Every finding on record at Canyon Colorado Home Care & Hospice LLC

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 418.56, IDG Care Planning, Coordination of Services (Condition) was out of compliance. --- A total of 8 clinical records were reviewed for compliance with the Condition and Standards for Core Services. Record review revealed a pattern of failures in regard to the hospice agency ensuring an appropriate system of communication and integration was maintained. Specifically the hospice interdisciplinary group (IDG) failed to ensure only qualified caregivers administered medications to patients. These failures had the potential to affect all patients served by the hospiceL0536 - Based on interview and record review, the hospice failed to maintain an appropriate system of communication and integration to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided. Specifically, this failure resulted in unqualified caregivers administering medications, including controlled substances, without hospice oversight or documentation, which prevented the IDG from fulfilling its regulatory duty to coordinate and supervise all care and services for 2 of 4 hospice patients who resided in an assisted living residence (Patients #1 and #2).

Based on interview and record review, the hospice failed to maintain an appropriate system of communication and integration to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided. Specifically, this failure resulted in unqualified caregivers administering medications, including controlled substances, without hospice oversight or documentation, which prevented the IDG from fulfilling its regulatory duty to coordinate and supervise all care and services for 2 of 4 hospice patients who resided in an assisted living residence (Patients #1 and #2).Survey findings and ongoing investigation showed the hospice agency failed to maintain an appropriate system of communication and integration to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided. The state agency (SA) determined these failures posed an immediate potential risk to the health, safety, and welfare for all patients served by the hospice agency on 10/28/25 at 4:45 p.m. the hospice agency was advised these failures created a situation of Immediate Jeopardy. The hospice agency submitted a plan to remove the Immediate Jeopardy which was accepted by the SA on 10/29/25 at 1:41 p.m. The Immediate Jeopardy was determined to be remediated by the SA on 10/30/25. --- Findings include: 1. A review of the hospice policy titled, “Administration of Patient Medications” dated 2/7/25, reads in pertinent parts:“Medications required for home care management are administered by the patient's family, primary caregiver, or licensed nursing personnel. Nurses will check on the appropriate administration.”2. The clinical record for Patient #1 was reviewed on 10/28/25. The patient was admitted to hospice care and services on 10/1/25 with a terminal diagnosis of severe protein-calorie malnutrition. The plan of care for the certification period dated 10/1/24 to 12/29/25 included orders for skilled nursing services three times per week, skilled nursing ten as needed visits for unmanaged symptoms, and nursing aide services two times per week.a. The hospice agency failed to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided which resulted in unqualified caregivers administering medications to Patient #1.Review of Patient #1’s record revealed medication orders dated 10/1/25 for 0.5 milliliter (mL) of lorazepam to be administered orally every four hours and 0.75 mL of morphine to be administered sublingually every two hours. During record review on 10/28/25 an initial hospice agency comprehensive assessment was completed by RN #2 on 10/1/25. Patient #1 was shown to reside in memory care at an assisted living residence. Under the section for medication administration and management, Patient #1 was assessed as not being able to self-administer medications. Under the section for support system,  caregivers from a non-medical agency were listed which could assist with medication prefilling/administration. Review of Patient #1’s comprehensive assessment failed to reveal an assessment of the qualifications of the caregivers for administering medications prescribed by the hospice agency. Record review revealed a narrative note documented by RN #1 on 10/2/25 at 12:58 a.m. which showed a call from the manager of Patient #1’s caregiver on behalf of her family for concerns of unresolved discomfort. Record review