Every finding on record at Life Choice Hospice of Colorado, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the hospice did not ensure that the Interdisciplinary Group completed the initial spiritual and psychosocial assessment no later than five (5) days after the election of hospice care. Clinical Record 5: The patient elected the hospice benefit on 08/14/2024. The Social Worker (SW) completed the initial psychosocial assessment on 08/20/2024, with six (6) days outstanding. The Chaplain (SC) completed the initial spiritual assessment on 08/21/2024, with seven (7) days outstanding. There was no documented reason for the delay. Clinical Record 11: The patient elected the hospice benefit on 06/27/2024. The initial nursing assessment dated 06/27/2024 documented a referral to the SC. A missed visit was documented on 07/01/2024. There was no documented evidence that the initial spiritual assessment was completed within 5 days. Clinical Record 14: The patient elected the hospice benefit on 10/13/2024. The SC documented a telephone call on 11/11/2024 (with 29 days outstanding) to introduce himself and set up the initial spiritual assessment visit. There was no documented reason for the delay. Clinical Record 15: The patient elected the hospice benefit on 06/21/2024. The SW completed the initial psychosocial assessment on 06/28/2024, with seven (7) days outstanding. There was no documented reason for the delay. Clinical Record 16: The patient elected the hospice benefit on 10/13/2023. The SC documented a telephone call on 10/27/2023 (with 14 days outstanding), documenting the patient declined the SC visit. There was no documented reason for the delay. During a joint record review and interview on 01/17/2025, the Administrator agreed there was no documented evidence that the Interdisciplinary Group completed the initial spiritual and psychosocial assessment no later than five (5) days after the election of hospice care. Additionally, the Administrator stated, "We had a PIP on this and need to reopen it due to the lack of follow-through in response to the education."

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluation programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. The hospice maintains documentation that each hospice aide has met the requirements. A qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; normal range of motion and positioning. Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: observation, reporting, and documentation of patient status and the care or service provided; basic infection control procedures; basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; maintenance of a clean, safe, and healthy environment; recognizing emergencies and the knowledge of emergency procedures and their application; the physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; adequate nutrition and fluid intake; any remaining task(s) that the hospice chooses to have an aide perform. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy, "HH-C13 Home Health Aide Services," stated in part, "ensures home health aides receive a competency and skills evaluation by a qualified RN prior to independent care delivery. Prior to independent care and at least annually, home health aides are evaluated for skills proficiency by direct observation." In 1 of 1 (100%) personnel record reviewed of a Hospice Aide, the hospice did not ensure a skills competency with the required observed skills was completed before the hospice aide began providing independent care to patients. Personnel Record 5: The Hospice Aide, contracted, was hired on 09/18/2023. A personnel record review revealed no documented evidence of an initial competency assessment before the aide began providing independent care. During a joint review of the personnel record and an interview on 01/17/2025, the Administrator agreed the hospice did not ensure an RN completed a competency with observed required aide skills before the aide performed independent care. Additionally, the Administrator stated, "We do not have any evidence that it was done. We are completing one now. We identified quality issues with the previous business office coordinator and Director of Clinical Services during that time. They are no longer here." The Administrator confirmed the Hospice Aide began visits just after 09/18/2023.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the agency's Hospice Volunteer Requirement Report on 01/17/2025 for 01/01/2024 through 12/31/2024 revealed a cost savings of 4.66%. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff in 2024. During a joint review of the Hospice Volunteer Requirement Report and interview on 01/17/2025, the Administrator agreed the hospice agency did not meet the minimum five percent cost savings requirement for 2024. Additionally, the Administrator stated, "We need to provide more education on being more proactive in getting volunteers in the homes."

