Luther Manor Hospice

“Based on record review and interview, this agency failed to ensure there is a comprehensive Emergency Preparedness Program, in 1 of 1 Emergency Programs reviewed. Findings include: On 03/19/2024 Administrator A presented a binder titled “Emergency Preparedness” not dated, revealed in part, the agency is an integrated healthcare system of Luther Manor. This was confirmed in interview with Hospice Administrator A on 03/19/2024 at 10:59 AM, “;All the patients are within the campus and we do not have a Hospice specific plan.” Interview with Administrator A on 03/19/2024 at 10:59 AM. Administrator A was asked if this Hospice had an emergency preparedness plan Administrator A stated, “There is no hospice Emergency Preparedness program, there is a plan going forward.” The cumulative effect of these systemic problems resulted in the Hospice Agencys ability to effectively develop or implement an emergency preparedness policy and procedures utilizing an all-hazards risk assessment, emergency preparedness communication plan, emergency preparedness training and testing program, and updated every 2 years. On 03/19/2024 Administrator A presented a binder titled “Emergency Preparedness” not dated, which revealed the agency was part of an integrated healthcare system. This was confirmed in an interview with Administrator A on 03/19/2024 at 10:59 AM, “;All the patients are within the campus and we do not have a Hospice specific plan; We are part of the nursing home plans.” The cumulative effect of these systemic problems resulted in the Hospice Agencys ability to effectively develop or implement a hospice emergency preparedness policy and procedures utilizing an all-hazards risk assessment, emergency preparedness communication plan, emergency preparedness training and testing program, and updated every 2 years. This agency failed to establish an Emergency Preparedness program that is reviewed and updated every two years. See tag E-0004. This agency failed to document a risk assessment using all hazards approach. See tag E-006 This agency failed to ensure the communication plan is reviewed every two years. See tag E-0029. This agency failed to coordinate the development of a hospice specific Emergency plan within the Integrated Healthcare system. See tag E-0042. The cumulative effect of these systemic problems resulted in the clinic’s inability to effectively develop or implement an emergency preparedness policy and procedures utilizing an all-hazards risk assessment, emergency preparedness communication plan, hospice specific plan within the Integrated Healthcare system, that is reviewed and updated every 2 years.”

“Based on interview and record review this agency failed to document an Emergency Plan risk assessment that is reviewed and updated every two years in 1 of 1 Emergency Preparedness Programs reviewed. Findings Include: Review of the binder titled “Emergency Preparedness” not dated, which revealed the agency was part of an integrated healthcare system, failed to contain the required documents supporting the hospice agency’s participation, development, and review of the plan every two years. This was confirmed in an interview with Administrator A on 03/19/2024 at 10:59 AM, “;All the patients are within the campus and we do not have a Hospice specific plan; We are part of the nursing home plans.””

“Based on interview and record review this agency failed to document an Emergency Plan risk assessment using an all-hazards approach, and is reviewed and updated every two years in 1 of 1 Emergency Preparedness Programs reviewed. Findings Include: Review of the binder titled “Emergency Preparedness” not dated, which revealed the agency was part of an integrated healthcare system, failed to contain a risk assessment, using an all hazards approach. This was confirmed in an interview with Administrator A on 03/19/2024 at 10:59 AM, “;All the hospice patients are within the campus and we do not have a Hospice specific plan; The emergency plan was developed by the nursing home.””

“Based on record review and interview this agency failed to ensure there is a written communication plan in 1 of 1 Emergency Preparedness programs reviewed. Findings Include: Review of the binder titled “Emergency Preparedness” not dated, which revealed the agency was part of an integrated healthcare system, failed to contain a collaborative communication plan that included contact information of hospice staff and emergency official contacts. This was confirmed in an interview with Administrator A on 03/19/2024 at 10:59 AM, “;All the hospice patients are within the campus and we do not have a Hospice specific plan; The emergency plan was developed by the nursing home.””

“Based on record review and interview the agency failed to demonstrate how it was actively involved in the development and maintenance of the unified and integrated emergency preparedness (EP) program, in 1 of 1 EP program reviewed. Findings Include: Review of the binder titled “Emergency Preparedness” not dated, which revealed the agency was part of an integrated healthcare system, did not show evidence of the hospice agency’s unique circumstances, patient population and services offered in the event of an emergency. This was confirmed in an interview with Administrator A on 03/19/2024 at 10:59 AM, “;All the hospice patients are within the campus and we do not have a Hospice specific plan; The emergency plan was developed by the nursing home.””

“Based on record review and interview, administration failed to employ a MSW (Masters in Social Work) supervisor to oversee, advise, and consult with staff social worker I in meeting the hospice needs of patients and families, in 1 of 1 Hospice program reviewed. Findings Include: Review of the agency’s position description titled “Hospice Social Worker,” dated 11/14/2023, revealed in part “Requirements: Wisconsin Social Work Certification and License, including a Master’s degree in social work or human services related field.” Record review of personnel record for Social Worker I, date of hire 04/11/2022, revealed a completed certification in social work and trained under the supervision of a Master’s prepared social worker. Review of additional documentation revealed, Social Worker I has actively participated in all Core activities, expected essential job functions and ongoing orientations. There was no evidence SW (Social Worker I) held a Master’s degree in social work or related field. During an interview with Administrator A on 03/19/2024 at 11:15 AM, when asked when the previous qualified social worker left, Administrator A replied, “early 2023.” Administrator A stated, “I wasn’t aware Social Worker I did not meet the qualifications and required credentialing for a hospice social worker.””