revealed RN #1 called the patient and spoke to the caregiver. During this call, the caregiver provided information on administered morphine and lorazepam as scheduled within the prior 90 minutes of the manager’s call to RN #1. Review of the narrative note revealed RN #1 provided medication administration directions over the phone. RN #1 instructed the lorazepam dose to be increased to 0.5 mL and given immediately then every four hours. Further review of the narrative note revealed RN #1 provided a caregiver to give as needed medication administration over the phone prior to assessing the qualifications of the caregiver. RN #1 instructed the lorazepam dose to be increased to 0.5 mL and given immediately then every four hours. An interview completed on 10/28/25 at 11:08 a.m., RN #1 confirmed the caregiver was on the phone when the medication instructions were given to increase and administer 0.5 mL of lorazepam over the phone to the caregiver for Patient #1. Record review revealed a narrative note dated 10/2/25 at 4:21 a.m. from RN #1. Documentation showed an in person RN visit was completed on 10/2/25 for Patient #1. During the visit, Patient #1’s son expressed concern regarding unmanaged pain. Record review revealed medication orders dated 10/2/25 for 0.5 mL of lorazepam every hour and 1 mL of morphine every hour. Further review revealed the caregiver was educated on the medication order changes.During an interview conducted on 10/28/25 at 11:08 a.m. RN #1 stated a medication log book was kept with the patient. RN #1 indicated the time, dose, and who administered the medication should be found on the medication log. Additionally RN #1 revealed she was not aware of the location of the medication log book for Patient #1.3. The clinical record for Patient #2 was reviewed on 10/28/25. The patient was admitted to hospice care and services on 9/8/25 with a terminal diagnosis of degeneration of the autonomic nervous system. The plan of care for the certification period dated 9/8/25 to 11/6/25 included orders for skilled nursing services two times per week, nurse aide services two times per week, medical social worker services one time a month, and speech therapy one time a week.a. The hospice agency failed to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided which resulted in unqualified caregivers administering medications to Patient #2.Review of Patient #2’s record revealed Patient #2 resided in an assisted living residence. Record review revealed a comprehensive assessment was completed on 9/8/25 by RN #2. The section labeled medication administration indicated Patient #2 was unable to safely self-administer medications. Assisted living residence staff were to assist Patient #2 with medication administration.Record review revealed narrative notes for visits dated between 10/3/25 to 10/13/25 indicated Patient #2 was declining. A narrative note dated 10/3/25 by RN #2 revealed Patient #2 was disorientated to place, time, and events. An order to increase skilled nursing visits to three times per week was received. Review of medication orders revealed an order for acetaminophen 1000 mg every eight hours for three days starting 9/30/25 and ending 10/2/25. A second order for acetaminophen 1000 mg three times a day as needed had a start date of 9/9/25 and a discontinued date of 9/30/25. No additional orders for acetaminophen were revealed. Review of a narrative note dated 10/4/25 at 8:25 p.m. revealed a request made by a quality medication administration person (QMAP) from assisted living residence for medication for Patient #2. Documentation shows the QMAP stated Patient #2 was having symptoms of confusion and requested an order for lorazepam. Further review revealed RN #3 instructed the QMAP to provide Patient #2 with acetaminophen. RN #3 documented no visit was requested. According to record review, Patient #2 did not have a current order for acetaminophen on 10/4/25.Review of a scheduled visit note on 10/6/25 at 4:19 p.m. RN #2 revealed Patient #2 was minimally responsive. RN #2 documented pain and discomfort of 7/10 on the non-verbal pain scale. An order for Fentanyl 12 micrograms (mcg) was received. According to the visit note, RN #2 discussed with Patient #2’s family bringing in private caregivers to ensure patient safety and to ensure Patient #2 would be able to have medications administered to him after he becomes unresponsive. The visit note indicated a non-skilled home health agency would meet with the family that day. Record review revealed an order to increase