Every finding on record at Colorado Palliative & Hospice Care, LLC

Based on record review and interview, the hospice interdisciplinary group (IDG) failed to determine the ability of the patient and/or family to safely self-administer drugs and biologicals for 14 of 14 sample hospice patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). --- Findings include:Fourteen sample hospice patient clinical records were reviewed from 5/18/26 through 5/20/26. Complete medical records for the fourteen patients, including initial, comprehensive, and updated assessments, plans of care, clinician notes, home visit encounters, coordination of care notes, physician orders, admission documentation, attachments to the medical records, and Interdisciplinary Groups (IDG) meeting notes, were reviewed.a) The hospice IDG failed to determine the ability of the patient and/or family to safely self-administer medications.Review of fourteen sample clinical records did not reveal documentation of the patients’ or their families’ abilities to safely self-administer medications.During an interview on 5/20/26 at 10:00 a.m., the hospice Director of Nursing (DON) confirmed the hospice medical records did not contain documentation regarding the ability of the patient and/or family to safely self-administer medications. The DON stated the information was discussed during IDG meetings, but was not documented in the medical record.

Upon patient record review, 1 of 19 (Patient #8) did not contain evidence that the patient had received effective pain management and symptom control from the Hospice, for conditions related to the terminal illness: Patient #8: During the SN visit dated 12/08/23 the nurse documented, "Dr. Singh notified of patient complaint of increased pain, left knee painful and swollen, severe pain/back spasms." There was no written order obtained, nor entered into the Medication Profile, regarding this pain management need and implementation until 12/12/23.

Upon patient record review 1 of 19 (Patient #13) did not contain evidence that the Hospice Interdisciplinary Group, in consultation with the individual's Attending Physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of Hospice care: Patient #13: There was no documented evidence that after the RN completion of the Initial Assessment, that the initial IDT POC was established with at least one other member of the IDG Team. The section of the EMR intended for such documentation had been left blank.

Upon patient record review, 1 of 19 (Patients #13) did not contain evidence that the Comprehensive Assessment included 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 post death Bereavement Plan of Care: Patient #13: There was no Bereavement Risk Assessment conducted/documented within 5 days of admission.

Upon patient record review, 1 of 19 (Patient #8) did not contain evidence that a Registered Nurse was designated to ensure continuous assessment of the patient and family's needs, and to coordinate activities with other members of the Interdisciplinary Group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family member: Patient #8: On the 12/04/23 SW visit, the SW notes, "Patient has urinary burning and and urgency. Notified RN." The RN made a visit on 12/05/23 to follow up, wherein she documents that, "The patient wants to try using cranberry juice before having a Physician order medication for these urinary symptoms." The next SN visit was made on 12/08/23. This visit note did not reference any further follow-up/assessment of the patient's urinary status.

Upon patient record review, 1 of 19 (Patient #8) did not contain evidence that the Hospice had developed an individualized written plan of care for each patient. The Plan of Care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions: Patient # 8: The 12/01/23 SOC Physician CTI noted, "pitting, lower extremity edema." There were no problems or interventions on the POC addressing this symptom of concern.

Upon patient record review, 1 of 19 (Patient #14) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, to include: A detailed statement of both the scope and frequency of services necessary to meet the specific patient and family needs: Patient #14: The POC dated 10/16/23 listed Volunteer services to be provided at a frequency of "Volunteer 1 p.r.n. per patient/caregiver needs", without a baseline visit frequency having been established.

Upon patient record review, 3 of 19 (Patients #1, 2, and 3) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: During surveyor-attended home visit on 01/03/24 it was noted that the patient had the following DME: Commode and Shower Chair. These were not included on the current POC. Patient #2: During surveyor-attended home visit on 01/03/24 it was noted that the patient had the following DME: Hospital bed. This was not included on the current POC. Patient #3: During surveyor-attended home visit on 01/03/24 it was noted that the patient had the following DME: Hospital bed and Shower Chair. These were not included on the current POC.

Upon patient record review, 2 of 19 (Patients #1, 5) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment(s): Patient #1: The POC as of 11/14/23 included, "SN to to monitor/assess skin breakdown, location, size, etc ... and instruct patient/caregiver on proper care of impaired skin." This order does not include the details of such impaired skin treatment of, "Wash with wound cleanser and apply barrier cream." Spiritual care/services were refused effective 10/29/23. The POC as of 01/03/24 continued to include both an incorrect frequency and scope for Spiritual care/services. Patient #5: The SN visit on 01/02/24 noted, "Skin intact." Yet the POC as of 01/04/24 continued to list, "Assess wound for status. Measure wound first visit of the week."

