Every finding on record at Kaya Hospice, Inc

Observed in Record Review. he hospice registered nurse completes the initial assessment of the patient within 48 hours of the of hospice care. The hospice complies with any request by the physician or other licensed practitioner, patient, or representative to conduct the assessment in less than 48 hours. During review of patient record 6 it was noted that the initial assessment was documented 5 days after the election statement was signed.

Observed in Record Review. In 14 of 14 patient records reviewed, The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of records 1-14 it was noted that goals did not have time frames associated with them. This was confirmed DPCS.

Observed in Record Review. In 9 of 14 patient records reviewed, The organization provides the patient with care, treatment, or services according to the patient's individualized plan of care. During review of patient records 2,3,4,5,6,7,8,9, and 10 ordered visit frequencies not followed. For example in record 2 aide visits were ordered 4 times the first week and no aide visits were provided, and in record 3 nursing was ordered 3 times per week and only two visits were provided. This was confirmed by the DPCS.

Observed in HR File Review. Staff competence was not assessed and documented once every three years, or more frequently as required by organization policy or in accordance with law and regulation. during review of HR records it was noted that in records 4 and 5 thee was no documentation of a competency for 2023 as part of annual competency checks required by policy. This was confirmed by the Administrator.

Observed in Individual Tracer. The hospice aide did not provide services that are ordered by the physician or allowed practitioner in the plan of care, consistent with the aide’s training, and that the aide is permitted to perform under state law. During home visit 2 it was observed that the aide placed Ketaconazole 2% ointment on the patient's genital area. This medication was not on the aide's care plan as prepared by the RN to be applied by the aide. This was confirmed by the Administrator.

Observed in Tracer Activities. Volunteer staff did not provide day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. During the volunteer systems tracer it was reported that the percent ov volunteer hours worked in 2025 was 3.2%. This was verified by the Administrator.

Observed in Record Review. The medical director, physician member of the interdisciplinary team, or physician designee did not review the clinical information for each hospice patient and provide written certification that the patient’s life expectancy is six months or less if the illness runs its normal course.During review of patient record 3 it was noted that the hospice physician did not sign the CTI before the certification period. This was confirmed by the DPCS.

Observed in Record Review. Before the recertification period for each patient, the medical director, physician member of the interdisciplinary team, or physician designee reviews the patient’s clinical information. During review of patient record 3 it was noted that the certification of terminal illness for the second certification period was not signed by the physician. This was confirmed by the DPCS.

Observed in Record Review. The organization did not provide a written summary to the patient’s physician or other licensed practitioner in accordance with law and regulation.For hospices that elect to use The Joint Commission deemed status option: Law and regulation require that the hospice inform the attending physician of the availability of a discharge summary. The discharge summary is provided to the practitioner upon the their request and includes the patient's medical and health status at the time of discharge. During review of record 13 it was noted that there was no documentation of a discharge summary being sent to the attending physician at the time of live discharge. This was confirmed by the DPCS.

Observed in Record Review. In 8 of 9 patient records reviewed, The organization did not ensure completion of the initial comprehensive assessment within five calendar days of the patient electing the hospice benefit. For example, the surveyor noted on HV #1/RR #1, HV #2/ RR #2, HV #3/RR #3, RR #4, RR #6, RR #7, RR #9, and RR #11, the was no documentation of the psychosocial or spiritual care assessments being completed within the five days of patient admission, nor was there documentation addressing the reason for delays. Regulations require the hospice organization assess and reassess the patient and the patient's condition according to defined time frames. These findings were reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 7 of 9 patient records reviewed, The organization did not ensure the initial bereavement assessment was completed on patients who elected the hospice benefit. For example, the surveyor noted in clinical records for HV #1/RR #1, HV #2/RR #2, HV #3/RR #3, RR #6, RR #7, RR #9 and RR #11, there was no documentation of an initial bereavement assessment being completed. Standards require an initial bereavement assessment be completed at time of patient admission, as a part of the patient-specific comprehensive assessment. These findings were reviewed, discussed and validated with the Administrator/DPCS.

