Every finding on record at Good Shepherd Hospice

Based on document review, and policy review the Hospice failed to develop policies and procedures based on all hazards identified in the risk analysis from the perspective of continuation of care for patients. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. --- Findings Include: Review of the Emergency Preparedness Plan (EPP) on 01/11/24 between 12:00 PM and 6:00 PM, revealed that the hospice failed to develop policies and procedures based on all hazards identified in the risk analysis from the perspective of continuation of care for patients. Review of the policy titled, "Disasters - Emergency Preparedness Plan" on 01/11/24 between 12:00 PM and 6:00 PM, revealed that the sub sections under "Procedure" does not contain a procedure for all hazards identified in the hazard risk analysis. Review of the policy titled, "Disasters - Emergency Preparedness Plan" on 01/11/24 between 12:00 PM and 6:00 PM, revealed that some sub sections under "Procedure" are designed for staff response in the event of the hazard or emergency effecting the office building and are not designed to address or provide a procedure for continuation of care if that emergency or hazard affected their patient population. This Hospice serves both home bound hospice patients and facility bound hospice patients. Failure to provide emergency preparedness policies and procedures may result the facility being under prepared in the event of an emergency. Additionally, this failure may result in a lack of training and preparedness in staff, as well as a delay in response and continued care in an emergency or disaster.

Based on interview and review of the Emergency Preparedness Plan (EPP), the Hospice failed to conduct or participate in exercises to test the Emergency Preparedness Plan (EPP). This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. --- Findings Include: Review of the Emergency Preparedness Plan (EPP) on 01/11/24 between 12:00 PM and 6:00 PM, revealed that the facility had not participated in a full-scale community-based exercise. It was also found that the facility did not conduct a full-scale facility-based exercise of their EPP, nor a Tabletop exercise of their EPP, or a Mock Drill of their EPP at any time prior to 01/09/24 when they activated the EPP due to a winter weather event. The facility had included in their EPP under testing/training that they had conducted in-office fire drills and tornado drills for office staff. These drills were not relevant to patient population or the EPP. It was also revealed that the facility had not had any actual events triggering the activation of the EPP in the previous years. During an interview on 01/11/24 between 4:30 PM and 6:00 PM, the Executive Director and the Compliance Officer, stated that there was no full-scale community-based emergency preparedness exercise due to the COVID-19 Public Health Emergency (PHE). It was also stated that there was no full-scale facility-based emergency preparedness exercise due to the COVID-19 Public Health Emergency (PHE). It was asked if they have had any actual events in previous years that triggered the activation of their EPP. The response was no, thankfully we havent had to activate the EPP in the past years. The only actual event that was documented was dated 01/09/24 for a Winter Weather Event.