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

Based on record review and interview, the hospice agency failed to update the comprehensive assessment as frequently as the condition of the patient required. Specifically, a comprehensive assessment was not completed after a change in condition for 2 of 5 records reviewed (Patients #3 and #5). --- Findings include:1. The clinical record for Patient #3 was reviewed on 11/3/25. The patient was admitted to hospice care and services on 4/19/23, with a terminal diagnosis of congestive heart failure. The plan of care for the certification period dated 10/5/25 to 12/3/25, included orders for Skilled Nursing (SN) one time per week with three as needed visits to assess the patient, manage medications and symptoms, and to provide education and support to the patient and family during the disease process and management of symptoms; Medical Social Worker (MSW) one time per month to provide emotional support and reassurance; and spiritual care one time per month for support and reassurance.a. The agency failed to complete and update the comprehensive assessment of Patient #3 following reported chest pain and reported falls.i. Review of the clinical notes dated 10/11/25 showed Patient #3’s caregiver called the agency to report the patient experienced chest pain. Further review of the clinical notes revealed a phone call visit was made on 10/12/25 by Licensed Practical Nurse #1 (LPN). The note read Patient #3 stated chest pain resolved. ii. Record review failed to reveal an in person visit for a comprehensive assessment update until 10/16/25. Review of the comprehensive assessment note dated 10/16/25 completed by a former agency clinical manager failed to address Patient #3’s report of chest pain on 10/11/25. Additional review of the comprehensive assessment failed to reveal an update to Patient #3’s plan of care or interventions for symptom management related to congestive heart failure.iii. Review of the clinical note dated 8/10/25 revealed Patient #3 reported a fall. Record review showed an LPN visit was completed on 8/11/25. The visit note included Patient #3 stated he experienced multiple falls over the past weekend. Record review revealed a second LPN #1 completed a routine visit on 8/14/25. Review of the visit notes failed to reveal an update to the comprehensive assessment for Patient #3.iv. Record review revealed a comprehensive assessment was completed on 8/21/25 by a former clinical manager for Patient #3. Further review of the comprehensive assessment failed to reveal an update to address recently reported falls. Review of the interdisciplinary team meeting note dated 8/19/24 and 9/2/25 failed to address reported falls. Additional review of the care plan dated 9/2/25 revealed interventions for fall prevention had not been updated since 9/27/24.v. During an interview on 11/5/25 at 4:32 p.m. LPN #1 stated the former clinical manager did not update the comprehensive assessment for Patient #3 after the report of a fall on 8/11/25 and chest pain on 10/11/25. Further, LPN #1 stated the former clinical manager did not complete an assessment of Patient #3 until the next routine visit.vi. The former clinical manager was unavailable for interview.2. The clinical record for Patient #5 was reviewed on 11/6/25. The patient was admitted to hospice care and services on 5/6/25, with a terminal diagnosis of Alzheimer’s disease. The plan of care for the certification period dated 8/24/25 to 11/1/25, included orders for SN one time a week to assess the patient, manage medications and symptoms, and to provide education and support to the patient and family during the disease process and management of symptoms. a. The agency failed to complete and update the comprehensive assessment of Patient #5 following a report of increased agitation and falls.i. Review of the clinical notes revealed a fall reported for Patient #5 on 9/30/25. Record review failed to reveal a visit to update the comprehensive assessment until 10/2/25. ii. Record review revealed a clinical note dated on 10/8/25 by LPN #1 revealed Patient #5 experienced a fall on 10/8/25 and increased agitation. Review of a routine visit clinical note dated 10/9/25 by LPN #1 failed to include an update to Patient #5’s comprehensive assessment. Review of a clinical note dated 10/10/25 by RN #1 revealed an assessment was made for an additional fall reported on 10/10/25. Record review revealed RN #1 failed to assess the previous reported falls and agitation. iii. During an interview on 11/6/25 at 2:07 p.m. RN #1 stated the agency does not make visits to assess patients for every fall. Additionally, RN #1 indicated it was up to facility staff if the hospice agency needed to make a visit following a fall.3. Interviews were conducted between 11/5/25 to 11/10/25 which indicated the agency failed to complete comprehensive assessments as often as needed.i. During an interview on 11/5/25 at 4:32 p.m. LPN #1 explained the agency used an on-call triage nurse system. The on-call triage nurse would notify agency nurses if a visit needed to be completed for a fall or change in condition call. LPN #1 stated the agency clinical manager did not assess the patient after every fall or change in condition.ii. During an interview on 11/10/25 at 12:46 p.m., the administrator stated triage nurses who worked for the parent company decided if a follow up visit was necessary following reports of a fall or change in condition. iii. During an interview on 11/10/25 at 1:35 p.m., the administrator revealed the hospice agency practice was to not send out an RN for a comprehensive assessment until the next scheduled visit. During an additional interview the administrator stated he initiated a new practice to send out a nurse for every reported patient fall. The administrator stated the agency would send out either an LPN or an RN for falls when they happen and the next day for reports of a change in condition. iv. During the interview on 11/10/25 at 12:46 p.m., the administrator was unable to provide information on current hospice regulations or the scope of practice for each hospice discipline including LPNs.v. The administrator was provided with education on where to review hospice regulations and where to review the scope of practice for each discipline in the hospice agency.

