Abode Hospice of Colorado

“It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 12 of 19 (63%) clinical records reviewed, the agency did not ensure that an initial bereavement assessment was completed. Clinical Record 1: The patient elected hospice care on 02/24/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 2: The patient elected hospice care on 11/16/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 3: The patient elected hospice care on 04/07/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 4: The patient elected hospice care on 11/14/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 6: The patient elected hospice care on 02/22/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 7: The patient elected hospice care on 02/06/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 11: The patient elected hospice care on 09/20/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 15: The patient elected hospice care on 07/05/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 16: The patient elected hospice care on 03/31/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 17: The patient elected hospice care on 07/13/2023. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 18: The patient elected hospice care on 01/16/2024. There was no documented evidence that an initial bereavement assessment was completed. Clinical Record 19: The patient elected hospice care on 02/24/2023. There was no documented evidence that an initial bereavement assessment was completed. During a joint review of the record and interview on 06/27/2024, the Executive Director agreed there was no documented evidence of an initial bereavement assessment.”

“This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with wound care, the hospice did not ensure that the Registered Nurse provided continuous assessments of the wounds. Clinical Record 7: The patient elected hospice care on 02/06/2023. A review of the Registered Nurse (RN) documentation dated 03/12/2024 through 06/26/2024 revealed a coccyx wound (#8), identified with an onset date of 03/12/2024 measuring 0.8 x 0.5 x 0.1, stage 3. There was no documented evidence that the wound was assessed or measured between 03/13/2024 and 05/05/2024. The wound was inactivated on 05/06/2024 and reactivated on 05/24/2024. There was no documented evidence that the wound was assessed or measured between 05/25/2024 and 06/26/2024. Additionally, the RN documentation reviewed for 03/12/2024 through 06/26/2024 revealed a left edge of the foot wound (#7), identified with an onset date of 02/28/2024, measuring 1.5 x 1 x 0.4. There was no documented evidence that the wound was assessed or measured between 02/29/2024 and 06/26/2024. During a joint review of the record and interview on 06/27/2024, the Executive Director stated, “Our wound policy is to measure weekly and assess the wound weekly.” Additionally, during an interview on 06/27/2024, the Executive Director agreed that there was no documented evidence that the wounds were assessed and measured weekly in the records and timeframes identified.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; [and] included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 15 (20%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the agency did not ensure that the HA provided services as ordered by the Interdisciplinary Group (IDG). Clinical Record 5: The patient elected hospice care on 05/17/2022. The plan of care, effective 07/11/2023 through 09/08/2023, ordered HA services “2wk1, 3wk8.” During the week of 09/03/2023 through 09/09/2023, a HA visit note was documented on 09/06/2023 and 09/08/2023. There was no documented evidence of a third HA visit or reason for the missed visit. Clinical Record 8: The patient elected hospice care on 04/12/2024. The plan of care, effective 04/12/2024 through 07/10/2024, ordered HA services “2wk12, 1wk1.” During the week of 05/05/2024 through 05/11/2024, a HA visit note was documented on 05/09/2024. There was no documented evidence of a second hospice aide visit or reason for the missed visit. During the week of 05/26/2024 through 06/01/2024, a HA visit note was documented on 05/30/2024. There was no documented evidence of a second hospice aide visit or reason for the missed visit. Clinical Record 12: The patient elected hospice care on 02/21/2024. The plan of care, effective 02/21/2024 through 05/20/2024, ordered HA services “2wk12.” During the week of 03/03/2024 through 03/09/2024, a HA visit note was documented on 03/05/2024. There was no documented evidence of a second HA visit or reason for the missed visit. During a joint review of the record and interview on 06/27/2024, the Executive Director agreed there was no documented evidence that the Hospice Aide completed the visits as ordered. Additionally, during an interview on 06/27/2024, the Executive Director agreed there was no documented reason for the missed visits.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 4 of 15 (27%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the agency did not ensure that the HA reported changes in the plan of care to the Registered Nurse (RN). Clinical Record 4: The patient elected hospice care on 11/14/2023. The physician’s order dated 12/03/2023 ordered HA services “2wk5.” A review of the clinical record revealed a documented missed HA visit dated 12/04/2024. The reason for the missed visit, the person notified of the missed visit, and the Physician/RN notified were blank. There was no documented evidence that the HA notified the RN of the missed visit. Clinical Record 9: The patient elected hospice care on 01/26/2023. The plan of care, effective 04/26/2023 through 07/24/2023, ordered HA services “1wk1, 2wk1.” A clinical record review revealed a documented missed HA visit dated 05/30/2023. The person notified of the missed visit and the Physician/RN notified were blank. There was no documented evidence that the HA notified the RN of the missed visits. Clinical Record 12: The patient elected hospice care on 02/21/2024. The plan of care, effective 02/21/2024 through 05/20/2024, ordered HA services “2wk12.” A clinical record review revealed documented missed HA visits dated 03/08/2024 and 04/04/2024. The reason for the missed visit, the person notified of the missed visit, and the Physician/RN notified, were blank for both missed visits. There was no documented evidence that the HA notified the RN of the missed visit. Clinical Record 15: The patient elected hospice care on 07/05/2023. The plan of care effective 07/05/2023 through 08/29/2023 ordered HA services “1wk1, 2wk7.” A clinical record review revealed a documented missed HA visit dated 07/11/2024; the patient refused. The person notified of the missed visit and the Physician/RN notified, were blank. There was no documented evidence that the HA notified the RN of the missed visit. During a joint review of the record and interview on 06/27/2024, the Executive Director agreed there was no documented evidence that the Hospice Aide notified the RN of the missed visits.”

“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. The Hospice Volunteer Requirement Report reviewed revealed the agency did not ensure that hospice volunteers provided 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. Document 1: The Hospice Volunteer Requirement Report reviewed for January through June 26, 2024, revealed volunteer cost savings of 3.04%. During a joint review of the Hospice Volunteer Requirement Report and interview on 06/27/2024, the Executive Director and the Volunteer Coordinator agreed that the hospice agency did not meet the minimum five percent cost savings requirement for 2024.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient was a live discharge, the hospice did not ensure that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 15: The patient elected hospice care on 07/05/2023 and was discharged (revocation) on 07/17/2023. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. Clinical Record 16: The patient elected hospice care on 03/31/2023 and was discharged as no longer terminally ill (NLTI) on 08/11/2023. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. During a joint review of the record and interview on 06/27/2024, the Executive Director agreed there was no documented evidence that the discharge summary was sent to the patient’s attending physician.”