Every finding on record at Amedisys Home Health

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 conducted this health and safety survey. Examination number: 22FCA1-H1 Onsite Dates: 05/04/26, 05/05/26, & 05/06/26 Offsite Date: 05/07/26 This survey was conducted by: Surveyor #1 DOH staff found the facility NOT IN COMPLIANCE with the following Conditions of Participation: 42 CFR 484.40 Release of Patient Identifiable OASIS Information. 42 CFR 484.55 Conditions of Participation for Comprehensive Assessment for Patients. Condition-level findings will require a revisit. .

Release of patient identifiable OASIS info. CFR(s): 484.40 Condition of participation: Release of patient identifiable OASIS information. The HHA and agent acting on behalf of the HHA in accordance with a written contract must ensure the confidentiality of all patient identifiable information contained in the clinical record, including OASIS data, and may not release patient identifiable OASIS information to the public. This CONDITION is not met as evidenced by: . Based on document review, record review and interview, the agency failed to accurately completed the Outcome and Assessment Information Set (OASIS) data for M0102 and M014 (repeated non-compliance from previous survey). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Findings Included: 1. Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner for 2 of 10 patients. 2. Repeated non-compliance identified in recertification survey conducted on 08/31/23. The agency was previously cited under Tag G0374, Accuracy of encoded OASIS data, 42.CFR 484.45 (b), Failure to accurately complete the OASIS data. Based on the scope and severity of deficiencies identified under 42 CFR 484.40 Condition of Participation: Release of patient identifiable OASIS information is NOT MET. Cross Reference: G0374 .

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 document review, record reviews, and interviews, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) datas for M0102 and M0104 for 3 of 10 patients (Patient #101, Patient #106, and Patient #109). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. . Findings included: 1. Document review of agency’s policy titled, “Oasis Outcome and Information Set,” (Last Review Date: 06/09/25) showed that as part of the condition of participation reporting OASIS in accordance with §484.55 encoded Oasis data must accurately reflect the patient's status at the time of assessment. 2. Record review of patient’s records for Patient #101, Patient #106, and Patient #109 showed: a. Patient #101 was admitted on 09/18/24 with the primary diagnosis of Left Knee Infection. Documentation showed the OASIS M0102 Start of Care (SOC) date of 09/18/24 rather than the accurate data of M0104 and the date of 09/10/24. In addition, documentation in the Intake Care Coordination note showed referral date of 09/10/24, and that there was no documentation of a physician order’s for M0102. b. Patient #106 was admitted on 03/17/26 with the primary diagnosis of Dementia. Documentation showed the OASIS M0102 SOC date of 03/17/26 rather than the accurate data of M0104 and the date of 03/16/26. In addition, documentation in the Intake Care Coordination note showed referral date of 03/16/26, and that there was no documentation of a physician order’s for M0102. c. Patient #109 was admitted on 12/28/24 with a primary diagnosis of Right Lower Extremity Amputation. Documentation showed the OASIS M0102 SOC date of 12/27/24 rather than the accurate data of M0104 and the date of 12/20/24. In addition, documentation in the Intake Care Coordination note showed referral date of 12/22/24, and that there was no documentation of a physician order’s for M0102. 3. On 05/06/26 at 2:00 PM, the Surveyor interviewed the agency’s Area Administrator (Staff #112) about lack of accuracy in OASIS Data entry for M0102 and M0104. Staff #112 acknowledged the OASIS data error findings and stated that the agency reviews the OASIS data for accuracy prior to submission but stated that they were not able to provide documentation as to why the OASIS M0102 and M0104 were inaccurate. This is a REPEAT CITATION, previously cited under Tag G0374 on the last CMS survey completed on 08/31/23. .

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: . Based on document review, record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral (repeated non-compliance from previous survey). Failure to conduct initial assessments within 48 hours of completing the referral puts patients at risk of physical harm due to not receiving services in a timely manner. . Findings Included: 1. Failure to conduct the initial assessment visit within 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 3 of 10 patients. 2. Repeated non-compliance identified in recertification survey conducted on 08/31/23. The agency was previously cited under Tag G0514, Initial Assessment Visit, 42.CFR 484.55(a)(1), for failure to do the initial assessment within forty-eight hours of referral, or forty-eight hours of the patient’s return home, or on the physician-ordered start of care date. Based on the scope and severity of deficiencies identified under 42 CFR 484.55 Condition of Participation: Comprehensive assessment of patients is NOT MET. Cross Reference: G0514 .