Based on interview and record review the hospice agency’s governing body failed to ensure an ongoing program for quality improvement and patient safety was maintained for the hospice agency. Specifically, the agency failed to ensure the quality assessment and performance improvement (QAPI) program reflected the complexity of its organization and services; the agency failed to ensure the QAPI program focused on agency-specific high risk, high volume, or problem-prone areas; and the agency failed to ensure the administrator participated in QAPI meetings and was included in the review of the QAPI plan. --- Findings include:1. Review of the hospice agency’s QAPI Program was completed on 11/6/25, and revealed the following:a) The agency’s QAPI Plan was to be reviewed annually. i. Documentation of review of the plan at the corporate level was provided. However, documentation of review of the plan by agency staff was not provided. Review of the plan was shown by signature at the end of the plan. The plan was signed by the corporate chief executive officer on 2/12/25. No signature or documentation of review of the plan was found for the agency medical director or agency administrator/clinical director. b) QAPI meetings were to be held at least quarterly.i. Evidence of the 1st Quarter 2025 QAPI meeting, held 4/15/25, was provided with meeting minutes and signatures of attendees attached. For evidence of the 2nd Quarter QAPI meeting, a printed paper with an agenda for a July meeting was provided, without any signatures of attendees or a date for the meeting. No documentation for a 3rd Quarter meeting was provided.c) Data gathered and discussed at QAPI meetings was not used to develop performance improvement projects that reflected agency-specific high risk, high volume, or problem-prone areas.i. Review of the QAPI meeting minutes from the QAPI meeting, held 4/15/25, revealed the corporate chief nursing officer discussed internal high risk documentation indicators for the agency and encouraged performance improvement projects (PIP) to be developed by the team in order to reduce payment denials. However, no agency-specific PIPs related to patient care were discussed in the meeting minutes.2. Interviews were conducted from 11/3/25 through 11/11/25, and revealed the following:a) During an interview with a registered nurse (RN #1) at 9:15 a.m. on 11/6/25, RN #1 stated she had worked for the agency since August 2025 and had not participated in the QAPI program or meetings. RN #1 stated the QAPI program was not conducted at her level, but at the administrative and corporate level.b) During an interview on 11/5/25 at 4:32 p.m., a licensed practical nurse (LPN #1) stated she was not invited to participate in the 2nd quarter QAPI meeting. Additionally, LPN #1 could not identify current quality performance improvement plans for the agency.c) During an interview with the administrator at 12:45 p.m. on 11/10/25, the administrator stated he did not attend, and could not provide a date for, the 2nd quarter 2025 QAPI meeting. 3. The hospice agency’s governing body failed to ensure that an ongoing program for quality improvement and patient safety was maintained for the hospice agency.a) During an interview on 11/6/25 at 1:42 p.m., the Chief Nursing Officer (CNO) for the hospice’s governing body stated she did not hold a Quality Assurance and Performance Improvement (QAPI) meeting for the hospice agency during the 2nd quarter.

