Saint Lukes Hospice of Leavenworth, LLC

“Based on review of the Emergency Preparedness Program (EPP) and interview the Hospice failed to review and update the emergency preparedness plan (EPP) at least every 2 years. Failure to review and update the EPP at least every 2 years places patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP failed to show the plan was reviewed and updated every 2 years, the last documented revision was October 2021. During an interview on 01/10/24 between at 9:00 AM and 2:30 PM, the Safety Administrator stated that the last documented revision of the EPP was November 2021, even though the EPP showed October 2021, and that the EPP was currently in the review and revision process at their facility now.”

“Based on review of the Emergency Preparedness Program (EPP) and interview the Hospice failed to develop and maintain an emergency preparedness plan (EPP) that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP failed to show an emergency preparedness plan (EPP) that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan. During an interview on 01/10/24 between at 9:00 AM and 2:30 PM, the Safety Administrator confirmed the Patient Population was not addressed within the Emergency Preparedness Program.”

“Based on review of the Emergency Preparedness Program (EPP) and interview the Hospice failed to develop and maintain an emergency preparedness plan (EPP) that includes a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP failed to show a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. During an interview on 01/10/24 between at 9:00 AM and 2:30 PM, the Safety Administrator confirmed that there was no process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster for the Emergency Preparedness Program.”

“Based on review of the Emergency Preparedness Program (EPP) and interview the Hospice failed to develop a procedure to follow up with on duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The hospice must inform State and local officials of any on-duty staff or patients that they are unable to contact. Failure to develop a procedure to follow up with on duty staff and patients has the potential to place staff an patients at risk for harm in an emergency situation. Findings Include: Review of the EPP failed to show an emergency preparedness plan (EPP) that procedure to follow up with on duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. During an interview on 01/10/24 between at 9:00 AM and 2:30 PM, the Safety Administrator confirmed that there were no procedures to follow up with on duty staff and patients to determine services, but that there were no timeframes of when follow-ups will occur. There were also no distinct differences in response between triaging levels of patients in the event that there is an interruption in services during or due to an emergency for the Emergency Preparedness Program.”

“Based on review of the Emergency Preparedness Program (EPP) and interview the Hospice failed to develop a procedure to inform State and local emergency preparedness officials about homebound hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. Failure to develop a procedure to inform State and local emergency preparedness officials about homebound hospice patients places them at risk for harm during an emergency. Findings Include: Review of the EPP failed to show a communication plan which addressed the procedures to inform State and local emergency preparedness officials about homebound hospice patients in need of evacuation from their residences at any time due to an emergency situation. During an interview on 01/10/24 between at 9:00 AM and 2:30 PM, the Safety Administrator confirmed there was no communication plan which addressed the procedures to inform State and local emergency preparedness officials about homebound hospice patients in need of evacuation from their residences.”

“Based on review of the Emergency Preparedness Program (EPP) and interview the Hospice failed to develop and implement policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. The failure to develop and implement policies and procedures for a system of medical documentation places patients at risk for the loss of continuity of care and violation of their privacy rights. Findings Include: Review of the EPP failed to include policies and procedure for a system of medical documentation during an emergency. During an interview on 01/10/24 between at 9:00 AM and 2:30 PM, the Safety Administrator confirmed there were no EPP policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.”

“Based on interview and record review, it was determined the hospice agency failed to ensure the completion of supervisory visits for 4 (Patient 2,11,15, & 16) of 8 patients receiving hospice aide services. This failure has the potential for patients to not receive the appropriate services and delay the patient’s progress toward meeting established goals. Findings Include: Patient 2 Review of Patient 2’s Plan of Care (POC) for the certification period dated 11/24/23 to 01/22/24, showed there was an order for hospice aide services for assistance with personal care one time per week for nine weeks. Review of Skilled Nurse note dated 12/06/23 indicated the RN made a supervisory visit. The next required aide supervisory visit would then be due on or before 12/20/23 however, the next documented aide supervisory visit was on 12/22/23, which was two days late. Patient 11 Review of Patient 11’s Plan of Care (POC) for the certification period dated 11/10/23 to 02/07/24, showed there was an order for hospice aide services for assistance with personal care two times per week for 11 weeks. Review of Skilled Nurse note dated 12/26/23 indicated the RN made a supervisory visit. The next required aide supervisory visit would then be due on or before 01/09/24 however, as of survey date of 01/11/24 there was no supervisory visit documented as being made. Patient 15 Review of Patient 15’s Plan of Care (POC) for the certification period dated 10/07/23 to 12/06/23, showed there was an order for hospice aide services for assistance with personal care one time per week for 9 weeks. Review of Skilled Nurse note dated 11/14/23 indicated the RN made a supervisory visit. The next required aide supervisory visit would then be due on or before 11/28/23 however, there was no documentation of the supervisory visit being made. Patient 16 Review of Patient 16’s Plan of Care (POC) for the certification period dated 10/18/23-01/15/24, showed there was an order for hospice aide services for assistance with personal care one time per week for 9 weeks. Review of Skilled Nurse not dated 10/25/23 indicated the RN made a supervisory visit. The next required aide supervisory visit would then be due on or before 11/08/23 however, the next documented supervisory visit was made on 11/10/23 which was 2 days late. During an interview on 01/10/24 at 3:55 PM, the Administrator confirmed the above findings of missed or late aide supervisory visits.”