Brighton Hospice Colorado, LLC

“It is required that the hospice designates a registered nurse member of the IDG to: ensure continuous assessment of each patient’s and family’s needs. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that continuous assessment of the patient’s needs occurred. CLINICAL RECORD 17: The patient elected the hospice benefit on 01/06/2025. On 11/12/2025, an Interdisciplinary Group (IDG) Meeting was conducted, during which it was determined that the patient had not had a bowel movement in four (4) days and was experiencing irregular bowel patterns. As a result, the patient was started on Senna-S to address constipation. Review of skilled nursing visit documentation dated 11/11/2025, 11/14/2025, and 11/18/2025 revealed no further assessment, monitoring, or follow-up documentation related to the patient’s constipation, bowel status, or response to the newly initiated bowel regimen. On 04/17/2026, during a joint clinical record review and interview, the Director of Clinical Quality confirmed that although the newly initiated medication was documented by the nurse, there was no evidence of documented follow-up after initiation. The Director acknowledged the absence of nursing documentation addressing the patient’s response, outcome, or effectiveness of the medication and agreed that additional follow-up documentation was expected and should have been completed to reflect appropriate monitoring and evaluation of the intervention.”

“It is required that each patient’s individualized written plan of care reflect the patient and family goals and identify planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, observation, and document review. 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that the patients’ plans of care reflected identified problems based on assessment data, with planned interventions and patient-specific measurable goals. The hospice’s policy “The Plan of Care” (No. 9-017) last revised 11/2024 read in part that “...The written plan of care will contain, but will not be limited to, the following...Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling...Individualized interventions to assist with end-of-life care...Statement of treatment goals and documentation of the progress of outcomes...Measurable outcomes anticipated from implementing and coordinating the plan of care....” The hospice’s policy, “FACILITATING COMMUNICATION” (Policy No. 9-006; last reviewed 11/2024) read in part, “To assure that patients, visitors, and personnel with speech, vision, or hearing impairments, as well as those who have a limited command of the English language, have access to appropriate interpretive assistance and other aids at no cost to patient(s) being served, (agency name) will facilitate communication by using special devices, interpreters or other communication aides. The initial assessment will determine the patient’s communication ability. If there is any question regarding the patient’s ability to communicate properly, the assessment should stop and an interpreter should be secured. For hearing impaired patients: A. The admitting clinician ascertains the patient’s preferred methods of communication, i.e., paper and pencil, lip reading, or sign language.” The agency’s policy “Care of the Dying Patient (No. 2-033),” dated 06/2022 and adopted 07/01/2024, reads in part that the “...Hospice interdisciplinary group members recognize the importance of each patient and family/caregiver’s unique and individual needs within the hospice setting.” Within this framework, responsive and respectful care for the dying patient will be planned, implemented, and monitored in order to...identify secondary symptoms, determine the patient’s response to treatment, and take action to limit them...An individualized plan of care will be developed in cooperation with the patient and family/caregiver, attending physician, and interdisciplinary group members, which facilitates: Prevention of secondary symptoms, including, but not limited to, nausea, vomiting, diarrhea, stomatitis, alopecia, GI disturbances, blood dyscrasia, etc... Monitoring of the response of secondary symptoms to treatment. With each patient visit, the hospice nurse will follow the plan of care and assess the need for changes/updates, and will document accordingly. Aspects of care that must be reflected in the clinical record, when applicable, include: Preventative and treatment/measures provided for secondary symptoms and/or pain/discomfort, and the response to treatment....” CLINICAL RECORD 3/HOME VISIT 3: The patient elected the hospice benefit on 02/12/2025 and resided in an Assisted Living Facility. On 04/14/2026, a skilled nursing visit note documented that the patient had severe hearing loss. During the observed home visit, conducted with the Social Worker (Personnel Record 7) on 04/16/2026, the use of a whiteboard was required to effectively communicate with the patient, confirming that the patient’s hearing deficit significantly impacted her ability to communicate verbally and necessitated assistive communication methods to participate in care discussions. Despite the documented severity of the patient’s hearing loss and the demonstrated need for alternative communication strategies, review of the patient’s plans of care for the benefit periods 02/07/2026 to 04/07/2026 and 04/08/2026 to 06/06/2026 revealed that the interdisciplinary care plans failed to identify severe hearing loss as a patient problem, did not include interventions to address the need for assistive communication such as use of a whiteboard and/or hearing aids, and did not establish any goals related to improving or accommodating effective communication. CLINICAL RECORD 15: The patient resided at home and elected the hospice benefit on 02/24/2026 with a terminal diagnosis of malignant neoplasm of the colon and secondary diagnoses of malignant ascites, thrombocytosis, and chronic pain, indicating a complex and high risk clinical profile. The patient revoked the hospice benefit on 03/03/2026 due to seeking aggresive treatment (total parenteral nutrition). During the Registered Nurse’s admission visit on 02/24/2026, the following was documented: the patient was alert and oriented, with an Edmonton Symptom Assessment System (ESAS) score of 3/10 for nausea necessitating the initiation of Ondansetron, and the patient was prescribed multiple medications for pain, nausea, gastrointestinal management, fluid balance, and electrolyte replacement. The Interdisciplinary Group (IDG) meeting notes on 02/27/2026, nursing documented identified admission goals of comfort, absence of pain, and avoidance of hospitalization. The nurse further documented frequent nausea and vomiting, daily large volume drainage of malignant ascites ranging from 300–500 cc and resulting fluid shifts with electrolyte imbalances such as hypokalemia (3.2), which the nurse noted increased the patient’s risk for arrhythmias, falls related to muscle weakness, and bowel obstruction. The patient was further described as experiencing severe weight loss secondary to poor nutritional intake from persistent nausea and vomiting, decreasing mobility in the context of malignancy and thrombocytosis (476K), and a significantly elevated risk for blood clots without anticoagulation therapy. A review of the patient’s plan of care for the benefit period dated 02/24/2026 to 05/24/2026 revealed that despite these clinical findings and risks identified during both the admission assessment and IDG review, the patient’s plan of care did not clearly reflect the full scope of identified problems, coordinated and planned interventions to address persistent nausea and vomiting, nutritional decline, and the potential thrombotic risk or goals to measure progress for treatment.”