​Based on interview and record review, the hospice agency failed to ensure licensed professionals participated in the hospice's quality and assessment performance improvement (QAPI) program. --- Findings include:1. Review of the hospice agency’s QAPI Program was completed on 11/6/25, and revealed the following:a) The agency’s QAPI Plan stated review of the plan was to be reviewed annually. Review of the plan was shown by signature at the end of the plan. The plan was signed by the corporate chief executive officer on 2/12/25. No signature or documentation of review of the plan was found for the medical director or director of nursing at the agency level.2. Interviews were conducted from 11/3/25 through 11/11/25, and revealed the following:a) During an interview with a registered nurse (RN #1) at 9:15 a.m. on 11/6/25, RN #1 stated she had worked for the agency since August 2025 and had not participated in the QAPI program or meetings. RN #1 stated the QAPI program was not conducted at her level, but at the administrative and corporate level.b) During an interview on 11/5/25 at 4:32 p.m., a licensed practical nurse (LPN #1) stated she was not invited to participate in the most recent QAPI meeting. Additionally, LPN #1 could not identify current quality performance improvement plans for the agency.c) During an interview with the administrator at 12:45 p.m. on 11/10/25, the administrator stated he talked with the chief nursing officer from the out-of-state corporate office daily to discuss the QAPI topics.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There was not evidence of participation in a full-scale exercise that is community-based every two years.

Upon patient record review 2 of 19 records (Patient #5,#7) did not have evidence in the patient record 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 #5:The patient was admitted on 11/18/23. The record indicated that the spiritual assessment was completed on 11/29/23. Patient #7: The patient was admitted on 8/30/23. The record indicated that the social work assessment was completed on 9/14/23.

Upon patient record review 3 of 19 records (Patient #5,#7,#11) did not have evidence in the patient record that the comprehensive assessment identifies the psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #5: There was not evidence of a psychosocial assessment. Patient #7,#11: There was not evidence of a spiritual assessment.

Upon patient record review, 6 of 19 records (Patient #1,#4,#7,#10,#12,#13) 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: Nurse documentation dated 11/16/23 indicated that the nurse spoke with the caregiver who stated that the patient was recently started on Prozac. There was not evidence that Prozac was in the medication profile. Patient #4: The medication profile contained Acetaminophen 650mg supp, administer 1 capsule, q4h prn. Insert 1 supp q4h prn fever. There was not evidence of a parameter for the fever or an accurate method of medication form (supp or capsule). In addition, oxygen was on the medication profile at 5L/min continuously via nasal cannula. Frequent nurse documentation indicated that the oxygen was 5-8L/min. Patient #7: A notation by the physician dated 12/14/23 indicated that the patient was requiring oxygen continuously at 4L/min (diagnosis is malignant neoplasm of the glottis). There was not evidence that oxygen was on the medication profile. In addition, nurse documentation dated 1/2/24, indicated that Doxycycline was started for a URI X 7 days. There was not evidence that this was on the medication profile. Also, nurse documentation from 11/28/23 indicated that the nurse advised the patient to take a 'brown cow,' (MOM, prune juice, butter) for constipation. There was not evidence that this was on the medication profile. Patient #10: The medication profile contained Amoxicillin 500mg, 1 by mouth as directed by physician for infection, dated 11/13/23. Patient #12:The medication profile contained oxygen 2L/min via nasal cannula continuously. Upon observed home visit, the patient was not wearing oxygen. Also the patient relayed that he had been constipated and a nurse had advised him to take 3 little red pills instead of the 2 he had been taking. The medication profile indicated only 1 listing of Senna 8.6-50, 1 tab BID. Patient #13: The medication profile contained Diclofenac, 1 application topical for pain 1-2 times/day as needed without evidence of a specific location. In addition, oxygen 1L/min via nasal cannula. May titrate up or down for comfort.

Upon patient record review, 4 of 19 records (Patient #5,#7,#8,#11) 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 #5: The patient was admitted on 11/18/23. The record indicated that the bereavement assessment was completed on 11/29/23. Patient #7,#8,#11: There was not evidence of a bereavement assessment.

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

Upon patient record review, 2 of 19 records (Patient #5,#12) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated 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 #5: From admission, (11/18/23) the record indicated that the patient had wounds on his right lower extremity, left lower extremity and right shin. There was not evidence of the exact location of the wounds, or evidence of any wound measurements. Documentation of the wound was incomplete. Nurse documentation dated 12/7/23 indicated that the left lower extremity wound had a strong foul odor and the right lower extremity wound was necrotic and gangrenous but the dressings were not changed. Documentation of dressing changes could not be found in the record until 12/15/23 when the nurse note documented dressings changed per orders. See care plan. Patient #12: The record indicated that the patient had a stasis wound left foot. Nurse documentation dated 1/4/23 indicated provided wound care per MD order.

