Every finding on record at Centerwell Certified Healthcare Corp

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: X2024-928 Dates Onsite: 10/22/24- 10/24/24 This survey was conducted by: Surveyor #4 Surveyor #2 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. ..

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to transmit patient data to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for 184 of 1990 records transmitted between 08/01/23 and 07/31/24. Failure to transmit the patient data in a timely manner could result in patients not receiving full benefits. Findings included: 1. As part of the pre-survey preparation, Surveyor #4 reviewed the “HHA Error Summary by Agency” report from 08/01/23 to 07/31/24 generated from the Website address iqies.com.gov site. The reviewed showed that the agency had 184 of 1990 patient assessments that were not submitted in a timely manner. This resulted in 9.25% late submission error rate. 2. On 10/23/24 at 4:00 PM, Surveyor #4 interviewed the agency executive director (Staff #401) about the error rate. Staff #401 stated that issues accrued with the transmission in July 2024 might have been caused by a failure in the system they are using to transmit data.

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: 2021-958 Dates Onsite: 11/08-10/21 and 11/12/21 This survey was conducted by: Surveyor #4 DOH staff found the facility 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. .

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 recorded review and interview, the agency failed to implement policies and procedures consistent with state licensing requirements for 1 of 7 staff reviewed, through failure to renew disclosure statement and criminal background check for 1 staff (Staff #404). Failure to maintain compliance with state licensing requirements puts patients at risk for harm from abuse and neglect. References: Washing ton Administrative Code WAC 246-335-525 (6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and other individuals 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. Surveyor #4 reviewed the agency's policy "WA 07-16: Background Investigations," revised 04/2021. The policy showed that all criminal history background checks and disclosure statements must be renewed within two years from the date of the previous check. 2. On 11/12/21 Surveyor #4 reviewed the personnel file of a Home Health Aide (Staff #404). a. Staff #404 was hired by the agency on 01/19/18. The file contained a disclosure statement and background check dated 01/03/18. There was no documentation showing that an updated disclosure statement or renewed background check was completed since that time. 3. Surveyor #4 interviewed the Executive Director, (Staff #401) on 11/12/21 at 11:00 AM about the missing disclosure and background check. Staff #401 stated that both the background check and disclosure statement should have been updated in January 2020, but was missing from the file. 4. Surveyor #4 received an email from Staff #401 on 11/12/21 at 4:43 PM. The emailed showed that the agency was unable to locate the missing information.