DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
191568 A. BUILDING __________
B. WING ______________ 		10/15/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ST JOSEPH HOSPICE, LLC 10615 JEFFERSON HIGHWAY, BATON ROUGE, LA, 70809
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0523      
33500 Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed no later than 5 days after the election of hospice care for 1 (#9) of 10 (#1-#10) sampled patients reviewed for completion of initial comprehensive assessments. Findings: Patient #9 Review of the clinical record for Patient #9 revealed the patient had an election of benefits signed on 08/08/2020. The patient was admitted with diagnoses that included Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung. Review of the patient's Plan of Care for the benefit period dated 08/08/2020 - 10/13/2020 revealed no documentation of an initial evaluation performed by a social worker within 5 days after the election of hospice was signed by the patient/caregiver. On 10/15/2020 at 1:03 p.m., an interview was conducted with S1ADM and S2ADON. After review of the clinical record for Patient #9, S1ADM verified the initial comprehensive assessment was not completed within 5 days of election of the hospice benefit as required. S2ADON verified a social worker visit was not conducted until 08/17/2020.
L0533      
33500 Based on interview and record review, the agency failed to ensure the IDG (interdisciplinary group) completed an assessment update no less than every 15 days for 2 (#1, #5) of 10 (#1-10) sampled patients reviewed for update of the plan of care. Findings: Review of the agency's policy entitled Interdisciplinary Group Meeting revealed, in part, the following: Purpose: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. Policy: The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. Procedure: 4. The patient's plan of care will be updated no less frequently than every 15 days or more frequently if the patient's condition requires; social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient. 5. A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. Patient #1 Review of the patient's clinical record revealed he was admitted to the agency on 02/25/2020 with a terminal diagnosis of Alzheimer's Disease with Early Onset. Further review of the record for the certification period of care from 05/25/2020 to 08/22/2020 revealed no documented evidence of an update to the patient's plan of care from 07/29/2020 to 08/19/2020, which was greater than 15 days. Patient #5 Review of the patient's clinical record revealed he was admitted to the agency on 02/20/2020 with a terminal diagnosis of Myasthenia Gravis with Acute Exacerbation. Further review of the record for the certification period of care from 02/20/2020 to 05/10/2020 revealed no documented evidence of an update to the patient's plan of care after 04/22/2020. The patient expired at home on 05/10/2020. On 10/15/2020 at 12:20 p.m., an interview was conducted with S1ADM and S2ADON. After reviewing the medical records for Patients #1 and #5, both verified the IDG assessment updates had not been conducted no less frequently than every 15 days as required.
L0543      
33500 Based on record review, staff interviews and home visits, the agency failed to ensure care and services were provided to patients and their families in accordance with the written plan of care as evidenced by: 1. Failure to provide SN visits as ordered for 7 (#1, #3, #4, #5, #6, #8, #10) of 10 (#1 - #10) patient records reviewed who had orders for SN visits. 2. Failure to provide aide visits as ordered for 1 (#5) of 4 (#2, #5, #7, #9) sampled patient records reviewed who had orders for aide visits. 3. Failure to provide MSW visits as ordered for 1 (#1) of 10 (#1-#10) sampled patient records reviewed who had orders for MSW visits. Findings: Review of the agency's policy entitled The Plan of Care revealed, in part, the following: Purpose: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. Procedure: 14. Care provided to the patient will be in accordance with the plan of care. Review of the agency's policy entitled Missed Visits revealed, in part, the following: Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. Procedure: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit B. Document in the patient's clinical record the following information: 2. Date and type of visit that was missed 3. Reason for the missed visit Patient #1 Review of the clinical record revealed the patient was admitted to the agency on 02/25/2020 with a terminal diagnosis of Alzheimer's Disease with Early Onset. A review of the certification period from 05/25/2020 to 08/22/2020 revealed the following orders: SN visits 1wk1, 1wk12, 4 PRN and MSW visits 1mo1, 2mo3, 2 PRN. A review of the Physician's Order revealed the following: 