4
Inspections
2
Deficiencies
0
Actual Harm or Above
0
Occurrences
May 20, 2026
Last Inspection
The most recent inspection of COLORADO PALLIATIVE & HOSPICE CARE, LLC on record is dated May 20, 2026. Across 4 published inspections, state surveyors cited 2 deficiencies, none of which reached the actual-harm level.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
Hospice (Certified)
Administrator
Bogue, Jason
Owner
COLORADO PALLIATIVE & HOSPICE CARE, LLC
Phone
(303) 727-5709
Payor Source
Medicare, Medicaid, Private Pay
City
CENTENNIAL
ZIP
80111-6410
Inspections & Citations
4 inspections · 2 deficiencies5/20/2026Recertification Survey · ID 232A00-H11 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A recertification survey was completed on 5/20/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0692ADMINISTRATION OF DRUGS AND BIOLOGICALS▼
Findings
Based on record review and interview, the hospice interdisciplinary group (IDG) failed to determine the ability of the patient and/or family to safely self-administer drugs and biologicals for 14 of 14 sample hospice patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). Findings include:Fourteen sample hospice patient clinical records were reviewed from 5/18/26 through 5/20/26. Complete medical records for the fourteen patients, including initial, comprehensive, and updated assessments, plans of care, clinician notes, home visit encounters, coordination of care notes, physician orders, admission documentation, attachments to the medical records, and Interdisciplinary Groups (IDG) meeting notes, were reviewed.a) The hospice IDG failed to determine the ability of the patient and/or family to safely self-administer medications. Review of fourteen sample clinical records did not reveal documentation of the patients’ or their families’ abilities to safely self-administer medications. During an interview on 5/20/26 at 10:00 a.m., the hospice Director of Nursing (DON) confirmed the hospice medical records did not contain documentation regarding the ability of the patient and/or family to safely self-administer medications. The DON stated the information was discussed during IDG meetings, but was not documented in the medical record.
Plan of correction · submitted by the facility
Plan of Correction: A root cause analysis determined that the cited deficiency was a lack of oversight and review of the interdisciplinary process and documentation following a change in ownership and transition to a new electronic medical record system. The patient sample group surveyed on 5/20/2026 was reviewed by the interdisciplinary group on 6/2/2026. Interdisciplinary group discussion reviewed individualized plan of cares, to include the determination and documentation of the ability of the patient and/or family/caregiver to safely administer medications/biologicals to the patient in their care setting. The plan to correct this deficiency is for all members of the interdisciplinary group and administrative staff involved in the interdisciplinary meetings will receive in-service training on the interdisciplinary group process and required documentation by 6/27/2026. The in-service will cover interdisciplinary group discussion regarding individualized care plans and the importance of determining who can safely administer medications/biologicals to the patient and how to properly document. Development with our electronic medical record provider has begun to include a required section within the interdisciplinary meeting documentation to detail the ability of the patient and/or family/caregiver to safely administer medications/biologicals to the patient in their care setting. This change to the electronic medical record system will ensure interdisciplinary discussion regarding the ability of the patient and/or family/caregiver to safely administer medications/biologicals and increase compliance of documentation regarding the safe administration of medications/biologicals in the patient’s care setting. The timeline given for this improvement is 60 days. Implementing the Plan of Correction: Implementation of the plan of correction as begun via the Director of Clinical Services, who shared the cited deficiency with the interdisciplinary group on 5/22/2026. Education on the importance of identifying who is responsible for safely administering medications/biologicals and how to properly document the discussion within the electronic medical record was provided to the interdisciplinary group. The in-service training on the interdisciplinary group process and required documentation will be completed by each member of the interdisciplinary group via Paylocity. Completion of the in-service will be monitored by the Director of Clinical Services. Monitoring and Quality Assurance: The Director of Clinical Services will audit 100% of interdisciplinary meeting notes through 6/27/2026 to monitor compliance and ensure improvement. If 100% compliance is met, the Director of Clinical Services will audit 50% of interdisciplinary meeting notes through 8/27/2026 to ensure ongoing compliance. If 100% compliance is not met within 30 days, the Director of Clinical Services will continue to audit 100% of interdisciplinary meeting notes until 100% compliance is reached for a period of 30 consecutive days. Monitoring efforts will be recorded on a performance improvement project form and updated bi-weekly following interdisciplinary group meetings by the Director of Clinical Services. The performance improvement plan will be evaluated by the quality assurance team every 30 days to monitor compliance. The performance improvement project will be reflected in Q2 & Q3 QAPI reporting. Responsible Party: Director of Clinical ServiceCompletion Date: Plan of Correction implementation – 6/27/2026
5/20/2026Re-Licensure Survey · ID 232A01-H11 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A re-licensure survey was completed on 5/20/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0001Survey Details▼
