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When CommonSpirit Health at Home took over ownership of the Mercy Hospice program in October, the transition was accompanied by operational deficiencies that put patients at immediate risk of serious harm or death, according to Colorado regulators\u2019 inspection reports. (Durango Herald file)\n<\/p>\n
The ownership transition of Durango\u2019s hospice program created serious problems in patient care and organizational oversight, according to state inspections that found multiple deficiencies and twice determined patients were at immediate risk of serious harm or death.<\/p>\n
In October 2025, the for-profit arm of the national CommonSpirit Health system \u2013 CommonSpirit Health at Home \u2013 took over ownership of the Mercy Hospice program.<\/p>\n
CommonSpirit assured the community the quality of care would not decline as a result of the transition.<\/p>\n
\u201cPatients and families will receive the same level of high-quality hospice care throughout this process without interruption,\u201d Josh Neff, president of CommonSpirit Mercy Hospital at the time, told The Durango Herald<\/a> in November.<\/p>\n However, in May, the Colorado Department of Public Health and Environment conducted two concurrent relicensing inspections that found the ownership transition created system-wide deficiencies that led to clinical care practices and poor organizational oversight that put patient health and safety at serious risk.<\/p>\n That included two findings of \u201cimmediate jeopardy\u201d caused by Health at Home\u2019s failure to respond to and address changes in medical condition in an acceptable time period for half the patient cases examined by state investigators.<\/p>\n \u201cThis deficient practice constitutes immediate jeopardy as it created a situation in which the patient\u2019s health and safety were at risk of serious injury, harm, impairment, or death,\u201d the report said.<\/p>\n CommonSpirit provided a boilerplate statement in response to a list of questions about the state and federal licensure reports.<\/p>\n \u201cCommonSpirit Health at Home is dedicated to continuous quality and regulatory compliance. If opportunities for improvement arise, prompt action is taken,\u201d a spokesperson for the organization said in a written response to the Herald.<\/p>\n Hospitals across the U.S are required to meet federal and state safety regulations and regularly undergo inspections from Medicaid and state regulatory agencies. A finding of \u201cimmediate jeopardy\u201d is the most severe level of noncompliance in health care regulations<\/a> and indicates that patients are at risk of serious injury or death.<\/p>\n According to the Association of Health Care Journalists, 46 hospital inspections resulted in a finding of immediate jeopardy in the first half 2024.<\/p>\n Additional deficiencies regarding the protection of patients\u2019 rights, clinical assessments, pain and symptom management, care planning, quality improvement, and organizational oversight were also recorded.<\/p>\n \u201cThese failures affected all patients served by the hospice agency,\u201d the Medicare recertification report said.<\/p>\n CDPHE conducts state regulatory reviews and, as a contractor, surveys facilities participating in the federal Medicare program.<\/p>\n The May inspections were the first regulatory surveys of Mercy Hospice under CommonSpirit Health at Home ownership. They included reviews required for state licensure and federal Medicare certification, as well as investigations into complaints filed during the roughly six months following the ownership change.<\/p>\n As part of the hospice\u2019s corrective action plan, the state required the organization to hire a registered nurse consultant for three months to strengthen internal operations and ensure compliance with state and federal regulations, CDPHE said.<\/p>\n CommonSpirit responded quickly to the concerns and immediate jeopardy was lifted May 21 while CDPHE was still completing the initial inspection, a CDPHE spokesperson said in an email to the Herald.<\/p>\n The state surveys and correction plans reviewed by the Herald said the operational and clinical failures at Hospice Mercy stem from three main root causes largely chalked up to the ownership transition: a new, electronic medical record system; clinical knowledge gaps and deficient protocols; and fragmented leadership, oversight and communication between local caretakers and corporate offices.<\/p>\n The facility\u2019s own official filing states the operational failures resulted from clinical knowledge gaps and \u201cthe electronic medical record transition in October 2025\u201d that created \u201cinsufficient clinical oversight\u201d and \u201crestricted technological access \u2026 necessitating a reliance on manual oversight.\u201d<\/p>\n CommonSpirit did not answer specific questions about how it would demonstrate to the public that the organization had returned to the standard of care promised, or why its national operating model failed to meet the hospital regulatory standards immediately following the transition.<\/p>\n Patients received delayed medical attention<\/p>\n CommonSpirit Health at Home failed to ensure patients received effective pain management, symptom control and appropriate medical responses to worsening health conditions, which led to a finding of immediate jeopardy.<\/p>\n For one patient who was diagnosed with pulmonary fibrosis, acute respiratory failure and dementia, necessary medical intervention was delayed for 30 hours following the development of concerning, strokelike symptoms, according to the inspection report.<\/p>\n Another patient reported increasing levels of pain suffered from a lack of in-person assessments, unaddressed pain severity, and medication confusion. In an interview with a state surveyor, the nurse responsible for providing care said no immediate home visit was made because they (the nurse) relied on their \u201cspidey senses\u201d to make those decisions rather than on standardized criteria.<\/p>\n Similar failures to respond to changes in condition were found in five other cases. In all, seven of the 14 patient records reviewed by state investigators involved severe delays that contributed to the finding of immediate jeopardy.<\/p>\n The report concluded that Health at Home had \u201cfailed to address and manage worsening symptoms of pain.\u201d<\/p>\n Hospice providers also failed to respond appropriately and timely enough in multiple instances of a new wound reported on the triage line, including one incident in which the appropriate clinical response happened four days late.<\/p>\n![\"A](\"https:\/\/www.europesays.com\/us\/wp-content\/uploads\/2026\/09\/1788342440_80_.jpeg\")
A finding of \u201cimmediate jeopardy,\u201d is the most severe level of noncompliance in health care regulations. CommonSpirit Health at Home received two counts in May. They were promptly addressed. (Jerry McBride\/Durango Herald file)Jerry McBride\n<\/p>\n
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According to inspection reports completed by the Colorado Department of Public Health and Environment, CommonSpirit Health at Home failed to provide effective pain management or respond to worsening health conditions for seven out of 14 patients surveyed. (Durango Herald file)Brandon Mathis\/Special to the Herald\n<\/p>\n