Every finding on record at Dignity Hospice of Colorado, LLC

Upon patient record review, 1 of 19 records reviewed (Patient #9) did not have evidence that the patient chooses a health care provider, including an attending physician Patient #9: The record indicated the patient chose "Sky Health" as their choice for an attending. There was no evidence Sky Health was a specific physician. COS.

Upon patient record review 2 of 19 records reviewed (Patient #1,5) 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 #1: The record indicated the start of care was 03/22/24. There was no evidence of the spiritual comprehensive assessment until 04/08/24. Patient #5: The record indicated the start of care was 07/11/24. There was no evidence of the spiritual comprehensive assessment until 07/18/24.

Upon patient record review 3 of 19 records reviewed (Patient #1,3,10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, 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 #1: The record indicated the start of care was 03/22/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #3: The record indicated the start of care was 01/15/24. There was no evidence of the spiritual comprehensive assessment being completed at the time of the survey. Patient #10: The record indicated the start of care 09/05/24. There was no evidence of the spiritual comprehensive assessment being completed at the time of the survey.

Upon patient record review, 1 of 19 (Patient #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 #3: Upon the in person visit the medication profile was reviewed. The patient was prescribed 2 Units of Insulin Glargine SQ QHS but was actually taking 10 Units SQ QHS. COS.

Upon patient record review, 6 of 19 records reviewed (Patient #1,2,3,4,5,11) 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 #1: The record indicated the start of care was 03/22/24. There was no evidence of the bereavement assessment until 04/8/24. Patient #2: The record indicated the start of care was 01/24/24. The bereavement assessment was not completed at the time of the survey. Patient #3: The record indicated the start of care was 01/15/24. The bereavement assessment was not completed at the time of the survey. Patient #4: The record indicated the start of care was 03/06/24. The bereavement assessment was not completed at the time of the survey. Patient #5: The record indicated the start of care was 07/11/24. There was no evidence of the bereavement assessment until 07/18/24. Patient #11: The record indicated the start of care was 09/05/24. The bereavement assessment was not completed at the time of the survey.

Upon observation during IDG surveyor was advised MD was in Montana, he was unable to get dialed in the meeting but a Nurse Practitioner was on the meeting line. When it was brought to the teams attention an MD had to be present surveyor was advised a physician subsequently logged into the meeting. COS.

Upon patient record review, 2 of 19 records reviewed (Patient #2, #12) 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 #2: The record indicated the patient had a fall on 2/2/24, the next nurse visit was on 2/6/24. There was no evidence on the 2/6/24 nursing visit of a fall follow up assessment. Policy C: 121 a follow up telephone call or visit is to be made during the next shift again to check on a patient's states post fall. Documentation of the call/visit will be made in the communication note to ensure the patient has remained stable. Patient #12: The record indicated the patient had a witnessed fall on 9/11/24. The next nursing visit was on 9/13/24 and 9/14/24 there was no evidence of a follow up assessment to include an assessment of the patients fall. Policy C: 121 a follow up telephone call or visit is to be made during the next shift again to check on a patient's status post fall. Documentation of the call/visit will be made in the communication note to ensure the patient has remained stable.

Upon patient record review, 1 of 19 (Patient #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 #4: The record indicated the patient resides in an Assisted Living Facility. The care plans do not contain evidence of coordination of care with facility. COS.

Upon patient record review, 1 of 19 (Patient #9) 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 #9: The record indicated the patient resides in an Assisted Living Facility with an MD order for wound care 2 x each week with the effective date 8/18/24. There were no assigned staff for who was responsible to complete the wound care. COS.

Upon client record review, 1 of 19 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9: The record indicated an order for wound care 3 X W to be done by the Hospice Nurse effective 4/19/24 to cleanse right medial heel wound with wound cleanser, apply skin prep to peri wound and cover with a bordered dressing. There was a nurse visit due on 4/20/24 to complete the 3 X W, this visit was not done.

Upon patient record review, 1 of 19 records reviewed (Patient #2) 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 #2: The record indicated the patient had a fall on 2/2/24, the facility requested a right hip X-Ray on 2/9/24. There was no evidence in the next IDT meeting on 2/22/24 there was any discussion of the patients fall.

Upon home visit with Patient #4: During the in person observation visit of the hospice nurse. The nurse placed her bag on the chair without a barrier. After she used her stethoscope, BP cuff, pulse ox and tape measure all were placed in the bag without cleaning each item.

Upon patient record review 1 of 19 records reviewed (Patient #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 #5: The record indicated the hospice aide frequency was order 1 X W. The record indicated missed visits on 07/17/24, 07/31/24, 08/09/24, 08/23/24, 09/13/24. There was no evidence of weekly visits and or the order frequency being updated at the time of the survey. COS.

Upon personnel record review, 1 of 16 records reviewed (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel Record #1: Upon reviewing the HR file for the Administrator the qualifications required a licensed professional. There was no evidence of a professional license on file. COS.

