The ownership transition of Durango’s 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.
In October 2025, the for-profit arm of the national CommonSpirit Health system – CommonSpirit Health at Home – took over ownership of the Mercy Hospice program.
CommonSpirit assured the community the quality of care would not decline as a result of the transition.
“Patients and families will receive the same level of high-quality hospice care throughout this process without interruption,” Josh Neff, president of CommonSpirit Mercy Hospital at the time, told The Durango Herald in November.
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.
That included two findings of “immediate jeopardy” caused by Health at Home’s failure to respond to and address changes in medical condition in an acceptable time period for half the patient cases examined by state investigators.
“This deficient practice constitutes immediate jeopardy as it created a situation in which the patient’s health and safety were at risk of serious injury, harm, impairment, or death,” the report said.
CommonSpirit provided a boilerplate statement in response to a list of questions about the state and federal licensure reports.
“CommonSpirit Health at Home is dedicated to continuous quality and regulatory compliance. If opportunities for improvement arise, prompt action is taken,” a spokesperson for the organization said in a written response to the Herald.
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 “immediate jeopardy” is the most severe level of noncompliance in health care regulations and indicates that patients are at risk of serious injury or death.
According to the Association of Health Care Journalists, 46 hospital inspections resulted in a finding of immediate jeopardy in the first half 2024.
Additional deficiencies regarding the protection of patients’ rights, clinical assessments, pain and symptom management, care planning, quality improvement, and organizational oversight were also recorded.
“These failures affected all patients served by the hospice agency,” the Medicare recertification report said.
CDPHE conducts state regulatory reviews and, as a contractor, surveys facilities participating in the federal Medicare program.
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.
As part of the hospice’s 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.
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.
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.
The facility's own official filing states the operational failures resulted from clinical knowledge gaps and “the electronic medical record transition in October 2025” that created “insufficient clinical oversight” and “restricted technological access … necessitating a reliance on manual oversight.”
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.
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.
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.
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 “spidey senses” to make those decisions rather than on standardized criteria.
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.
The report concluded that Health at Home had “failed to address and manage worsening symptoms of pain.”
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.
Concerns about problems with the triage line’s responsiveness were not isolated to the state’s investigation report. Longtime hospice volunteers raised similar concerns in a hospice volunteer meeting hosted by CommonSpirit Health at Home in July.
Volunteers said they, along with families of patients, had encountered non-working or outdated phone numbers, which affected their ability to get through to triage or on-call help.
One volunteer described an incident in which a dying patient desperately required medication and help but their family called several times and got an out-of-state triage person.
“Where were the nurses?” the volunteer asked the Health at Home representatives at the meeting.
Health at Home received multiple similar reports that demonstrated a delay between initial triage calls and local follow up – reports that were seen daily. The administrator interviewed by the state surveyor admitted that the concerns were not “adequately” addressed.
Based on the provided regulatory documentation and interviews with facility staff, the agency pointed to a major transition to a new EMR system in October 2025. This transition created “new admission notification issues” and systemic administrative disruptions that hindered staff from seeing clinical notifications and tracking care timelines properly.
Additionally, a lack of standardized clinical practices were recorded in the report.
The transition from a locally based care model to one operated by a national health system raised concerns among some Durango residents and hospice volunteers, who questioned whether the new structure provided adequate local oversight.
“It was always just like, ‘Who’s in charge?’” said the daughter of a hospice patient about trying to find someone at the hospice who could address her concerns about her mother’s condition. She spoke to the Herald on the condition of anonymity.
In March, she filed a formal complaint with the state, alleging she could not access her mother’s records after the ownership transition and that hospice staff failed to respond adequately to changes in her mother’s medical condition.
State surveys substantiated two of her three claims, she said.
In the reports, state investigators found that the governing body of Mercy Hospice failed to employ an administrator responsible for day-to-day management.
During the survey, the agency lacked a physically present administrator to manage day-to-day operations. The primary administrator was managing another hospice facility several hours away, while the alternate administrator was pulled into direct patient care, leaving the facility unable to promptly provide investigators with critical record access.
Technological problems compounded those issues.
The state found onboarding under previous leadership had been done incorrectly, delaying Health at Home’s ability to provide the clinical records, complaints and incident logs surveyors requested.
The state also found limitations in how the organization handled incident and complaint information. Patient information was routinely redacted from incident and complaint records at the corporate level before local review, according to the survey documents. Executive leadership was unable to explain to surveyors how local staff could accurately identify harmful clinical trends using the redacted data.
The alternate administrator also lacked access to high-level complaints and incident records. Incidents, including patient falls, were coded by number, requiring leadership to open individual files to identify broader operational problems.
Local leadership also had to request permission from the parent corporation to review past incident or complaint reports, according to the survey documents, creating delays in identifying and addressing potentially harmful trends.
For the daughter of a hospice patient, her experience with the issues left her questioning whether CommonSpirit’s national operating model was appropriate for a rural community.
“Are they really assessing if their model works well for a rural environment?” she asked.
jbowman@durangoherald.com
