VILLA GROVE ASSISTED LIVING

The facility's discharge policy was not updated to include a policy for involuntary discharge grievance process as of the date of the survey. The state surveyor emailed the facility a copy of the policy. The facility updated their policy and procedures manual to include the following policy a of June 19, 2025. The policy is as follows:D-15 Discharge PolicyReview Date: 6/19/2025Revised on: 6/19/2025Implementation Date: 6/19/2025PURPOSETo ensure that the discharge process provides for continuing care based upon the client’s assessed needs. POLICYDischarge planning begins when the client is admitted for services and continues throughout the time the client is receiving services from Villa Grove. For clients receiving skilled services under a Home Care Agency Plan of Care, the RN case manager will make an initial assessment of client need, establish goals and, at this time, predict as far as possible realistic outcomes. For clients receiving non-skilled services only, the administrator, clinical administrator or designee will make an initial evaluation of client need, establish goals and, at this time, predict as far as possible realistic outcomes. The client/family/caregiver will participate in the formulation of these plans and will be informed of the intended visit frequency and duration of service. If no improvement or no discharge is expected, Villa Grove RN staff will document this assessment in the client’s clinical record. Villa Grove personnel shall develop a written plan of discharge which includes a summary of services provided and outlines the services needed by the client upon discharge. Villa Grove personnel will utilize the Inter-Facility Transfer Form created by the State of Colorado Department of Public Health and Environment to assist in the process of transferring a client to another facility or level of care if necessary to meet the client’s needs. Villa Grove shall notify the State of Colorado Department of Public Health and Environment before it initiates discharge of any consumer who requires and desires continuing paid care or services where there are no known transfer arrangements to protect the consumer’s health, safety or welfare. Emergency discharges necessary to protect the safety and welfare of staff shall be reported to the State of Colorado Department of Public Health and Environment within forty-eight (48) hours of the occurrence. PROCEDUREClients are discharged from service when:The client’s condition has improved, care goals have been met and the service is no longer necessary;The client/family/caregiver has demonstrated an ability to manage the client’s care needs or health regimen;The physician recommends discharge (if applicable);The client moves out of the geographic areas covered by Villa Grove; The client is not home/not found;The client is admitted/ transferred to a Health Care Facility;The client/family/caregiver refuses service or requests that services be discontinued;Other community resources become more appropriate based on assessed need. Administrative Discharge is executed when:The client’s needs are beyond the scope of the service that Villa Grove can provide or safely meet at home. Client/family/caregiver directs physical or verbal abuse at a staff member, which negatively impacts their safety. Client/family/caregiver is non-compliant with care regime thereby negatively impacting on the client’s welfare. Client/family/caregiver demonstrates they will not maintain a safe level of care. The client/family/caregiver is able but unwilling to participate with Villa Grove staff in planning for the provision of ongoing care thereby creating an unsafe situation. When environmental safety is a direct threat to the provider(s) of care and no safe plan can be implemented, Villa Grove will take necessary steps to provide safe and appropriate discontinuation of service to the client taking into consideration continuing care needs. In the event of non-payment for services in accordance with the Villa Grove payment requirements which will be provided to the client on admission to the agency. Discharge Process:Upon admission to Villa Grove, the RN case manager or qualified designee discusses with the client/family/caregiver the services to be provided and the anticipated length of service. This discussion is documented in the clinical record. The RN case manager or qualified designee will, at the time of admission, take into consideration the long term needs of the client and begin planning with the client/family/caregiver for the care needed when the client is discharged from Villa Grove. The RN case manager, clinical supervisor or designee contacts any assigned caregiver on the case to discuss the client’s discharge prior to the anticipated discontinuation of home care agency services. The RN case manager or designee contacts/discusses with the client/family/caregiver in advance to discuss the anticipated discharge date, documents in the clients record the client’s status and any continuing care needs that will require planning after discharge. Once admitted, Villa Grove shall not discontinue or refuse services to a client unless documented efforts have been made to resolve the situation that triggered such discontinuation or refusal to provide services. The client or authorized representative shall be notified verbally and in writing of the agency’s intent to discharge and the reasons for the discharge. Villa Grove shall assist each client or authorized representative to find an appropriate placement with another agency if the client continues to require care and/or services upon discharge. Villa Grove shall document due diligence in ensuring continuity of care upon discharge as necessary to protect the client’s safety and welfare. Clients who are transferred to another agency or organization will receive information, when available, with the name, address, telephone number, and contact person at the referral system. For clients receiving skilled services under a home care agency plan of care, the RN case manager notifies the physician in advance of the anticipated discharge date indicating client’s current status and any unachievable goals with the reasons that Villa Grove is unable to achieve such goals, documenting such telephone call to physician in the client’s record. For those clients requiring continued care after