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 for Home Health Services conducted this health and safety survey. Examination number: X2023-899 Dates Onsite: 01/29/24, 01/30/24, 01/31/24, 02/01/24, 02/02/24 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. DOH recommends recertification based on an acceptable plan of correction.

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 2 of 17 patients (Patients #308 and #310). 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 2 patient records showed the following: a. Patient #308 was admitted on 12/12/23 for primary diagnoses of strain muscle, fascia, tendon of lower back and hypertensive chronic kidney disease-not a complete list. The agency completed the referral on 11/24/23 for physical therapy and occupational therapy, however the start of care (SOC) for physical therapy did not occur until 12/12/23. The record also showed that the agency received an additional referral on 12/09/23. The plan of care (485) showed a verbal SOC as 12/04/23 and the start of care OASIS showed a M102 (Physician Ordered Start of Care) date of 12/12/23. There was no documentation of why the start of care did not occur within 48 hours of the referral or supporting documentation for the M102 date. b. Patient #310 was admitted on 12/14/23 for primary diagnoses of poly osteoarthritis and mild cognitive impairment-not a complete list. The agency received a referral on 11/28/23 for skilled nursing, physical therapy, occupational therapy, and home health aide services, however the SOC did not occur until 1214/23. The record also showed that the clinician documented the M102 (Physician Ordered Start of Care) date as 11/28/23. There was no documentation of why the start of care did not occur within 48 hours of the referral. 3. On 02/01/24 at 1:30 PM, the Surveyor interviewed the agency's Branch Director (Staff #301) and Clinical Manager (Staff #311) about the delays in the start of care for Patient #308 and #310. Staff #311 acknowledged the findings and stated that they were unable to locate additional documentation that explains why the services did not occur within 48 hours of the referral. Staff #311 also stated that the agency uses the date the referral was received as the verbal SOC date on the plan of care (485). The agency utilizes a central intake department that will enter a care coordination note when the referral has been received, entered, and sent to the agency for review. The agency will review the referral and request any additional documents to complete the referral. Once the agency has completed the referral, staff will enter a care coordination note to indicate that the referral is complete and ready to schedule. Staff #311 also stated that the Clinical Managers will adjust the M102 and M104 dates as appropriate prior to the OASIS being locked.

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 record review and interview, the agency failed to ensure the plan of care was followed as ordered by the physician for 4 of 17 patients (Patient #305, #306, #310, and #314). Failure to follow the plan of care, as ordered by the physician, puts the patient at risk of worsening symptoms of existing diagnoses. Findings included: 1. Record review of 4 patient records showed the following: a. Patient #305 was admitted on 12/07/23 with diagnoses of unspecified open wound to left lower leg and essential hypertension–not a complete list. On 12/11/23, the physician ordered Skilled Nursing (SN) services 2 time a week for 8 weeks. On 12/26/23, the agency received a verbal order to increase the SN visit frequency to 3 times per week. The week of 12/26/23 and 12/31/23 the patient received 2 of the 3 SN ordered visits. There was no documentation to explain the missed visits, and no evidence the agency notified the patient's physician. b. Patient #306 was admitted on 12/20/23 with diagnoses of complete intestinal obstruction and pressure ulcer sacral region stage 2 -not a complete list. On 12/30/23 at 11:58 AM, the agency received a verbal order for Skilled Nursing (SN) services 2 times per week. The week of 12/31/23 the patient received no SN visits. There was no documentation to explain the missed visits, and no evidence the agency notified the patient's physician. c. Patient #310 was admitted on 12/14/23 with diagnoses of poly osteoarthritis, mild cognitive impairment, and essential hypertension-not a complete list. On 12/19/23 at 4:49 PM, the agency received a verbal order for Skilled Nursing (SN) services weekly for 5 weeks, Home Health Aide (HHA) services weekly for 2 weeks then 2 visits per week for 6 weeks starting 12/21/23, and Physical Therapy (PT) services weekly for 3 weeks then 2 visits per week for 5 weeks starting 12/22/23. The week of 12/24/23 and 12/31/23 the patient did not receive HHA services. The weeks of 01/07/24, 01/14/24 and 01/21/24 the patient received 1 of 2 HHA visits. The week of 01/14/24 the patient received no PT visits and the week of 01/21/24 the patient received 1 of 2 PT visits. The record showed documentation of the reason for the missed visits, however it failed to show that the physician was notified of the missed visits. d. Patient #314 was admitted on 08/12/22 with diagnoses of displaced femur fracture, pressure ulcer sacral region and hypertension-not a complete list. The plan of care (485) showed that the physician ordered Skilled Nursing (SN) services 2 visits per week for 1 week then 3 visits per week for 3 weeks then 2 visits per week for 4 weeks. The week of 09/04/22 the patient received 2 of 3 ordered SN visits. The week of 09/11/22 the patient received 1 of 2 ordered SN visits. There was no documentation to explain the missed visits, and no evidence the agency notified the patient's physician. 