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 document review, record reviews, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral for 2 of 10 patients (Patient #101 and Patient #109). Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency's policy titled, "Initial Referral/Admission Process," (Policy AA-002, Last Review date: 06/09/25) indicated that the admitting discipline will perform the admission assessment within 48 hours of both the facility discharge and receipt of referral. 2. Record review of patient’s records for Patient #101 and Patient #109 showed: a. Patient #101’s Start of Care (SOC) date was 09/18/24. The patient was admitted for primary diagnosis of Left Knee Infection. The agency completed the referral on 09/10/24 for the Skilled Nursing (SN) initial assessment, but the SOC for the SN services did not occur until 09/18/24. There was no documentation of why SN services did not occur within 48 hours of the referral, and no documentation that the patient and the patient’s physician was notified of the delayed admission. b. Patient #109’s SOC date was 12/28/24. The patient was admitted for primary diagnosis of Right Lower Extremity Amputation. The agency completed the referral on 12/22/24 for the Physical Therapy (PT) initial assessment, but the SOC for the PT services did not occur until 12/28/24. There was no documentation of why the PT services did not occur within 48 hours of the referral, and no documentation that the patient and the patient’s physician was notified of the delayed admission. 3. On 05/06/26 at 11:00 AM, the Surveyor interviewed the agency’s Office Manager (Staff #111) regarding the lack of documentation that explains why the services did not occur within 48 hours of the referral and the notification of the patient and their physician of the delayed SOC. Staff #111 acknowledged the findings and stated that referrals go through the agency’s centralized intake, but stated that they were not able to provide documentation as to why the services were delayed. This is a REPEAT CITATION, previously cited under Tag G0514 on the last CMS survey completed on 08/31/23.

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR 484, conducted this health and safety survey. Onsite Dates: 08/28/23, 08/29/23, 08/30/23, and 08/31/23 Examination number: X2023-641 The survey was conducted by: Surveyor #1 DOH staff found the agency in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction. .

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: . Based on document review and interview, the agency failed to review and update, at least every 2 years, the Emergency Preparedness (EP) communication plans that comply with Federal, State, and local laws. Failure to update and review the agency’s EP communication plans puts the agency at risk for emergency disasters that would affect the agency’s ability to provide care to patients. Findings included: 1. Document review of the agency’s EP communication plan indicated that the EP plan was last reviewed on 12/2020. There is no documentation of information of staff, services under arrangement, patients, or federal, state, tribal, regional, and other sources of assistance in the agency’s EP communication plans. 2. On 08/29/23 at 2:00 PM, Surveyor #1 interviewed the agency’s Director of Operation (Staff #112) about the EP findings. Staff #112 stated that the agency had not updated or reviewed their EP communication plan since 12/2020. .

