Interim Healthcare of Southeastern Colorado Inc.

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included all required services and supplies. Specifically, the agency did not include the patient’s feeding tube in the plan of care for 1 of 5 sample patients (Patient #4). Findings include: The clinical record for Patient #4 was reviewed on 12/11/25. Plan of care orders for the certification period dated 12/2/25 to 1/30/26 revealed a start of care date of 12/2/25; diagnoses included pressure ulcer of the left buttock, weakness, anemia, and heart failure. Plan of care orders included home health aide once per week for eight weeks for bathing and grooming, occupational therapy once per month for one month for evaluation, physical therapy twice a week for four weeks for balance and gait training, and skilled nursing three times a week for eight weeks for wound care and to assess nutrition measures. a) The agency failed to ensure Patient #4’s feeding tube, including maintenance, precautions, and feeding tube site care, was included in the plan of care. 1. The comprehensive assessment, dated 12/2/25, completed by a registered nurse upon start of care for Patient #4, stated the patient had a feeding tube. However, the plan of care, dated 12/2/25, created for Patient #4 based on the comprehensive assessment, did not include the feeding tube or any information regarding the maintenance, precautions, and site care for the feeding tube. 2. During an interview with the director of nursing (DON) at 9:29 a.m. on 12/12/25, the DON stated it had been an oversight to not include the feeding tube in Patient #4’s plan of care. The DON stated the information from the assessment regarding the feeding tube should have been transferred from the comprehensive assessment to the plan of care.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview, and record reviews, the agency failed to provide services and treatments only as ordered by a physician or allowed practitioner for 2 of 5 records reviewed (Patients #1 and #2). Findings Include 1. The clinical record for Patient #1 was reviewed on 12/11/25. The Plan of Care certification period dated 10/13/25 to 12/11/25 revealed a start of care date of 10/18/24; diagnosis included Alzheimer’s disease, Down syndrome, artificial openings of the gastrointestinal tract, and orders for a G-tube. The Plan of Care orders included skilled nurse (SN) visits five times a week for 24 hour supervision, aspiration precautions, equipment safety, fall precautions, and use of assistive devices. a) The agency failed to provide 24 hour supervision as ordered by the physician. Record review for Patient #1 revealed SN visits scheduled 12 hours five days a week, Monday through Friday. Record review failed to reveal documentation of 24 hour supervision per the plan of care orders signed by Patient #1’s primary physician on 10/15/25. During an interview conducted on 12/11/25 at 1:21 p.m., the Registered Nurse (RN) case manager stated Patient #1 was watched by care givers at a day program. Record review failed to reveal documentation of who provided supervision to Patient #1 while at the day program. b) The agency failed to obtain orders for protective mittens which were applied by SN to Patient #1. During a home visit conducted on 12/11/25, the state surveyor observed LPN #3 apply protective mittens to Patient #1. During an interview conducted at the home visit LPN #3 revealed Patient #1 would have mittens applied daily. LPN #3 stated the previous care plan included orders for mittens. At an interview completed at the home visit, Patient #1’s primary care giver stated SN applied mittens to Patient #1 daily. Record review failed to reveal orders for protective mittens for Patient #1. During an interview on 12/11/25 at 1:21 p.m., the RN case manager admitted SN applied mittens to Patient #1. Further interview revealed the RN case manager failed to ensure a physician’s order for the mittens was in Patient #1’s record. 2. The clinical record for Patient #2 was reviewed on 12/10/25. The Plan of Care certification period dated 10/13/25 to 12/11/25 revealed a start of care date of 10/18/24; diagnosis included cerebral palsy, gastro-esophageal reflux disease, and orders for a G-tube. The plan of care orders included SN visits five times a week for 23 hours of supervision per day, G/J-tube removal prevention at all hours of the day and night, and mandatory nursing accompaniment and monitoring during daily weekday program outings per terms of program enrollment. a) The agency failed to provide 23 hours of supervision as ordered by the physician. Record review for Patient #2 revealed SN visits scheduled 12 hours five days a week, Monday through Friday. Review of nursing notes failed to reveal who provided 23 hours of supervision outside of SN visits. During an interview on 12/11/25 at 11:29 a.m., the RN case manager stated Patients #1 and #2 had their allotted home health hours reduced. The RN case manager admitted current orders did not reflect the care provided for Patients #1 and #2.