Upon patient record review, 3 of 19 (Patients #2, 7, and 12) did not contain evidence that the IDG had ensured that care and services were provided in accordance with the Plan of Care: Patient #2: The 05/17/23 POC did not include any scope or frequency for Volunteer services. Yet a Volunteer made visits on 05/24, 05/26, 06/02, 06/16, and 06/30/2023. The Hospice POC included and order, effective from 06/16/23, for, "Irrigate Foley with 60 ml NS once a week and p.r.n increased sediment." This intervention was not completed the weeks of 12/17/23 nor 12/24/23. Patient #7: The POC ordered an SN visit frequency, effective 12/01/23 as, "2 x per week x2." There was only one (1) visit made the week of 12/03-12/09/23. Patient #12: The POC effective 12/13/23 ordered SN visits at a frequency of 2x per week x2 weeks. The week of 12/17-12/23/23 there was only (1) visit made.

Upon personnel record review, 1 of 12 (Personnel #8) did not contain evidence that an Aide Skills Competency Assessment had been conducted, which included all CMS-required content, as follows: Personnel #8: Was hired 12/28/22, and provided her first independent patient care/services on 02/22/23. A Skills Competency Assessment was conducted by an RN on 02/18/23. However, the following skills/tasks were not evaluated for/documented for competency: • Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other Hospice staff. • Observation, reporting, and documentation of patient status and the care or service furnished • Basic elements of body functioning and changes in body function that must be reported to an Aide's supervisor • Recognizing emergencies and knowledge of emergency procedures and their application • The physical, emotional, and developmental needs of and ways to work with the populations served by the hospice,

Upon patient record review 5 of 19 (Patient #1, 2, 3, 4, and 10) did not contain evidence that the Hospice Aide had provided care/services that were: • 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 #1: The last Aide services were provided on 11/07/23. This same POC continued to include an expired frequency and scope for Aide care/services. Patient #2: The IDG POC effective 11/29/23 included, "Aide 3x per week x 8 weeks." There were only x2 Aide visits the week(s) of December 3-9, December 11-14, and December 24-30, 2023. Patient #3: The POC included, "Aide 2x per week x 13 weeks." There were x3 Aide visits the week of December 3-9, and there were no Aide visits the week of December 10-16, 2023. Patient #4: The POC included, "Aide 2x per week." There were no Aide visits the week of December 10-16, 2023. Patient #10: The current POC orders Aide services at a frequency of 2x per week beginning 12/24/23. There were no Aide visits located in the record. The Aide was contacted during survey by the Hospice Clinical Manager. The Aide reported that at the date of the first attempted Aide visit, the patient refused Aide services. Aide stated that he reported to the RN that the Aide was not needed at this time. Aide orders remain on the 12/27/23 Hospice POC.

Upon patient record review 1 of 19 (Patient #9) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #9: The Aide was ordered 2x per week. The Aide made visits on 11/21/23 and 11/24/23 and the patient refused personal care/services. On the 11/24/23 visit the Aide documents that the patient's daughter states, "The patient is refusing personal care services. She had not bathed for five years. Family would like for the Aide to continue to come to the home and 'offer' these services, but if patient refuses, for the Aide to remain and interact otherwise with the patient," There is no documentation indicating that the Aide had notified the RN after the 11/21/23 visit of this situation. The IDG POC dated 12/27/23 continued to include Aide 2x per week, with multiple personal tasks assigned. Aide services were not being provided as ordered.

Upon patient record review, 2 of 19 (Patients #7 and 8) did not contain documented evidence that a Registered Nurse had made an on-site visit to these patients' homes, no less frequently than every 14 days, to assess the quality of care and services provided by the hospice Aide and to ensure that the services ordered by the Hospice Interdisciplinary Group meets the patient's needs: Patient #7: The first Aide visit was made on 12/07/23. The first completed/documented Aide Supervisory Visit was made on 12/12/23, and then not again until 01/01/24. Patient #8: The first Aide visit was made on 12/12/23. The first completed/documented Aide Supervisory Visit was made on 12/14/23, and then not again until 01/02/24.