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. 3 of 16 (18%) records reviewed revealed the hospice did not ensure the clinical records contained the initial bereavement assessment. Record #89679: the patient elected hospice care on 11/18/2021. The clinical record did not contain an initial bereavement assessment. Record #78977: the patient elected hospice care on 7/15/2020. The clinical record did not contain an initial bereavement assessment. Record #37374: the patient elected hospice care on 10/29/2021. The clinical record did not contain an initial bereavement assessment. The agency’s policy “Bereavement Risk Assessment and Acuity Scale” “Procedure: C_19A Bereavement Risk Assessment with Acuity Scale” revision date: 11/2018 stated, in part: “The Social Worker completes the initial bereavement risk assessment during the social worker’s comprehensive assessment conducted within 5 days of the hospice election. A Spiritual Counselor (chaplain) or RN Case Manager may be asked to complete the assessment if the Social Worker is not able to complete the assessment timely.” The Director of Clinical Services was interviewed on 3/10/2022 and stated, there were no initial bereavement assessments within the records identified.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by observation, interview, and document review. 1 of 4 (25%) observations during home visits revealed the hospice did not ensure adherence to agency infection prevention and control policies and procedures for bag technique. During observation of Patient #43462, on 3/9/2022 at 10:15 am, Chaplain #48418 entered the patient’s room and removed the bag from her shoulder, and placed the non-wheeled bag on the floor in front of the patient. The agency's policy “Infection Control: Bag Technique in Home Care and Standard Precautions” “Procedure: C_11G Bag Technique and Standard Precautions” revision date: 4/22/20 stated, in part: “Standard Bag Technique: Place hand-carried bags on a clean, dry surface or hang on a doorknob. Rolling bags may be kept on the floor or hung on a doorknob but should not be placed on furnishings. The Director of Clinical Services was interviewed on 3/9/2022 and stated, the staff did not follow agency policy and procedures for bag technique.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 5 of 12 (41%) records reviewed with a hospice aide services accepted revealed the hospice did not ensure that the hospice aide followed the plan of care as ordered. Record #78538: A physician order was included in the plan of care on 9/1/2021 for a hospice aide twice weekly. During the week of 9/1/2021-9/4/2021, there was no documented evidence of a hospice aide visit or missed visit. Record #43462: A physician order was included in the plan of care on 11/26/2021 for a hospice aide once weekly to start 11/28/2021. During the week of 11/28/2021-12/4/2021, there was no documented evidence of a hospice aide visit or missed visit. Record #78977: A physician order was included in the plan of care on 7/15/2020 for a hospice aide twice weekly. During the week of 7/15/2020-7/18/2020, there was no documented evidence of a hospice aide visit or missed visit. During the week of 7/19/2020-7/25/2020, there was no documented evidence of a hospice aide visit or missed visit. Record #81977: A physician order was included in the plan of care on 10/26/2021 for a hospice aide once weekly. During the week of 10/26/2021-10/30/2021, there was no documented evidence of a hospice aide visit or missed visit. Record #37374: A physician order was included in the plan of care on 10/31/2021 for a hospice aide twice weekly. During the week of 10/31/2021-11/6/2021, there was no documented evidence of a hospice aide visit or missed visit. During the week of 11/7/2021-11/13/2021, there was a hospice aide visit on 11/9/2021. There was no documented evidence of a second hospice aide visit or missed visit. The Director of Clinical Services was interviewed on 3/10/2022 and stated, “these are a miss” and confirmed there was no documentation within the records identified on why the hospice aide didn't follow the plan of care.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care, hospice election form, physician certification, and recertification of the terminal illness. This standard was not met as evidenced by observation, record review, and interview. 1 of 2 (50%) patients reviewed in a SNF revealed the hospice did not ensure the most recent hospice plan of care, hospice election form, physician certification, and recertification of the terminal illness were provided to the SNF by the designated IDG member. During a joint visit with the hospice aide #39376 to Patient #23970, on 3/8/2022 at 8:40 am, a review of the facility chart revealed there was no evidence that the most recent hospice plan of care, hospice election form, physician certification, and recertification of the terminal illness were provided to the SNF. The Director of Clinical Services was interviewed on 3/8/2022 and confirmed this finding.