discharge, assistance is provided in obtaining those services. The physician is notified of the availability of a discharge summary upon request. The discharging clinician or supervisor submits completes a written discharge summary within one (1) day of the discharge date. The discharge summary will include:Reasons for discharge. A listing of client’s problems and needs. The goals established with client and the client’s progress toward those goals. A summary of the care provided. The client’s status at time of discharge. A copy of the discharge summary will be placed in the client’s record. Involuntary Discharge (Administrative Discharge) Grievance ProcessThe facility owners will be the designated person(s) to receive involuntary discharge grievances. A resident may file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (a), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residenceThe resident, or other person allowed to file a grievance may receive assistance in preparing and filing a grievance without interference from the assisted living residence. Grievances related to involuntary discharge may be submitted to the individual designated by the facility in accordance with subpart (a) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (a), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness’s name and contact information, and shall keep that information as part of the grievance documentation. No later than 5 business days after the submission of a grievance in accordance with subpart (d), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal: “If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation.” (cdphe_legalservices@state.co.us)Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S.The assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal. The assisted living residence will continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. The resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. The facility administrator's met with residents and staff to make sure everyone was notified of the new policy and if they had any questions. The meetings were documented in the facility's QMP manual. The meeting took place on June 19, 2025. Moving forward, any discharge will follow the updated policy in the manual. Facility administrator's will discuss and review all discharges to make sure the new policy is administered.

The facility administrator's will follow Chapter 7, 6 CCR1011-1 and arrange to evaluate the resident prior to re-admission or discharge in accordance with the facility's discharge procedure and policy. The facility administrator's met to discuss the changes to the updated policy and discuss the findings with staff to make sure the facility conducts re-assessments and document in the resident's anecdotal notes. This meeting was conducted on June 19, 2025 with owner's and staff and documented in the QMP.

The state surveyor emailed the facility a copy of the policy. The facility updated their policy and procedures manual to include the following policy a of June 19, 2025. The entire policy is as follows and will now include the steps for a written notice of involuntary discharge:D-15 Discharge PolicyReview Date: 6/19/2025Revised on: 6/19/2025Implementation Date: 6/19/2025PURPOSETo ensure that the discharge process provides for continuing care based upon the client’s assessed needs. POLICYDischarge planning begins when the client is admitted for services and continues throughout the time the client is receiving services from Villa Grove. For clients receiving skilled services under a Home Care Agency Plan of Care, the RN case manager will make an initial assessment of client need, establish goals and, at this time, predict as far as possible realistic outcomes. For clients receiving non-skilled services only, the administrator, clinical administrator or designee will make an initial evaluation of client need, establish goals and, at this time, predict as far as possible realistic outcomes. The client/family/caregiver will participate in the formulation of these plans and will be informed of the intended visit frequency and duration of service. If no improvement or no discharge is expected, Villa Grove RN staff will document this assessment in the client’s clinical record. Villa Grove personnel shall develop a written plan of discharge which includes a summary of services provided and outlines the services needed by the client upon discharge. Villa Grove personnel will utilize the Inter-Facility Transfer Form created by the State of Colorado Department of Public Health and Environment to assist in the process of transferring a client to another facility or level of care if necessary to meet the client’s needs. Villa Grove shall notify the State of Colorado Department of Public Health and Environment before it initiates discharge of any consumer who requires and desires continuing paid care or services where there are no known transfer arrangements to protect the consumer’s health, safety or welfare. Emergency discharges necessary to protect the safety and welfare of staff shall be reported to the State of Colorado Department of Public Health and Environment within forty-eight (48) hours of the occurrence. PROCEDUREClients are discharged from service when:The client’s condition has improved, care goals have been met and the service is no longer necessary;The client/family/caregiver has demonstrated an ability to manage the client’s care needs or health regimen;The physician recommends discharge (if applicable);The client moves out of the geographic areas covered by Villa Grove; The client is not home/not found;The client is admitted/ transferred to a Health Care Facility;The client/family/caregiver refuses service or requests that services be discontinued;Other community resources become more appropriate based on assessed need. Administrative Discharge is executed when:The client’s needs are beyond the scope of the service that Villa Grove can provide or safely meet at home. Client/family/caregiver directs physical or verbal abuse at a staff member, which negatively impacts their safety. Client/family/caregiver is non-compliant with care regime thereby negatively impacting on the client’s welfare. Client/family/caregiver demonstrates they will not maintain a safe level of care. The client/family/caregiver is able but unwilling to participate with Villa