skilled nursing visits to once daily on 10/6/25. An order for 2 mg of loperamide given as needed for diarrhea with a start date of 9/9/25. An order for 0.25 mL of morphine every 2 hours with a start date of 10/7/25. An order for 0.25 mL of lorazepam every four hours as needed to be administered by the hospice nurse to start on 10/10/25.Record review of Patient #2 revealed private caregivers from a non-skilled agency were providing care on 10/8/25. RN #2 directed assisted living QMAP and private caregivers to apply barrier cream to Patient #2. Review of the record revealed a visit note dated 10/8/25 at 11:18 a.m. revealed RN #2 directed the assisted living residence QMAP to administer as needed loperamide for diarrhea. An interview conducted on 10/28/25 at 11:50 a.m. RN #2 stated that the non-skilled agency caregivers could administer medications to unresponsive patients. RN #2 confirmed non-skilled agency caregivers hired to provide care for Patient #2 administered medications as directed by hospice orders. Additionally, RN #2 stated hospice RN’s usually took pictures of the medication log to keep with each patient’s chart. RN #2 was unable to provide Patient #2’s medication log.4. On 10/28/25, a request for medication administration logs for Patients #1 and #2 was made to the hospice administrator and director of nursing (DON).During an interview completed on 10/28/25 at 10:28 a.m. the administrator and DON do not keep track of who gives the hospice patients medications. Per the DON, the hospice agency did not give medications directly once they were in a patient’s home environment. Therefore, the agency did not keep track of who is administering the medications.During an additional interview conducted on 10/28/25 at 11:50 a.m. RN #2 revealed medications ordered to be given as needed would sometimes include instructions for the assisted living residence QMAPs to call the hospice nurse. RN #2 stated not all of the phone calls for these medications result in an in-person visit. RN #2 indicated PRN medications can be given by an assisted living residence QMAP without a hospice RN assessment. During an interview on 10/28/25 at 4:45 p.m. the compliance officer (CO) stated the hospice agency relied on outside staff to meet the needs of patients. Further interview indicated the hospice agency failed to coordinate with outside agencies on the administration of medications by qualified staff.An interview completed on 10/28/25 at 11:08 a.m., RN #1 revealed personal care givers employed by a non-medical agency were directed by hospice RNs to administer medications to Patient #2.

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, document review and interview. In 1 of 5 (20%) clinical records reviewed the agency did not ensure that plan of care included individualized interventions based on problems identified in the initial or updated comprehensive assessment. AGENCY POLICY: O-06 Plan of Care Content [reviewed 02/07/2025] stated in part: " Planned Interventions: Including what services are provided, by whom, with what frequency, and what actions are expected to take plan. Hospice service interventions include: an explanation of the palliative care focus at time of admission to services. Evaluating patient /family's ability to understand information and caregiver routines. CLINICAL RECORD 1: The hospice benefit of election was 10/01/2025 with a primary diagnosis of severe protein calorie deficient malnutrition. There were orders for all the care provided. The patient arrived home from the hospital and was admitted in the am with oxygen, a foley catheter and a pain level of 10/10. Morphine and lorazepam were administered during the visit and the patient slept through most of the visit. At the end of visit morphine and lorazepam doses were repeated and patient repositioned. The patient reported no pain at this time. The plan of care dated 10/01/2025 did not document interventions for the oxygen, pain related to the foley catheter, or imminent death which was documented on the initial comprehensive assessment. Additionally, the fall risk score was 10 with 4/10 categorized as a fall risk. There were no interventions documented for the fall risk. The initial comprehensive assessment also documented a skin tear on the left forearm and an abrasion on right elbow. There were no documented interventions. During interview with the Hospice Clinical Director on 10/31/2025 stated that the staff had 24 hours to complete the paperwork. She stated the plan of care had not been completed.