Upon patient record review, 4 of 19 records (Patient #4,#7,#8,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #4: The care plan contained the goal of 'patient/caregiver to demonstrate the ability to maintain the pleural catheter.' There was not evidence that the patient has or has ever had a pleural catheter. Patient #7: The record indicated that the patient was having trouble with swallowing. Diagnosis was malignant neoplasm of the glottis. There was not evidence that the plan of care reflected goals and interventions related to nutrition and swallowing. Patient #8: The patient was admitted with a diagnosis of fronto-temporal neurocognitive disorder. There was not evidence of a neurological care plan that reflects the patient's goals and interventions. Patient #10: The patient was admitted with a diagnosis of ALS. Documentation revealed that the patient had worsening paralysis, neuropathy of feet, legs and hands, intermittent difficulty swallowing, decreased appetite and weight loss. There was not evidence of a neurological care plan that reflects the patient's goals and interventions. In addition, nurse documentation dated 12/29/23, indicated that a Foley catheter was inserted. There was not evidence of a care plan.

Upon patient record review, 6 of 19 records (Patient #1,#4,#7,#10,#12,#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 #1: Nurse documentation dated 11/16/23 indicated that the nurse spoke with the caregiver who stated that the patient was recently started on Prozac. There was not evidence of an order for Prozac. Patient #4: The record contained an order for Acetaminophen 650mg supp, administer 1 capsule. q4h prn. Insert 1 supp q4h prn fever. There was not evidence of a parameter for the fever or an accurate method of medication form (supp or capsule). In addition, oxygen was ordered at 5L/min continuously via nasal cannula. Frequent nurse documentation indicated that the oxygen was 5-8L/min. There was not evidence of an order to adjust the liter flow. Patient #7: A notation by the physician dated 12/14/23 indicated that the patient was requiring oxygen continuously at 4L/min (diagnosis is malignant neoplasm of the glottis). There was not evidence of an order. In addition, nurse documentation dated 1/2/24, indicated that Doxycycline was started for a URI X 7 days. There was not evidence of an order. And a notation by the nurse indicated that a Z-pack was ordered on12/12/23 without evidence of an order. Also, nurse documentation from 11/28/23 indicated that the nurse advised the patient to take a 'brown cow,' (MOM, prune juice, butter) for constipation. There was not evidence of an order. Patient #10: The record contained an order for Amoxicillin 500mg, 1 by mouth as directed by physician for infection, dated11/13/23. In addition, the nurse documentation dated 12/29/23, indicated that a Foley catheter was inserted. There was not evidence of an order. Patient #12: The record contained an order for oxygen 2L/min via nasal cannula continuously. Upon observed home visit, the patient was not wearing oxygen. Also the patient relayed that he had been constipated and a nurse had advised him to take 3 little red pills instead of the 2 he had been taking. The record indicated only 1 order for Senna 8.6-50, 1 tab BID. Patient #13: The record contained an order for Diclofenac, 1 application topical for pain 1-2 times/day as needed without evidence of a specific location. In addition, oxygen 1L/min via nasal cannula. May titrate up or down for comfort.

Upon client record review, 1 of 19 records (Patient #4) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #4: The last documented review, and revision of the individualized plan of care was dated 12/11/23 which is greater than the 15 day requirement.

Upon patient record review, 1 of 19 records (Patient #7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #7: The record indicated frequent documentation of the patient having issues with constipation/no BM for several days at a time. The patient is on high doses of Morphine. There was not evidence that bowel management/constipation was included in the revised plan of care noting progress and outcomes.