Upon patient record review, 1 of 19 records reviewed (Patient #3) 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 #3: The record indicated the start of care was 01/05/24. The Initial Certification was from 01/05/24 to 04/03/24. The physician did not sign the CTI until 01/16/24. There was no evidence of a verbal ordered documented by the RN at the time of the survey.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1: The record indicated the start of care was 03/22/24. The Initial Certification was from 03/22/24 to 05/05/24, the patient was in their 2nd benefit period. The physician did not sign the CTI until 3/26/24. There was no evidence of a verbal ordered documented by the RN at the time of the survey.

Upon patient client record review, 2 of 19 records reviewed (Patient #2,9) 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 record indicated the patient chose "Dr. Grubbs" as their attending physician for hospice. There was no evidence the patients choice had a first name listed for the physician they chose. COS. Patient #9: The record indicated the patient chose "Sky Health" as their choice for an attending. There was no evidence Sky Health was a specific physician. COS.

Upon patient client record review, 1 of 19 (Patient #6) did not evidence that each patient record contains physician orders. Patient #6: The record indicated the patient had an Initial Certification Order for 11/03/24 to 01/31/24, policy number C: 91 page 2 under Procedure #2 c.) The attending physician will be provided with all orders to be signed within 30 days. There was no evidence of the attending physician signed until 2/4/24.

Upon patient record review, 2 of 19 (Patient #2) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient #2: The record indicated there was a request by the facility for a right hip X-Ray s/p a patient fall. The record indicated the patient is a resident at a SNF. There was no evidence on the hospice record of an MD order for the right hip X-Ray. COS.

Upon client record review, 2 of 19 records reviewed (Patient #2,3) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: The record indicated the patient is in a SNF. There was no evidence the plan of care was established and maintained in consultation with the SNF staff/representatives. COS. Patient #3: The record indicated the patient is in a SNF. There was no evidence the plan of care was established and maintained in consultation with the SNF staff/representatives. COS.

Upon patient record review, 2 of 19 records reviewed (Patient #2,3) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #2: There were no hospice consents on the chart, the recertification CTI starting 7/22/24 was not on the chart. COS. Patient #3: The record indicated the patient is a resident at a SNF. There was no evidence of hospice consents on the chart, the recertification CTI starting on 9/1/24 was not on the chart and there were no plan of care updates from the IDT updates since 8/8/24 at the time of the survey. COS.

Upon patient record review, 13 of 13 records (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 2 of 13 records (Patient #5,#11) 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 #5: The record indicated an order for Polyethylene Glycol 1, q 24h prn . Mix 1 packet q 24h prn. There was not evidence of a diluent. Corrected on site. Patient #11: The medication profile indicated Metamucil Fiber Oral Powder 63%, 1 q24h prn, 30cc. There was not evidence of a diluent and the direction is unclear.

Upon patient record review, 2 of 13 records (Patient #11,#13) 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 #11: The record indicated an order to cleanse the sacral wound with wound cleanser, pat dry. Apply Xeroform to wound bed and cover with dry dressing qd and prn until healed. There was not evidence of wound assessments by the hospice nurse. Patient #13: The record indicated that the patient had bilateral heel wounds and a wound on her right gluteal area. There was not evidence of a wound assessment by the hospice nurse. In some of the nurse documentation, the wounds were not mentioned, but skin was noted to be cool and clammy or dry.

Upon patient record review, 4 of 13 records (Patient #1,#2,#8,#13) 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 #1: The admitting hospice diagnosis was Parkinson's Disease. Notations in the record from the social worker indicated that the patient was talking in word salad, the nurse documentation indicated that the patient was confused and restless. The certification of terminal illness indicated that the patient had impulsive movements, tremors in his bilateral upper extremities and had braiding feet with ambulation. There was not evidence that the plan of care reflected goals and interventions related to neurological disease. Corrected on site. Patient #2: The patient was admitted with a hospice diagnosis of hypertensive heart disease with chronic kidney disease. There was not evidence of care plan problems with goals and interventions related to the patients cardiac diagnosis. Corrected on site. Patient #8:The record indicated an order dated 7/29/21 to cleanse the mid back area with wound cleanser, pat dry, apply Betadine to area and cover with foam dressing 2x/week and prn as tolerated until healed. There was an order for wound care dated 8/30/21 to cleanse mid back area with wound cleanser, pat dry. Apply Silvasorb and cover with dry dressing qd and prn as tolerated. There was not evidence that the plan of care reflected patient/family goals and interventions based on the wound problems. Corrected on site. Patient #13: The patient was admitted with a diagnosis of senile degeneration of the brain. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems related to her senile/neuro diagnosis (toileting, mobility, eating, cognition, communication).