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 document review, record review, and interview the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0102 that indicated a physician ordered specific Start of Care (SOC) date for home health services for 12 of 13 patients (Patients #101, #102, #103, #104, #105, #106, #107, #109, #110, #111, #112 and #113). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency’s policy titled, “Oasis Outcome and Information Set,” (Last Review Date: 06/26/23) showed that as part of the condition of participation reporting OASIS in accordance with §484.55 and with accuracy of encoded OASIS data. 2. Record review of patient records for Patients #101, #102, #103, #104, #105, #106, #107, #109, #110, #111, #112 and #113 showed: a. Patient #101 was admitted for primary diagnoses of Failure to thrive, Urinary tract infection (UTI), and History of falls—not a complete list. The patient’s OASIS M0102 data showed a date of 08/02/23, there was no documentation of physician’s orders to indicate the specific SOC date of 08/02/23 for home health services. b. Patient #102 was admitted for primary diagnoses of Status post Colorectal surgery, Cecum cancer, and Anemia—not a complete list. The patient’s OASIS M0102 data showed a date of 08/09/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 08/09/23 for home health services. c. Patient #103 was admitted for primary diagnoses of Cellulitis of lower left extremities, Type 2 Diabetes Mellitus (DM)—not a complete list. The patient’s OASIS M0102 data showed a date of 08/23/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 08/23/23 for home health services. d. Patient #104 was admitted for primary diagnoses of Congested Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and Dysphagia—not a complete list. The patient’s OASIS M0102 data showed a date of 05/31/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 05/31/23 for home health services. e. Patient #105 was admitted for primary diagnoses of Sigmoid volvulus, Cholelithiasis, and Hypertension (HTN)—not a complete list. The patient’s OASIS M0102 data showed a date of 08/15/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 08/15/23 for home health services. f. Patient #106 was admitted for primary diagnoses of COPD, Anemia, and Depression—not a complete list. The patient’s OASIS M0102 data showed a date of 04/08/22, there was no documentation of a physician’s orders to indicate the specific SOC date of 04/08/22 for home health services. g. Patient #107 was admitted for primary diagnoses of Dementia, UTI, and Coronary artery disease—not a complete list. The patient’s OASIS M0102 data showed a date of 06/09/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 06/09/23 for home health services. h. Patient #109 was admitted for primary diagnoses of Respiratory Failure and Chronic lower extremities wounds—not a complete list. The patient’s OASIS M0102 data showed a date of 0810/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 08/10/23 for home health services. i. Patient #110 was admitted for primary diagnoses of CHF and HTN—not a complete list. The patient’s OASIS M0102 data showed a date of 06/05/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 06/05/23 for home health services. j. Patient #111 was admitted for primary diagnoses of Diverticulitis, Hypertension, and History of falls—not a complete list. The patient’s OASIS M0102 data showed a date of 07/26/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 07/26/23 for home health services. k. Patient #112 was admitted for primary diagnoses of COPD, DM, and History of falls—not a complete list. The patient’s OASIS M0102 data showed a date of 06/29/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 06/29/23 for home health services. l. Patient #113 was admitted for primary diagnoses of Subdural hematoma, and Anxiety—not a complete list. The patient’s OASIS M0102 data showed a date of 06/30/23, there was no documentation of a physician’s orders to indicate the specific SOC date of 06/30/23 for home health services. 3. On 08/29/23 at 3:00 PM, Surveyor #1 interviewed the agency’s Director of Clinical Operations (Staff #112) about the inaccurate documentation of the OASIS M0102. Staff #112 acknowledged the findings and stated that the staff are not aware of how to complete the M0102 and needed education on completing the OASIS data.