St Joseph Hospice of Bayou Region

“Based on interviews and record reviews, the agency failed to ensure all interdisciplinary assessments were completed within 5 calendar days of the patient’s start of care date for 5 (Patient #1, Patient #3, Patient #13, Patient #15, Patient #19) of 20 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19, Patient #20) sampled patients reviewed for interdisciplinary comprehensive assessment requirements. Findings: On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice to do so by 11/06/2025. Patient #1Review of Patient #1’s Plan of Care revealed a start of care date of 05/31/2025. Review of Patient #1’s record revealed a spiritual assessment was not completed within 5 calendar days of Patient #1’s start of care. In an interview on 11/06/2025 at 2:43PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice. Patient #3Review of Patient #3’s Plan of Care revealed a start of care date of 06/18/2025. Review of Patient #3’s record revealed a spiritual assessment was not completed within 5 calendar days of Patient #3’s start of care. In an interview on 11/06/2025 at 2:43PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice. Patient #13Review of Patient #13’s Plan of Care revealed a start of care date of 10/13/2025. Review of Patient #13’s record revealed a bereavement assessment was not completed within 5 calendar days of Patient #13’s start of care. In an interview on 11/06/2025 at 2:57PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice. Patient #15Review of Patient #15’s Plan of Care revealed a start of care date of 02/02/2024. Review of Patient #15’s record revealed a bereavement assessment was not completed within 5 calendar days of Patient #15’s start of care. In an interview on 11/06/2025 at 2:57PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice. Patient #19Review of Patient #19’s Plan of Care revealed a start of care date of 01/29/2025. Review of Patient #19’s record revealed a bereavement assessment was not completed within 5 calendar days of Patient #19’s start of care. In an interview on 11/06/2025 at 3:03PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice.”

“Based on interviews and record reviews, the agency failed to complete an initial bereavement assessment for 2 (Patient #13, Patient #19) of 20 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19, Patient #20) sampled patients reviewed for initial bereavement assessment requirements. Findings: On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Review of the agency’s Bereavement Assessment policy, revised on 10/2025, revealed, in part, upon admission, the social worker or registered nurse will complete a bereavement risk assessment. Patient #13 Review of Patient #13’s Plan of Care revealed Patient #13 was admitted to the agency on 10/13/2025. Review of Patient #13’s record revealed no documented evidence an initial bereavement assessment was not on Patient #13 since admit. In an interview on 11/06/2025 at 2:57PM, S2DON indicated the agency did not complete an initial bereavement assessment, as required. Patient #19Review of Patient #19’s Plan of Care revealed Patient #19 was admitted to the agency on 01/29/2025. Review of Patient #19’s record revealed an initial bereavement assessment was not completed on Patient #19 since admit. In an interview on 11/06/2025 at 3:03PM, S2DON indicated the agency did not complete an initial bereavement assessment as required.”