Upon client record review, 8 of 19 records (Patient #1,#2,#4,#5,#8,#9,#11,#13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The visit frequency for the skilled nurse was 2w2 then 1w6. The patient was admitted on 11/14/23 and the record indicated that this was the only skilled nurse visit for week 1. Patient #2: The visit frequency for the skilled nurse was 2w2 (11/14/23-11/25/23), then 1w9. The record indicated 2 routine visits for the week of 12/10/23-12/16/23, and 2 routine visits for the week of 12/17/23-12/23/23 and no visits for the week of 12/24/23-12/30/23. Patient #4: The skilled nurse visit frequency was 2w2, then every 2 weeks. The patient was admitted on 11/28/23. For the week of 11/26/23-12/2/23, the record indicated only 1 visit on 11/28/23 and for the week of 12/3/23-12/9/23, the record indicated only 1 visit on 12/4/23. Patient #5: The visit frequency for the skilled nurse was 2w2, the 1w7. the patient was admitted on 11/18/23 and that was the only visit this week. For week 2, 11/19/23-11/25/23, only 1 visit was conducted on 11/22/23. Patient #8: The visit frequency for the skilled nurse was 2w5, then changed to 1x/week on 12/17/23. For the weeks of 11/19/23-11/25/23, 11/26/23-12/2/23, 12/3/23-12/9/23, and 12/10/23-12/16/23, the record indicated only 1 visit each of these weeks. Patient #9: The record indicated that the spiritual care counselor conducted a visit on 11/21/23. There was not evidence of an order. In addition, the social work visit frequency was 1x/month. There was not evidence of a visit by the social worker for the month of December. Patient #11: The skilled nurse visit frequency was 2x/week for 2 weeks (admitted 12/17/23), then 1x/week. The record indicated visits on 12/17/23 and 12/20/23. There was not evidence of visits since 12/20/23. Patient #13: The skilled nurse visit frequency beginning 12/10/23 was 2x/week. For the weeks of 12/10/23-12/16/23 and 12/24/23-12/30/23, the record indicated only 1 visit each of these weeks. In addition, the volunteer frequency for the benefit period 10/9/23-12/7/23 was 1x/week. The record indicated no visits for the weeks of 11/5/23-11/11/23 and 11/19/23-11/25/23. Also there was a visit on 12/15/23 without evidence of an order.

Upon patient record review, 1 of 19 records (Patient #14) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #14: The record indicated an on call visit on 12/22/23 due to an unwitnessed fall. The patient was found on the floor by the facility staff at 8:00 pm. The hospice nurse arrived at 9:10 pm where the hospice nurse found the patient still on the floor, a large tennis ball contusion on the patient's left fronto-temporal area with 2 small bleeding abrasions at the site. BP was low. Within 1 minute of the assessment, the patient became stuporous, lethargic and minimally responsive, with right facial drooping. An ambulance was called to assist with putting the patient back to bed. There was not evidence the hospice physician was notified.

Upon patient record review, 1 of 19 records (Patient #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 specifically 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 #9: The aide plan of care indicated to provide a shower 1x/week, bed bath if patient refuses a shower.

Upon patient record review 5 of 19 records (Patient #1,#6,#8,#10,#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 #1: The aide visit frequency for the benefit period beginning 12/22/23 was 2w9. The record indicated only 1 'visit' on 12/28/23 where the aide documented that she walked around with the caregiver, talked to the caregiver and set up a schedule. No care was provided. Patient #6: The aide visit frequency was 1w1 for the weeks of 11/14/23-11/18/23 and 11/19/23-11/25/23. The record indicated only 1 'visit' on 11/21/23 where the aide documented that she left supplies and chatted. Patient #8: The aide visit frequency was 2x/week. for the weeks of 11/19/23-11/25/23 and 12/10/23-12/16/23, the record indicated only 1 visit each of these weeks. On 12/28/23, the documentation revealed that no task was completed. For the dates of 11/29/23, 12/1/23, 12/21/23, and 12/22/23, shower and shampoo were both documented as N/A. (Both tasks were to be completed 1x/week). Also, there were several dates that indicated shampoo, mouthcare and deliver supplies were documented as, 'instructed for future use.' In addition, on 11/22/23, 12/6/23, and 12/27/23, 'hygiene is maintained, wishes are respected, and patient/family receives assistance with ADL's' was documented by the aide as 'progressing as expected.' Patient #10: The aide visit frequency was 3x/week from admission on 11/8/23. There was not evidence of contact by the aide until 11/15/23. From 11/15/23-11/29/23, aide documentation indicated, 'assisted patient with care plan.' The first visit of the aide providing care occurred on 11/29/23. In addition, documentation revealed only 2 visits for the week of 12/24/23-12/30/23. Patient #11: From 12/20/23-1/4/23, 'hygiene is maintained, wishes are respected, and patient/family receives assistance with ADL's' was documented by the aide as 'progressing as expected.' In addition, the aide visit frequency was 3x/week. For the weeks of 12/17/23-12/23/23 and 12/24/23-12/30/23, the record indicated only 2 visits each of these weeks.

