Every finding on record at Sun Tree Hospice of Colorado LLC

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles. This standard was not met as evidenced by a review of personnel records and interviews. In 8 of 10 (80%) personnel records reviewed, the hospice did not ensure that initial training of the agency's emergency preparedness policies and procedures was completed upon hire. Record 1 (Executive Director): hire date 2/10/2020. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 2 (Director of Nursing): hire date 1/4/2021. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 3 (Hospice Medical Director): hire date 6/28/2020. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 4 (Chaplain/Bereavement Coordinator): hire date 8/31/2020. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 5 (Medical Social Worker/Volunteer Coordinator): hire date 11/30/2020. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 7 (Hospice Aide): hire date 9/27/2021. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 9 (Registered Nurse): hire date 6/6/2022. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 10 (Volunteer): hire date 11/12/2021. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. The Executive Director was interviewed on 10/28/2022 and agreed there was no documented evidence that initial training in emergency preparedness policies and procedures was documented as completed upon hire. Record 1 (Executive Director): hire date 2/10/2020. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 2 (Director of Nursing): hire date 1/4/2021. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 3 (Hospice Medical Director): hire date 6/28/2020. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 4 (Chaplain/Bereavement Coordinator): hire date 8/31/2020. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 5 (Medical Social Worker/Volunteer Coordinator): hire date 11/30/2020. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 7 (Hospice Aide): hire date 9/27/2021. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 9 (Registered Nurse): hire date 6/6/2022. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. Record 10 (Volunteer): hire date 11/12/2021. There was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire. The Executive Director was interviewed on 10/28/2022 and agreed, there was no documented evidence that initial training in emergency preparedness policies and procedures was completed upon hire.

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 a review of clinical records and interviews. In 4 of 13 (31%) clinical records reviewed, the hospice did not ensure that an initial bereavement assessment was completed. Record 2: The patient’s date of hospice election was 10/18/2022. There was no documented evidence an initial bereavement assessment was completed. Record 3: The patient’s date of hospice election was 4/11/2022. There was no documented evidence an initial bereavement assessment was completed. Record 9: The patient’s date of hospice election was 4/26/2022. There was no documented evidence an initial bereavement assessment was completed. Record 10: The patient’s date of hospice election was 1/21/2022. There was no documented evidence an initial bereavement assessment was completed. The Director of Clinical Services was interviewed on 10/28/2022 and agreed there were no initial bereavement assessments documented in the records identified. Record 2: The patient’s date of election was 10/18/2022. There was no documented evidence an initial bereavement assessment was completed. Record 3: The patient’s date of election was 4/11/2022. There was no documented evidence an initial bereavement assessment was completed. Record 9: The patient’s date of election was 4/26/2022. There was no documented evidence an initial bereavement assessment was completed. Record 10: The patient’s date of election was 1/21/2022. There was no documented evidence an initial bereavement assessment was completed. The Director of Clinical Services was interviewed on 10/28/2022 and agreed, there were no initial bereavement assessments in the records identified.