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure an accurate and complete clinical record for 2 of 5 sample patients (Patient #1, #2). Findings include: 1. The clinical record for Patient #1 was reviewed on 12/11/25. Plan of care orders for the certification periods dated 8/14/25 to 10/12/25, 10/13/25 to 12/11/25, and 12/12/25 to 2/9/26 revealed a start of care date of 10/18/24; diagnoses included Alzheimer’s disease, dementia, chronic obstructive pulmonary disease, and down syndrome. Plan of care orders included skilled nursing five times per week for 12 hours per day for 10 weeks to provide medication management, nutrition management, care of oxygen equipment, and safety measures. a) The agency failed to ensure Patient #1’s clinical record contained documentation of safety mitts applied for Patient #1. i) Review of Patient #1’s safety measures for the current certification period, dated 12/12/25, and the previous certification period, dated 10/13/25 revealed safety mitts were to be applied to prevent Patient #1 from removing his feeding tube. However, the clinical record did not contain documentation that the mitts were being applied for Patient #1 within the nursing visit notes. ii) During a home visit interview at 3:00 p.m. on 12/11/25, the consumer’s caregiver and licensed practical nurse (Employee #5) stated although the mitts were being applied, they had not documented the application of the mitts in Patient #1’s record. b) The agency failed to ensure Patient #1’s clinical record contained documentation of rights modification for Patient #1. i) Review of Patient #1’s plan of care for the current certification period, dated 12/12/25, and the previous certification period, dated 10/13/25 revealed the agency had not placed the Rights Modification form for safety mitt use in Patient #1’s clinical record. ii) During an interview with the Director of Nursing (DON) and Registered Nurse (RN) Case Manager at 1:21 p.m. on 12/11/25, the RN Case Manager stated the Rights Modification form had been requested by the caregivers. The DON stated the agency would get the form from the caregivers and put the form in the file. When asked why they did not have the form, the RN Case Manager stated that they did not know they needed it or that it was a required document that needed to be in the consumers record. iii) The Rights Modification form was provided by the agency and reviewed at approximately 4:00 p.m. on 12/11/25. 2. The clinical record for Patient #2 was reviewed on 12/11/25. Plan of care orders for the certification periods dated 10/13/25 to 12/11/25, and 12/12/25 to 2/9/26, revealed a start of care date of 10/18/24; diagnoses included cerebral palsy, obstructive sleep apnea, and gastro-esophageal reflux. Plan of care orders included skilled nursing five times per week for 12 hours per day for 10 weeks to provide medication management, nutrition management, care of oxygen equipment, and safety measures. a) The agency failed to ensure Patient #2’s clinical record contained documentation of the safety mitts applied for Patient #2. i) Review of Patient #2’s plan of care for the current certification period, dated 12/12/25, and the previous certification period, dated 10/8/25 revealed safety mitts were to be applied to prevent Patient #2 from removing his feeding tube. However, the clinical record did not contain documentation that the mitts were being applied for Patient #2. ii) During a home visit interview at 3:00 p.m. on 12/11/25, the patient’s caregiver and licensed practical nurse (Employee #5) stated although the mitts were being applied, they had not documented the application of the mitts in Patient #2’s record. b) The agency failed to ensure Patient #2’s clinical record contained documentation of rights modification for Patient #2. i) Review of Patient #2’s plan of care for the current certification period, dated 12/12/25, and the previous certification period, dated 10/8/25 revealed the agency had not placed the Rights Modification form for safety mitt use in Patient #2’s clinical record. ii) During an interview with the administrator at 9:40 a.m. on 12/12/25, the administrator stated the Rights Modification form had been obtained by the caregivers/family but the agency had not placed it into the clinical record. The administrator stated the agency would get the form from the caregivers. iii) The Rights Modification form was provided by the agency and reviewed at approximately 10:10 a.m. on 12/12/25.”