas to address management of the patient's oxygen under the areas titled, “Precaution/Safety” and “Special Instructions”. There was no documentation completed by the RN in these sections that described the aide's interventions related to the patient's oxygen use and if the patient's oxygen could be removed or not while providing care. Clinical Record 13: The patient elected the hospice benefit on 3/18/2023. In the "Hospice Nursing Clinical Note" dated 4/7/2023, the nurse documented that the patient had two wounds. Wound number 1 was documented as a stage 2 sacral pressure ulcer, and wound number 2 was a left heel stage 2 pressure ulcer. "Mepilex applied by wound care nurse" was documented as well. A physician order for sacral wound care stated: "Hospice nurse to apply mepilex to sacral wound, change weekly. Facility nurse to apply mepilex to sacrum as needed if soiled/loose." A physician order dated 3/21/2023 was also present for treatment to the left heel wound care: "hospice and facility nurse to keep covered with mepilex and change weekly or PRN if soiled." Documentation was present on the "Hospice Aide Assignment" dated 4/7/2023, that stated in the section titled, "Precautions/Safety" and "other: patient has wounds". There was no documentation completed by the RN that provides instruction for the aide on what to do should the dressing on either wound become wet, loose, or soiled. Clinical Record 3: The patient elected the hospice benefit on 6/29/2022. The hospice physician's certification of terminal illness dated 6/29/2022 documented that the patient had a history of chronic respiratory failure and was on 3 liters per minute of oxygen. In the "Hospice Nursing Clinical Note" dated 8/17/2022, the nurse documented that the patient was on 4 liters per minute (LPM) of oxygen per nasal cannula (NC). The "Hospice Aide Assignment" dated 8/22/2023, has areas titled, “Precaution/Safety” and “Special Instructions”, to address oxygen use and instructions for the aide to follow. The box for "Oxygen safety" was checked and an entry stated, "oxygen use: 3 L per nasal cannula". There was no documentation of specific instructions to direct the aide regarding if the oxygen may be removed during the shower. Clinical Record 6: The patient elected the hospice benefit on 6/1/2022. In the "Hospice Nursing Clinical Note" dated 4/4/2023, the nurse documented: "Continued encouraging patient to utilize PRN morphine and nebulizer treatments for SOB. Utilizing 0 morphine syringes, still 6 syringes remain available... Remains on 6L O2." Also, documentation in the "Hospice Nursing Clinical Note" dated 5/22/2023, stated: "...continues to appear to be much more SOB at rest and very fatigued at any activity... continues on 6L O2." The "Hospice Aide Assignment" dated 5/25/2023, had areas titled, “Precaution/Safety” and “Special Instructions”, to address oxygen use and instructions for the aide to follow. The boxes for "Oxygen safety" and "other" were checked and an entry stated, "continuous NC". The entry under "Special Instructions" stated, "Oxygen: 6-8 L continuous NC" was documented; however, the nurse did not document if the oxygen could be removed by the aide during any part of the patient's shower. Clinical Record 9: The patient elected the hospice benefit on 2/13/2023. In the "Hospice Nursing Clinical Note" dated 4/11/2023, the nurse documented that the patient was on 4 liters per minute (LPM) of oxygen per nasal cannula (NC), and in the "PRN Progress Note" dated 5/11/2023, the nurse documented that the patient was using increased oxygen at 7 LPM NC. In the "Hospice Aide Assignment" dated 5/8/2023, under the areas titled “Precaution/Safety” and “Special Instructions”, both sections have an area for oxygen to be addressed. The box for "Oxygen safety" was checked and under “Special Instructions” an entry stated, "Oxygen: Pt on 4 L" was documented. In the “Special Instructions” area, the nurse did not document if the oxygen could be removed by the aide during any part of the patient's shower. During an interview with the Director of Clinical Services on 6/7/2023, it was confirmed that the RN provided no instructions on the aide care plans to direct the aides on how to manage the patient's oxygen during care or instruction for what the aide should do if the patient's dressing became wet, soiled or loose.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 3 of 13 (23%) personnel records reviewed in which a competency assessment for field staff was required, it was revealed that the agency did not ensure that all staff providing care to patients had a skills competency assessment documented as completed in their personnel record, as described in the agency's policy. The agency's policy, "Competencies" (HR: 13), with the revised date of 5/13/2020, read in part: "The agency will provide for competency assessment by qualified individuals. The agency may determine competency in one of the following ways: successful completion of multiple choice test, specific to specialty, competency assessments are accomplished by either demonstration, observation, written test, or verbally... the agency will assess and document staff competency once a year... professional healthcare personnel that provide care to Agency patients will have their competency reviewed by their prospective peers at least once every year... staff competence is assessed during orientation, prior to working independently within the 90-day orientation and annual performance evaluations." The agency policy, "Performance Evaluations" (HR: 16), with the effective date of 8/1/2019, read in part: "An annual written performance evaluation process is completed on all employees... and includes... on site evaluation reports/competency testing for clinical/field/service staff...". Personnel Record 12: The personnel record for this Massage Therapist, with a date of hire of 9/9/2021, did not have evidence of a completed 90-day or annual competency assessment present in the personnel file, as described in the agency's policy. Personnel Record 15: The personnel record for this Hospice physician, with a date of hire of 3/16/2021, did not have evidence of a completed 90-day or annual competency assessment present in the personnel file. as described in the agency's policy. Personnel Record 14: The personnel record for this Hospice Medical Director, with a date of hire of 2/1/2021, did not have evidence of a completed 90-day or annual competency assessment present in the personnel file. as described in the agency's policy. In an interview and review of personnel record findings with the Administrator, Corporate Compliance Officer, and the Director of Clinical Services on 6/8/2023 they confirmed that there were no documented competency assessments present in the identified personnel records and no additional documentation was provided prior to the end of the site visit.