Every finding on record at Pikes Peak Hospice & Palliative Care

Upon patient record review 1 of 30 (Patient #18) 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 18: The patient was admitted on 12/12/22, the initial psychosocial assessment was completed on 12/20/22.

Upon patient record review, 9 of 30 (Patient #8, 9, 11, 15, 16, 18, 19, 20, 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 08: The patient was admitted on 12/6/23 with a primary diagnosis of COPD, and uses 3Lpm of oxygen, this is not included in the medication profile. Patient 09: The medication profile includes orders for Triamcinolone External Ointment apply topically twice a day for pain, the application site is not indicated. The medication profile includes Oxygen orders entered on 3/5/24 for Oxygen 1-12L via n/c as needed, this is not patient specific (the patient record indicates the patient uses 2-3L continuously. The medication profile includes orders entered on 4/29/24 for Voltaren External Gel 1% take up to 4 times daily as needed for arthritis pain, it does not include an application site. Patient 11: The medication profile includes Diclofenac External Gel 1% apply every 8 hours as needed for pain management, it does not include an application site. Patient 15: The medication profile includes Oxygen orders entered on 1/5/23/24 for Oxygen 1-12L via n/c as needed, this is not patient specific. The medication profile effective 2/16/24 includes Voltaren Gel 1%, "per box instructions", there is no frequency of of use or application site indicated. Zithromax 250mg initiated on 4/12/24 was indicated for 5 days of use and remains on the medication profile to date. Effective 11/15/23, LidoRX gel use prior to foley placement, the comprehensive assessment effective 4/1/24 and to date does not indicate the use of a foley catheter. Patient 16: The medication profile includes Oxygen 1-12L via n/c as needed, this is not patient specific. Patient 18: The medication profile includes Oxygen orders entered on 12/12/22 for Oxygen 1-12L via n/c as needed, this is not patient specific. Patient 19: The medication profile includes Aspercreme 4% as needed for discomfort do not include a frequency or an application site. The medication profile includes Calmoseptine ointment apply to affected area 4 times a day as needed, it does not include an indicator and an application site. Medications entered on 11/10/23 for Miralax 17G packet daily as needed, do not inlcude an indicator for use or instructions for a diluent. Patient 20: The medication profile includes Miralax 17G powder by mouth daily as needed for constipation, it does not include a diluent. Patient 22: The medication profile includes Oxygen orders entered on 4/22/24 for Oxygen 1-12L via n/c as needed, this is not patient specific, the patient record indicates the patient utilizes 3-4LPM.

Upon patient record review, 4 of 30 (Patient #2, 14, 16, 22) 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 02: The patient was admitted on 3/25/24, the bereavement assessment is not completed to date. Patient 14: The patient was admitted on 3/7/24, the bereavement assessment is not completed to date. Patient 16: The patient was admitted on 4/11/24, the bereavement assessment is not completed to date. Patient 22: The patient was admitted on 4/22/24, the bereavement assessment is not completed to date.

Upon patient record review, 6 of 30 (Patient #4, 9, 10, 12, 14, 16) 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 04: The patient was admitted on 4/22/24 and the comprehensive assessment identifies a stage II pressure ulcer to the left buttock, the plan of care does not include a problem statement with interventions and goals to address the skin breakdown. Patient 09: The patient was admitted on 3/5/24 with identified issues of shortness of breath with cough, right shoulder pain, dysphagia, and oxygen use, the initial plan of care does not include problem statements with interventions and goals related to the symptom management. Patient 10: The patient was admitted on 12/29/23, the patient record indicates a history of seizures with medication management using midazolam 5mg, the plan of care does not include a problem statement with interventions and goals for the neurological management. Patient 12: The patient was admitted on 4/20/24 with a secondary diagnosis of atrial fibrillation and uses Clopidogrel (a blood thinner) 75mg daily, the plan of care does not include bleeding precautions. Patient 14: The patient was admitted on 3/7/24 with complications related to pancreatic cancer, he has secondary diagnosis' of diabetes mellitus type II and moderate protein calorie malnutrition, he takes Lispro and Lantus for diabetes management. The plan of care does not include a problem statement with interventions and goals for the management of the diabetes and the malnutrition. Patient 16: The patient was admitted on 4/11/24 with a primary diagnosis of Neurocognitive disorder with Lewy bodies, the plan of care does not include a neurological problem statement with goals and interventions. The patient takes Entresto (a medication used for heart failure) and Eliquis (a medication used for atrial fibrillation) and furosemide (used to decrease fluid retention and edema), the comprehensive assessment includes symptoms of edema and shortness of breath, the plan of care does not include a cardiac problem statement with interventions and goals or safety precautions for bleeding.