Grove staff in planning for the provision of ongoing care thereby creating an unsafe situation. When environmental safety is a direct threat to the provider(s) of care and no safe plan can be implemented, Villa Grove will take necessary steps to provide safe and appropriate discontinuation of service to the client taking into consideration continuing care needs. In the event of non-payment for services in accordance with the Villa Grove payment requirements which will be provided to the clienton admission to the agency. Discharge Process:Upon admission to Villa Grove, the RN case manager or qualified designee discusses with the client/family/caregiver the services to be provided and the anticipated length of service. This discussion is documented in the clinical record. The RN case manager or qualified designee will, at the time of admission, take into consideration the long term needs of the client and begin planning with the client/family/caregiver for the care needed when the client is discharged from Villa Grove. The RN case manager, clinical supervisor or designee contacts any assigned caregiver on the case to discuss the client’s discharge prior to the anticipated discontinuation of home care agency services. The RN case manager or designee contacts/discusses with the client/family/caregiver in advance to discuss the anticipated discharge date, documents in the clients record the client’s status and any continuing care needs that will require planning after discharge. Once admitted, Villa Grove shall not discontinue or refuse services to a client unless documented efforts have been made to resolve the situation that triggered such discontinuation or refusal to provide services. The client or authorized representative shall be notified verbally and in writing of the agency’s intent to discharge and the reasons for the discharge. Villa Grove shall assist each client or authorized representative to find an appropriate placement with another agency if the client continues to require care and/or services upon discharge. Villa Grove shall document due diligence in ensuring continuity of care upon discharge as necessary to protect the client’s safety and welfare. Clients who are transferred to another agency or organization will receive information, when available, with the name, address, telephone number, and contact person at the referral system. For clients receiving skilled services under a home care agency plan of care, the RN case manager notifies the physician in advance of the anticipated discharge date indicating client’s current status and any unachievable goals with the reasons that Villa Grove is unable to achieve such goals, documenting such telephone call to physician in the client’s record. For those clients requiring continued care after discharge, assistance is provided in obtaining those services. The physician is notified of the availability of a discharge summary upon request. The discharging clinician or supervisor submits completes a written discharge summary within one (1) day of the discharge date. The discharge summary will include:Reasons for discharge. A listing of client’s problems and needs. The goals established with client and the client’s progress toward those goals. A summary of the care provided. The client’s status at time of discharge. A copy of the discharge summary will be placed in the client’s record. Involuntary Discharge (Administrative Discharge) Grievance ProcessThe facility owners will be the designated person(s) to receive involuntary discharge grievances. A resident may file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (a), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residenceThe resident, or other person allowed to file a grievance may receive assistance in preparing and filing a grievance without interference from the assisted living residence. Grievances related to involuntary discharge may be submitted to the individual designated by the facility in accordance with subpart (a) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (a), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. If the grievance is orally submitted and witnessed,the assisted living residence shall ensure that the resident or other person filing the grievance has the witness’s name and contact information, and shall keep that information as part of the grievance documentation. No later than 5 business days after the submission of a grievance in accordance with subpart (d), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal: “If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation.” (cdphe_legalservices@state.co.us)Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S.The assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal. The assisted living residence will continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. The resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. The facility administrator's met with residents and staff to make sure everyone was notified of the new policy and if they had any questions. The meetings were documented in the facility's QMP manual. The meeting took place on June 19, 2025. Moving forward, any discharge will follow the updated policy in the manual that includes written notice as stated above. Facility administrator's will discuss and review all discharges to make sure the new policy is administered. Addendum:The facility administrator's will monitor each discharge as they may occur within the next six (6) months to make sure the new policy is being followed. Any discharge will require both administrator review prior to a discharge being completed. The sample will be all discharges within the next since months as they occur. The monitoring will be documented in the QMP process that each step of the process is followed and signed off by each administrator. Any 30 day notice within the next six months will be sent to the state and local ombudsmen. In staff and resident meetings for the next six (6) months, the new policy will be discussed to make sure everyone understands and will be documented in the QMP for each meeting to make sure resident's understand their right to appeal and the grievance policy. This teamwork approach in our QAPI process will hold the facility accountable for each other with meetings with residents, staff and administrators so everyone is aware of the updated policy.