It is required that each patient’s individualized written plan of care: Reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 13 (30%) clinical records reviewed, the hospice did not ensure the plans of care reflected patient and family goals and interventions based on all problems identified in comprehensive assessments. Record 2: The patient’s date of hospice election was 10/18/2022 with a primary diagnosis of malignant neoplasm of lower lobe right bronchus or lung. The plan of care dated 10/18/2022 was reviewed. The comprehensive nursing assessment completed on 10/18/2022 documented the presence of "4+ edema, dyspnea, on 3.5 L oxygen". The plan of care did not include documentation of interventions or goals to address the patient's edema or dyspnea. Record 5: The patient’s date of hospice election was 7/19/2022 with a primary diagnosis of malignant neoplasm of unspecified ovary. The plan of care dated 7/19/2022 was reviewed. The comprehensive nursing assessment completed on 7/19/2022 documented the presence of "dyspnea, on 3L oxygen continuously". The plan of care did not include documentation of interventions or goals to address the dyspnea. Record 7: The patient’s date of hospice election was 6/27/2022 with a primary diagnosis of Huntington’s disease. The plans of care present for the period dated from 6/27/2022 to 10/25/2022 were reviewed. A Registered Nurse assessment on 7/1/2022 documented the presence of a wound to the back of head, and the Registered Nurse assessment on 7/21/2022 revealed the presence of bleeding from the back of the patient's head and wound care was provided. A Registered Nurse assessment on 8/3/2022 revealed the presence of multiple bruises on the patient's back, and multiple scabs and abrasions to extremities. The plans of care did not include interventions or goals to specific to management of the wounds or skin integrity. Record 9: The patient’s date of hospice election was 4/26/2022 with a primary diagnosis of Alzheimer’s disease. The plan of care dated 4/26/2022 was reviewed. The comprehensive nursing assessment on 4/26/2022 revealed: The patient had bladder and bowel incontinence and went to the hospital the week before admission for a urinary tract infection and was taking an antibiotic; Redness to buttock; and using O2 continuously for dyspnea. The plan of care did not include interventions or goals to specifically manage the genitourinary problems, skin integrity or dyspnea. The Director of Clinical Services was interviewed on 10/28/2022 and agreed the plans of care did not include documented evidence of interventions or goals to address all problems identified in the comprehensive assessments for the records identified. Record 2: The patient’s date of election was 10/18/2022 with a primary diagnosis of malignant neoplasm of lower lobe right bronchus or lung. The plans of care dated 10/18/2022 to 10/25/2022 were reviewed. The comprehensive nursing assessment on 10/18/2022 revealed 4+ edema, dyspnea, on 3.5 L oxygen. The plan of care did not include interventions or goals to manage the edema or dyspnea. Record 5: The patient’s date of election was 7/19/2022 with a primary diagnosis of malignant neoplasm of unspecified ovary. The plans of care dated 7/19/2022 to 10/25/2022 were reviewed. The comprehensive nursing assessment on 7/19/2022 revealed dyspnea, on 3L oxygen continuously on 3L oxygen continuously. The plan of care did not include interventions or goals to manage the dyspnea. Record 7: The patient’s date of election was 6/27/2022 with a primary diagnosis of Huntington’s disease. The plans of care dated 6/27/2022 to 10/25/2022 were reviewed. A Registered Nurse assessment on 7/1/2022 revealed a wound to the back of head. A Registered Nurse assessment on 7/21/2022 revealed pt back of head bleeding, wound care provided. A Registered Nurse assessment on 8/3/2022 revealed multiple bruises on back, multiple scabs and abrasions to extremities. The plan of care did not include interventions or goals to manage the wounds or skin integrity. Record 9: The patient’s date of election was 4/26/2022 with a primary diagnosis of Alzheimer’s disease. The plans of care dated 4/26/2022 to 5/4/2022 were reviewed. The comprehensive nursing assessment on 4/26/2022 revealed the patient has bladder and bowel incontinence, went to the hospital the week before admission for a urinary tract infection and is currently taking antibiotic; Redness to buttock; O2 continuously for dyspnea. The plan of care did not include interventions or goals to manage the genitourinary problems, skin integrity or dysnea. Record 12: The patient’s date of election was 6/21/2022 with a primary diagnosis of malignant neoplasm of unspecified ovary. The plans of care dated 6/21/2022 to 7/22/2022 were reviewed. The comprehensive IDG documentation on 6/26/2022 revealed high fall risk, risk of elopement, gait unsteady. The plan of care did not include interventions or goals to manage the safety risk. The Director of Clinical Services was interviewed on 10/28/2022 and agreed, the plans of care did not include documented evidence of interventions or goals based on problems identified in the comprehensive assessments for the records identified.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; the frequency of service delivery. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 3 of 3 (100%) clinical records reviewed for patients discharged from hospice due to death, the hospice did not ensure adherence to the agency's bereavement services protocol. The agency’s "Bereavement Binder" stated in part, "All bereaved receive sympathy card within 2 weeks, 1-month call and letter 1 month after death, 3-month letter 3 months after death." Record 4: The patient’s date of death was 4/30/2022. The bereavement record was reviewed and revealed a bereavement call was made on 5/2/2022 and a 1-month letter mailed on 6/6/2022. There was no documented evidence a sympathy card was sent within 2 weeks and no documented evidence a 3-month letter was mailed. There was no documented evidence of an established bereavement plan of care or additional follow up. Record 8: The patient’s date of death was 5/8/2022. The bereavement record was reviewed and revealed a bereavement call was made on 5/10/2022. There was no documented evidence a sympathy card was sent within 2 weeks and no documented evidence a 1-month letter and a 3-month letter was mailed. There was no documented evidence of additional follow up. Record 9: The patient’s date of death was 5/4/2022. The bereavement record was reviewed and revealed a bereavement letter was mailed on 5/6/2022. There was no documented evidence a sympathy card was sent within 2 weeks and no documented evidence that a 1-month letter and a 3-month letter was mailed. There was no documented evidence of an established bereavement plan of care or additional follow up. The Bereavement Coordinator was interviewed on 10/28/2022 and stated, “These weren’t done. I wasn’t familiar with the timeframe.” The Director of Clinical Services was interviewed on 10/28/2022 and agreed that the bereavement follow-up didn’t follow the agency protocol stated in the "Bereavement Binder". Agency’s Bereavement Binder stated in part, ALL bereaved receive sympathy card within 2 weeks, 1-month call and letter 1 month after death, 3-month letter 3 months after death. Record 4: The patient’s date of death was 4/30/2022. The bereavement record was reviewed and revealed a bereavement call on 5/2/2022 and a 1-month letter mailed on 6/6/2022. There was no documented evidence a sympathy card was sent within 2 weeks. There was no documented evidence a 3-month letter was mailed. There was no documented evidence of a bereavement plan of care or any additional follow up. Record 8: The patient’s date of death was 5/8/2022. The bereavement record was reviewed and revealed a bereavement call on 5/10/2022. There was no documented evidence a sympathy card was sent within 2 weeks. There was no documented evidence a 1-month letter was mailed. There was no documented evidence a 3-month letter was mailed. There was no documented evidence of any additional follow up. Record 9: The patient’s date of death was 5/4/2022. The bereavement record was reviewed and revealed a bereavement letter mailed on 5/6/2022. There was no documented evidence a sympathy card was sent within 2 weeks. There was no documented evidence a 1-month letter was mailed. There was no documented evidence a 3-month letter was mailed. There was no documented evidence of a bereavement plan of care or any additional follow up. The Bereavement Coordinator was interviewed on 10/28/2022 and stated, “these weren’t done, I wasn’t familiar with the timeframe.” The Director of Clinical Services was interviewed on 10/28/2022 and agreed, the bereavement follow up didn’t follow agency protocol stated in the bereavement binder. The Director of Clinical Services stated, “these are all missing, more education is needed.”

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by a review of document reviews, interviews and personnel records. In 1 of 2 (50%) personnel records of hospice aides reviewed, the hospice did not ensure that a competency assessment was completed upon hire. . Agency policy, “Competency Based Orientation,” stated in part, “Hospice ensures that the competency of all personnel is assessed on hire, prior to providing care to hospice patients.” Record 7 (Hospice Aide): hire date 9/27/2021. There was no documented evidence that a competency evaluation was completed upon hire. The Director of Clinical Services was interviewed on 10/28/2022 and agreed there was no documented evidence that the competency evaluation was completed upon hire. The Director of Clinical Services confirmed the hospice aide has been making visits and stated, “This should have been completed before the aide was making visits on their own.” Agency policy, “Competency Based Orientation,” stated in part, “Hospice ensures that the competency of all personnel is assessed on hire, prior to providing care to hospice patients.” Record 7 (Hospice Aide): hire date 9/27/2021. There was no documented evidence that a competency evaluation was completed upon hire. The Director of Clinical Services was interviewed on 10/28/2022 and agreed, there was no documented evidence that the competency evaluation was completed upon hire. The Director of Clinical Services confirmed the hospice aide has been making visits and stated, “This should have been completed before the aide was making visits on their own.”