Upon patient record review, 1 of 19 (Patient #7) did not contain evidence that each patient record contained their Advance Directives: Patient #7: The POC reflected that the patient had a DPOA-Healthcare. There was no copy in the clinical record.

Upon patient record review, 3 of 19 (Patients #2, 3, and 4) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated, in accordance with the organizations policies and procedures and currently accepted standards of practice: Patients #2 and 3: All entries in these records by Aide (SC) did not include this Aide's credentials. Patient #4: All entries in the record by Aide (SY) did not include this Aide's credentials.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 3 of 5 (Patient #2,3,4) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #2, Patient had chest pain documented as lasting for hours on visit 10/13/23 and 10/23/23, no evidence of pain assessment completed. Patient #3, SN visit on 9/27/23 documents patient has moderate pain 4-6 on pain scale of 0-10. No evidence of managing pain. Patient only medication is Gabapentin 400mg 1x/day. Patient has a stage 3 decub on sole of right foot documented on initial comprehensive assessment. Progress note by provider states left foot ulceration with necrosis of muscle. Patient #4, 6/19/23 RN received orders for Transdermal patch 12.5mg change every 72 hours, D/C MS Contin 15mg every 12 hours on 6/19/23, D/C Hydrocodone/acetaminophen 10-325mg 1 tab every 6 hours PRN on 6/19/23 and morphine 20mg/ml 5mg every 4 hours PRN d/c on 6/20/23. On 6/19/23 RN documented terminal restlessness. On 6/20/23 RN documented patient restless and agitated, mottled and jerking. Pain assessment documented as unable to assess.

Upon patient record review, 3 of 5 (Patient #1,2,3) 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 #1, Patient is receiving chemotherapy for leukemia, no evidence of chemotherapy agent noted on medication profile. Patient #2, Order obtained 10/17/23 for morphine 20mg/ml 5 mg every 4 hours as needed for pain/shortness of breath. Nitro 0.4mg 1 tab sl every 5 minutes as needed for chest pain. No evidence of these medications on medication sheet. Patient #3, SN visit 9/30/23 documents RN applied triple antibiotic ointment to wound however, there was no evidence of triple antibiotic ointment on medication profile.

Upon patient record review, 1 of 5 (Patient #1) 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 #1, There was no no evidence of bereavement assessment was completed.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 4 of 5 (Patient #1,2,3,4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1, No measurement of wounds on initial comprehensive visit. Patient has right outer ankle wound and right calf wound. Patient #2, Patient on oxygen 3l/nc cont, no evidence of assessment of oxygen on initial comprehensive visit. Patient #3, SN visit assessed pain and skin only, no measurement of wounds. Patient #4, No wound measurement for right buttock wound and left buttock wound.

Upon patient record review, 1 of 5 (Patient #1,3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1, No care plan for IV port and who would manage port. Patient #3, No evidence of wound care on plan of care.

Upon patient record review, 1 of 5 (Patient #1) 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 #1, Patient was receiving chemotherapy for leukemia, no evidence of orders for chemotherapy, IV port and who would manage port.

Upon client record review, 4 of 5 (Patient #1,2,3,4,) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, SN frequency 2w2, 5 PRN for patient needs, visits on 7/12/23, 7/13/23, 7/14/23, Patient #2, SN frequency 3w1, 2w12, 5 PRN for patient needs, visits on 10/10/23, 10/12/23, 10/13/23, 10/19/23, 10/23/23, 10/31/23, 11/2/23, 11/6/23. MSW had no order for visit, evidence of visit on 10/13/23. SC had no order for visit, evidence of visit on 10/13/23. Patient #3, SN frequency 2w2, 5 PRN for patient needs, order 10/8/23 2w12. Visits on 9/27/23, 9/30/23, 10/5/23, 10/11/23, 10/13/23, 10/17/23, 10/24/23, documented as on call, 11/6/23. Patient #4, MSW no evidence of frequency order, visit on 6/20/23. SC no evidence of frequency order, visit on 6/20/23.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #3, Patient lives in basement of friends home, documented on RN assessment home has no running water, hoarded home and patient has no support. On initial MSW assessment, no evidence of these issue documented on MSW assessment. MSW documented no financial provided this visit, had documented patient has motorized w/c and battery has ran out. MSW made referral to SNF and patient could not decide if he wants to go to SNF or return out east . All visits were made outside the home. MSW order to discontinue on 10/25/23.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review 3 of 5 (Patient #1,4,5) 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 #1, HHA frequency 1w1, 2w12, no evidence of visits completed. Patient #4, HHA frequency 2x/w, no evidence of visits completed. Patient #5, HHA frequency 2w13, no evidence of visits completed.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There was no evidence the governing body assumed responsibility for human resource management, no verification of valid nursing license for CNO, no evidence of education/experience for administrator or alternate administrator. In addition, lack of oversight for patient care.

