Every finding on record at St. Joseph Hospice of Southwest Louisiana, LLC

Observed in HR File Review. In 3 of 11 HR charts reviewed the organization did not provide initial education and training in emergency management to all individuals providing services under arrangement, and volunteers that is consistent with their roles and responsibilities in an emergency. Identified in the review of personnel records: HR9 Volunteer, HR10 Physician Designee, and HR11 Medical Director, there was no evidence that Emergency Management education and training was provided. This was reviewed and validated with the Office Manager, Volunteer Coordinator, Executive Director, and Regional Director.

Observed in Record Review. In 1 of 2 Live Discharge records reviewed, the organization did not respect the patient's right to participate in decisions about their care, treatment, or services. Identified in the record review of RRNHV#5, MRN 4602, the patient was discharged for no longer meeting hospice terminal criteria, but was not provided with a 2-day notice of Medicare Non-Coverage (NOMNC) to facilitate an appeal of the discharge decision, instead receiving the NOMNC on the date of discharge.

Observed in Patient Home. In 1 of 2 Skilled Nursing visits conducted, the hospice did not conduct a patient-specific comprehensive reassessment that identified all areas of hospice care related to the palliation and management of the terminal illness and related conditions in accordance with organizational policy no. 2-031.1 - Ongoing Comprehensive Assessments: The nurse will assess the patient on each visit, for: G. Skin integrity. Observed during RRHV#3, MRN 4902, the Registered Nurse did not conduct a thorough skin assessment, looking only at the patient's bilateral feet and ankles. This was reviewed with the Executive Director who was present for the home visit.

Observed in Record Review. In 9 of 9 active patient records reviewed, the written plans of care lacked individual and measurable outcomes anticipated from implementing and coordinating the plan of care. For example, the written plans of care for all 9 active patient records reviewed included the goal for pain: Pain will be managed at a level acceptable to patient or Pain is currently managed at a level acceptable to patient without indication of what pain level was or would be acceptable to the patients. In 8 of 9 records reviewed the written plans of care contained the goal Pulse Ox reading obtained and appropriate interventions initiated without indicating each individual patient’s goals for oxygenation. In 9 of 9 records reviewed the written plan of care included a spiritual goal of Patient/Caregiver experiences effective communication without indication of what constitutes effective for each patient; and in 8 of 9 records reviewed the written plans of care included a Psychosocial goal of Patient/Caregiver exhibit improved coping skills without indicating what constitutes improvement for each patient. This is a repeat finding from the previous survey and was reviewed and validated with the Executive Director and Regional Director Observed in Record Review. In 9 of 9 active patient records reviewed, the written plans of care lacked time frames required to meet the patients' identified goals. This was reviewed and validated with the Executive Director who acknowledged that this is a limitation within the current Electronic Medical Record.

Observed in Patient Home. In 1 of 1 home visits conducted where the patient received hospice aide services, the organization did not implement the infection prevention and control activates it had planned. Observed in HV#2, MRN 9802 the hospice aide failed to change wash and rinse waters following cleaning the patients perineal and rectal areas in which fecal matter was present, instead continuing with the bed bath cleaning and rinsing the patient's back with the contaminated water. This was confirmed with the Executive Director who was present during the visit.

Observed in HR File Review. In 2 of 11 personnel records reviewed there was no evidence that competencies had been assessed and documented in accordance to organizational Policy no. 1-008.1 - Ongoing Assessments 1: Competency assessments will be completed at least one (1) time per year. Identified in the personnel files for HR10 Physician Designee/Alternate Medical Director hired in 2019, and HR11 Medical Director hired in 2017, there were no records of competency assessments being completed since the initial upon hire competency assessments. This was reviewed and validated with the Office Manager, Executive Director, and Regional Director.