Every finding on record at Alpowa Healthcare, Inc.

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 Part 484 for Home Health Services conducted this health and safety survey. Examination number: X2025-325 Dates Onsite: 04/08/25 - 04/10/25 This survey was conducted by: Surveyor #3 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard- level deficiencies listed below.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0102 that requires obtaining a physician order for a Start of Care (SOC) date for 10 of 13 patients (Patients #301, #304, #305, #306, #307, #308, #309, #310, #311, and #313). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. 1. Patient record review for 10 of 13 records showed the following: a. Patient #301 was admitted on 01/29/25 with the primary diagnosis of Type 2 Diabetes Mellitus with foot ulcer. The referral was accepted on 01/27/25 for a Skilled Nursing (SN) initial assessment. Documentation showed the M0102 date of 01/29/25 entered on the Start of Care (SOC) OASIS. There is no documentation to show that a physician’s order was obtained for the SOC date. Documentation showed an audit trail that indicated that the M0102 data was changed to “No” but there was no evidence that the M0102 date was deleted and M0104 (Referral Date) date was entered. The record should have had a M0104 date of 01/27/25 as the patient’s admission to services was timely, within 48 hours of accepting the referral. b. Patient #304 was admitted on 03/10/25 with a primary diagnosis of paroxysmal atrial fibrillation. The referral was accepted on 02/28/25 for an SN initial assessment and Occupational Therapy (OT) evaluation. Documentation showed the M0102 of 03/10/25 entered on the SOC OASIS. There is no documentation to show that a physician’s order was obtained for the SOC date. c. Patient #305 was admitted on 03/26/25 with a primary diagnosis of other chronic pain, primary generalized osteoarthritis. The referral was accepted on 03/18/25 for Physical Therapy (PT) initial assessment. The documentation showed that the agency received a physician’s order to delay the SOC until 03/24/25. Documentation showed the M0102 date of 03/26/25 entered on the SOC OASIS. There is no documentation to show that an updated physician’s order was obtained for the SOC date. d. Patient #306 was admitted on 02/28/25 with a primary diagnosis of cellulitis of the left toe. The referral was accepted on 02/21/25 for an SN initial assessment, PT evaluation and OT evaluation. Documentation showed the M0102 date of 02/28/25 entered on the SOC OASIS. There is no documentation to show that a physician’s order was obtained for the SOC date. e. Patient #307 was admitted on 02/26/25 with a primary diagnosis of displ. mid-cervical fracture of the left femur. The referral was accepted on 02/21/25 for PT initial assessment, OT evaluation and Home Health Aide (HHA) services. Documentation showed the M0102 date of 02/26/25 entered on the SOC OASIS. There is no documentation to show that a physician’s order was obtained for the SOC date. f. Patient #308 was admitted on 03/01/25 with a primary diagnosis of Type 2 Diabetes Mellitus with other specified complication. The referral was accepted on 02/28/25 for an SN initial assessment, PT evaluation, OT evaluation and MSW assessment. Documentation showed the M0102 date of 03/01/25 entered on the SOC OASIS. There is no documentation to show that a physician’s order was obtained for the SOC date. Documentation showed an audit trail that indicated that the M0102 data was changed to “No” but there was no evidence that the M0102 date was deleted and M0104 date was entered. The record should have had a M0104 date of 02/28/25 as the patient’s admission to services was timely, within 48 hours of accepting the referral. g. Patient #309 was admitted on 12/26/24 with a primary diagnosis of aftercare following surgery for neoplasm. The referral was accepted on 12/24/24 for an SN initial assessment. Documentation showed the M0102 date of 12/26/24 entered on the SOC OASIS. There is no documentation to show that a physician’s order was obtained for the SOC date. Documentation showed an audit trail that indicated that the M0102 data was changed to “no” but there was no evidence that the M0102 date was deleted and M0104 date was entered. The record should have had a M0104 date of 12/24/24 as the patient’s admission to services was timely, within 48 hours of accepting the referral. h. Patient #310 was admitted on 07/11/24 with a primary diagnosis of pressure ulcer of sacral region stage 4. The referral was accepted on 07/09/24 for an SN initial assessment and PT evaluation. Documentation showed the M0102 date of 07/11/24 entered on the SOC OASIS. There is no documentation to show that a physician’s order was obtained for the SOC date. Documentation showed an audit trail that indicated that the M0102 data was changed to “no” but there was no evidence that the M0102 date was deleted