“Based on record review, observation and interview, the agency staff failed to clean and disinfect reusable medical equipment after each patient use per agency policy in 2 of 3 home visits observed (Patient #1 and Patient #2). Findings Include: Date of Discovery: Patient #2 - 03/18/2024 Patient #1- 03/19/2024 Date of Violation: Patient #2 - 03/18/2024 Patient #1- 03/19/2024 Facility policy entitled, “Cleaning and Disinfection of Resident-Care Equipment” (revised 10/23) revealed in part: “3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident.” During an observation on a home visit for Patient #2 on 03/18/2024 at 11:30 AM with RN C, RN C did not clean and disinfect the following reusable equipment after using them on Patient #2 and prior to placing them back inside the medical supply bag: stethoscope, pulse oximeter, temporal thermometer, and blood pressure cuff. During an interview with RN C, when asked when C would clean and disinfect her reusable equipment, RN C stated, “I clean all my equipment at the end of the day. Unless they are noticeably soiled, I would then clean that right away.” When asked how RN C would clean and disinfect the equipment RN C stated that she would use a bleach wipe and wipe all of the equipment down using agency provided supplies. During an observation on a home visit for Patient #1 on 03/19/2024 at 10:53 AM with RN F, RN F did not clean and disinfect the following reusable equipment after using the equipment on Patient #1 and prior to placing them back inside the medical supply bag: stethoscope, pulse oximeter, temporal thermometer, and blood pressure cuff. During an interview with RN F, when asked about the cleaning and disinfecting of the reusable equipment, RN F stated, “I go downstairs to the office and wipe off all of my equipment after my visit with wipes.” RN F stated that after the reusable medical equipment is used the equipment is placed back into the cloth medical supply bag and taken downstairs to the hospice office and wiped down with bleach wipes before putting the equipment back into the cloth medical supply bag without the medical supply bag being cleaned or disinfected. RN F confirmed there was a potential for cross-contamination within the medical supply bag when the reusable equipment is not cleaned and disinfected immediately after each use and placed back into the same cloth medical supply bag. During an interview with Administrator A on 03/18/2024 at 2:45 PM, Administrator A was asked what the expectations were for cleaning and disinfecting reusable equipment. Administrator A stated “I would expect that our policy would be followed. We have the wipes and they should use the wipes on their reusable equipment after each patient not at the end of the day.” Administrator A confirmed RN C did not follow their “Cleaning and Resident Care Equipment” policy. During an interview with Administrator A on 03/19/2024 at 3:50 PM, Administrator A confirmed RN C and RN F did not follow the general guidelines or agency policy regarding proper cleaning and disinfecting of reusable medical equipment. Findings Include: Facility policy entitled, “Cleaning and Disinfection of Resident-Care Equipment” (revised 10/23) revealed in part: “3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident.” During an observation on a home visit for Patient #2 on 03/18/2024 at 11:30 AM with RN C, RN C did not clean and disinfect the following reusable equipment after using them on Patient #2 and prior to placing them back inside the medical supply bag: stethoscope, pulse oximeter, temporal thermometer, and blood pressure cuff. During an interview with RN C, when asked when C would clean and disinfect her reusable equipment, RN C stated, “I clean all my equipment at the end of the day. Unless they are noticeably soiled, I would then clean that right away.” When asked how RN C would clean and disinfect the equipment RN C stated that she would use a bleach wipe and wipe all of the equipment down using agency provided supplies. During an observation on a home visit for Patient #1 on 03/19/2024 at 10:53 AM with RN F, RN F did not clean and disinfect the following reusable equipment after using the equipment on Patient #1 and prior to placing them back inside the medical supply bag: stethoscope, pulse oximeter, temporal thermometer, and blood pressure cuff. During an interview with RN F, when asked about the cleaning and disinfecting of the reusable equipment, RN F stated, “I go downstairs to the office and wipe off all of my equipment after my visit with wipes.” RN F stated that after the reusable medical equipment is used the equipment is placed back into the cloth medical supply bag and taken downstairs to the hospice office and wiped down with bleach wipes before putting the equipment back into the cloth medical supply bag without the medical supply bag being cleaned or disinfected. RN F confirmed there was a potential for cross-contamination within the medical supply bag when the reusable equipment is not cleaned and disinfected immediately after each use and placed back into the same cloth medical supply bag. During an interview with Administrator A on 03/18/2024 at 2:45 PM, Administrator A was asked what the expectations were for cleaning and disinfecting reusable equipment. Administrator A stated “I would expect that our policy would be followed. We have the wipes and they should use the wipes on their reusable equipment after each patient not at the end of the day.” Administrator A confirmed RN C did not follow their “Cleaning and Resident Care Equipment” policy. During an interview with Administrator A on 03/19/2024 at 3:50 PM, Administrator A confirmed, RN F did not follow the general guidelines or agency policy regarding proper cleaning and disinfecting of reusable medical equipment.”