Every finding on record at Rocky Mountain Hospice of Butte, LLC

Based on interviews and record review, the agency failed to ensure complaints were investigated, resolved, and documented for 2 (#'s 1 and 2) of 6 sampled patients. This deficient practice resulted in the patient #s 1 and 2 families becoming frustrated and moving to another agency for services. Findings include: --- 1. During an interview on 4/15/26 at 9:02 a.m., NF1 stated he had voiced complaints about medications requiring he wake patient #1 every two hours 24 hours a day and wanted a fentanyl patch to better manage her pain without waking her as frequently. NF1 stated the agency was repeatedly running low or out of patient #1's pain medications and he would have to call them to get more. NF1 stated he also complained about a leaky G-tube bag and staff member D told him the only bag available was the same bag they were using that leaked. NF1 stated family had to go out and purchase bags that did not leak themselves. NF1 stated he complained to staff member C regarding his concerns and shared his frustration regarding staff member D scaring patient #1 by telling her she may start having the feeling of snakes or spiders in her bed or crawling up the wall as hallucinations. NF1 stated he complained to staff member C about staff arriving 20 minutes to an hour late for every visit and staff member D sharing her personal problems and staying far too long after completing her visit tasks. NF1 stated staff member C did change the nurse to another nurse, but it still took a while to get the fentanyl patches in place to allow her to rest comfortably and they were so frustrated by that time, the family made the decision to transfer to a different agency where they had a much better experience.During an interview on 4/15/26 at 2:57 p.m., staff member D stated patient #1's family said she talked too much. Staff member D stated the daughter was upset because she was explaining the symptoms patient #1 might expect like hallucinations and delusions because patient #1 was asking what to expect. Staff member D stated the family reported to staff member C they did not want her back at the home. Review of patient #1's Coordination Note, dated 8/28/25, showed family reported concerns about a leaking G-tube connector.Review of patient #1's Coordination Note, dated 9/2/25, showed the family had changed the G-tube and used another connector but the agency staff believed it was the same type of connector previously used. The site was taped in order to keep it in place as it disconnected without tape in place.Review of patient #1's Coordination Note, dated 9/4/25, showed patient #1's G-tube connector was again leaking. Note indicated nurse would check the office for any other types of connectors to try.Review of patient #1's Coordination Note, dated 9/9/25, showed staff member C spoke with NF1 regarding pain medication running out over the weekend. Review of patient #1's Coordination Note, dated 9/11/25, showed patient #1 had a new bag on the G-tube site and was no longer leaking and G-tube site care was done by family.Review of patient #1's Coordination Note, dated 10/15/25, showed family voiced frustration over communication and showing up for visits on time.Review of patient #1's Coordination Note, dated 10/27/25, showed patient #1 was started on fentanyl over the weekend and family stated they would like patient #1 transferred to another agency for services. 2. During an interview on 4/15/26 at 8:43 a.m., staff member E stated patient #2's family was upset with her because she had not been clear with them that patient #2 needed 24 hour care givers for safety. Staff member E stated she went on vacation and returned to learn patient #2 had a fall during the night and was not found until the next morning laying on the floor. Staff member E stated she should have been clearer with the family about patient #2's decline of condition and his need for more help. Staff member E stated the family filed a complaint about her with the agency. During an interview on 4/15/26 at 4:36 p.m., NF2 stated the family had a lot of challenges with consistent communication and lacked professionalism with the agency. NF2 stated the agency was not supportive or attentive in helping the family with meeting patient #2's needs. NF2 stated when patient #2 fell and she found him; she called the agency number as the family had been educated to do. NF2 stated it took more than 20 minutes to get a nurse on the phone because the answering service did not speak clear English and had difficulty understanding what was needed. NF2 stated that when she did get a nurse on the phone, the nurse told her she would need to call the fire department for lift assistance. NF2 stated she was very frustrated because she could have done that originally instead of the "run around", she experienced with the agency. NF2 stated she was not happy with the lack of response or knowledge of the agency leadership when she called to complain about the lack of nursing care and the communication concerns.Review of patient #2's Coordination Notes, dated 3/30/26, showed patient #2's family requested to be transferred to another agency. The note showed family felt communication was not up to par, and family was not prepared for patient #2's change in condition. Request for the Complaint/Grievance log for 2025 and 2026 was requested on 4/14/26 at 1:14 p.m. Staff member B stated the complaint/grievance log for 2026 was empty and the 2025 complaint/grievance log was provided. There were four complaint/grievances logged. No complaints or grievances were logged for patient #1 or #2. Staff member B stated there were no other complaints or grievances investigation notes. During an interview on 4/15/26 at 4:49 p.m., staff member B stated he only filled out a complaint form if a patient was harmed, had potential for harm, or if family stated, "I want to file a complaint." Staff member B stated NF2 was not happy with the nurse being re-educated and he did not believe the concern warranted an investigation because he did not believe the concern was egregious. Staff member B stated staff member E did not clearly explain to the family the level of care needed for patient #2. During an interview on 4/15/26 at 5:04 p.m., staff member A stated she expected a complaint form would be completed with any complaint coming into the agency to help resolve the complaint, watch for trends, and fix them. Staff member A stated the agency probably needed to provide education with agency staff on the handling of complaints. Review of the agency's policy, Complaints and Grievances, dated 7/7/25, showed:-"... Definitions...A) Complaint or grievance- a concern expressed by anyone about quality of care, care delivery, services, colleagues, or any area under the influence or responsibility of the [Agency name] program ...4a. Complete the top portion of the Complaint Report...ii. Begin initial investigation of the complaint to include initial determination of the nature of complaint, whether escalation to the internal compliance/legal team is needed, and take immediate corrective steps to mitigate concern if appropriate...b. Submit the Complaint Report to the Area Executive of Clinical Services or Designee within 24-hours of receiving complaint.  ... 5h. Maintain a file/notebook (in the Area Executive of Clinical Services or designee's office) containing the Complaint Log, and all Complaint Reports, investigation data, and follow-up communication. ..."