“It is required that each patient’s individualized written plan of care include all services necessary for the palliation and management of the terminal illness, including the following medical supplies and appliances to meet the patient’s needs. This standard was not met as evidenced by clinical record review, and interview. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure documentation of all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances to meet the patient’s needs. CLINICAL RECORD 12: The patient resided at an assisted living facility and elected the hospice benefit on 02/20/2026. On review of the clinical record, it was noted that the Registered Nurse visit on 04/08/2026, documented a 16Fr Foley catheter with a 30cc balloon was placed. There was no physician’s order for the catheter, and the Foley catheter was not included in the plan of care for the initial benefit period dated 02/20/2026 to 05/20/2026. On 04/17/2026, during a joint clinical record review and interview, the Director of Clinical Quality acknowledged that the patient’s Foley catheter was not listed on the plan of care and that the corresponding physician order documentation was missing from the medical record. The Director confirmed that the Foley catheter should have been included on the patient’s plan of care and that the omission did not meet care planning and documentation requirements.”

“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. On 04/17/2026, during a review of the hospice’s Volunteer Program documentation and an interview with the Volunteer Coordinator (VC - Personnel Record 5), it was determined that the hospice did not ensure volunteers contributed at least 5% of the total patient care hours provided by paid hospice employees and contract staff, as required. Analysis of volunteer contribution data showed an average of 5.84% from January 1, 2024, through December 31, 2024, which declined to 4.46% from January 1, 2025, through December 31, 2025, and remained below the minimum requirement of 4.48% year-to-date for 2026. The Volunteer Coordinator confirmed that a QAPI Performance Improvement Project (PIP) was initiated on 07/01/2025 in response to declining volunteer hours, with interventions including monthly accountability meetings, incorporation of Social Work and Spiritual Care interns, and reallocation of staff duties to allow additional time for volunteer recruitment activities. Documented recruitment efforts included advertisements on volunteer recruitment and employment websites, participation in local health career fairs, outreach to a local university photography program to assess student interest in volunteering to photograph patients and families, partnership with a local pet therapy organization, and increased outreach to public health colleges. Planned retention initiatives included Volunteer Appreciation Week activities such as gift bags with hospice merchandise (T-shirts, cups, and treat bags), efforts to keep volunteers informed through regular care updates for patients they support, recognition of significant volunteer milestones or events, and individualized one-on-one “coffee talks” between the Volunteer Coordinator and volunteers. Despite these actions, the hospice has yet to meet the required percentage of volunteer service hours. On 04/17/2026, during a review of the hospice’s Volunteer Program documentation and an interview with the Volunteer Coordinator (VC) (Personnel Record 5), it was determined that the hospice did not ensure volunteers contributed at least 5% of the total patient care hours provided by paid hospice employees and contract staff, as required. Analysis of volunteer contribution data showed an average of 5.84% from January 1, 2024, through December 31, 2024, which declined to 4.46% from January 1, 2025, through December 31, 2025, and remained below the minimum requirement of 4.48% year-to-date for 2026. The Volunteer Coordinator confirmed that a QAPI Performance Improvement Project (PIP) was initiated on 07/01/2025 in response to declining volunteer hours, with interventions including monthly accountability meetings, incorporation of Social Work and Spiritual Care interns, and reallocation of staff duties to allow additional time for volunteer recruitment activities. Documented recruitment efforts included advertisements on volunteer recruitment and employment websites, participation in local health career fairs, outreach to a local university photography program to assess student interest in volunteering to photograph patients and families, partnership with a local pet therapy organization, and increased outreach to public health colleges. Planned retention initiatives included Volunteer Appreciation Week activities such as gift bags with hospice merchandise (T-shirts, cups, and treat bags), efforts to keep volunteers informed through regular care updates for patients they support, recognition of significant volunteer milestones or events, and individualized one-on-one “coffee talks” between the Volunteer Coordinator and volunteers. Despite these actions, the hospice has yet to meet the required percentage of volunteer service hours.”

“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. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the clinical record included physician orders. CLINICAL RECORD 17: The patient elected the hospice benefit on 01/06/2025. On 11/12/2025, an Interdisciplinary Group (IDG) Meeting was conducted, during which it was determined that the patient had not had a bowel movement in four (4) days and was experiencing irregular bowel patterns. As a result, the patient was started on Senna-S to address constipation. However, no physician order was entered to support the initiation of this medication. On 04/17/2026, during a joint clinical record review and interview, the Director of Clinical Quality confirmed that no physician order was present in the clinical record to authorize or support initiation of the medication.”