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 11 (18%) clinical records reviewed with a hospice aide ordered, the hospice did not ensure the hospice aide reported a change in condition to the registered nurse. Record 2: The hospice aide documentation on 10/19/2022 stated, “Pt was in pain at my arrival. Pt c/o pain to both feet. Pt has blisters on feet and are very swollen.” There was no documented evidence that the hospice aide notified the registered nurse. Record 7: The hospice aide documentation on 7/1/2022 stated, “This CNA observed some open wounds on head and right shoulder. There was no documented evidence that the hospice aide notified the registered nurse. The Director of Clinical Services was interviewed on 10/28/2022 and agreed, there was no documented evidence the hospice aide notified the registered nurse with the observed changes. Record 2: The hospice aide documentation on 10/19/2022 stated, “Pt was in pain at my arrival. Pt c/o pain to both feet. Pt has blisters on feet and are very swollen.” There was no documented evidence that the hospice aide notified the registered nurse. Record 7: The hospice aide documentation on 7/1/2022 stated, “This CNA observed some open wounds on head and right shoulder. There was no documented evidence that the hospice aide notified the registered nurse. The Director of Clinical Services was interviewed on 10/28/2022 and agreed, there was no documented evidence the hospice aide notified the registered nurse with the change in condition.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by a review of documents, interviews and personnel records. In 4 of 10 (40%) personnel records reviewed, the hospice did not ensure that a competency assessment was completed upon hire. Agency policy, “Competency Based Orientation,” stated in part: “Hospice ensures that the competency of all personnel is assessed on hire, prior to providing care to hospice patients.” Record 2 (Director of Nursing): hire date 1/4/2021. There was no documented evidence that a competency evaluation was completed upon hire. Record 4 (Chaplain/Bereavement Coordinator): hire date 8/31/2020. There was no documented evidence that a competency evaluation was completed upon hire. Record 5 (Medical Social Worker/Volunteer Coordinator): hire date 11/30/2020. There was no documented evidence that a competency was completed evaluation upon hire. Record 10 (Volunteer): hire date 11/12/2021. There was no documented evidence that a competency evaluation was completed upon hire. The Director of Clinical Services was interviewed on 10/28/2022 and agreed there was no documented evidence that the competency evaluations were completed upon hire. The Director of Clinical Services confirmed the staff identified have been making visits and stated, “These should have been completed before the staff were making visits on their own.” Agency policy, “Competency Based Orientation,” stated in part, “Hospice ensures that the competency of all personnel is assessed on hire, prior to providing care to hospice patients.” Record 2 (Director of Nursing): hire date 1/4/2021. There was no documented evidence that a competency evaluation was completed upon hire. Record 4 (Chaplain/Bereavement Coordinator): hire date 8/31/2020. There was no documented evidence that a competency evaluation was completed upon hire. Record 5 (Medical Social Worker/Volunteer Coordinator): hire date 11/30/2020. There was no documented evidence that a competency was completed evaluation upon hire. Record 10 (Volunteer): hire date 11/12/2021. There was no documented evidence that a competency evaluation was completed upon hire. The Director of Clinical Services was interviewed on 10/28/2022 and agreed, there was no documented evidence that the competency evaluations were completed upon hire. The Director of Clinical Services confirmed the staff identified have been making visits and stated, “These should have been completed before the staff were making visits on their own.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 4 (50%) clinical records reviewed with a wound identified, the hospice did not ensure the clinical record included a physician order for wound care. Record 7: The patient’s date of election was 6/27/2022. The Registered Nurse documentation on 7/21/2022 revealed, “RNCM requested this RN to make a visit because pt back of head was bleeding. Pt was agitated at baseline on his bed. This RN provided wound care.” There was no documented evidence of a physician order for wound care to be provided. Record 9: The patient’s date of election was 4/26/2022. The Registered Nurse documentation on 5/3/2022 revealed a stage 2 pressure wound on left buttock and a stage 1 on lower back with the narrative, “This nurse educated and encouraged PCG to change frequently and to use barrier cream as ordered.” There was no