Abode Hospice of Colorado

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs; supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview and observation. 1 of 19 (5%) clinical records reviewed and 1 of 4 (25%) home visit observations revealed that the hospice did not ensure the comprehensive assessment included an updated medication profile that contained the patient’s current medications. HOME VISIT 1/CLINICAL RECORD 4: The patient elected the hospice benefit on 01/14/2026 with a diagnosis of Malignant neoplasm of bladder, co-morbidity of Type 2 Diabetes Mellitus. During the observed home visit with the Registered Nurse (RN - Personnel Record 7) on 05/20/2026, the patient’s medications were reviewed with the son and compared to the hospice medication profile (printed on 05/19/2026). The son reported that the patient was receiving insulin via Insulin Pen twice a day, “for the last two decades.” The RN (Personnel Record 7) was interviewed after the visit and stated, “I knew he was taking insulin, but it looks like I missed adding it to the medication list.” There was no documented evidence that the hospice medication profile included the Insulin Pen, thus no evidence that the comprehensive assessment included a complete drug profile of the patient’s current medications. During a joint record review and interview on 05/22/2026, the Clinical Manager agreed there was no documented evidence that the Insulin Pen was added to the hospice medication profile.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 2 of 19 (11%) clinical records reviewed revealed that the hospice did not ensure the plans of care included planned interventions with goals for the problems identified in the comprehensive assessments. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/14/2026 with a diagnosis of Malignant neoplasm of bladder, co-morbidity of Type 2 Diabetes Mellitus (DM). During Home Visit 1 with the Registered Nurse (Personnel Record 7) on 05/20/2026, the patient’s medications were reviewed with the son and compared to the hospice medication profile (printed on 05/19/2026). The son reported that the patient was receiving Insulin via Insulin Pen twice a day, “for the last two decades.” The Registered Nurse (Personnel Record 7) was interviewed after the visit and stated, “I knew he was taking insulin, but it looks like I missed adding it to the medication list.” The wound documentation by the Registered Nurse revealed a coccyx wound with an onset date of 02/04/2026 and a restaged date of 05/20/2026. The plans of care dated 01/14/2026-04/13/2026 and 04/14/2026-07/12/2026 reviewed on 05/22/2026 did not identify Type 2 DM or the coccyx wound as problems with planned interventions and goals. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/13/2026 with a diagnosis of Malignant neoplasm of lower lobe, left bronchus or lung. The Registered Nurse (RN) assessment on 01/13/2026 documented, “dressing on pleurx drain site.” The RN visit on 01/25/2026 documented, “Drained pleurovac, output 550ml of sanguineous pleural fluid.” The RN visit on 01/28/2026 documented, “RN drained 250ml of sanguineous fluid from her left lung.” The RN visit on 01/30/2026 documented, “RN drained 400ml sanguineous fluid.” A review of the plan of care dated 01/13/2026-02/06/2026 revealed that the PleurX drain was not identified as a problem with the intervention to drain the site and goals. During a joint record review and interview on 05/22/2026, the Clinical Manager agreed there was no documented evidence that the plans of care included the problems identified with planned interventions and goals.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. 2 of 4 (50%) home visit observations revealed that the hospice did not ensure staff followed the agency’s hand hygiene policy. DOCUMENT 3: Agency Policy, “Hand Hygiene”, Policy No. 7-009.1-7.009.2, stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: Before having direct contact with patients, after contact with a patient’s intact skin, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.” HOME VISIT 3: During the observed home visit with the Social Worker (Personnel Record 9) in an Assisted Living Facility on 05/21/2026, the Social Worker was observed signing in at the front table, reviewing the patient’s binder at the facility, and touching the patient’s hand and lifting the patient’s spoon to queue the patient to eat. The Social Worker was not observed washing her hands prior to or during the visit. The Social Worker was interviewed and agreed that she did not wash her hands. HOME VISIT 4: During the observed home visit with the Chaplain (Personnel Record 10) in a long-term care facility on 05/21/2026, the Chaplain was observed entering the facility, reviewing the patient’s binder at the facility, entering the patient’s room, touching the patient’s bed remote, pillows, and hand during the visit. The Chaplain exited the building to retrieve an item from her car then reentered the facility and patient’s room. The Chaplain was not observed washing her hands prior to or during the visit. The Chaplain was interviewed and agreed that she did not wash her hands. During a review of the observed home visits and agency policy, the Clinical Manager agreed that the staff did not adhere to the agency’s hand hygiene policy.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the Volunteer Requirement/Cost Savings Report revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. DOCUMENT 1: A review of the Volunteer Requirement/Cost Savings Report for 01/01/2025-12/31/2025 revealed volunteer hours at 2.57% of the total patient care hours of all paid hospice employees and contract staff. A review of the Volunteer Requirement/Cost Savings Report for 01/01/2026-05/21/2026 revealed volunteer hours at 3.47% of the total patient care hours of all paid hospice employees and contract staff. A review of the Volunteer Requirement/Cost Savings Report for 05/01/2025-05/01/2026 revealed volunteer hours at 3.45% of the total patient care hours of all paid hospice employees and contract staff. During a joint review of the documentation and interview on 05/22/2026, the Executive Director agreed there was no documented evidence that the volunteer hours equaled at least 5% of the total patient care hours. Additionally, the Executive Director stated, “We need to increase our recruitment efforts in outlying areas of our territory. We are also struggling with short length of stays affecting the numbers. We have a PIP (Performance Improvement Project) in place for this.” During a joint review of the documentation and interview on 05/22/2026, the Volunteer Coordinator agreed there was no documented evidence that the volunteer hours equaled at least 5% of the total patient care hours. Additionally, the Volunteer Coordinator stated, “We have volunteers, but we have a large territory and need to get volunteers in the outside areas.” A review of the Volunteer Requirement/Cost Savings Report revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“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 clinical record review, interview and observation. 2 of 19 (11%) clinical records reviewed revealed that the hospice did not ensure physician’s orders were obtained. CLINICAL RECORD 4/HOME VISIT 1: The patient elected the hospice benefit on 01/14/2026 with a diagnosis of Malignant neoplasm of bladder, co-morbidity of Type 2 Diabetes Mellitus. During the observed home visit with the Registered Nurse (RN - Personnel Record 7) on 05/20/2026, the patient’s medications were reviewed with the son and compared to the hospice medication profile (printed on 05/19/2026). The son reported that the patient was receiving insulin via Insulin Pen twice a day, “for the last two decades.” Insulin was not listed on the medication profile. The RN (Personnel Record 7) was interviewed after the visit and stated, “I knew he was taking insulin, but it looks like I missed adding it to the medication list.” There was no documented evidence that the hospice obtained a physician’s order for the insulin. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/13/2026 with a diagnosis of Malignant neoplasm of lower lobe, left bronchus or lung. The RN comprehensive assessment on 01/13/2026 documented, “dressing on PleurX drain site.” The RN visit on 01/25/2026 documented, “Drained pleurovac, output 550ml of sanguineous pleural fluid.” The RN visit on 01/28/2026 documented, “RN drained 250ml of sanguineous fluid from her left lung.” The RN visit on 01/30/2026 documented, “RN drained 400ml sanguineous fluid.” There was no documented evidence of a physician’s order to drain the PleurX. During a joint record review and interview on 05/22/2026, the Clinical Manager agreed there was no documented evidence that physician orders were obtained for the insulin or to drain the PleurX.”