“Based on interviews and record reviews, the agency failed to ensure the patients received services per the plan of care for 11 (Patient #1, Patient #2, Patient #3, Patient #5, Patient #8, Patient #9, Patient #11, Patient #12, Patient #14, Patient #15, Patient #17) of 20 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19, Patient #20) sampled patients reviewed for services provided per the plan of care. Findings: On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Patient #1Review of Patient #1’s Plan of Care (POC) for the certification period of 08/29/2025 through 11/26/2025 revealed Patient #1 was to receive hospice aide services twice a week. Review of Patient #1’s record revealed, in part,No hospice aide visits were completed for the week of 09/21/2025 through 09/27/2025; and, The only visit hospice visit completed the week of 10/19/2025 through 10/25/2025 was completed on 10/21/2025. In an interview on 11/06/2025 at 2:34PM, S2DON indicated Patient #1 did not receive the required hospice aide visits per the POC. Patient #2 Review of Patient #2’s Plan of Care for the certification period of 08/15/2025 through 11/12/2025 revealed Patient #2 was to receive hospice aide services once a week for one week, and then three times a week. Further review revealed Patient #2 was to receive skilled nursing services twice a week. Review of Patient #2’s record revealed, in part:The only hospice aide visit completed the week of 08/31/2025 through 09/06/2025 was completed on 09/05/2025;The only documented hospice aide visits completed the week of 09/21/2025 through 09/27/2025 were completed on 10/22/2025 and 10/25/2025; The only skilled nurse visit completed the week of 09/28/2025 through 10/04/2025 was completed on 10/02/2025; and, The only documented hospice aide visits completed the week of 10/19/2025 through 10/25/2025 were completed on 10/20/2025 and 10/21/2025. In an interview on 11/06/2025 at 2:38PM, S1Administrator indicated Patient #2 did not receive services per the POC, and had nothing to present to dispute the above. Patient #3Review of Patient #3’s Plan of Care for the certification period of 09/16/2025 through 12/14/2025 revealed, in part, skilled nurse services effective 09/16/2025 five times a week for one week; and, hospice aide services effective 09/16/2025 twice a week for one week, and three times a week for 12 weeks. Review of Patient #3’s record revealed, in part:The only skilled nurse visits completed the week of 09/14/2025 through 09/20/2025 were completed on 09/16/2025 and 09/18/2025;The only hospice aide visits completed the week of 09/21/2025 through 09/27/2025 were completed on 09/22/2025 and 09/24/2025; and,The only hospice aide visits completed the week of 10/19/2025 through 10/25/2025 were completed on 10/20/2025 and 10/21/2025. In an interview on 11/06/2025 at 2:39PM, S2DON indicated the above mentioned disciplines had not provided services per Patient #3’s Plan of Care. Patient #5Review of Patient #5’s Plan of Care for the certification period of 09/16/2025 through 11/14/2025 revealed, in part, hospice aide services twice a week. Review of Patient #5’s record revealed, in part:The only hospice aide service completed the week of 10/05/2025 through 10/11/2025 was on 10/09/2025; and,The only hospice aide service completed the week of 10/19/2025 through 10/25/2025 was completed on 10/21/2025. In an interview on 11/06/2025 at 2:44PM, S2DON indicated hospice aide services were not completed per the plan of care as required for Patient #5. Patient #8Review of Patient #8’s Plan of Care for the certification period of 10/07/2024 through 01/04/2025 revealed, in part, hospice aide services once a week for one week, then three times a week for 12 weeks. Review of Patient #8’s record revealed, in part:The only hospice aide service completed the week of 10/12/2025 through 10/18/2025 was completed on 10/13/2025;The only hospice aide service completed the week of 10/19/2025 through 10/25/2025 was completed on 10/24/2025;The only hospice aide visits completed the week of 10/26/2025 through 11/01/2025 were completed on 10/28/2025 and 10/30/2025; and,The only hospice aide visit completed the week of 11/02/2025 through 11/08/2025 was completed on 11/04/2025. In an interview on 11/06/2025 at 2:52PM, S2DON indicated the agency failed to ensure services were provided per the plan of care for Patient #8. Patient #9Review of Patient #9’s Plan of Care for the certification period of 08/19/2025 through 11/16/2025 revealed, in part, hospice aide services once a week for one week, then twice a week for 12 weeks. Review of Patient #9’s record revealed, in part:No hospice aide visits were completed the week of 08/24/2025 through 08/30/2025; The only hospice aide visit completed the week of 08/31/2025 through 09/06/2025 was completed on 09/06/2025;The only hospice aide visit completed the week of 10/05/2025 through 10/11/2025 was completed on 10/07/2025; and,The only hospice aide visit completed the week of 10/19/2025 thorough 10/25/2025 was completed on 10/21/2025. In an interview on 11/06/2025 at 2:55PM, S2DON indicated the agency did not ensure Patient #9 received hospice aide services per the plan of care. Patient #11Review of Patient #11’s Plan of Care for the certification period of 09/23/2025 through 12/21/2025 revealed Patient #11 was to receive hospice aide services twice a week for one week, then three times a week for 12 weeks. Review of Patient #11’s record revealed, in part:The only hospice aide visit completed the week of 09/21/2025 through 09/27/2025 was completed on 09/26/2025;The only hospice aide visit completed the week of 10/12/2025 through 10/18/2025 was completed on 10/15/2025;The only hospice aide visits completed the week of 10/19/2025 through 10/25/2025 were completed on 10/21/2025 and 10/24/2025; and,The only hospice aide visits completed the week of 10/26/2025 through 11/01/2025 were completed on 10/27/2025 and 10/29/2025. In an interview on 11/06/2025 at 2:55PM, S2DON indicated the agency had not provided services per the plan of care for Patient #11. Patient #12Review of Patient #12’s Plan of Care for the certification period of 07/25/2025 through 10/22/2025 revealed, in part, hospice aide services effective 07/27/2025 twice a week for 12 weeks. Further review revealed skilled nurse services twice a week for 13 weeks. Review of Patient #12’s physician order dated 07/28/2025 revealed chaplain services once a month for one month, then twice a month for three months effective 07/25/2025. Review of Patient #12’s record revealed, in part:No documented evidence a hospice aide visit was completed the week of 07/27/2025 through 08/02/2025; The only skilled nurse visit completed the week of 08/31/2025 through 09/06/2025 was completed on 09/02/2025;No documented evidence of a hospice aide visit was completed for the week of 08/31/2025 through 09/06/2025;The only skilled nurse visit completed the week of 09/21/2025 through 09/27/2025 was completed on 09/23/2025; The only hospice aide visit completed the week of 09/21/2025 through 09/27/2025 was completed on 09/26/2025;The only skilled nurse visit completed the week of 10/05/2025 through 10/11/2025 was completed on 10/09/2025; The only hospice aide visit completed the week of 10/05/2025 through 10/11/2025 was completed on 10/07/2025; and, No documented evidence of a chaplain visit completed in August 2025. In an interview on 11/06/2025 at 2:56PM, S2DON indicated the agency had not ensured Patient #12 was provided the above mentioned services per the POC as required. Patient #14Review of Patient #14’s Plan of Care for the certification period of 09/17/2025 through 12/15/2025 revealed Patient #14 was to receive hospice aide services once a week for one week then twice a week for 12 weeks effective 09/17/2025. Review of Patient #14’s record revealed no evidence Patient #14 received hospice aide services the week of 10/19/2025 through 10/25/2025. In an interview on 11/06/2025 at 2:58PM, S2DON indicated the hospice aide failed to provide services per the plan of care for the above mentioned week for Patient #14. Patient #15Review of Patient #15’s Plan of Care for the certification period of 09/24/2025 through 11/22/2025 revealed, in part, hospice aide services twice a week for one week, then three times a week for eight weeks effective 09/24/2025. Review of Patient #15’s record revealed, in part:The only hospice aide visits completed the week of 10/12/2025 through 10/18/2025 were completed on 10/15/2025 and 10/17/2025; and,The only hospice aide visits completed the week of 10/19/2025 through 10/25/2025 were completed on 10/20/2025 and 10/24/2025. In an interview on 11/06/2025 at 2:59PM, S2DON indicated the agency did not ensure Patient #15 received hospice aide services per the plan of care as required. Patient #17 Review of Patient #17’s Plan of Care for the certification period of 05/28/2025 through 06/29/2025 revealed, in part, Patient #17 was to receive hospice aide services twice a week effective 06/01/2025. Review of Patient #17’s record revealed the only documented evidence of a hospice aide visit was completed during the period of 05/28/2025 through 06/29/2025 was the hospice aide visit completed on 06/10/2025. In an interview on 11/04/2025 at 1:48PM, S2DON indicated Patient #17 indicated she had nothing to present to dispute the above mentioned deficient practice and verified that Patient #17 did not receive services per the POC. In an interview on 11/06/2025 at 2:34PM, S2DON indicated the agency had an issue with the hospice aide not completing home visits and not notifying the office. In an interview on 11/06/2025 at 2:35PM, S1Administrator indicated the agency was aware of an issue with a hospice aide not completing the home visits per the patients’ plans of care, and the above mentioned patients did not receive services per their POC as required.”

