Dignity Hospice of Colorado, LLC

“Upon patient record review 2 of 19 records reviewed (Patient #1,5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: The record indicated the start of care was 03/22/24. There was no evidence of the spiritual comprehensive assessment until 04/08/24. Patient #5: The record indicated the start of care was 07/11/24. There was no evidence of the spiritual comprehensive assessment until 07/18/24.”

“Upon patient record review 3 of 19 records reviewed (Patient #1,3,10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #1: The record indicated the start of care was 03/22/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #3: The record indicated the start of care was 01/15/24. There was no evidence of the spiritual comprehensive assessment being completed at the time of the survey. Patient #10: The record indicated the start of care 09/05/24. There was no evidence of the spiritual comprehensive assessment being completed at the time of the survey.”

“Upon patient record review, 1 of 19 (Patient #3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3: Upon the in person visit the medication profile was reviewed. The patient was prescribed 2 Units of Insulin Glargine SQ QHS but was actually taking 10 Units SQ QHS. COS.”

“Upon patient record review, 6 of 19 records reviewed (Patient #1,2,3,4,5,11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patient #1: The record indicated the start of care was 03/22/24. There was no evidence of the bereavement assessment until 04/8/24. Patient #2: The record indicated the start of care was 01/24/24. The bereavement assessment was not completed at the time of the survey. Patient #3: The record indicated the start of care was 01/15/24. The bereavement assessment was not completed at the time of the survey. Patient #4: The record indicated the start of care was 03/06/24. The bereavement assessment was not completed at the time of the survey. Patient #5: The record indicated the start of care was 07/11/24. There was no evidence of the bereavement assessment until 07/18/24. Patient #11: The record indicated the start of care was 09/05/24. The bereavement assessment was not completed at the time of the survey.”

“Upon patient record review, 2 of 19 records reviewed (Patient #2, #12) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2: The record indicated the patient had a fall on 2/2/24, the next nurse visit was on 2/6/24. There was no evidence on the 2/6/24 nursing visit of a fall follow up assessment. Policy C: 121 a follow up telephone call or visit is to be made during the next shift again to check on a patient’s states post fall. Documentation of the call/visit will be made in the communication note to ensure the patient has remained stable. Patient #12: The record indicated the patient had a witnessed fall on 9/11/24. The next nursing visit was on 9/13/24 and 9/14/24 there was no evidence of a follow up assessment to include an assessment of the patients fall. Policy C: 121 a follow up telephone call or visit is to be made during the next shift again to check on a patient’s status post fall. Documentation of the call/visit will be made in the communication note to ensure the patient has remained stable.”

“Upon patient record review, 1 of 19 (Patient #4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4: The record indicated the patient resides in an Assisted Living Facility. The care plans do not contain evidence of coordination of care with facility. COS.”

“Upon client record review, 1 of 19 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9: The record indicated an order for wound care 3 X W to be done by the Hospice Nurse effective 4/19/24 to cleanse right medial heel wound with wound cleanser, apply skin prep to peri wound and cover with a bordered dressing. There was a nurse visit due on 4/20/24 to complete the 3 X W, this visit was not done.”

“Upon patient record review 1 of 19 records reviewed (Patient #5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #5: The record indicated the hospice aide frequency was order 1 X W. The record indicated missed visits on 07/17/24, 07/31/24, 08/09/24, 08/23/24, 09/13/24. There was no evidence of weekly visits and or the order frequency being updated at the time of the survey. COS.”

“Upon patient record review, 1 of 19 records reviewed (Patient #3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient #3: The record indicated the start of care was 01/05/24. The Initial Certification was from 01/05/24 to 04/03/24. The physician did not sign the CTI until 01/16/24. There was no evidence of a verbal ordered documented by the RN at the time of the survey.”

“Upon patient record review, 1 of 19 (Patient #1) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient’s clinical information and provide written documentation that it is anticipated that the patient’s life expectancy is 6 months or less. Patient #1: The record indicated the start of care was 03/22/24. The Initial Certification was from 03/22/24 to 05/05/24, the patient was in their 2nd benefit period. The physician did not sign the CTI until 3/26/24. There was no evidence of a verbal ordered documented by the RN at the time of the survey.”

“Upon patient client record review, 2 of 19 records reviewed (Patient #2,9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: The record indicated the patient chose “Dr. Grubbs” as their attending physician for hospice. There was no evidence the patients choice had a first name listed for the physician they chose. COS. Patient #9: The record indicated the patient chose “Sky Health” as their choice for an attending. There was no evidence Sky Health was a specific physician. COS.”

“Upon patient record review, 2 of 19 (Patient #2) did not have evidence that the hospice assumes responsibility for professional management of the resident’s hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient’s care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient #2: The record indicated there was a request by the facility for a right hip X-Ray s/p a patient fall. The record indicated the patient is a resident at a SNF. There was no evidence on the hospice record of an MD order for the right hip X-Ray. COS.”

“Upon client record review, 2 of 19 records reviewed (Patient #2,3) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: The record indicated the patient is in a SNF. There was no evidence the plan of care was established and maintained in consultation with the SNF staff/representatives. COS. Patient #3: The record indicated the patient is in a SNF. There was no evidence the plan of care was established and maintained in consultation with the SNF staff/representatives. COS.”

“Upon patient record review, 2 of 19 records reviewed (Patient #2,3) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice’s 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #2: There were no hospice consents on the chart, the recertification CTI starting 7/22/24 was not on the chart. COS. Patient #3: The record indicated the patient is a resident at a SNF. There was no evidence of hospice consents on the chart, the recertification CTI starting on 9/1/24 was not on the chart and there were no plan of care updates from the IDT updates since 8/8/24 at the time of the survey. COS.”