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 3 (100%) clinical records reviewed for patients who received volunteer services, the agency did not ensure volunteer services were included in the patient's plan of care. Agency policy #HOS-C09 "Written Interdisciplinary Plan of Care" (dated 01/02/2026, stated in part "The content of the plan includes at minimum detail of scope and frequency of services necessary to meet the assessed needs." CLINICAL RECORD 3: The patient elected hospice care on 11/28/2025 with a diagnosis of chronic respiratory failure. The patient's plan of care dated 02/18/2026 ordered: "assess for volunteer needs." Volunteer visits were documented as completed on 02/19/2026 and 02/26/2026. The plan of care did not include documentation of the frequency, interventions, or goals for volunteer services. CLINICAL RECORD 2: The patient elected hospice care on 03/06/2026 with a diagnosis of senile degeneration of the brain. The patient's plan of care dated 03/06/2026 ordered: "assess for volunteer needs." Volunteer visits were documented as completed on 03/30/2026 and 04/08/2026. The plan of care did not include documentation of the frequency, interventions, or goals for volunteer services. CLINICAL RECORD 7: The patient elected hospice care on 03/14/2026 with a diagnosis of cerebral Infarction. The patient's plan of care dated March 18, 2026, did not specify the frequency of volunteer services, interventions, or goals. The volunteer documented visits on 03/30/2026 and 04/08/2026. During an interview on 04/15/2026, the Administrator/Alternate Clinical Director agreed with the finding.

It is required that a hospice aide provides services that 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. In 1 of 16 (6%) clinical records reviewed in which a hospice aide (HA) provided care, the care provided by the HA did not follow the HA plan of care. Clinical Record 14: On 6/5/23, the HA documented putting a gauze dressing over a sore on the patient’s left hip to keep him from scratching. The hospice aide care plan dated 6/2/2023 did not direct the HA to apply gauze to the open sore on the patient’s left hip. An interview with the Regional Director of Clinical Services on 6/13/2023 confirmed this finding. He stated that the HA had good intentions but should not have put the gauze on the patient if it was not on the HA plan of care.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care and documented in the patient record. This standard was not met as evidenced by clinical record review and interview. In 9 of 19 (47%) clinical records reviewed, there was no evidence that a volunteer was offered and/or the patient declined volunteer services. Clinical Record 1: The patient’s benefit election was dated 11/30/2022. There was no documentation that a volunteer was offered. Clinical Record 4: The patient’s benefit election was dated 11/22/2023. There was no documentation that a volunteer was offered. Clinical Record 8: The patient’s benefit election was dated 4/27/2023. There was no documentation that a volunteer was offered. Clinical Record 9: The patient’s benefit election was dated 3/23/2023. There was no documentation that a volunteer was offered. Clinical Record 10: The patient’s benefit election was dated 5/9/2023. There was no documentation that a volunteer was offered. Clinical Record 11: The patient’s benefit election was dated 1/31/2022. There was no documentation that a volunteer was offered. Clinical Record 12: The patient’s benefit election was dated 3/14/2023. There was no documentation that a volunteer was offered. Clinical Record 18: The patient’s benefit election was dated 4/13/2022. There was no documentation that a volunteer was offered. Clinical Record 19: The patient’s benefit election was dated 3/17/2023. There was no documentation that a volunteer was offered. An interview with the Director of Clinical Services-float on 6/13/23 confirmed that there was no documentation regarding offering a volunteer. He stated that he did not know why it was not consistently documented that the volunteer was offered and/or refused.