documented evidence of a physician order for wound care. The Director of Clinical Services was interviewed on 10/28/2022 and agreed there were no physician orders documented for the wounds identified. Record 7: The patient’s date of election was 6/27/2022. The Registered Nurse documentation on 7/21/2022 revealed, “RNCM requested this RN to make a visit because pt back of head was bleeding. Pt was agitated at baseline on his bed. This RN provided wound care.” There was no documented evidence of a physican’s order for wound care. Record 9: The patient’s date of election was 4/26/2022. The Registered Nurse documentation on 5/3/2022 revealed a stage 2 pressure wound on left buttock, stage 1 on lower back with the narrative, “This nurse educated and encouraged PCG to change frequently and to use barrier cream as ordered.” There was no documented evidence of a physican’s order for wound care. The Director of Clinical Services was interviewed on 10/28/2022 and agreed, there were no physician orders for the wounds identified.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 3 (67%) clinical records reviewed with a discharge from hospice revealed the hospice did not ensure that the discharge summary provided to the attending physician included the current plan of care. Record 10: The patient’s date of hospice election was 1/21/2022 and the patient was discharged from hospice on 7/18/2022. There was no documented evidence the discharge summary sent to the attending physician included the current plan of care. Record 11: The patient’s date of hospice election was 11/9/2021 and the patient was discharged from hospice on 8/17/2022. There was no documented evidence the discharge summary sent to the attending physician included the current plan of care. The Director of Clinical Services was interviewed on 10/28/2022 and agreed that the discharge summaries did not include the patients' current plans of care. Record 10: The patient’s date of election was 1/21/2022. The discharge was reviewed and revealed the patient was discharged on 7/18/2022. There was no documented evidence the discharge summary sent to the attending included the current plan of care. Record 11: The patient’s date of election was 11/9/2021. The discharge was reviewed and revealed the patient was discharged on 8/17/2022. There was no documented evidence the discharge summary sent to the attending included the current plan of care. The Director of Clinical Services was interviewed on 10/28/2022 and agreed, the discharge summary sent to the attending did not include the current 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 and any advance directives; physician certification and recertification of the terminal illness. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 2 (100%) records reviewed during a visit to patients residing in a SNF, the hospice did not ensure the most recent hospice plan of care, hospice election form, and physician certification and recertification of the terminal illness were provided to the SNF. Record 2: The patient’s date of election was 10/18/2022. The hospice binder in the facility was reviewed on 10/27/2022 with the hospice Director of Clinical Services. There was no documented evidence that the most recent hospice plan of care, hospice election form, and physician certification and recertification of the terminal illness were provided to the SNF. Record 7: The patient’s date of election was 6/27/2022. The hospice binder in the facility was reviewed on 10/27/2022 with the hospice Director of Clinical Services. There was no documented evidence that the most recent hospice plan of care, hospice election form, and physician certification and recertification of the terminal illness were provided to the SNF. The Director of Clinical Services was interviewed on 10/27/2022 and agreed there was no documented 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 for the identified patients. The Director of Clinical Services stated, “Our Medical Records confirmed these items were not sent to the facility.” Record 2: The patient’s date of election was 10/18/2022. The hospice binder in the facility was reviewed on 10/27/2022 with the hospice Director of Clinical Services. There was no documented evidence the most recent hospice plan of care, hospice election form, physician certification and recertification of the terminal illness were provided to the SNF. Record 7: The patient’s date of election was 6/27/2022. The hospice binder in the facility was reviewed on 10/27/2022 with the hospice Director of Clinical Services. There was no documented evidence 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 10/27/2022 and agreed, there was no documented evidence 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 stated, “Our Medical Records confirmed these items were not sent to the facility.”