Every finding on record at Hospice of Metro Denver, Inc

Upon patient record review, 11 of 31 (Patient #1,2,5,9,11,12,15,16,17,18,22) 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 8/18/25-SN states "pt now on IV/SQ meds as pt is no longer able to swallow, no evidence that PO meds (Eliquis, Simvastatin, Vitamin B12, Vitamin D3) were discontinued on medication profile. Corrected on Site. Patient #2 8/9/25 order for Gabapentin 300mg PO every other day x7 days then discharge remains on profile, no evidence that the order was discontinued on 8/17/25 per orders on medication profile. Corrected on Site. Patient #5 6/6/25, Duplicate Tylenol orders with no evidence of one order being discontinued on the medication profile. Corrected on Site. Patient #9 7/3/25-Hydrocodone/Acetaminophen 5/325 1-2 tabs PO Q4-6 hours PRN, 4/4/25 Arthritis pain relief ER 650mg tab PO BID, with no evidence of "Not to Exceed "parameters on medication profile. Corrected on Site. Patient #11 4/5/25, Hydrocortisone Cream, apply TID to "affected area", no evidence of specific location to be applied on the medication profile. Corrected on Site. 3/12/25 Tylenol 650mg Q4 PRN and 7/6/25 Acetaminophen 325mg 2 tab PO QD, no evidence of "Not to exceed" parameters on medication profile. Corrected on site. Patient #12 2/7/23 Calciptriene Cream BID and 7/3/24 Triamcinolone Ointment q6 PRN with no evidence on either order of specific location for application on medication profile. Corrected on Site. Patient #15 2/16/25 Capsaicin Cream apply QD with no evidence of specific location on medication profile. Corrected on Site. 6/14/25 Macrobid 100mg x7d remains on medication profile, no evidence it was discontinued after the 7 day order on medication profile. Corrected on Site. Patient #16 7/10/25 Diclofenac Gel, apply TID and 8/8/25 Nystop Powder apply TID, no evidence of specific location on medication profile. Corrected on Site. Patient #17 8/18/24, Lidocaine Ointment apply BID, no evidence of specific location on medication profile. Corrected on Site. Patient #18 7/14/25 Sarna lotion for "itching" PRN and Chamosyn Cream applied PRN,no evidence of specific location on medication profile. Corrected on Site. Patient #22 Duplicate orders on 7/5/25 and 7/14/25 for Acetaminophen/Codeine 300/60mg Q6 PRN on medication profile. Corrected on site.

Upon patient record review, 1 of 31 (Patient #18) 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 #18-SN 7/11/25 states visit for wound care, no evidence of wound care orders in place. Corrected on site.

Upon patient record review, 1 of 31 (Patient #19 did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #19-Duplicate Aide visit frequency orders, 7/25/25 1-2x/week and 8/14/25 2-3x/week. Corrected on site.

Upon patient record review, 11 of 31 (Patient #1,2,5,9,11,12,15,16,17,18.22) 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 8/18/25-SN states "pt now on IV/SQ meds as pt is no longer able to swallow, no evidence that PO meds (Eliquis, Simvastatin, Vitamin B12, Vitamin D3) were discontinued on POC. Corrected on Site. Patient #2 8/9/25 order for Gabapentin 300mg PO every other day x7 days then discharge remains on POC, no evidence that the order was discontinued on 8/17/25 per orders on POC. Corrected on Site. Patient #5 6/6/25, Duplicate Tylenol orders with no evidence of one order being discontinued on the POC. Corrected on Site. Patient #9 7/3/25-Hydrocodone/Acetaminophen 5/325 1-2 tabs PO Q4-6 hours PRN, 4/4/25 Arthritis pain relief ER 650mg tab PO BID, with no evidence of "Not to Exceed "parameters on POC. Corrected on Site. Patient #11 4/5/25, Hydrocortisone Cream, apply TID to "affected area", no evidence of specific location to be applied on the POC. Corrected on Site. 3/12/25 Tylenol 650mg Q4 PRN and 7/6/25 Acetaminophen 325mg 2 tab PO QD, no evidence of "Not to exceed" parameters on POC. Corrected on site. Patient #12 2/7/23 Calciptriene Cream BID and 7/3/24 Triamcinolone Ointment q6 PRN with no evidence on either order of specific location for application on POC. Corrected on Site. Duplicate orders for 4% Lidocaine patch. 10/25/24 Lidocaine 4% patch to lower back 3x/day and 3/19/25 Lidocaine 4% patch to lower back daily. Corrected on Site. Patient #15 2/16/25 Capsaicin Cream apply QD with no evidence of specific location on POC. Corrected on Site. 6/14/25 Macrobid 100mg x7d remains on POC, no evidence it was discontinued after the 7 day order on POC. Corrected on Site. Patient #16 7/10/25 Diclofenac Gel, apply TID and 8/8/25 Nystop Powder apply TID, no evidence of specific location on POC. Corrected on Site. Patient #17 8/18/24, Lidocaine Ointment apply BID, no evidence of specific location on POC. Corrected on Site. Patient #18 7/14/25 Sarna lotion for "itching" PRN and Chamosyn Cream applied PRN,no evidence of specific location on POC. Corrected on Site. Patient #22 Duplicate orders on 7/5/25 and 7/14/25 for Acetaminophen/Codeine 300/60mg Q6 PRN on POC. Corrected on site.