Upon contract review, 1 of 5 contracts (Katy Picard) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. The contract for the Alternate Medical Director was listed as Hospice Physician with no evidence of a delegation document or a provision in the contract indicating the Alternate Medical Director.

Upon patient record review, 1 of 19 records (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #5: There was not evidence of a narrative statement by the medical director. Admission date was 11/18/23.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #4, Patient initial assessment RN documented patient has intermittent confusion and forgetfulness. Patient signed her own initial paperwork for admission to hospice.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #4, Patient initial assessment RN documented patient has intermittent confusion and forgetfulness. Patient signed her own initial paperwork for admission to hospice.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #4, Patient initial assessment RN documented patient has intermittent confusion and forgetfulness. Patient signed her own initial paperwork for admission to hospice.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence of the appropriate documentation for release of confidential information. Patient #4, Patient initial assessment RN documented patient has intermittent confusion and forgetfulness. Patient signed her own initial paperwork for admission to hospice.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #4, Patient initial assessment RN documented patient has intermittent confusion and forgetfulness. Patient signed her own initial paperwork for admission to hospice.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #4, Patient initial assessment RN documented patient has intermittent confusion and forgetfulness. Patient signed her own initial paperwork for admission to hospice.

Upon patient record review, 2 of 5 (Patient #1,5) 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 has oxygen @ 3l/nc which was not documented on the medication list. Patient #5, patient has order for Janument, duoneb on 9/8/23 which was not updated to medication list. Order for Haldol, bisacodyl supp and mucinex on 9/25/23, which was not updated to medication sheet.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 5 no evidence of nursing visits from 9/8/23-9/29/23 and no update to the comprehensive assessment.

Upon patient record review, 1 of 5 (Patient #1) 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, RN initial comprehensive assessment 8/18/23, patient has coccyx wound, under wound documentation noted as not addressed. On SN visit 8/24/23, documented wound measurements would be requested from facility nurse. Bilateral heel wounds were not measured on comprehensive assessment. No assessment of the wounds.

Upon patient record review, 2 of 5 (Patient #2 and 4) 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 #2, Upon initial assessment, RN documented patient beard and mustache had clearly burnt off at the ends. RN asked patient what happened and he stated he thought he had taken off the oxygen and then "boom, my whole face lit up". Patient was admitted on 7/17/23, care plan for oxygen safety was not initiated until 8/25/23. Patient has diagnosis of diabetes, no care plan for dx of diabetes. Patient #4, No care plan that patient is living in assisted living.

Upon patient record review, 1 of 5 (Patient #3) 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 #3, On 10/31/23, RN on call advised triple antibiotic ointment to tip of penis for meatus tear from foley catheter. No evidence of MD order for triple antibiotic ointment.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1, Patient was transferred to another hospice. Plan of care states patient was discharged. Patient goal states "Patient will have death with dignity" marked as goal met. Goal states perineal remains free of breakdown was marked as met. Patient has coccyx wound receiving wound care.

Upon client record review, 2 of 5 (Patient #3,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3, SN frequency 2w2 then 1x/week. Patient seen 10/16/23, 10/17/23, 10/20/23 the first week then only once the second week on 10/24/23. Patient was then seen twice the 3rd week on 10/31/23, 11/1/23. Patient #5, SN frequency 2w2 then 1w12. Only one visit the week of 8/20 on 8/25/23. No visits the weeks of 9/10 and 9/17/23.

Upon patient record review, 1 of 5 (Patient #2) 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, Aide care plan states PR which means per plan of care or PD patient decision. No evidence documented on plan of care of patient able to make their own decision.

