Every finding on record at Ayas Hospice Inc

Upon patient record review, 1 of 14 (Patient #12) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. #12-SN documented in SOC note dated 11/03/25 that the patient "takes hydrocodone 10/325 1 tab q6 hours. She also has gabapentin 100mg PO TID." These medications are not documented on the medication profile.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. #12-SN documented in SOC note dated 11/03/25 that the patient "takes hydrocodone 10/325 1 tab q6 hours. She also has gabapentin 100mg PO TID." These medications are not documented on the Plan of Care.

Observed in Patient Home. In 2 of 3 home visits conducted, the Hospice Surveyor noted the HCO had not implemented the Pain Assessment and Reassessment Policy No. 9.9.1. During HOS HV #2, the patient had expressed that she was uncomfortable because of pain. The clinician did not perform any in-depth assessment of the pain that included: the location, intensity, duration, frequency, character, or effectiveness of current treatment per their policy. HOS HV #3, The patient had 3 different medications for pain; however, the clinician only asked when was the last time that the patient took the Tylenol. There had been no further pain assessment conducted to include the required elements of assessment. This was validated with the Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the Hospice Surveyor noted the HCO had not implemented its Infection Control Policy No. 5.7.1A, Bag Technique related to cleaning of reusable equipment. HOS HV #1 and HOS HV #2 and, the clinician had been observed to clean equipment with 'Antiseptic Hand Sanitizer Wipes', labeled for 'handwashing to reduce bacteria on skin', and not labeled for cleaning of reusable equipment. In HOS HV #3, the clinician cleaned equipment with First Aid Antiseptic wipes with indication for use: to help prevent the spread of infection in minor cuts, scrapes and burns, and not labeled for cleaning of reusable equipment. This was validated with the Administrator/DOPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, the Hospice Surveyor had been unable to validate initial competency had been completed for a new field clinician. In HR #1 the competency had been incomplete as the competency had one date and then a line down the page. There had also been several areas identified as a ‘required proficiency’ that had been blank. This was validated with the owner of the agency present during HR file review.

Observed in Patient Home. In 1 of 3 home visits conducted, the Hospice Surveyor noted the medications the patient had been taking was not accurately documented in the hospice medication profile. In HOS HV #2, the patient had been taking Losartan 25 mg 1 tab daily for a long time; however, this medication had not been included on the hospice medication profile. This was validated with the Director of Patient Care Services.

Observed in Emergency Management Session. During the Emergency Management session the surveyor noted that the organization’s exercise did not sufficiently stress its Emergency Operations Plan to identify weaknesses in key areas of safety. For example, the organization had documentation of an Earthquake drill over the summer that included a list of employees who took part in the exercise. The organization reported 12 employees and only 4 took part in the exercise and one was the DPCS and another was the DPCS designee. This did not test patient acuity assignment and tracking procedures to validate the organization’s ability to identify and locate high risk patients and did not test key care, treatment, or service processes consistent with planned response activities. This was confirmed with the Owner and RN present.

Observed in Emergency Management Session. During the Emergency Management session the surveyor noted that the management and staff had not identified deficiencies and opportunities for improvement following the emergency exercise. For example, the organization had documentation of an Earthquake drill over the summer that included a list of employees who took part in the event and the event itself, but did not include documentation of identified deficiencies and opportunities for improvement. This was confirmed with the Owner and RN present. Observed in Emergency Management Session. During the Emergency Management session the surveyor noted that the management and staff had not evaluated the emergency response exercise. For example, the organization had documentation of an Earthquake drill over the summer that included a list of employees who took part in the event and the event itself, but did not include documentation of an evaluation of the exercise. This was confirmed with the Owner and RN present.

Observed in Data Session. During the Data session it was noted that the organization had not provided adequate oversight of policies and procedures as evidenced by the Covid-19 policy that had the organization's name at the top of the page, but within the text of the document Alexius Hospice was referred to. Also, the forms for documentation of medical and religious exemptions for Covid-19 vaccination were Alexius Hospice. The RN/DPCS designee/Admin was texting throughout the discussion and shortly after went to the fax machine and brought over the same policy with corrected names and RN/DPCS designee/Admin requested this be considered. The date of the document 2/1/22 remained the same, with no documentation to indicate the document was updated.10/19/22. This was discussed with the RN/DPCS designee/Admin and Owner.

Observed in Record Review. During record review it was noted that that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, in record HV#2 the nurse documented the use of and education to the patient and family for the use of compression stockings 5 weeks after the date of admission. The POC did not include therapy with compression stockings and there was no supplemental order for this therapy. This was confirmed with the DPCS designee/Admin present.

Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor noted that the organization did not implement its infection prevention and control activities. For example, during HV#1 the RN was observed going in and out of her supply bag without performing hand hygiene. HV#2 the RN was observed interacting with the patient and the patient's environment, such as checking medications, and not performing hand hygiene. The organization's Hand Hygiene Policy and Compliance Program stated Indications for hand hygiene are: ...Before re-entering nursing bag or patient's clean supplies and Before and after direct patient care.

Observed in Data Session. During the Data session discussion and review of the Infection Control Plan the surveyor noted that the organization had not documented any education for the licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. The RN present was not employed with the company during the 2021-22 influenza season and the Owner was not able to speak to any education received. The organization was not able to produce any education received with the current influenza season.

Observed in Leadership Session. During review it was noted that the governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: .418.60 and 418.113

Observed in HR File Review. In 4 of 8 HR files reviewed, it was noted that staff competence was not initially assessed and documented as part of orientation. For example, review of the RN record included a RN competency. However the Governing Board minutes included that in the absence of the DPCS/ADMIN Designee, this RN Supervisor, will act on their behalf and there was no documentation of competency for RN Supervisor or DPCS/ADMIN Designee. For example, the DPCS/Administrator record did not include a competency related to the role of DPCS or Administrator. It did include a single RN competency document that was signed for 2020, 2021 and 2022. This document was a one use document and was written over. The 2022 competency was incomplete, with the first 2 pages signed and the last 4 pages not signed. These pages included assessments and other regularly required RN duties. For example, the Spirtual Counselor's record included a competency from Faith and Hope Hospice and documented observations at a time Ayas Hospice did not have any patients. For example, the MSW's record included a competency from Hospice of St John Inc and documented observations at a time Ayas Hospice did not have any patients. This was discussed with the owner.