Facility administrator's met with staff on June 19, 2025 to educate everyone that if a resident walks out of the facility, additional efforts are needed to ensure a safe environment. This may include contacting the Pueblo Police Department if a resident walks off the facility, refusing facility assistance and make all attempts to verify the resident's safety. Owners will follow the resident until the Pueblo PD arrive to meet with the resident. These procedures are documented in the facility QMP.Addendum:The facility administrator's will monitor each discharge as they may occur within the next six (6) months to make sure the new policy is being followed. Any discharge will require both administrator review prior to a discharge being completed. The sample will be all discharges within the next since months as they occur. The monitoring will be documented in the QMP process that each step of the process is followed and signed off by each administrator. Any 30 day notice within the next six months will be sent to the state and local ombudsmen. In staff and resident meetings for the next six (6) months, the new policy will be discussed to make sure everyone understands and will be documented in the QMP for each meeting to make sure resident's understand their right to appeal and the grievance policy. This teamwork approach in our QAPI process will hold the facility accountable for each other with meetings with residents, staff and administrators so everyone is aware of the updated policy. Addendum No. 2As part of the discharge process, staff and administrator's will verify that the resident has agreed to a safe discharge. Should a resident refuse to leave with a staff member or await a safe discharge, the facility has created a checklist of appropriate numbers to notify, including state and local omsbudsman and the facility will contact Pueblo PD to file a missing person report as a staff member may not be available to follow the resident on foot. If Administrators are available, they will attempt to keep the resident within site until Pueblo PD arrives. All appropriate agencies will be notified and facility will follow-up to verify the resident made it to a safe destination or the Pueblo PD placed the resident in a safe environment, whether shelter, etc. The sample of the monitoring will be for all discharges for the next 6 months. Administrator's will review all discharges to make sure the steps within the policy are followed. The monitoring will be documented in their anecdotal notes and QMP Discharge checklist that staff and administrator's confirmed a safe discharge even if the resident refuses to work with the facility and the facility must resort to contacting Pueblo PD. Administrator's will sign off on all discharges within the next 6 months of monitoring. If a resident refuses a safe discharge, the checklist will be included in the QMP and resident's notes detailing the situation, confirming who was contacted, document Pueblo PD police report number. This teamwork approach in our QAPI process will hold the facility accountable for each other with meetings with residents, staff and administrators so everyone is aware of the updated policy. Facility will meet with staff and residents and document in the QMP so everyone is aware of the new checklist.

Facility administrator's met with staff on June 19, 2025 to educate everyone that if a resident walks out of the facility, additional efforts are needed to ensure a safe environment. This may include contacting the Pueblo Police Department if a resident walks off the facility, refusing facility assistance and make all attempts to verify the resident's safety. Owners will follow the resident until the Pueblo PD arrive to meet with the resident. These procedures are documented in the facility QMP.The facility administrator's will monitor each discharge as they may occur within the next six (6) months to make sure the new policy is being followed. Any discharge will require both administrator review prior to a discharge being completed. The sample will be all discharges within the next since months as they occur. The monitoring will be documented in the QMP process that each step of the process is followed and signed off by each administrator. Any 30 day notice within the next six months will be sent to the state and local ombudsmen. In staff and resident meetings for the next six (6) months, the new policy will be discussed to make sure everyone understands and will be documented in the QMP for each meeting to make sure resident's understand their right to appeal and the grievance policy. This teamwork approach in our QAPI process will hold the facility accountable for each other with meetings with residents, staff and administrators so everyone is aware of the updated policy. Addendum:The facility administrator's will monitor each discharge as they may occur within the next six (6) months to make sure the new policy is being followed. Any discharge will require both administrator review prior to a discharge being completed. The sample will be all discharges within the next since months as they occur. The monitoring will be documented in the QMP process that each step of the process is followed and signed off by each administrator. Any 30 day notice within the next six months will be sent to the state and local ombudsmen. In staff and resident meetings for the next six (6) months, the new policy will be discussed to make sure everyone understands and will be documented in the QMP for each meeting to make sure resident's understand their right to appeal and the grievance policy. This teamwork approach in our QAPI process will hold the facility accountable for each other with meetings with residents, staff and administrators so everyone is aware of the updated policy. Addendum No. 2As part of the discharge process, staff and administrator's