Upon patient record review 3 of 5 (Patient #1,3,4) 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, Aide frequency 2xweek, 8/24/23 only one visit first week, Visit stated it was a introductory visit only and explained what she would be doing starting the next week. Patient #3, Aide frequency 2x/week, visit on 10/17/23. Only one visit made first week. Patient #4, Aide frequency 1w13 thru 10/27/23. Visit notes for 5/6/23, 5/13/23, 5/19/23, 5/27/23, 6/10/23, 6/16/23, 6/23/23 documented in aide note as missed visit, no visits made. No evidence of visits completed from 7/22/23 to 11/1/23. No order for the 11/1/23 visit.

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. No evidence of personnel files were provided to ensure proper credentialing for staff, background checks were completed, or any of the required personnel file documents. Concern is demonstrated as to patient rights as evidence of allowing confused patient to sign their own consents, election statement, and admission paperwork.

Upon personnel record review, 3 of 3 (Personnel #1,2,3) did not have evidence that the hospice employees have received orientation on their specific job requirements.

Upon personnel record review, 3 of 3 (Personnel #1,2,3) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #1,2,3, HR recorded requested several times without receiving record for review.

Upon patient client record review, 1 of 5 (Patient #4) 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 #4, Patient initial assessment RN documented patient has intermittent confusion and forgetfulness. Patient signed her own initial paperwork for admission to hospice.

Upon patient client record review, 1 of 5 (Patient #2) 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 #2 MSW frequency 1x/month with 3 PRN for patient needs. PRN visits on 7/31/23, 8/25/23 and 9/1/23 for documentation of application submitted for patient. No patient visits completed for those 3 prn visits, MSW was using visit frequency to complete her documentation.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #1, no evidence transfer summary and copy of the patient record was faxed to receiving hospice.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #4, Patient initial assessment RN documented patient has intermittent confusion and forgetfulness. Patient signed her own initial paperwork for admission to hospice.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 3 of 3 (Personnel #1,2,3) 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 #1,2,3, HR recorded requested several times without receiving record for review.

Upon personnel record review, 3 of 3 (Personnel #1,2,3) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #1,2,3, HR recorded requested several times without receiving record for review.

Upon patient record review, 1 of 13 (Patient #13) 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 Pt #13 - Pt was on oxygen - no evidence this was on the medication profile.

Upon patient record review, 4 of 13 (Patient #2, 5, 8, 10) 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. Pt # 2- No evidence in record of a bereavement risk assessment completed in 5 days. Pt #5 - No evidence in record of a bereavement risk assessment completed in 5 days. Pt # 8 - No evidence in record of a bereavement risk assessment completed in 5 days. Pt # 10 - No evidence in record of a bereavement risk assessment completed in 5 days.

Upon patient record review, 1 of 13 (Patient # 9) 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. Pt # 9 -8/4/22 Phone call stated that "Pt was having severe pain unmanaged related to fall injuries; including jaw, hip, shoulder, etc. PCG reports they ran out of pain meds today and when they went to the pain clinic, they were notified that they had violated a pain contract and they could no longer get their pain med refills through them. They notified the MSW that patient was having severe pain and needed treatment. This RN called, gathered information and would follow up with Dr. Picard to see if she would order refills of the medications that have been working for her pain management previously, as soon as possible". Upon record review, no evidence documented of follow up on patient chart. 8/6 - RN attempted a call for a visit - unable to reach patient and next RN visit was 8/10/22. Noted on the medication profile only- pt did receive meds.

Upon patient record review, 1 of 13 (Patient #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. Pt # 13- No evidence of MD order for oxygen at 6 l/min and then at 9 l/min nc.

Upon client record review, 1 of 13 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #4 - Pt receiving volunteer services on 8/26/22, 8/30/22, 9/6/22. No visit frequency orders on chart.

Upon patient record review, 2 of 8 applicable (Patient #4, 6) 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. Pt # 4- Aide assignment intervention states - Partial/Complete Bed Bath - if patient unable, resists or refuses shower or tub bath, may have twice weekly. Assignment is not specific in what the aide should do. (Corrected on site) Pt #6 - Patient's aide assignment states - Partial/Complete Bed Bath - if patient unable, resists or refuses shower or tub bath, may have - 1x per week + if patient soiled. Assignment is not specific what the aide should do. (Corrected on site)

Upon client record review, 1 of 1 applicable (Patient #12) did not have evidence that the discharge summary includes all required information. Pt # 12- No discharge summary noted on record.