Upon personnel record review, 3 of 3 (Personnel #1,2,3) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #1,2,3, There was no evidence of signed form of hospice philosophy in HR chart.

Upon patient client record review, 5 of 5 (Patient 1,2,3,4,5) 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 1,2,3,4,5, Missing signature of MD for 8/9/23 and 8/23/23 IDG.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #1, No evidence of discharge summary being completed or sent to MD.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 3 (Personnel #1 ) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #1, There was no evidence of licensure in state of Colorado was provided in HR record.

Upon patient record review, 4 of 13 (Patients #5,#8,#11,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 5: The medication profile contained Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Patient 13: The medical record contained nursing documentation 2/18/23 identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile.

Upon patient record review, 1 of 13 (Patient #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: The care plan contained problems, goals, and interventions for spiritual support designated to be completed by the chaplain. There was no evidence of an order or visits being completed for spiritual care. Corrected on site.

Upon patient record review, 4 of 13 (Patients #5,#8,#11,#13) 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: The medical record contained an order for Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Patient 13: The medical record contained nursing documentation 2/18/23 identifying patient use of oxygen. There was no evidence of an order for oxygen.

Upon patient record review, 1 of 13 (Patient #6) 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 6: The medical record contains a CTI signed 2/8/23 identifying patient increase use of oxygen. There was no evidence of oxygen equipment included on the plan of care. Corrected on site.

Upon client record review, 3 of 13 (Patients #2,#3,#7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of second visit made the weeks of 2/19/23 and 3/5/23. Corrected on site with documentation regarding reason for missed visits. Patient 3: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit made the week of 3/5/23. Corrected on site with documentation regarding reason for missed visit. Patient 7: The medical record contained an order for volunteer services. There was no evidence that the patient received volunteer services. After agency investigation, the order should have been discontinued and was not appropriate.

Upon patient record review, 5 of 13 (Patients #2,#4,#6,#7,#8) 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 2, 4, 6, 8: The aide care plan contained a task for shower with instructions if patient is unable, resists or refuses may have a bed bath. There were no instructions regarding the cognitive ability of the patient to make their own decisions. Corrected on site. Patient 7: The aide care plan contained two bath tasks of tub bath and bed bath. Corrected on site.

Upon patient record review 3 of 13 (Patient #5, 6, 11) 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 5: The medical record contained documentation identifying aide services ended 2/26/23. There was no evidence of an order to discontinue aide services. Patient 6: The medical record contained an order for aide frequency of three times a week. There was no evidence of third visits completed the weeks of 2/5/23 and 2/26/23. Corrected on site with documentation of reason for missed visits. Patient 11: The medical record contained an order for aide frequency of twice weekly. Nursing documentation stated family was providing care and aide was not assigned to the patient.

Upon patient client record review, 3 of 13 (Patients #2,#3,#7) 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 2: The medical record contained an election form identifying patient representative requested the Notice of Hospice Non-Covered Items upon admission 2/17/23. The addendum form was received 2/24/23, not meeting the 5 day requirement. Patient 3: The medical record contained an election form identifying patient representative requested the Notice of Hospice Non-Covered Items upon admission 6/15/22. The addendum form was not received. Patient 7: The medical record contained an election form identifying patient representative requested the Notice of Hospice Non-Covered Items upon admission 6/15/22. The addendum form was not received. Agency disclosed this was self identified and billing has been on hold since December 2022.

Upon patient client record review, 1 of 13 (Patient #6) 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: The medical record contained a verbal certification form stating for benefit period 11/11/22-2/9/23 in error. The end date for the period was 2/8/23. The written certification was correct with dates.

Upon SNF/NF contract review, 1 of 5 (Montage Hills NF contract) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day.