Every finding on record at Rocky Mountain Hospice LLC

Upon patient record review, 1 of 6 (Patient #4) 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 4: Patient admitted 2/11/25. There is no evidence of initial bereavement assessment in the medical record.

Upon client record review, 3 of 6 (Patient #2,3,4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: Physician’s SN visit frequency order is twice weekly. There is evidence of only one SN visit during week of 3/30/25. Patient 3: Physician’s SN visit frequency order is twice weekly. There is evidence of only one SN visit documented during week of 3/30/25. Patient 4: Physician’s MSW visit frequency order is twice monthly. There is evidence of no MSW made in March 2025. Physician’s SC visit frequency order is weekly. There is no evidence of SC visit made 3/20/25-4/3/25.

Upon patient record review, 3 of 6 (Patient #1,2,3) 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 Patients 1,2: There is no evidence of frequencies for assigned tasks in aide care plan. COS Patient 3: There is no evidence of frequencies for assigned tasks in aide care plan.

Upon patient record review 1 of 6 (Patient #2) 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 2: Physician’s aide visit frequency order: once weekly for one week, beginning 3/6/25, then twice weekly. There is no evidence of aide visit during week of 3/6/25.