will verify that the resident has agreed to a safe discharge. Should a resident refuse to leave with a staff member or await a safe discharge, the facility has created a checklist of appropriate numbers to notify, including state and local omsbudsman and the facility will contact Pueblo PD to file a missing person report as a staff member may not be available to follow the resident on foot. If Administrators are available, they will attempt to keep the resident within site until Pueblo PD arrives. All appropriate agencies will be notified and facility will follow-up to verify the resident made it to a safe destination or the Pueblo PD placed the resident in a safe environment, whether shelter, etc. The sample of the monitoring will be for all discharges for the next 6 months. Administrator's will review all discharges to make sure the steps within the policy are followed. The monitoring will be documented in their anecdotal notes and QMP Discharge checklist that staff and administrator's confirmed a safe discharge even if the resident refuses to work with the facility and the facility must resort to contacting Pueblo PD. Administrator's will sign off on all discharges within the next 6 months of monitoring. If a resident refuses a safe discharge, the checklist will be included in the QMP and resident's notes detailing the situation, confirming who was contacted, document Pueblo PD police report number. This teamwork approach in our QAPI process will hold the facility accountable for each other with meetings with residents, staff and administrators so everyone is aware of the updated policy. Facility will meet with staff and residents and document in the QMP so everyone is aware of the new checklist.

Facility administrator's met with staff on June 19, 2025 to educate everyone that if a resident walks out of the facility, additional efforts are needed to ensure a safe environment. This may include contacting the Pueblo Police Department if a resident walks off the facility, refusing facility assistance and make all attempts to verify the resident's safety. Owners will follow the resident until the Pueblo PD arrive to meet with the resident. These procedures are documented in the facility QMP.The facility updated their policy and procedures manual to include the following policy a of June 19, 2025. The policy is as follows:D-15 Discharge PolicyReview Date: 6/19/2025Revised on: 6/19/2025Implementation Date: 6/19/2025PURPOSETo ensure that the discharge process provides for continuing care based upon the client’s assessed needs. POLICYDischarge planning begins when the client is admitted for services and continues throughout the time the client is receiving services from Villa Grove. For clients receiving skilled services under a Home Care Agency Plan of Care, the RN case manager will make an initial assessment of client need, establish goals and, at this time, predict as far as possible realistic outcomes. For clients receiving non-skilled services only, the administrator, clinical administrator or designee will make an initial evaluation of client need, establish goals and, at this time, predict as far as possible realistic outcomes. The client/family/caregiver will participate in the formulation of these plans and will be informed of the intended visit frequency and duration of service. If no improvement or no discharge is expected, Villa Grove RN staff will document this assessment in the client’s clinical record. Villa Grove personnel shall develop a written plan of discharge which includes a summary of services provided and outlines the services needed by the client upon discharge. Villa Grove personnel will utilize the Inter-Facility Transfer Form created by the State of Colorado Department of Public Health and Environment to assist in the process of transferring a client to another facility or level of care if necessary to meet the client’s needs. Villa Grove shall notify the State of Colorado Department of Public Health and Environment before it initiates discharge of any consumer who requires and desires continuing paid care or services where there are no known transfer arrangements to protect the consumer’s health, safety or welfare. Emergency discharges necessary to protect the safety and welfare of staff shall be reported to the State of Colorado Department of Public Health and Environment within forty-eight (48) hours of the occurrence. PROCEDUREClients are discharged from service when:The client’s condition has improved, care goals have been met and the service is no longer necessary;The client/family/caregiver has demonstrated an ability to manage the client’s care needs or health regimen;The physician recommends discharge (if applicable);The client moves out of the geographic areas covered by Villa Grove;The client is not home/not found;The client is admitted/ transferred to a Health Care Facility;The client/family/caregiver refuses service or requests that services be discontinued;Other community resources become more appropriate based on assessed need. Administrative Discharge is executed when:The client’s needs are beyond the scope of the service that Villa Grove can provide or safely meet at home. Client/family/caregiver directs physical or verbal abuse at a staff member, which negatively impacts their safety. Client/family/caregiver is non-compliant with care regime thereby negatively impacting on the client’s welfare. Client/family/caregiver demonstrates they will not maintain a safe level of care. The client/family/caregiver is able but unwilling to participate with Villa Grove staff in planning for the provision of ongoing care thereby creating an unsafe situation. When environmental safety is a direct threat to the provider(s) of care and no safe plan can be implemented, Villa Grove will take necessary steps to provide safe and appropriate discontinuation of service