06/03/2020 - MSW effective 06/07/2020 1wk1, 1Q2wk10. Review of the MSW visit notes revealed MSW visits were conducted on 05/26/2020, 06/12/2020, 06/24/2020, 07/07/2020, and then not again until 07/28/2020, which was greater than 2 weeks. There was no documentation in the record explaining why the visit was delayed. Review of the SN visit notes revealed no SN visits were conducted the weeks of 08/02/2020 and 8/09/2020. There was no documentation in the record explaining why the visits were missed. Patient #3 Review of the clinical record revealed the patient was admitted to the agency on 01/12/2019 with a terminal diagnosis of Pulmonary Fibrosis. A review of the certification period from 07/05/2020 to 09/02/2020 revealed the following order: SN 2wk1, 2wk7, 1wk1, 4 PRN. Review of the SN visit notes revealed only one SN visit was conducted during the weeks of 08/02/2020, 08/09/2020, 08/16/2020, and 08/23/2020. There was no documentation in the record explaining why the visits were missed. Review of the certification period from 09/03/2020 to 09/07/2020 revealed the following order: SN 1wk1, 2wk8, 4 PRN. Review of the SN visit notes revealed no SN visit was conducted during the week of 09/3/2020. There was no documentation in the record explaining why the visit was missed. Patient #4 Review of the clinical record revealed the patient was admitted to the agency on 08/08/2020 with a terminal diagnosis of Heart Failure, Unspecified. A review of the certification period from 08/08/2020 to 11/05/2020 revealed the following order: SN 1wk1, 2wk13, 4 PRN. Review of the SN visit notes revealed only one SN visit was conducted during the weeks of 08/09/2020, 08/16/2020, 09/20/2020, and 09/27/2020. There was no documentation in the record explaining why the visits were missed. Patient #5 Review of the clinical record revealed the patient was admitted to the agency on 02/20/2020 with a terminal diagnosis of Myasthenia Gravis with Acute Exacerbation. A review of the certification period from 02/20/2020 to 05/10/2020 revealed the following orders: SN 2wk1, 2wk12, 1wk1, 4 PRN; aide 1wk1, 3wk13, 1wk1. A review of the Physician's Order revealed the following: 03/23/2020 - Increase hospice CNA to 5 times a week. Review of the SN visit notes revealed only one SN visit was conducted the week of 03/01/2020. Review of the aide visit notes revealed only four aide visits were conducted the week of 04/05/2020. There was no documentation in the record explaining why the visits were missed. Patient #6 Review of the clinical record revealed the patient was admitted to the agency on 03/04/2020 with a terminal diagnosis of Acute on Chronic Systolic CHF. A review of the certification period from 06/02/2020 to 08/30/2020 revealed the following orders: SN 1wk1, 1wk12, 4 PRN. A review of the Physician's Orders revealed the following: 06/04/2020 - SN effective 06/02/2020 5wk1, 1wk12. Review of the SN visit notes revealed only one SN visit was conducted the week of 06/02/2020. There was no documentation of SN visits during the week of 08/09/2020. There was no documentation in the record explaining why the visits were missed. Review of the certification period from 08/31/2020 to 10/29/2020 revealed the following orders: SN 1wk1, 1wk8, 4 PRN. Review of the SN visit notes revealed no SN visits were conducted the week of 09/06/2020. There was no documentation in the record explaining why the visit was missed. Patient #8 Review of the clinical record revealed the patient was admitted to the agency on 03/23/2020 with a terminal diagnosis of Chronic Systolic CHF. A review of the certification period from 07/21/2020 to 09/18/2020 revealed the following order: SN 2wk1, 2wk8, 4 PRN. Review of the SN visit notes revealed only one SN visit was conducted the week of 08/02/2020, no SN visits were conducted the week of 08/09/2020, and only one SN visit was attempted the week of 09/13/2020. There was no documentation in the record explaining why the visits were missed. Patient #10 Review of the clinical record revealed the patient was admitted to the agency on 07/18/2019 with a terminal diagnosis of Breast Cancer. A review of the certification period from 07/12/2020 to 08/21/2020 revealed the following order: SN 2wk1, 2wk7, 1wk1, 4 PRN. Review of the SN visit notes revealed only one SN visit was conducted the week of 08/09/2020. There was no documentation in the record explaining why the visit was missed. On 10/15/2020 at 1:15 p.m., an interview was conducted with S1ADM and S2ADON. After reviewing the patients' clinical records as stated above, both confirmed all missing visits for the patients. They further verified there was no documentation explaining the reason for the missed visits. S1ADM verified the clinical record should contain an explanation for missed visits if the visits were not conducted according to each patient's POC.