Upon patient record review, 3 of 13 records (Patient #5,#11,#12) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #5: The record indicated an order for Polyethylene Glycol 1, q 24h prn . Mix 1 packet q 24h prn. There was not evidence of a diluent. Corrected on site. Patient #11: The medication profile indicated Metamucil Fiber Oral Powder 63%, 1 q24h prn, 30cc. There was not evidence of an order or of a diluent and the direction is unclear. Patient #12: The following medications were listed on the medication profile but there was not evidence of orders: Oxycodone 5-10mg q4h prn pain, started on 6/5/21 and discontinued on 6/11/21. Oxycontin ER 30mg 1 q12h. 6/8/21-6/11/21 Lorazapam 0.5mg, 1 tab TID anxiety 6/8/21-6/10/21 MS Contin 15mg, 1 q12h 6/7/21-6/8/21 haloperidol 0.5mg po/sl oral concentrate q12h prn agitation. Started 6/15/21 Lorazapam 1mg q3h sl/po. Started 6/18/21

Upon patient record review, 10 of 12 applicable records (Patient #1,#2,#3,#4,#5,#8,#9,#10,#11,#13) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide that are prepared by a Registered Nurse while include all tasks and precautions, 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 specifically indicate what tasks are to be done by the Aide and the frequency of these tasks. Patient #1; The certification of terminal illness indicated that the patient was a high fall risk. Nurse documentation indicated that the patient was a 9 of 10 on the fall risk scale/activity. and an IDG indicated that the patient had 2 recent falls. There was not evidence that fall risk was on the aide plan of care. Corrected on site. Patient #2: The aide plan of care dated 5/21/21 indicated to provide a complete bed bath if patient refused a shower. In addition, the record indicated that the patient was on Xarelto and there was not evidence of bleeding precaution on the aide plan of care. (The aide task also included to shave the patient 2x/week). Corrected on site Patient #3: The aide plan of care dated 6/4/21 indicated to provide a complete bed bath if patient refused a shower. Corrected on site Patient #4: The aide plan of care dated 8/16/21 indicated to provide a complete bed bath if patient refused a shower. In addition, the nurse documentation indicated that the patient was a high fall risk and there was not not evidence that fall precautions were a part of the aide plan of care. Corrected on site. Patient #5: The aide plan of care dated 7/26/21 indicated to provide a complete bath if shower is refused. Corrected on site. Patient #8: The aide plan of care dated 7/26/21 indicated for a complete bed bath if a shower was refused. Corrected on site. Patient #9: The aide plan of care dated 7/15/21 indicated to provide a complete bed bath if unable to shower and prn. Also the tasks of footcare, shampoo and nailcare were indicated as 2x/week and prn. Corrected on site. Patient #10: The aide plan of care dated 8/27/21 indicated to complete a bed bath if shower is refused. In addition, the record indicated that the patient was a high fall risk due to safety awareness and the patient sustained falls on 9/5/21, 9/13/21, 9/14/21 and 9/19/21. There was not evidence that fall precautions were on the aide plan of care. Corrected on site. Patient #11: The aide plan of care dated 7/16/21 indicated, may complete bed bath if shower refused. The record also indicated that the patient had a history of falls with a fractured hip. There was not evidence that fall precautions were on the aide plan of care. In addition, the patient was on Eliquis and bleeding precautions were not on the aide plan of care. Patient #13: The aide plan of care dated 6/9/21 indicated to provide a complete bath if shower is refused.

Upon patient record review 1 of 12 applicable records (Patient #9) 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 Patient #9: The aide visit frequency was initially ordered 5-7x/week. On 7/29/21, the aide visit frequency was ordered at 1-2x/week. The record indicated only 2 visits for the week of 7/18/21-7/24/21 and no visits for the week of 7/26/21-7/30/21. Corrected on site

Upon SNF/NF contract review, 1 of 2 applicable contracts (Avamere) did not have evidence of the provision that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home.

Upon SNF/NF contract review, 1 of 2 applicable contracts (Avamere) did not have evidence of a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon SNF/NF contract review, 1 of 2 applicable contracts (Avamere) did not have evidence of a provision for the delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon client record review, 4 of 13 records (Patient #2,#8,#11,#13) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #2: An order dated 8/19/21 indicated to cleanse sacral wound with wound cleanser, pat dry. apply medihoney to wound bed and cover with foam dressing qod and prn as tolerated until healed. There was not evidence of which provider was to perform this treatment. Corrected on site. Patient #8:The record indicated an order dated 7/29/21 to cleanse the mid back area with wound cleanser, pat dry, apply Betadine to area and cover with foam dressing 2x/week and prn as tolerated until healed. There was not evidence of which provider was to perform this treatment. In addition there was an order for wound care dated 8/30/21 to cleanse mid back area with wound cleanser, pat dry. Apply Silvasorb and cover with dry dressing qd and prn as tolerated. There was not evidence of which provider was to perform this treatment. Corrected on site. Patient #11: The record indicated an order to cleanse the sacral wound with wound cleanser, pat dry. Apply Xeroform to wound bed and cover with dry dressing qd and prn until healed. There was not evidence of who was to perform this treatment. Patient #13: The record indicated that the patient had wounds with wound care being provided. Orders did not specify which provider was to do this treatment.