3. On 02/01/24 at 1:00 PM, the Surveyor interviewed the agency’s Clinical Manager (Staff #311) of the lack of documentation on the missed visits. Staff #311 stated that Home Care Home Base allows clinicians to complete a missed visit report and document notification of the physical by phone. If the physician is not notified by phone, clinicians mark the field "Office to fax notification to provider (if unable to notify by phone)." The office staff will then fax the missed visit note to the physician's office. Home Care Home Base (an online data sharing and documentation application for home health and hospice) does not allow the agency to easily document and track the faxing of missed visit notes within the system. Staff #311 acknowledged the findings and stated that they were unable to find any additional documentation on the missed visits or evidence that the notes were sent to the physician.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to timely provide secondary services as ordered by the physician for 5 of 17 patients (Patient #308, #309, #310, and #311). 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. Record review for 5 of 17 patient records showed: a. Patient #308 had a start of care of 12/12/23. The patient was admitted for primary diagnoses of strain muscle, fascia, tendon of lower back and hypertensive chronic kidney disease—not a complete list. The referral orders dated 11/21/23 and 12/09/23 Physical Therapy (PT) evaluation and Occupational Therapy (OT) evaluation and Home Health Aides (HHA). The plan of care (485) showed that effective 12/31/23 Occupational Therapy would visit the patient 1 time that week. The OT evaluation did not occur. Patient #308 was transferred to the hospital on 12/04/23. The start of care case conference showed documentation that Patient #308 declined the OT evaluation. The record showed no documentation that the physician was notified of patient refusing the OT evaluation. b. Patient #309 had a start of care of 09/14/23. The patient was admitted for primary diagnoses of laceration without foreign body and essential hypertension—not a complete list. The referral orders dated 09/13/23 included skilled nursing (SN), a Physical Therapy (PT) evaluation, an Occupational Therapy (OT) evaluation and Home Health Aides (HHA). The plan of care (485) showed that effective 10/01/23 Occupational Therapy would visit the patient 1 time that week. The Occupational Therapy eval did not occur the week of 10/01/23. A new order for an Occupational Therapy evaluation was received on 10/20/23. The OT evaluation did not occur until 10/24/23. 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 #310 had a start of care of 12/14/23. The patient was admitted for primary diagnoses of poly osteoarthritis and mild cognitive impairment—not a complete list. The referral orders dated 11/28/23 for skilled nursing (SN), Physical Therapy (PT) evaluation and Occupational Therapy (OT) evaluation and Home Health Aides (HHA). The plan of care (485) showed that effective 01/07/24 Occupational Therapy would visit the patient 1 time that week. The OT evaluation did not occur. A PT visit note dated 01/08/24 showed documentation that Patient #308 declined the OT evaluation. The record showed no documentation that the physician was notified of patient refusing the OT evaluation. d. Patient #311 had a start of care of 08/11/23. The patient was admitted for primary diagnoses of hemiplegia following cerebral vascular accident right side, aphasia, and apraxia—not a complete list. The referral orders dated 08/09/23 included a Physical Therapy (PT) evaluation, an Occupational Therapy (OT) evaluation and a Speech Language Pathology (ST) evaluation. The plan of care (485) showed that effective 08/13/23 Occupational Therapy would visit the patient 1 time that week. Patient #310 did not receive an Occupational Therapy evaluation. There was no documentation as to why the OT evaluation did not occur and no documentation that the physician was notified. e. Patient #314 had a start of care of 08/12/22. The patient was admitted for primary diagnoses of displaced femur fracture and pressure ulcer sacral region—not a complete list. The referral orders dated 08/11/22 included Skilled Nursing (SN), Social Worker (MSW) evaluation, Physical Therapy (PT) evaluation, and Occupational Therapy (OT) evaluation. The record showed no evidence that Patient #314 received an MSW evaluation as ordered on the referral. The plan of care (485) showed that effective 08/21/22 Occupational Therapy would visit the patient 1 time that week. The Occupational Therapy evaluation did not occur the week of 08/21/22. The OT evaluation did not occur until 08/29/22. 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 and missed MSW evaluation. 3. On 02/01/24 at 1:15 PM, the Surveyor interviewed the agency's Branch Director (Staff #301) about the failure to complete OT evaluations timely and notify the physician if unable to complete the evaluations. Staff #301 stated that the agency currently only has 1 part time Occupational Therapist. Due to the scheduling, it is difficult for the agency to complete the OT evaluations on time. Staff #301 also stated that the agency’s marketing staff notifies the referral sources of the delay in OT services. However, the marketing staff is unable to document this communication in the patient records. Staff #301 also acknowledged that the agency is not documenting notification to the physician of the delayed or missed evaluations.