L0556      
33500 Based on record review and interview, the agency failed to ensure the patient received care and services based on assessments of the patient's needs for 3 of 3 (#1, #4, #9) sampled patients reviewed that required wound care out of a total sample of 10 patients (#1-10). Findings: Review of the agency's policy titled Wound Care Protocol revealed, in part: PURPOSE: To provide clinical guidance on wound care with the goal to prevent further wound deterioration while maintaining the patient's dignity and respect. PROCESS: The Registered Nurse will assess the wound bed and collaborate with the Hospice Medical Director to establish the most appropriate plan of care to meet the palliative goals in coordination with the patient/family, and all contracted care provider. Wound care treatment and interventions will be individualized and may include, but not be limited to the following: 2. Current status of the patient and progression of the disease process(es) 3. Weekly wound care measurements by the RN in coordination with facility staff if under contract Patient #1 Review of Patient #1's clinical record revealed the patient had an election of benefits signed on 02/25/2020. The patient's primary diagnosis was Alzheimer's Disease with Early Onset. Review of the patient's POC for the benefit period dated 05/25/2020 - 08/22/2020 revealed orders for the following visit frequency: SN 1wk1, 1wk12, 4 PRN. Review of Physician's Orders for the benefit period dated 05/25/2020 - 08/22/2020 revealed the following: 06/01/2020 - SN 1 time a week on Thursdays starting this week, 06/04/2020. Review of the patient's POC for the benefit period dated 08/23/2020 - 10/21/2020 revealed orders for the following visit frequency: SN 1wk1, 1wk7 and 4 PRN. Review of the SN visit notes revealed the following: 07/16/2020 - RN performed visit. An unstageable wound/DTI was identified to the patient's right heel that measured 5.5 cm x 9 cm x 0 cm. 07/23/2020 - LPN performed the weekly SN visit. There was no documentation of a wound assessment or wound care performed. There was no documentation of an assessment of the right heel wound by the RN for the week of 07/19/2020 - 07/25/2020. 09/04/2020 - RN performed the weekly SN visit. There was no documentation of a wound assessment or wound care performed. 09/11/2020 - LPN performed the weekly SN visit. There was no documentation of a wound assessment or wound care performed. There was no documentation of an assessment of the right heel wound by the RN for the week of 09/06/2020 - 09/12/2020. Patient #4 Review of Patient #4's clinical record revealed the patient had an election of benefits signed on 08/07/2020. The patient's primary diagnosis was Heart Failure, Unspecified. Review of the patient's Plan of Care for the benefit period dated 08/08/2020 - 11/05/2020 revealed orders for the following: SN 1wk1, 2wk13, 4 PRN. Hospice nurse to perform wound care to stage 2 on sacrum. Utilizing clean technique - cleanse with wound cleaner, cover with dressing. Review of SN visit notes revealed the following: 08/08/2020 (Start of Care note) - Integumentary assessment section: Abnormal integumentary assessment findings: pale, wound(s). Were wounds assessed using the wound assessment tool? No. Number of pressure ulcers - stage 2: one. There was no documented assessment of the stage 2 sacral pressure ulcer. There was no documentation of SN visits performed during the following week of 08/16/2020 - 08/22/1010. 08/24/2020 - RN performed visit. There was no documentation of wound measurements. 08/27/2020 - RN performed visit. There was no documentation of wound measurements. 09/01/2020 - RN performed visit. There was no documentation of a wound assessment. 09/03/2020 - RN performed visit. There was no documentation of a wound assessment. 09/10/2020 - RN performed visit. There was no documentation of a wound assessment. 09/15/2020 - RN performed visit. There was no documentation of a wound assessment. 09/21/2020 - RN performed visit. There was no documentation of a wound assessment. 09/28/2020 - RN performed visit. There was no documentation of a wound assessment. Patient #9 Review of Patient #9's clinical record revealed the patient had an election of benefits signed on 08/08/2020. The patient's primary diagnosis was Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung. Review of the patient's Plan of Care for the benefit period dated 08/08/2020 - 11/05/2020 revealed orders for the following visit frequency: SN 1wk1, 1wk1, 3wk1, 2wk11, 4 PRN. Review of Physician's Orders for the benefit period dated 08/08/2020 - 11/05/2020 revealed the following: 08/25/2020 - Increase nurse visits to 3 times/week. SN effective 08/23/2020 3wk10, 2wk1. Review of SN visit notes revealed the following: 09/02/2020 - RN performed visit. Documentation included: stage 2 to coccyx. There was no documentation of a wound assessment. There was no documentation of SN visits performed during the following week of 08/16/2020 - 08/22/1010. 09/04/2020 - RN performed visit. Documentation included: stage 3 to coccyx. There was no documentation of a wound assessment. 09/09/2020 - RN performed visit. There was no documentation of wound measurements. 09/11/2020 - RN performed visit. There was no documentation of wound measurements. 09/15/2020 - RN performed visit. There was no documentation of wound measurements. 09/18/2020 - RN performed visit. There was no documentation of wound measurements. 09/21/2020 - RN performed visit. There was no documentation of wound measurements. 09/25/2020 - RN performed visit. There was no documentation of wound measurements. 09/28/2020 - RN performed visit. There was no documentation of wound measurements. 10/05/2020 - RN performed visit. There was no documentation of wound measurements. On 10/15/2020 at 1:03 p.m., an interview was conducted with S1ADM and S2ADON. After review of the clinical records for Patients #1, #4, and #9, both verified the above findings. S1ADM stated she would expect nurses to assess patients' wounds on every visit unless the patient/caregiver refused. She stated the RN would be expected to obtain pressure ulcer wound measurements weekly.