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: . Based on document review, record review, and interview, the agency failed to inform patients of all aspects of their plan of care, including the total frequency of the proposed services and the manner in which the agency will provide those care and services. The agency also failed to review the plan of care with the patient on an ongoing basis as changes to their plan of care occurred for 6 of 13 patient records (Patient #101, #105, #106, #111, #112, and #113). Failure to inform patients and their representatives of the frequencies of the proposed care and services prevent patients from participating in their care. Findings included: 1. Document review of agency’s document titled, “Plan of Care (POC)/Care Planning Process,” (Policy: AA-014, Last Review Date: 05/09/22) showed that the patient has the right to be informed about and consent in advance of and during treatment the care to be furnished, the disciplines that will furnish the care, the frequency of visits, and receive all services outlined in the plan of care. 2. Record review for Patient #101, #105, #106, #111, #112, and #113 showed: a. Patient #101 was admitted on 08/02/23. The consent showed Skilled Nursing (SN) for 2 visits every week for 8 weeks, Physical Therapy (PT) for 1 visit for 1 week, and Occupational Therapy (OT) for 1 visit for 1 week. The PT ordered varying frequencies for 1 visit every week for 2 weeks, then 1 visit every 2 weeks for 2 weeks starting 08/13/23. There was no documentation on the patient’s records to show the agency informed the patient or their representative of the varying frequencies for the ordered PT services. b. Patient #105 was admitted on 08/15/23. The consent showed SN for 1 visits every week for 6 weeks, PT for 2 visits every week for 8 weeks, and OT for 2 visits every week for 4 weeks. The SN ordered varying frequencies for 2 visits every week for 2 weeks then 1 visits every week for 3 weeks, and then 1 visits every 2 weeks for 4 weeks starting 08/20/23. The PT ordered varying frequencies for 2 visits every 2 weeks for 4 weeks starting 08/23/23. There was no documentation on the patient’s records to show the agency informed the patient or their representative of the varying frequencies for the ordered SN and PT services. c. Patient #106 was admitted on 04/08/22. The consent showed SN for 1 visits every week for 3 weeks, and PT for 1 visits every week for 3 weeks. The SN ordered varying frequencies for 2 visits every week for 1 week, then 1 visit every week for 1 week, and then 1 visit every 2 weeks for 2 weeks starting 04/10/22. The PT ordered varying frequencies for 1 visit every week for 4 weeks, then 2 visits every 2 weeks for 4 weeks starting 04/10/22. There was no documentation on the patient’s records to show the agency informed the patient or their representative of the varying frequencies for the ordered SN and PT services. d. Patient #111 was admitted on 07/26/23. The consent showed SN for 3 visits every week for 4 weeks and 2 visits every week for 4 weeks. The SN ordered varying frequencies for 2 visits every week for 1 week, then 1 visit every week for 3 weeks, and then 1 visit every 2 weeks for 4 weeks starting 07/26/23. The PT ordered varying frequencies for 1 visit every week for 4 weeks, then 2 visits every 2 weeks for 4 weeks starting 07/30/26. There was no documentation on the patient’s records to show the agency informed the patient or their representative of the varying frequencies for the ordered SN and PT services. e. Patient #112 was admitted on 06/09/23. The consent showed Start of Care (SOC) for PT. The PT ordered varying frequencies for 1 visit every 2 weeks for 8 weeks starting 08/27/23. There was no documentation on the patient’s records to show the agency informed the patient or their representative of the varying frequencies for the ordered PT services. f. Patient #113 was admitted on 06/30/23. The consent showed SOC for PT. The PT ordered varying frequencies for 1 visit every week for 5 weeks, then 1 visit every 2 weeks for 4 weeks starting 06/30/23. There was no documentation on the patient’s records to show the agency informed the patient or their representative of the varying frequencies for the ordered PT services. 3. On 08/31/23 at 9:30 AM, Surveyor #1 interviewed the agency’s Home Health Director (Staff #112) and the agency’s Area Vice President of Clinical for the West Region (Staff #114) regarding the varying SN and PT frequencies. Staff #112 and Staff #114 acknowledged the findings and stated that admitting clinicians discussed the visit schedule with the patient during their SOC admission. Staff #112 stated that the patient’s plan of care shows the frequencies and is sent to the patients but was not able to provide documentation that the POCs were sent for the records reviewed. In addition, Staff #114 stated that the varying frequencies are listed on the patient’s consents but was unable to provide documentation that the patient’s consent listed the varying frequencies. .

