Every finding on record at Colorado Palliative & Hospice Care of the Front Range LLC

Upon patient record review, 1 of 8 (Patient #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; specifically medications and treatments. An order was obtained on 04/21/22 for, "Left Ankle. Cleanse with wound cleanser, apply Calmoseptine, then apply padded dressing, every three days, or as needed, by patient's in-home caregiver." This is not a complete order, as there is no indication for the provision of such 'as needed' dressing change.

Upon patient record review, 1 of 5 applicable (Patient #3) did not contain documented evidence that a Hospice Aide had provided care/services that were: • Ordered by the interdisciplinary group • Included in the plan of care The current Aide Plan of Care assigned: 1) Housekeeping; and 2) Change bed linens." On the Aide visits dated 04/25, 04/29, and 05/02/22 the Aide documented "N/A" next to these assigned tasks. There was no documented evidence of the Aide having communicated this to the assigning RN.

Upon patient record review, 1 of 8 (Patient #1) did not contain evidence that all entries were appropriately authenticated through both a clinician signature and credential. For all entries made in this record by Aide (Personnel #4), there was no credential attached to her signature(s).

Upon inpatient contract review, 1 of 1 (Avamere Transitional Care/GIP/RIP) did not contain a provision that the inpatient provider has established patient care policies consistent with those of the Hospice, and agrees to abide by the palliative care protocols and Plan of Care established by the Hospice for its patients.

Upon inpatient contract review, 1 of 1 (Avamere Transitional Care/GIP/RIP) did not contain a provision that: A copy of the Discharge Summary shall be provided to the Hospice at the time of the patient's discharge from the Facility.

Upon inpatient contract review, 1 of 1 (Avamere Transitional Care/GIP/RIP) did not contain a provision that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 6 applicable (Patient #1) 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. Pt #1 - There was no evidence that the spiritual care assessment was completed within 5 days. Pt admitted 11/17/21 SC assessment documented 11/23 - on day 6.

Upon patient record review, 1 of 7 (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. Pt # 1 -The patient was admitted 11/17/21. The bereavement risk assessment was not completed until 11/23/21- day 6.

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

Upon patient record review, 1 of 7 (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. Pt # 1 - 12/31 Prn RN visit noted visit secondary to new extreme weakness and increased confusion. Neuro assessment completed. Pupils unequal, L greater than right. New right sided facial droop, increased confusion. Talked to family about possible stroke. Educated family about options. Social worker will contact family on Monday. No evidence that the social worker was notified of visit and follow up needed and no evidence of further documentation in visit notes or IDG notes by any IDG members. Also no evidence the physician was called to notify of the change in the patient's status. Patient remains on service.

Upon patient record review, 1 of 7 (Patient #2) 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 #2 - Pt has an order that reads Insert foley catheter size 14 F with 10 cc balloon filled with sterile saline. Patient actually has a suprapubic catheter. (COS) Patient also has a BiPap machine recently delivered into the home, no orders nor settings on chart for this BiPap. (COS)

Upon client record review, 1 of 7 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #1 - 12/10/21 RN documents "unmade visit. Patients nurse became ill - unable to complete visit." No evidence that another visit was offered to patient. Visits are ordered weekly. No evidence of visit documented nor refused for the week.

Upon patient record review, 1 of 4 applicable (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 Pt #2 - This patient is on Xarelto. Patient has fall precautions listed under general clinical tab. Bleeding precautions not listed on aide plan of care or notes aide has access to under general clinical in the computer system that includes bleeding precautions are present with the fall precautions. (COS)

Upon personnel record review, 1 of 11 (Personnel # 9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. #9 - On orientation checklist for social worker, Conducts Admission Psychosocial Assessment was not assessed nor signed off on the review date and performance date. This SW staff has completed a psychosocial assessment on all current patients.