Upon patient record review, 1 of 31 (Patient #5) 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 #5-POC does not include DME of walker and wheelchair that patient utilizes for mobility. Corrected on Site.

Upon patient record review, 1 of 31 (Patient #23) 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 #23, current POC still has goals and interventions for MSW, however the MSW was declined by family on 3/5/25 and there is no evidence the POC was updated. Corrected on Site.

Upon home visit observation 1 of 6, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2, during the visit with the Aide, she placed her personal bag on the countertop in the patients room without placing a barrier down per policy.

Upon patient record review 4 of 31 (Patient #9,17,20,22) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #9-No evidence of aide supervisory visit completed by due date of 8/13/25. Patient #17-No evidence of aide supervisory visit completed by due date of 8/4/25 Patient #20-No evidence of aide supervisory visit completed by due date of 7/15/25. Patient #22-No evidence of aide supervisory visit completed by due date of 8/7/25.

Upon client record review, 1 of 31 (Patient #27) did not have evidence that the physician provides a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Patient #27, CTI dated 7/10/2025 there is no evidence the physician provided a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Corrected on Site.

Upon patient client record review, 1 of 31 (Patient #12) 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 #12-8/14/25 RN completed LPN supervisory visit, however no LPN visits on POC.

Upon client record review, 2 of 31 (Patient #25, 26) 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 #25, 26-No evidence the hospice agency forwarded a copy of the discharge summary to the patients attending physician.

Upon patient record review, 1 of 20 (Patient #10) 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. Patient # 10 - 6/7/22 Patient noted to have oxygen 2 l/min continuous. No evidence of a respiratory care plan . (Corrected on site)

Upon patient record review, 2 of 20 (Patient #9, 12) 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 -RN note 7/29/22 documents dexamethasone 2mg which was taken last 10 days to be discontinued with daughter updated. No order on chart to discontinue medication. (Corrected on site) Patient # 12 - 3/29/22 Order for oxygen states oxygen at 3-4 l/min n/c continuous. On admission assessment of 3/12/22 - nursing documentation reports patient is on O2 at 5 l/min cont. There is no order for O2 at 5L/min. (Corrected on site)

Upon patient record review, 4 of 10 applicable (Patient #1, 2, 3, 5) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #1- Aide POC interventions states for patient to receive a Complete bed bath and Shower - offer shower first - facility nurse functionally and cognitively able to decide shower to bed bath. No evidence of communication with facility staff regarding shower/bath. Corrected on site. Patient # 2- Aide POC interventions include Complete bed bath and Shower. No evidence of instructions as to when each bath type should be completed. Corrected on site. Patient #3- Patient is on Eliquis. No evidence of bleeding precautions on aide POC nor in patient home safety listings. Corrected on site. Patient #5 - Aide POC interventions state Complete bed bath and Shower - if patient is able to tolerate. Missing evidence of whether patient is cognitively and functionally able to decide between bath types. Corrected on site.

Upon patient record review 3 of 10 applicable (Patient #2, 3, 16) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #2 - Visit orders state for aide 1-2 times a week starting 3/27/22. Discontinue aide services order dated 5/19/22. Evidence of visits 3/28, 4/4, 4/7, 4/11, and 4/18. Patient #3- Signed Visit orders state 1-2 times a week. Visits documented at 1 time a week. No parameters or instructions for how the frequency is determined 1x/week vs. 2x/week. Patient # 16 - Order on patient record for aide services 8/1/22 for 1 x week. Aide documentation in patient record on 8/10/22 as a missed visits note stating patient refused care as patient wants a female aide. No evidence of a d/c order and no further aide visits. (Corrected on site)

Upon client record review, 1 of 3 applicable (Patient #12) did not have evidence that the hospice sent the discharge summary or clinical information to the patient's attending physician.