“Based on interviews and record reviews, the agency failed to ensure patient’s wounds were measured weekly to assess for healing status for 3 (Patient #9, Patient #12, Patient #18) of 4 (Patient #9, Patient #10, Patient #12, Patient #18) sampled patients with identified wounds reviewed for weekly wound care measurements. Findings: Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Further review revealed, in part, comprehensive wound assessment included dimensions and depth, presence, location and depth of any sinus tracts or undermining areas, status and characteristics of the wound bed, volume, color, and odor of exudates, and evidence of infection in surrounding tissues. Further review revealed when recorded over time, this information can be used to track the progress of wound healing. Review of the agency’s undated Wound Care Protocol revealed, in part, the agency would require weekly wound care measurements by the registered nurse. On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Patient #9Review of Patient #9’s physician order dated 10/03/2025 revealed, in part, right medial great toe (the part of the right large toe which faces the other foot) wound clean with betadine and leave open to air. Review of Patient #9’s record for the period of 10/03/2025 through 11/05/2025 revealed Patient #9’s right great toe wound was not measured the weeks of 10/10/2025, the week of 10/17/2025, and the week of 10/24/2025. In an interview on 11/06/2025 at 2:55PM, S2DON indicated Patient #9’s right great toe wound was not measured weekly as required. Patient #12Review of Patient #12’s nurse’s note dated 09/02/2025 revealed, in part, Patient #12 had a right heel blister to the right heel which opened last night. Further review revealed Patient #12’s wound to the right hell was not measured on 09/02/2025. Review of Patient #12’s nurse’s note dated 09/09/2025 revealed, in part, Patient #12 had a right heel blister which was now scabbed. Review of Patient #12’s record revealed no documented evidence of any wound care measurements for Patient #12’s right heel wound until 11/04/2025. In an interview on 11/06/2025 at 2:56PM, S2DON indicated Patient #12’s right heel wound was not measured from 09/02/2025 through 11/04/2025. Patient #18Review of Patient #18’s record revealed Patient #18 had an abdominal surgical wound on 10/22/2024. Review of Patient #18’s record for the period of 10/21/2024 through 11/06/2024 revealed Patient #18’s above mentioned wound was not measured since 10/26/2025. In an interview on 11/06/2025 at 3:02PM, S2DON indicated Patient #18’s abdominal surgical wound was not measured weekly as required.”

