Every finding on record at Home Hospice Denver

Based on record review and interview, the hospice failed to provide for an ongoing sharing of information in accordance with policies and procedures. Specifically, for hospice patients residing in assisted living residences, the hospice did not have written agreements which included determining how plan of care services would be furnished in a safe and effective manner by qualified personnel. --- Findings include:Agency documents, including six sample hospice patient clinical records and agency policies and procedures, were reviewed from 1/9/26 through 1/13/26.  a) The hospice failed to have policies and procedures in place for written agreements for the provision of plan of care services, to be furnished in a safe and effective manner by qualified personnel, for patients residing in non-hospice assisted living residences.Review of agency policies and procedures did not reveal a policy for written agreements between the hospice and non-hospice assisted living residences where patients resided.During an interview with the hospice director of operations (DOO) on 1/12/26 at 2:46 p.m., the DOO confirmed the hospice agency accepted patients who lived in assisted living residences and the hospice did not have written agreements or policies and procedures regarding coordination of care with assisted living residences. During an interview with the hospice administrator on 1/13/26 at 9:15 a.m., the administrator confirmed the agency did not have policies and procedures or written agreements for coordination between the hospice and assisted living residences where non-hospice employees provided care for patients.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not assess/reassess the patient and the patients condition according to defined timeframes. The MSW psychosocial assessment was not completed within five (5) days of the patient's election of hospice care. In RR#4, the MSW/psychosocial assessment was not completed before the patient's death on day 13 of admission to hospice, with no explanation documented. In RR#6, the MSW assessment was completed eight (8) days after the patient's election of hospice care. This was reviewed and verified with the Clinical Review Lead RN.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not conduct and document a patient-specific comprehensive assessment and reassessment that identified the patient's need for hospice care and services, including survivor risk factors. In RR#4, the initial bereavement assessment was not completed/documented. This was reviewed and verified with the Clinical Review Lead RN.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization did not plan the patient's care by ensuring the plan of care included all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatments necessary to meet the patient's needs. In review of the record for HV#1, the patient's Oxygen order was not included in the hospice plan of care. It was also note that the order on the patient's medication profile for Senokot tablets did not include the dosage and frequency. The patient's plan of care also included both Haldol prn and Ativan prn for agitation, with no clear indications for use (which prn medication to take when). In RR#3, the patient's Oxygen order was not included in the hospice plan of care. In RR#5, the RN documented an order for antifungal powder would be obtained for the reddened areas under the patient's breast and pannus. The order for the powder was not included/documented in the hospice plan of care. Additionally, the patient's Oxygen order was not included in the hospice plan of care. In RR#6, it was documented the patient had an indwelling urinary catheter, with no specific skilled nursing orders related to the catheter management, changes, and care noted in the plan of care. This was reviewed and verified with the Clinical Review Lead RN.

Observed in Infection Control System Tracer. During the infection control system tracer discussion, it was noted that patient infections and related plan of care updates were discussed at the hospice interdisciplinary team meetings. The infection risk assessment, however, did not include an analysis of its surveillance activities, as the organization was not collecting/reporting data on these patient infections. This was reviewed with the Clinical Supervisor and VP of Ambulatory Operations.

Observed in Record Review. 1 of 7 patient records reviewed with hospice aide services, the organization did not provide care, treatment, or services in accordance with orders. In RR#5, the hospice aide did not provide services as ordered in the plan of care. The RN documented the aide applied corn starch powder under patient's breast. The application of the powder was not included in the aide plan of care. This was reviewed and verified with the Clinical Review Lead RN.