to the client taking into consideration continuing care needs. In the event of non-payment for services in accordance with the Villa Grove payment requirements which will be provided to the client on admission to the agency. Discharge Process:Upon admission to Villa Grove, the RN case manager or qualified designee discusses with the client/family/caregiver the services to be provided and the anticipated length of service. This discussion is documented in the clinical record. The RN case manager or qualified designee will, at the time of admission, take into consideration the long term needs of the client and begin planning with the client/family/caregiver for the care needed when the client is discharged from Villa Grove. The RN case manager, clinical supervisor or designee contacts any assigned caregiver on the case to discuss the client’s discharge prior to the anticipated discontinuation of home care agency services. The RN case manager or designee contacts/discusses with the client/family/caregiver in advance to discuss the anticipated discharge date, documents in the clients record the client’s status and any continuing care needs that will require planning after discharge. Once admitted, Villa Grove shall not discontinue or refuse services to a client unless documented efforts have been made to resolve the situation that triggered such discontinuation or refusal to provide services. The client or authorized representative shall be notified verbally and in writing of the agency’s intent to discharge and the reasons for the discharge. Villa Grove shall assist each client or authorized representative to find an appropriate placement with another agency if the client continues to require care and/or services upon discharge. Villa Grove shall document due diligence in ensuring continuity of care upon discharge as necessary to protect the client’s safety and welfare. Clients who are transferred to another agency or organization will receive information, when available, with the name, address, telephone number, and contact person at the referral system. For clients receiving skilled services under a home care agency plan of care, the RN case manager notifies the physician in advance of the anticipated discharge date indicating client’s current status and any unachievable goals with the reasons that Villa Grove is unable to achieve such goals, documenting such telephone call to physician in the client’s record. For those clients requiring continued care after discharge, assistance is provided in obtaining those services. The physician is notified of the availability of a discharge summary upon request. The discharging clinician or supervisor submits completes a written discharge summary within one (1) day of the discharge date. The discharge summary will include:Reasons for discharge. A listing of client’s problems and needs. The goals established with client and the client’s progress toward those goals. A summary of the care provided. The client’s status at time of discharge. A copy of the discharge summary will be placed in the client’s record. Involuntary Discharge (Administrative Discharge) Grievance ProcessThe facility owners will be the designated person(s) to receive involuntary discharge grievances. A resident may file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (a), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residenceThe resident, or other person allowed to file a grievance may receive assistance in preparing and filing a grievance without interference from the assisted living residence. Grievances related to involuntary discharge may be submitted to the individual designated by the facility in accordance with subpart (a) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (a), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness’s name and contact information, and shall keep that information as part of the grievance documentation. No later than 5 business days after the submission of a grievance in accordance with subpart (d), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal: “If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation.” (cdphe_legalservices@state.co.us)Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S.The assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal. The assisted living residence will continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. The resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. The facility administrator's met with residents and staff to make sure everyone was notified of the new policy and if they had any questions. The meetings were documented in the facility's QMP manual. The meeting took place on June 19, 2025. Moving forward, any discharge will follow the updated policy in the manual. Facility administrator's will discuss and review all discharges to make sure the new policy is administered. Addendum:The facility administrator's will monitor each discharge as they may occur within the next six (6) months to make sure the new policy is being followed. Any discharge will require both administrator review prior to a discharge being completed. The sample will be all discharges within the next since months as they occur. The monitoring will be documented in the QMP process that each step of the process is followed and signed off by each administrator. Any 30 day notice within the next six months will be sent to the state and local ombudsmen. In staff and resident meetings for the next six (6) months, the new policy will be discussed to make sure everyone understandsand will be documented in the QMP for each meeting to make sure resident's understand their right to appeal and the grievance policy. This teamwork approach in our QAPI process will hold the facility accountable for each other with meetings with residents, staff and administrators so everyone is aware of the updated policy.