and M0104 date was entered. The record should have had a M0104 date of 07/09/24 as the patient’s admission to services was timely, within 48 hours of accepting the referral. i. Patient #311 was admitted on 01/08/25 with a primary diagnosis of immune thrombocytopenic purpura. The referral was accepted on 01/02/25 for an SN initial assessment, PT evaluation and OT evaluation. Documentation showed the M0102 date of 01/08/25 entered on the SOC OASIS. There is no documentation to show that a physician’s order was obtained for the SOC date. Documentation showed an audit trail that indicated that the M0102 data was changed to “No” but there was no evidence that the M0102 date was deleted and M0104 date was entered. j. Patient #313 was admitted on 07/22/24 with a primary diagnosis of gastroparesis. The referral was accepted on 07/22/24 for an SN initial assessment, PT evaluation, OT evaluation, MSW assessment and HHA services. Documentation showed the M0102 date of 07/22/24 entered on the SOC OASIS. Documentation also showed an audit trail that indicated that M0102 was changed to M0104 with the date 07/19/24 entered. The record showed that the agency accepted the referral on 07/22/24 not 07/19/24 therefore the M0104 date is incorrect. 2. On 04/10/25 at 9:30 AM, the Surveyor interviewed the agency’s Director of Clinical Services for Home Health (Staff #302) about the agency’s documentation of M0102 and M0104 on the SOC OASIS. Staff #302 stated that the agency utilizes staff as “OASIS scrubbers” to review the SOC OASIS data completed by clinicians before the OASIS is locked and submitted. One area the “scrubbers” review is the use of M0102 and M0104. In reviewing the patient records listed above, Staff #302 identified that an agency “scrubber” is not removing the M0102 date but is changing the M0102 response to “No” and not adding the M0104 date if appropriate. During the survey Staff #302 escalated the finding for more research as to why the OASIS can be submitted and locked with an incomplete answer to M0102 and no date in M0104 if appropriate. Staff #302 stated that education will be provided to the “scrubbers” to ensure consistent and accurate entry of M0102 and M0104.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral for 4 of 13 patients (Patients #304, #306, #307, and #311). Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Record review of the agency’s undated policy titled, “Intake Process,” showed that the scheduler will assign personnel and schedule an initial assessment visit. The initial assessment visit will be performed either within 48 hours of the completed referral, or within 48 hours of the patient’s return home, or on the start of care date ordered by the physician. 2. Patient record review for 4 of 13 records showed the following: a. Patient #304 was admitted on 03/10/25 with a primary diagnosis of paroxysmal atrial fibrillation. The referral was accepted on 02/28/25 for an SN initial assessment and Occupational Therapy (OT) evaluation, and the SOC for SN services did not occur until 03/10/25. There was no documentation that the agency notified the physician of the delay and received a physician’s order for the delayed SOC. b. Patient #306 was admitted on 02/28/25 with a primary diagnosis of cellulitis of the left toe. The referral was accepted on 02/21/25 for an SN initial assessment, PT evaluation and OT evaluation, and the SOC for SN services did not occur until 02/28/25. There was no documentation that the agency notified the physician of the delay and received a physician’s order for the delayed SOC. c. Patient #307 was admitted on 02/26/25 with a primary diagnosis of displ. mid-cervical fracture of the left femur. The referral was accepted on 02/21/25 for PT initial assessment, OT evaluation and Home Health Aide (HHA) services, and the SOC for PT services did not occur until 02/26/25. There was no documentation that the agency notified the physician of the delay and received a physician’s order for the delayed SOC. d. Patient #311 was admitted on 01/08/25 with a primary diagnosis of immune thrombocytopenic purpura. The referral was accepted on 01/02/25 for an SN initial assessment, PT evaluation and OT evaluation, and the SOC for SN services did not occur until 01/08/25. There was no documentation that the agency notified the physician of the delay and received a physician’s order for the delayed SOC. 3. On 04/10/25 at 9:45 AM, the Surveyor interviewed the Director of Clinical Services for Home Health (Staff #302) about the timely initiation of care. Staff #302 stated that they have had staff turnover in the position responsible for ensuring timely initiation of care. The new staff member responsible is utilizing a “smart sheet” to describe when to notify the referral source and physician. Staff #302 also stated that education has been provided to staff and timely initiation of care was a previous Performance Improvement Project (PIP) for the agency.