“Based on interviews and record reviews, the agency failed to conduct a spiritual assessment for 2 (Patient #1, Patient #3) of 20 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19, Patient #20) sampled patients reviewed for spiritual counseling requirements. Findings: On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Patient #1Review of Patient #1’s Plan of Care revealed a start of care date of 05/31/2025. Review of Patient #1’s record revealed a spiritual assessment was not completed on Patient #1 since Patient #1’s start of care. In an interview on 11/06/2025 at 2:43PM, S2DON indicated he had nothing to present to show that a spiritual assessment was completed on Patient #1. Patient #3Review of Patient #3’s Plan of Care revealed a start of care date of 06/18/2025. Review of Patient #3’s record revealed a spiritual assessment was not completed on Patient #3 since Patient #3’s start of care. In an interview on 11/06/2025 at 2:43PM, S2DON indicated he had nothing to present to show that a spiritual assessment was completed on Patient #3.”

“Based on interview and record reviews, the agency failed to ensure a registered nurse made an on-site visit to the patient’s home at least every 14 days to assess the quality of care and services provided by the hospice aide for 1 (Patient #8) of 12 (Patient #1, Patient #2, Patient #3, Patient #5, Patient #8, Patient #9, Patient #11, Patient #12, Patient #14, Patient #15, Patient #17, Patient #20) sampled patients receiving hospice aide services reviewed for supervisory visits. Findings: On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Review of the agency’s undated Supervision policy revealed, in part, a registered nurse was to ensure all hospice aide services were supervised every 14 days. Review of Patient #8’s Plan of Care for the certification period of 10/07/2025 through 01/04/2025 revealed Patient #8 was to receive hospice aide services. Review of Patient #8’s record revealed Patient #8 received hospice aide services on 10/10/2025, 10/13/2025, 10/24/2025, 10/28/2025, and 10/30/2025. Further review revealed a hospice aide supervisory visit was not completed by a registered nurse for the time period of 10/07/2025 through 10/30/2025. In an interview on 11/06/2025 at 2:52PM, S2Director of Nursing (DON) indicated the agency failed to ensure the registered nurse completed a hospice aid supervisory visit every 14 days as required.”

“Based on interviews and record reviews, the agency failed to:1. Document signs and symptoms of infection on a patient’s assessment (Patient #4); and, 2. Accurately document the services a patient received (Patient #7).This deficient practice was identified for 2 (Patient #4, Patient #7) of 20 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19, Patient #20) sampled patients reviewed for documentation requirements. Findings: On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) was presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Review of the agency’s Clinical Record Review policy, revised on 10/2015, revealed, in part, clinical records were to be reviewed for completeness and accuracy. Patient #4Review of Patient #4’s physician order dated 09/04/2025 revealed Patient #4 was prescribed Keflex (antibiotic a medication used to treat infections) for a toe infection. Review of Patient #4’s record revealed no documented evidence of an assessment of Patient #4’s toe had been documented, nor any documented evidence of an assessment of Patient #4’s response to the infection. In an interview on 11/06/2025 at 2:43PM, S2DON indicated Patient #4’s record did not include the required documentation related to Patient #4’s toe infection assessment. Patient #7Review of Patient #7’s Plan of Care for the certification period of 07/29/2025 through 10/26/2025 revealed no documented evidence hospice aide services were ordered for Patient #7. Review of Patient #7’s record for the certification period of 07/29/2025 through 10/26/2025 revealed no documented evidence hospice aide services had been provided to Patient #7. Review of Patient #7’s skilled nursing notes dated 09/15/2025, 09/21/2025, and 09/25/2025 revealed the skilled nurse had completed hospice aide supervisory visits. In an interview on 11/06/2025 at 2:50PM. S2DON indicated the above mentioned hospice aide supervisory visits were inaccurate because Patient #7 had not received hospice aide services.”