Observed in Record Review. In 8 of 8 patient records reviewed, The organization did not ensure patient care plan goals were individualized, measurable and realistic. Examples include the following: Trudy and Family will demonstrate appropriate pain management., changes in neurologic status will be addressed appropriately, Sabrina and Rhonda will demonstrate ability to assist Trudy with ADL's.”, Karen and Brandi will benefit from/have requested a decrease in skilled nursing visit to prevent exposure to pandemic illness within the 90-day certification period. Pt will receive assistance with personal care and hygiene and other activities of daily living per established CHHA plan of care by 1/1/23”, “Medications will be managed appropriately as evidenced by steady symptom control. cg will verbalize compliance with medication regime...caregiver will demonstrate/verbalize measures to prevent/manage skin breakdown”, “Pt will follow effective bowel program to prevent/relieve constipation., changes in neurologic status will be addressed appropriately. pt/cg will verbalize knowledge of preventative measure/response in the event of hemorrhage”, “pt will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms”, (Pt has no cardiac diagnoses). And “Bleeding/hemorrhage will be recognized early for management”. These stated goals do not contain information, including realistic time frames, that can be accurately measured to assist staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 5 of 9 patient records reviewed, The organization did not ensure the interdisciplinary group discussed/revised the patient’s plan of care at required intervals. For example, the surveyor noted in clinical records for HV #1/RR #1, HV #2/RR #2, HV #3/RR #3, RR #4, and RR #7, there were greater than 15-day intervals documented for the interdisciplinary group collaborations. Standards require the interdisciplinary group, in collaboration with the attending physician, review and revise the patient’s plan of care at least every fifteen calendar days. These findings were reviewed, discussed and validated with the Administrator/DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, The organization’s staff failed to perform hand hygiene at times required by the organization's policies. For example, on HV #1/RR #1, the surveyor observed the RN conducting a patient physical assessment, obtaining vital signs, entering data into the tablet and removing and replacing tape measures in the patient’s home folder, without conducting hand hygiene between tasks. And, on HV #3/RR #3, the RN collected the barriers and gloves that were used during care in one hand and attempted to perform hand hygiene will continuing to hold them. The organization’s policies require standard precautions to be used, including hand hygiene after contact with patient’s intact skin, after contract with inanimate objects, to prevent and control infection when conducting direct patient care. These findings were reviewed, discussed, and confirmed with the Administrator/DPCS.

Observed in Record Review. The organization did not ensure hospice aide supervisory visits were completed every fourteen days. For example, on HV #1/RR #1, the surveyor noted there were at least four intervals where the aide provided patient care without a registered nurse providing a supervisory visit. These findings were reviewed, discussed, and validated by the Administrator/DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, The organization did not take actions to ensure safe storage of the patient’s oxygen cylinders. For example, on HV #3/RR #3, the surveyor observed the patient’s oxygen cylinders shut up in the closet, piled up on each other, not secured in racks. The RN stated the durable medical equipment company did “not bring racks with the oxygen”. Standards require the organization take actions to identify and minimize risks to patient safety. These findings were observed by the Administrator/DPCS, who took immediate action in removing the cylinders from the closet floor and contacting the durable medical equipment company, to bring storage racks.

Observed in Patient Home. The organization’s staff failed to follow proper bag technique as required by the organization’s policy. For example, on HV #3/RR #3, the surveyor observed the RN, obtaining the patient’s vital signs, taking the medical equipment out of the nursing bag one at a time and cleaning each after use with a sanitizing wipe, then placing on a barrier near the bag. The organization’s bag technique policy requires a clean and dirty area be established prior to care and medical equipment be cleaned after the completion of the visit, with alcohol. These findings were reviewed, discussed, and confirmed with the Administrator/DPCS.