Findings
Standards for Hospitals and Health Facilities Chapter 21 - Hospices6 CCR 1011-1 Chapter 21 Part 11 Pharmaceutical Services11.6 The interdisciplinary group, as part of the review of the individualized plan of care, shall determine and document the ability of the patient and/or family to safely administer medications to the patient in their care setting. This REGULATION is not met as evidenced by:Based on record review and interview, the hospice interdisciplinary group (IDG) failed to determine the ability of the patient and/or family to safely self-administer drugs and biologicals for 14 of 14 sample hospice patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). Findings include:Fourteen sample hospice patient clinical records were reviewed from 5/18/26 through 5/20/26. Complete medical records for the fourteen patients, including initial, comprehensive, and updated assessments, plans of care, clinician notes, home visit encounters, coordination of care notes, physician orders, admission documentation, attachments to the medical records, and Interdisciplinary Groups (IDG) meeting notes, were reviewed.a) The hospice IDG failed to determine the ability of the patient and/or family to safely self-administer medications. Review of fourteen sample clinical records did not reveal documentation of the patients’ or their families’ abilities to safely self-administer medications. During an interview on 5/20/26 at 10:00 a.m., the hospice Director of Nursing (DON) confirmed the hospice medical records did not contain documentation regarding the ability of the patient and/or family to safely self-administer medications. The DON stated the information was discussed during IDG meetings, but was not documented in the medical record.
Plan of correction · submitted by the facility
Plan of Correction: A root cause analysis determined that the cited deficiency was a lack of oversight and review of the interdisciplinary process and documentation following a change in ownership and transition to a new electronic medical record system. The patient sample group surveyed on 5/20/2026 was reviewed by the interdisciplinary group on 6/2/2026. Interdisciplinary group discussion reviewed individualized plan of cares, to include the determination and documentation of the ability of the patient and/or family/caregiver to safely administer medications/biologicals to the patient in their care setting. The plan to correct this deficiency is for all members of the interdisciplinary group and administrative staff involved in the interdisciplinary meetings will receive in-service training on the interdisciplinary group process and required documentation by 6/27/2026. The in-service will cover interdisciplinary group discussion regarding individualized care plans and the importance of determining who can safely administer medications/biologicals to the patient and how to properly document. Development with our electronic medical record provider has begun to include a required section within the interdisciplinary meeting documentation to detail the ability of the patient and/or family/caregiver to safely administer medications/biologicals to the patient in their care setting. This change to the electronic medical record system will ensure interdisciplinary discussion regarding the ability of the patient and/or family/caregiver to safely administer medications/biologicals and increase compliance of documentation regarding the safe administration of medications/biologicals in the patient’s care setting. The timeline given for this improvement is 60 days. Implementing the Plan of Correction: Implementation of the plan of correction as begun via the Director of Clinical Services, who shared the cited deficiency with the interdisciplinary group on 5/22/2026. Education on the importance of identifying who is responsible for safely administering medications/biologicals and how to properly document the discussion within the electronic medical record was provided to the interdisciplinary group. The in-service training on the interdisciplinary group process and required documentation will be completed by each member of the interdisciplinary group via Paylocity. Completion of the in-service will be monitored by the Director of Clinical Services. Monitoring and Quality Assurance: The Director of Clinical Services will audit 100% of interdisciplinary meeting notes through 6/27/2026 to monitor compliance and ensure improvement. If 100% compliance is met, the Director of Clinical Services will audit 50% of interdisciplinary meeting notes through 8/27/2026 to ensure ongoing compliance. If 100% compliance is not met within 30 days, the Director of Clinical Services will continue to audit 100% of interdisciplinary meeting notes until 100% compliance is reached for a period of 30 consecutive days. Monitoring efforts will be recorded on a performance improvement project form and updated bi-weekly following interdisciplinary group meetings by the Director of Clinical Services. The performance improvement plan will be evaluated by the quality assurance team every 30 days to monitor compliance. The performance improvement project will be reflected in Q2 & Q3 QAPI reporting. Responsible Party: Director of Clinical ServiceCompletion Date: Plan of Correction implementation – 6/27/2026
1/15/2026Complaint Survey · ID 1DE1B6-H1No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A survey prompted by #CO 2690134 was completed on 1/15/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1/15/2026Licensure Complaint Survey · ID 1E0BF7-H1No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A survey prompted by #CO 2690408 was completed on 1/15/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
0 recordsNo reportable occurrences
The state has not published occurrence summaries for this facility.