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 document review, record review, and interview, the agency failed to conduct an initial assessment visit within the 48 hours of the referral date for 11 of 13 patients (Patients #101, #103, #104, #105, #106, #108, #109, #110, #111, #112 and #113) Failure to meet this requirement places patients at risk of physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency's policy titled, "Initial Referral/Admission Process," (Policy AA-002, Last Review date: 08/26/2021) indicated that the admitting discipline will perform the admission assessment within 48 hours of both the facility discharge and receipt of referral. 2. Record review for Patients #101, #103, #104, #105, #106, #108, #109, #110, #111, #112 and #113 showed: a. Patient #101’s Start of Care (SOC) date was 08/02/23. The patient was admitted for primary diagnoses of Failure to thrive and Urinary tract infection (UTI). The date of the referral was 07/27/23 for Skilled Nursing (SN) services, Physical Therapy (PT), and Occupational Therapy (OT), but the SOC for the SN initial assessment did not occur until 08/02/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. b. Patient #103’s SOC date was 08/09/23. The patient was admitted for primary diagnoses of Cellulitis of lower left extremities and Type 2 Diabetes Mellitus (DM). The date of the referral was 07/21/23 for SN and PT services, but the SOC for the SN initial assessment did not occur until 08/23/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. c. Patient #104’s SOC date was 05/31/23. The patient was admitted for primary diagnoses of Congestive Heart Failure and Chronic Obstructive Pulmonary Disease (COPD). The date of the referral was 05/24/23 for a SN and PT services, but the SOC for the SN initial assessment did not occur until 05/31/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. d. Patient #105’s SOC date was 08/15/23. The patient was admitted for primary diagnoses of Sigmoid volvulus and Cholelithiasis. The date of the referral was 08/11/23 for SN and PT services, but the SOC for the SN initial assessment did not occur until 08/15/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. e. Patient #106’s SOC date was 04/08/22. The patient was admitted for primary diagnoses of COPD and Anemia. The date of the referral was 03/18/22 for SN and PT services, but the SOC for the SN initial assessment did not occur until 04/08/22. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. f. Patient #108’s SOC date was 07/29/23. The patient was admitted for a primary diagnosis of Parkinson’s disease. The date of the referral was 07/21/23 for PT services, but the SOC for the PT initial assessment did not occur until 07/29/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. g. Patient #109’s SOC date was 08/10/23. The patient was admitted for primary diagnoses of Respiratory Failure and Chronic lower extremities wounds. The date of the referral was 07/09/23 for SN and PT services, but the SOC for the PT initial assessment did not occur until 08/10/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. h. Patient #110’s SOC date was 06/07/23. The patient was admitted for primary diagnoses of Diabetes and Alzheimer’s. The date of the referral was 06/01/23 for PT and OT services, but the SOC for the PT initial assessment did not occur until 06/07/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. i. Patient #111’s SOC date was 07/26/23. The patient was admitted for primary diagnoses of Diverticulitis and Hypertension. The date of the referral was 07/21/23 for SN, PT, and OT services, but the SOC for the SN initial assessment did not occur until 07/26/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. j. Patient #112’s SOC date was 06/29/23. The patient was admitted for primary diagnoses of COPD and DM. The date of the referral was 06/13/23 for PT services, but the SOC for the PT initial assessment did not occur until 06/29/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. k. Patient #113’s SOC date was 06/30/23. The patient was admitted for primary diagnoses of Subdural hematoma, and Anxiety. The date of the referral was 06/19/23 for PT and OT services, but the SOC for the PT initial assessment did not occur until 06/30/23. There was no documentation in the record that explained why the services did not occur within the 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. 3. On 08/29/23 at 3:00 PM, Surveyor #1 interviewed the agency’s Director of Clinical Operations (Staff #112) about the delayed SOC and lack of provider notification. Staff #112 acknowledged the findings and stated that they were unable to provide documentation for each of the record review to explain the delayed SOC. .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: . Based on document review, record review, and interview, the agency failed to timely provide secondary services as ordered by the physician for 9 of 13 patients (Patients #101, #102, #104, #105, #106, #107, #108, #110, and #111). Failure to provide timely services, as ordered by the physician, could place the patient at risk of worsening symptoms of existing diagnoses. Findings included: 1. Document review of agency’s policy titled, “Patient Assessment/Reassessment,” (last reviewed: 03/03/22) showed that completion of the comprehensive assessment must occur in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the Start of Care (SOC). 2. Record review of patient records for Patients #101, #102, #104, #105, #106, #107, #108, #110, and #111 showed: a. Patient #101’s SOC was on 08/02/23. The referral orders dated 07/27/23 was for Skilled Nursing (SN) assessment, a Physical Therapy (PT) evaluation, and an Occupational Therapy (OT) evaluation. The OT evaluation did not occur until 08/24/23. There was no documentation as to why the OT evaluation did not occur timely, and no documentation that the physician was notified of the delayed OT evaluation. b. Patient #102’s SOC was on 08/09/23. The referral orders dated 08/07/23 were for a SN assessment and an OT evaluation. The OT evaluation did not occur until 08/24/23. There was no documentation as to why the OT evaluation did not occur timely, and no documentation that the physician was notified of the delayed OT evaluation. c. Patient #104’s SOC was on 05/31/23. The referral orders dated 05/24/23 were for a PT assessment, an OT evaluation, a Speech Therapy (ST) evaluation, and a Social Worker (SW) evaluation. There was no documentation as to why the OT, ST, and SW evaluations did not occur, and no documentation that the physician was notified of why the evaluations did not occur. d. Patient #105’s SOC was on 08/15/23. The referral orders dated 08/11/23 for a SN assessment, a PT evaluation, and an OT evaluation. The PT evaluation did not occur until 08/23/23. There was no documentation as to why the PT evaluation did not occur timely, and no documentation that the physician was notified of the delayed PT evaluation. In addition, there is no documentation as to why the OT evaluation was not completed, and no documentation that the physician was notified as to why the OT evaluation did not occur. e. Patient #106’s SOC was on 04/08/22. The referral orders dated 03/18/22 for a SN assessment, a PT evaluation, and an OT evaluation. There was no documentation of why the OT evaluation was not completed. There is no documentation that the physician was notified as to why the OT evaluation did not occur. f. Patient #107’s SOC was on 06/09/23. The referral orders dated was 06/08/23 for a PT assessment and an OT evaluation. The OT evaluation did not occur until 06/23/23. There was no documentation as to why the OT evaluation did not occur timely, and no documentation that the physician was notified of the delayed OT evaluation. g. Patient #108’s SOC was on 07/29/23. The referral orders dated 07/21/23 for a PT assessment and an OT evaluation. There was no documentation of why the OT evaluation was not completed. There is no documentation that the physician was notified of why the OT evaluation did not occur. h. Patient #110’s SOC was on 06/07/23. The referral orders dated 06/01/23 for a PT assessment and an OT evaluation. The OT evaluation did not occur until 06/27/23. There was no documentation of why the OT evaluation did not occur timely, and no documentation that the physician was notified of the delayed OT evaluation. i. Patient #111’s SOC was on 07/26/23. The referral orders dated 07/21/23 for a SN assessment, a PT evaluation, and an OT evaluation. The OT evaluation did not occur until 08/03/23. There was no documentation of why the OT evaluation did not occur timely, and no documentation that the physician was notified of the delayed OT evaluation. 3. On 08/29/23 at 3:30 PM, Surveyor #1 interviewed the agency’s Director of Clinical Operations (Staff #112) about the lack of documentation of the delayed or missed secondary services. Staff #112 acknowledged the findings and stated that there were unable to provide any documentation of the delayed or missed secondary services. .

