Northwest Colorado Health

“Based on the record review and interview, the agency failed to develop and maintain an emergency preparedness plan. Specifically, the agency did not have an annual updated and reviewed community-based risk assessment.Findings include: 1. Record review completed on 6/11/26, revealed an emergency preparedness plan provided to surveyors by the agency. Further review revealed the agency did not have a current emergency plan or an updated community-based risk assessment.The agency failed to ensure the agency’s emergency preparedness plan contained an updated and completed assessment of hazards or potential emergencies the agency could encounter.During an interview on 6/11/26 at 11:58 a.m., when questioned specifically regarding the lack of an updated plan, Personnel #10 and Personnel #11 reviewed the emergency preparedness plan with surveyors. Upon review, they stated the plan was last reviewed on 3/26/26; however, this was not documented anywhere. They further stated they did not have an updated risk assessment, and the agency was aware of the regulatory requirement. During continued interview, Personnel #10 and Personnel #11 stated the agency was securing further funding and was working with the agency staff to establish a more robust emergency preparedness plan, including an updated community-based risk assessment.”

“Based on record review and interview, the hospice agency failed to maintain an effective system for supervision, monitoring, and evaluation processes for 2 of 2 volunteer records reviewed (Personnel #12 and #13).Findings include: 1. Record review completed on 6/12/26 at 12 p.m. for Personnel #12 revealed a start date of 1/29/15.a) The hospice agency failed to maintain a system of volunteer oversight. Record review revealed documentation of identification verification, initial orientation, and continued education. Review of Personnel #12’ s record failed to reveal completed volunteer oversight.During an interview on 6/12/26 at 12:39 p.m., the volunteer coordinator (#14) described the hospice agency’s orientation process, including orientation, hospice disciplines’ education, and volunteer manuals. The volunteer coordinator stated that they did not have a process for evaluations and oversight of volunteers and that they were not aware that they needed to. Similar findings were found for Personnel #13.”

“Based on interview and record review, the hospice failed to ensure the plan of care (POC) established by the interdisciplinary group (IDG) and in collaboration with the attending physician included all services provided to the patient for 1 of 2 patients who received volunteer services records reviewed (Patient #3). Findings include: 1. The clinical record for Patient #3 was reviewed on 11/27/23. The patient was admitted to hospice care on 6/13/23 with a terminal diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations. The POC for the certification period, dated 9/11/23 to 12/9/23, included orders for skilled nursing (SN) visits and medical social worker (MSW) visits. a) The agency failed to ensure that the POC included all services provided to Patient #3. Review of Patient #3’s records revealed the patient received volunteer visits for a massage from Volunteer #1 during the previous certification period on 7/21/23, 7/28/23 and 9/5/23. Further review of the record revealed a verbal order dated 7/20/23 for volunteer services once a week for two weeks for a total of two visits and another verbal order on 9/5/23 for volunteer service once a week for one week. Record review of verbal orders, IDG meeting notes, and the POC failed to reveal an order for a volunteer to go out to visit Patient #3 during any part of the month of November. During an home visit interview on 11/28/23 at approximately 1:30 p.m., Patient #3 stated she enjoyed getting the massage from Volunteer #1. Patient #3 also stated the last time she got a massage was maybe one or two weeks ago and could not recall exactly what day the volunteer came. Review of the IDG meeting notes on 10/11/23 and 10/25/23, revealed the the IDG discussed that volunteer services, specifically massage services, would begin again for Patient #3 in November. During an interview on 11/29/23 at 12:07 p.m., Volunteer #1 stated she had seen Patient #3 the week before the Thanksgiving holiday. Volunteer #1 could not recall exactly on what day she visited Patient #3. Record review of the IDG note dated 11/8/23, revealed the IDG set a visit frequency of SN visit once weekly, MSW visits once weekly, and chaplain visits as needed, but did not set a frequency for volunteer visits. During an interview on 11/29/23 at 12:13 p.m., MSW #4 who was in charge of volunteer visits stated the agency did not have a record of the volunteer visit for November in the system. MSW #4 acknowledged the visit did happen. MSW #4 also stated she would have to check the system to see if the agency had orders for the volunteer visit in November. No order for the visit was found.”