Upon patient record review, 10 of 30 (Patient #1, 8, 9, 11, 15, 16, 18, 19, 21, 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 01: The plan of care includes orders for wound care to LLE/RLE heels, the wound care order does not indicate a frequency to perform wound care. Patient 08: The patient is admitted for COPD and the documentation in the medical record indicates that the patient utilizes Oxygen 3L/pm via NC, the plan of care does not include orders for oxygen. Paitent 09: Medication ordered entered on 3/5/24 for Triamcinolone External Ointment apply topically twice a day for pain, does not include an application site. Oxygen orders entered on 3/5/24 for Oxygen 1-12L via n/c as needed, are not patient specific (the patient record indicates the patient uses 2-3L continuously. Medication orders entered on 4/29/24 for Voltaren External Gel 1% take up to 4 times daily as needed for arthritis pain, do not include an application site. Patient 11: The medication order on 2/21/24 for Diclofenac External Gel 1% apply every 8 hours as needed for pain management, does not include an application site. Patient 15: Order for Oxygen entered on 1/5/23/24 for Oxygen 1-12L via n/c as needed, this is not patient specific. The medication orders effective 2/16/24 includes Voltaren Gel 1%, "per box instructions", there is no frequency of of use or application site indicated. Zithromax 250mg initiated on 4/12/24 was indicated for 5 days of use and has not been discontinued. Effective 11/15/23, LidoRX gel use prior to foley placement, the comprehensive assessment effective 4/1/24 and to date does not indicate the use of a foley catheter, the order has not been discontinued. Patient 16: Oxygen orders entered on 4/11/24 are 1-12L via n/c as needed for dyspnea, this is not patient specific. Patient 18: Order for Oxygen entered on 12/12/22 for Oxygen 1-12L via n/c as needed, this is not patient specific. Wound care ordered entered on 4/10/24 for Stage II ulcer of the coccyx indicates "cover area with bordered foam dressing to pad and protect, may leave on for up to 7 days, it does not include a cleaning regimen. Patient 19: Orders on 2/7/24 for Aspercreme 4% as needed for discomfort do not include a frequency or an application site. The medication orders on 11/20/23 Calmoseptine ointment apply to affected area 4 times a day as needed, it does not include an indicator and an application site. Orders on 11/10/23 for Miralax 17G packet daily as needed, the order does not inlcude an indicator for use or instructions for a diluent. Patient 21: Medication orders on 11/21/23 for Miralax 17G powder, daily by mouth as needed for constipation, do not include a diluent. Patient 22: Oxygen orders entered on 4/22/24 for Oxygen 1-12L via n/c as needed, this is not patient specific, the patient record indicates the patient utilizes 3-4LPM.

Upon patient record review, 6 of 30 (Patient #1, 2, 8, 9, 14, 15) 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 01: The patient record includes evidence that the patient utilizes a hoyer lift as ordered by hospice, this is not included in the DME plan of care. Patient 02: The patient record indicates that a low air loss mattress was ordered and utilized starting on 3/31/24, this in not included in the DME plan of care. . Patient 08: The patient was admitted on 12/6/23 with a primary diagnosis of COPD and requires oxygen, which is not included in the DME plan of care. Patient 09: The patient record indicates that the patient DME includes a walker, bed, bed rails, shower chair, over the bed table, and pull ups, these items are not included in the plan of care. Patient 14: The patient record has evidence of the use of a walker, bedside commode, chux, briefs, wipes, gloves and a urinal, these items are not included in the plan of care. Patient 15: The medication profile indicates that the patient utilizes Duonebs effective 1/26/23 and inhalation therapy of sodium chloride effective 4/12/24, the nebulizer is not included in the DME plan of care.

Upon patient record review, 3 of 30 (Patient #9, 10, 14) 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 09: The patient record reflects the following changes that have not been identified in a problem statement with interventions and goals; right shoulder pain requiring medication orders for lidocaine patches (3/7/24 and 3/11/24), fever (3/11/24), increased coughing requiring chest xray orders and begin treatments with Duonebs (3/12/24), pain requiring medication orders for Voltaren gel (4/29/24.) Patient 10: The patient record reflects medication changes on 2/22/24 for Clonazepam, related to the management of nighttime seizures, the plan of care is not updated to include a problem statement with interventions and goals for the neurological management. Patient 14: The patient record indicates that the patient has a wound to the right foot requiring treatment twice a day, the plan of care does not indicate interventions for teaching the patient or family members on the performance of the wound care.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During the home visit with Patient #2 it was observed by the RN that she utilized gloves while providing patient care, then while wearing the same gloves performed documentation on her laptop then returned to perform patient care with the same gloves. It was observed that upon completion of patient care, the nurse sanitized/cleaned her nursing tools (blood pressure cuff, thermometer) and immediately placed them back into plastic bags and into her nursing bag without allowing proper drying time.