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to follow state requirements to conduct a Tuberculosis (TB) screening using a TB risk assessment form provided or approved by the department for 2 of 3 staff contractors (Staff #109 and #110) . Failure to screen staff for TB places staff and patients at risk from TB exposure. Reference: WAC 246-335-525 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (c) Tuberculosis (TB) infection control program. Key elements include, but are not limited to: (i) Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency's responsibility to conduct TB testing of new employees. Findings included: 1. Document review of the agency’s policy titled, "Infection Prevention Program Overview," (Last Review Date: 05/10/23) showed the agency's Washington state specific TB infection control program conducts a TB risk assessment for all new employee upon hire, and that the agency must use a TB risk assessment form provided by the department. 2. Record review of personnel contractor records for Staff #109 and #110. The review showed: a. Staff #109 was hired on 07/31/23. The record failed to contain a completed department approved initial TB risk assessment. b. Staff #110 was hired on 06/29/23. The record failed to contain a completed department approved initial TB risk assessment. 3. On 08/31/23 at 10:00 AM, Surveyor #1 interviewed the agency’s Office Manager (Staff #113) about the agency's policy and TB screening process on contractors. Staff #113 acknowledged the findings and stated that they are currently working to complete the contractors’ TB risk assessments. .

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to provide job descriptions that contain specific job responsibilities and are consistent with health care professional credentialing and scope of practice as defined in relevant practice acts and rules with state requirements for 3 of 3 contracted staff (Staff#108, #109, and #110). Failure to maintain compliance with state requirements regarding job descriptions put patients at risk of receiving care from un-vetted or unqualified staff. References: Washington Administrative WAC 246-335-525 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (2) Job descriptions that contain responsibilities and are consistent with health care professional credentialing and scope of practice as defined in relevant practice acts and rules. Findings included: 1. Document review of the agency policy titled, "Personnel File Requirements for Agency Staff," (Last Review Date: 08/26/21) showed that personnel files will include a signed job description. In addition, the Washington state specific requirements indicated that the agency will operationalize the personnel, contractor, and volunteer policies to include job descriptions that contain responsibilities and are consistent with health care professional credentialing and scope of practice as defined n relevant practice acts and rules. 2. Record review of personnel contractor records for 3 contracted staff (Staff #108, #109, and #110) showed: a. Staff #108 was hired on 06/19/23 as an Occupational Therapist (OT). The staff record failed to document an OT job description on hire. b. Staff #109 was hired on 09/23/19 as a Registered Nurse (RN). The staff record failed to document an RN job description on hire. c. Staff #110 was hired on 06/29/23 as a Licensed Practical Nurse (LPN). The staff record failed to document an LPN job description on hire. 3. On 08/31/23 at 10:00 AM, Surveyor #1 interviewed the agency’s Office Manager (Staff #113) about the missing job descriptions for the contracted staff. Staff #113 acknowledged the agency must work with the contracted companies to ensure job descriptions are provided to contracted staff and in compliance with the state requirements.

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR 484, conducted this health and safety survey. Onsite dates: 06/01/21 to 06/03/21 Examination number: X2021-436 The survey was conducted by: Surveyor #1 Surveyor #3 DOH staff found the Agency in substantial compliance with all Conditions of Participation except for the standard-level deficiencies listed below. .