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. 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. 2 of 3 (67%) home visits revealed the agency did not ensure the patient's medication profile contained the patient's current prescription and over-the-counter (OTC) drugs. The agency's policy #N-31, "Medication Management" (reviewed 1/11/2023), stated in part, "At the time of admit, the comprehensive assessment shall include a review of all current medications, including over-the-counter (OTC) medications …. All current medications will be listed in the clinical record or medication profile, including OTC drugs, herbal remedies, vitamins, and minerals...Medications lists are updated for each change to reflect current medications, new and/or discontinued medications. Home Visit 1: The patient elected hospice care on 2/21/2023. During the home visit on 3/15/23, the caregiver reported giving the patient Miralax as needed (PRN). Miralax was not included on the agency's medication profile. The agency's medication profile documented the patient's current medications: "Propranolol forty (40) mg tablet. take one tablet three (3) times daily; Atorvastatin Calcium forty (40) mg. take one tablet orally once a day; Lisinopril forty (40) mg. take one tablet orally daily; Amlodipine ten (10) mg. take one (1) tablet orally daily. The caregiver reported that the patient took no medication daily. There was no evidence of Propranolol, Atorvastatin Calcium, Lisinopril, or Amlodipine in the home. The agency's medication profile did not include the patient's current medications. Home Visit 2: The patient elected hospice care on 3/7/2023. During the home visit on 3/15/23, a review of the patient's medications with the Clinical Manager revealed the Assisted Living Facility (ALF) medication profile documented the patient's current medications: " Amlodipine five (5) mg. take one tablet daily; polyethylene glycol 17 grams mix with eight (8) ounces of fluid and take orally every day." The agency medication profile did not contain Amlodipine or Polyethylene glycol. During an interview and a joint record review on 3/15/2023, the Clinical Manager confirmed the medication profiles were not accurate and up-to-date.

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, document review, and interview. 1 of 3 (33%) records reviewed where hospice aide services were accepted revealed the agency did not ensure a specific aide was assigned to each hospice patient by the RN. The agency's policy #N-08, "Assignment of CNA/HHA or Homemaker"(reviewed 1/11/2023), stated in part, " Aides/ Homemakers will review the care plan prior to delivery of care to the indicated patient...." Clinical Record 3: The patient elected hospice care on 2/20/2023 with a diagnosis of Alzheimer's Disease. A clinical record review revealed that the patient received a hospice aide visit on 2/20/2023. However, the Registered Nurse (RN) did not assign the patient to the hospice aide until 2/22/2023. During an interview and a joint record review on 3/14/2023, the Clinical Manager confirmed the RN did not assign a specific aide to provide care until 2/22/2023.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 3 (33%) clinical records reviewed where hospice aide services were accepted revealed the agency did not ensure that the aide provided services ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 3: The patient elected hospice care on 2/20/2023 with a diagnosis of Alzheimer's Disease. A clinical record review revealed the hospice aide completed a visit on 2/20/2023. The narrative section of the hospice aide visit note on 2/20/2023 stated, " Not all tasks completed CM notified." However, the Interdisciplinary Group (IDG) did not order hospice aide services until 2/22/2023. During an interview and a joint record review on 3/14/2023, the Clinical Manager confirmed the hospice aide made a visit on 2/20/2023 without an aide care plan in place.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by interview and observation. The hospice did not ensure that medical supplies were checked for expiration dates and removed from the supply room. An inspection of the medical supply room with the Alternate Clinical Manager on 3/14/2023 revealed the following expired items: five (5) bottles of Dr. Easy Hand Sanitizer wipes with an expiration date of 10/13/2022; three (3) non-adherent Telfa pads with an expiration date of 11/1/2022; seventy-five (75) yellow top lab tubes with an expiration date of 7/5/2022, and four (4) Endoform natural dermal template with an expiration date of 1/31/2023. The expiration dates for all medical supplies were not checked. During an interview and a joint inspection of the supply room on 3/14/23, the Alternate Clinical Manager confirmed the supplies were expired. An inspection of the medical supply room on 3/14/2023 revealed the agency did not verify expiration dates for medical supplies. The following expired items were revealed: five (5) expired bottles of Dr. Easy Hand Sanitizer wipes with an expiration date of 10/13/2022, three (3) non-adherent Telfa pads with an expiration date of 11/1/2022, and seventy-five (75) yellow top lab tubes with an expiration date of 7/5/2022, and four (4) Endoform natural dermal template with an expiration date of 1/31/2023.