Every finding on record at Seasons Hospice & Palliative Care 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 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the initial comprehensive assessment was completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 10: The patient was admitted to hospice on 05/15/2025 with a malignant brain tumor. The initial skilled nursing (SN) assessment, dated 05/15/2025, documented that the patient accepted all disciplines. A missed visit note was recorded on 05/16/2025, indicating that the Social Worker visit would be scheduled for the following week; however, no rationale was provided for the delay. The Social Worker completed an assessment on 05/22/2025, with seven (7) days outstanding. During an interview on 09/16/2025, the Administrator confirmed that the clinical record did not provide a rationale for the late social work visit and reported that the assigned social worker is no longer with the organization.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that all the medical supplies and appliances were included in the plan of care. CLINICAL RECORD 3: The patient elected hospice care on 06/18/2025 with a diagnosis of congestive heart failure. The skilled nurse assessment documented that the patient was dependent on oxygen and had a heel wound requiring wound care. The plan of care dated 06/18/2025 included orders for oxygen and wound care. The plan of care did not include documentation of "Durable Medical Equipment (DME) and Supplies", which were listed as "NONE" During an interview and a joint record review on 09/16/2025, the Administrator confirmed the findings.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed of a patient transferred to a Medicare/Medicaid certified facility, the agency did not ensure that the receiving facility received a copy of the hospice discharge summary. CLINICAL RECORD 11: The patient elected hospice care on 11/20/2025. The patient resided at home. The patient experienced severe nausea and vomiting on 12/15/2025 and was transported by the family to the hospital and admitted. The family notified the hospice on 12/16/2025. The clinical record contained no evidence that a discharge summary was provided to the hospital. During an interview on 09/18/2025, the Administrator stated, "You won't find a discharge summary that was sent to the facility. We know they were not doing them appropriately.”

Observed in Record Review. In 2 of 13 patient records reviewed, During RR#4 and RR#6 it was noted the initial bereavement assessments were not completed within 5 day of the initial RN assessment. Both initial bereavement assessment were completed 15 days after the initial assessment. This was discussed with the leader assisting with record reviews.

Observed in Record Review. In 2 of 13 patient records reviewed, During RR#8 it was noted the patient's Foley catheter (F/C) was removed the end of March 2022. The IDG meeting RN summary after the F/C was removed, the beginning of April 2022, lacked the information to the IDG of the F/C removal. In addition there was lack of documentation of RN summaries of clinical findings from the prior 2 weeks during 2 IDG meeting in August 2022. During RR#10 it was noted lack of documentation of an RN summary of clinical findings from the prior 2 weeks during 2 IDG meetings the end of September and the beginning of October 2022. This was discussed with the leader assisting with record reviews.

Observed in Record Review. In 11 of 13 patient records reviewed, During HV#1-3, RR#2 -6, #8-#10 it was noted the written plans of care were not based on the patient’s goals and the time frames required to meet those outcomes/goals. The POC lacked measurable outcomes of all goals established by SN, MSW and Chaplain to assess if goals were accomplished. Examples throughout records reviewed: pt/caregiver will verbalize understanding of preventive skin care, pt. will exhibit reduction and relief of any pulmonary symptoms, pt. caregiver verbalize understanding of fall prevention measures, pt/family verbalizes understanding of the stages of grief, facility staff is knowledgeable and involved in hospice care plan for pt., pt. to express increased feeling of security and peacefulness, pt/cg demonstrates understanding of preventative skin care, and pt./cg verbalize understanding of safety precautions. This was discussed with the leader assisting with record reviews.

Observed in Record Review. In 1 of 13 patient records reviewed, During RR#8 it was noted an order for oxygen at 2l/min PRN. The intervention lacked the reason for the PRN need. Observed in Record Review. In 2 of 13 patient records reviewed, During HV#3 record review it was noted the patient contracted COVID-19 in August 2022. The POC lacked a documented update to include interventions and outcomes related to the COVID-19 infection. During RR#8 it was noted in September 2022 a safety issue that was identified related to the potential of the patient seeking to exit the facility. Interventions and outcome/ goals were not added to the POC to address the potential safety issue. This was discussed with the leader assisting with record reviews.

Observed in Record Review. In 1 of 13 patient records reviewed, During HV#3 record review it was noted a Chaplain frequency of PRN visits without an indication of the number or reason for PRN visits to be performed. This was discussed with leadership during record review.

Observed in Record Review. During HV#1 record review it was noted the plan of care did not include treatments necessary to meet the patient’s needs. The POC lacked an order for wound care to a stage lV pressure ulcer that was performed twice weekly by the SN. This was discussed with the leader assisting with record reviews.

Observed in Individual Tracer. In 1 of 3 home visits conducted, During HV#3 it was noted the SN did not adhere to the manufacturer direction of a 2 minute wet to dry contact time required to disinfectant equipment used during the visit. The equipment included a BP cuff, stethoscope, tape measure and pulse oximetry device that was immediately placed in a small bag after wiping with disinfectant wipe. This was discussed with the organization leaders.

Observed in Record Review. In 2 of 13 patient records reviewed, During RR#2 it was noted the patient was on continuous oxygen at 3L/min. The hospice aide care plan did not address whether the oxygen should remain in place or could be removed for the patient's bath. During RR#9 it was noted the patient was on continuous oxygen therapy at 4L/min. The hospice aide care plan did not address whether the oxygen should remain in place or could be removed for the patient's bath. This was discussed with the organization leader assisting with record reviews.