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to screen newly hired staff for Tuberculosis (TB) and failed to provide annual TN screening for current staff, consistent with state regulations, for 6 of 6 staff files reviewed (Staff #105, #106, #107, #108, #109, and #110). Failure to screen staff for TB upon hire and annually, places staff and patients at risk from TB exposure. Reference: WAC 246-335-525 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (c) Tuberculosis (TB) infection control program. Key elements include, but are not limited to: (i) Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency's responsibility to conduct TB testing of new employees. If TB testing is required, follow the department's tuberculosis risk assessment form testing recommendations; (ii) Conducting an annual assessment of new TB risk factors for all employees. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine agency's responsibility to conduct TB testing of employees. Retesting should only be done for persons who previously tested negative and have new risk factors since the last assessment; Findings included: 1. Document review of the agency policy titled, "Tuberculosis Screening and Testing # TBP-003," showed that the Washington State Department of Health recommended following CDC Tuberculosis recommendations that included use of department-approved risk assessment for all new employees and follow up testing when appropriate. The policy also showed that agencies should conduct an annual assessment for new TB risk factors for all employees. Record review of personnel records for Staff #105, #106, #107, #108, #109, and #110 showed no completed TB Risk assessments at the time of hire. Record review of personnel record for staff #107, hired on 03/12/18, showed documentation of annual TB screening. 2. On 06/02/21 at 4:30 PM, Surveyor #1 interviewed the Agency Administrator (Staff #101) about the use of the form described in their agency policy. Staff #101 stated that the agency was not following the policy. .

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to ensure their mandatory reporting policy is in compliance with the state regulations. Failure to follow this compliance may result in a delay in mandated reporting of potential abuse, neglect, or exploitation to a vulnerable adult. Reference: WAC 246-335-525 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (8) Mandatory reporting: (a) Mandatory reporters shall report failure to comply with the requirements of chapters 246-335 WAC and 70.127 RCW to the department. The report must be submitted on department forms. Reports must be submitted within fourteen calendar days after the reporting person has knowledge of noncompliance that must be reported; Findings included: 1. Document review of the agency policy titled, "Assessment and Reporting of Abuse, Neglect and Exploitation # AA-010A," showed that the agency staff will assess, identify, and intervene on behalf of victims during instances of abuse, neglect and exploitation. The policy also showed that the agency will investigate and initiate intervention for any allegations of abuse, neglect or exploitation against clients, consistent with state regulation. 2. On 06/03/21 at 9:00 AM, Surveyor #1 interviewed the agency administrator (Staff #101) regarding the agency's mandatory reporting policy. Staff #101 stated that the agency was not aware of all the requirements of the WAC 246-335-525 on mandatory reporting. .

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: . Based on record review and interview, the Agency failed to be in compliance with specific state regulations, as required by WAC 246-335 including failure to do background checks through the Washington State Patrol (WSP) for 2 of 6 staff files reviewed (1), failed to complete disclosure statements on new hired staff for 2 of 6 staff files reviewed (2), and failed to renew disclosure statements every two years for 1 of 6 staff files reviewed (3). Failure to implement and comply with state regulation violates the rights of patients to be cared for by appropriately credentialed staff. Reference: WAC 246-335-525 The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following: (a) Criminal history background checks must be processed through the Washington state patrol; (b) Disclosure statements must be approved by the department; and (c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check; Findings included: 1. On 06/02/21, Surveyor #1 reviewed agency personnel records. The record review showed: a. A Physical Therapist (Staff #105) was hired on 11/01/20. The agency failed to obtain a criminal disclosure statement upon hire. b. An Occupational Therapist (Staff #107) was hired on 03/12/18. The agency failed to obtain a criminal disclosure statement at the time of hire and failed to obtain a renewal of the criminal disclosure statement consistent with state law. c. A Registered Nurse (Staff #106) was hired on 04/12/21. The agency failed to obtain a WSP criminal background check consistent with state law. d. A Speech Therapist (Staff #109) was hired on 11/02/20. The agency failed to obtain a WSP criminal background check consistent with state law. 2. On 06/02/21 at 4:30 PM, Surveyor #1 interviewed office manager (Staff #104) regarding the initial criminal disclosure statements for Staff #105 and #107, renewal of the criminal disclosure statements for Staff #107, and WSP background checks on Staff #106 and #109. Staff #104 was unable to locate these items.