Upon patient record review, 7 of 30 (Patient #1, 2, 3, 4, 8, 28, 30 ) 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 Patient 01: The aid task assignment for shower, hair care, nail care, oral care, skin care, and linen changes do not include a frequency. The aide task does not include assignment to perform pericare/incontinent care although the patient is incontinent and can not perform toileting independently. Patient 02: The aid task assignment for shower, hair care, denture care, nail care, skin care, assist with dressing does not indicate a frequency. Patient 03: The aide task assignment for shower, hair care, nail care, oral care, skin care and offer massage to back/foot/hands do not indicate a frequency. Patient 04: The aide task assignment for shower, hair care, nail care, oral care, perineal care, assist with dressing, and change bed linens do not indicate a frequency. Patient 08: The aide task assignment effective 3/5/24 for perineal care, and change bed linens do not include a frequency. Patient 28: The aide assignment for bathing, nail care, oral care, skin care, perineal care, dressing and back/foot/hand rub do not include a frequency in which to perform the task. Patient 30: The aide assignment for hair care and oral care do not include a frequency. The aide assignment does not include task assignments for positioning, incontinent care (patient has a foley catheter and is bed dependent) or skin care.

Upon patient record review 4 of 30 (Patient #9, 11, 28, 30) 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 09: The hospice aide visit frequency is ordered for 2 times per week, effective 3/5/24, there are no hospice aide visits documented prior to 3/26/24. Patient 11: The hospice aide frequency effective 2/19/24 is ordered for 2 times per week, the first documented aide visit was 2/23/24 performed by the SN. Patient 28: The hospice aid frequency is effective 2/6/24 is ordered for 3 times per week, the patient received 1 visit for the week of 2/6/24 - 2/10/24, the patient received 2 visits the week of 2/11/24 - 2/17/24. The hospice aide task for shampoo is indicated for 1 times per week, the aide indicated that this task was performed 2 x for the week of 2/11/24 - 2/17/24 and performed 3 times for the week of 2/18/24 - 2/24/24. Patient 30: The hospice aide documentation on 1/25/24 includes performing repositioning, changing brief and housekeeping (tidying room) the aide care plan assignment does not include these tasks. On 1/24/24, the hospice aide documentation includes performing linen change, and emptied foley bag, these tasks are not included in the aide care plan assignment.

Upon patient record review 1 of 30 (Patient #3) 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 03: There is no evidence in the patient record that a supervisory visit was performed for aide services from 1/5/24 to 2/6/24 and 2/6/24 to 3/5/24.

Based on interview and record review, the hospice failed to ensure visit frequencies were provided as established by the interdisciplinary group (IDG) in accordance with the plan of care for 1 of 4 patients receiving certified nurse assistant services (Patient #4). Findings include: AGENCY POLICY According to the agency policy titled, "The Plan of Care," dated 4/2020 (in pertinent parts): "The care provided to the patient must be in accordance to the plan of care." According to the agency policy titled, "Missed Visits, dated 4/2020 (in pertinent parts): "Missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record." 1. The clinical record for Patient #4 was reviewed on 5/10/22. The plan of care for the certification periods dated 9/25/21 to 12/23/21 and 12/24/21 to 3/23/22 revealed a start of care date of 9/25/21; diagnoses included breast cancer. Plan of care orders included skilled nurse (SN) services once a week for twelve weeks for intravenous access maintenance, assessments, education, and vital signs, certified nurse assistant (CNA) services three times a week for twelve weeks for personal care, masters of social work (MSW) services twice a month for three months for supportive presence, and spiritual care (SC) services every two weeks for twelve weeks for spiritual counsel and supportive services. a) The hospice failed to ensure CNA visits were provided in accordance with Patient #4's plan of care. Review of the plan of care dated 9/25/21 to 12/23/21 and 12/24/21 to 3/23/22, revealed physician orders for CNA services three times a week for twelve weeks for personal cares. Review of the CNA visit schedule dated 11/1/21 to 1/12/22 revealed the CNA only made two visits a week for the weeks of 11/28/21 to 12/4/21 and 12/12/21 to 12/18/21. Clinical record review for the period 11/1/21 to 1/12/22, revealed no evidence of physicians orders to decrease CNA frequencies to twice a week. Review of the clinical record dated 11/1/21 to 1/12/22 revealed no evidence of missed visit documentation for the weeks of 11/28/21 to 12/4/21 and 12/12/21 to 12/18/21. Further review revealed no evidence of the CNA visits having been canceled by the physician or the IDG. During an interview on 5/11/22 at 9:30 a.m., Employee #4 stated the agency expectation for missed visits was that the staff member involved was to document the missed visit with the reason why the visit was missed and notify the nurse case manager of the missed visit. Employee #4 stated the CNA made only two visits for the weeks of 11/28/21 to 12/4/21 and 12/12/21 to 12/18/21. During an interview on 5/11/22 at 9:47 a.m., Employee #7 stated all missed visits were to be documented in the patient record and her supervising nurse case manager would be notified. She further stated she was unsure why the visits for Patient #4 were only done two times a week for the weeks of 11/28/21 to 12/4/21 and 12/12/21 to 12/18/21 if there were no orders from the physician to change the visit frequency.