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document supervision of Physical Therapy Assistants by a Physical Therapist as required for 4 of 12 sampled patients who received Physical Therapy services (Patient #301, #304, #307 and #308). Failure to supervise Physical Therapy Assistants as required places patients at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patient's changing needs. Reference: RCW 18.74.180 Professional and legal responsibilities - Supervision of assistive personnel. Physical therapist is professionally and legally responsible for patient care given by assistive personnel under his or her supervision. If a physical therapist fails to adequately supervise patient care given by assistive personnel, the board may take disciplinary action against the physical therapist. (2) If patient care is given by a physical therapist assistant, or other assistive personnel, supervision by the physical therapist requires that the patient reevaluation is performed: (a) The later of every fifth visit or every thirty days if a physical therapist has not treated the patient for any of the five visits or within the thirty days; (b) When there is any change in the patient's condition not consistent with planned progress or treatment goals. Findings included: 1. Record review of the agency's policy titled, "03-17 Patient Care Supervision" revised 10/2022, showed that unless otherwise specified by state regulations, the minimum frequency of patient care supervisory visits for Therapy Assistants is every 60 days. 2. Record review of 3 patient records showed the following: a. Patient #301 was admitted on 12/27/23 with diagnoses of bilateral primary osteoarthritis of knee, pain in right ankle, lumbago with sciatica and chronic pain. Patient #301 received Physical Therapy (PT) services 2 times weekly for 4 weeks then weekly for 4 weeks. PT services were provided by both a Physical Therapist and Physical Therapy Assistant. The records showed no documentation of supervision of the Physical Therapy Assistant the later of every fifth visit or 30 days as required in Washington state law. b. Patient #304 was admitted on 11/16/23 with diagnoses of pneumonitis, chronic respiratory failure, malignant neoplasm of the right breast and malignant pleural effusion. Patient #304 received Physical Therapy (PT) services 2 times weekly for 9 weeks. PT services were provided by both a Physical Therapist and Physical Therapy Assistant (PTA). In the episode from 11/16/23 to 01/14/24, the patient received PTA services on 12/05/23, 12/07/23, 12/27/23, 01/03/24, and 01/09/24. For the current episode starting on 01/15/24, the patient received PTA services on 01/22/24,01/26/24, and 01/31/24. The records showed a PTA supervisory visit completed on 12/13/23. The record showed no documentation of supervision of the Physical Therapy Assistant the later of every fifth visit or 30 days as required in Washington state law. c. Patient #308 was admitted on 12/12/23 with diagnoses of strain muscle, fascia, tendon of lower back, hypertensive chronic kidney disease-not a complete list. Patient #308 received Physical Therapy (PT) services 2 times weekly for 9 weeks. PT services were provided by both a Physical Therapist and Physical Therapy Assistant. The patient received PTA services on 12/15/23, 12/21/23. 12/22/23, 12/26/23, and 12/29/23. The records showed no documentation of supervision of the Physical Therapy Assistant the later of every fifth visit or 30 days as required in Washington state law. 3. On 02/01/24 at 2:00 PM, the Surveyor interviewed the agency’s Branch Director (Staff #301) and the agency’s Clinical Manager (Staff #311) regarding the lack of PTA supervisory visits. Staff #301 and #311 acknowledged the findings and stated that they were unable to provide documentation that PTA supervisory visits were conducted on the patients noted above.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide documentation of adequate competency training to Home Health Aides that addresses the required subject areas before providing care. Failure to provide adequate competency training to Home Health Aides puts the patients at risk of harm from untrained and unqualified caregivers. Cross Reference: G0764 1. On 01/29/24 the Surveyor reviewed the personnel record of the agency’s only Home Health Aide (Staff #309). The record showed that Staff #309 was hired on 03/01/23. The records showed no evidence that the agency completed the Home Health Aide competency training before providing patient care that addresses the required subject areas as listed on CFR 484.80(b)(3)(i-xv). Cross Reference: G0764 2. On 02/01/24 at 2:00 PM, the Surveyor interviewed the agency’s Branch Director (Staff #301) about the missing documentation of Home Health Aide competency training with the required subject areas before providing patient care. Staff #301 stated that Staff #309 completed the competency training before providing care but acknowledged that the agency was unable to locate the documentation. Staff #301 also stated that the agency’s Clinical Manager (Staff #312) was currently on a joint visit with Staff #309 to complete the competency training. Prior to survey exit, Staff #301 provided the Surveyor with documentation that Staff #309 completed the HHA competency evaluation on 02/01/24.

Supervision of home health aides CFR(s): 484.80(h) Standard: Supervision of home health aides. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to document Home Health Aide (HHA) supervisory visits no less frequently than every 14 days for 3 of 4 patients receiving HHA services (Patient #308, #309, and #315). Failure to supervise the Home Health Aide at least every 14 days places the patients at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patient’s changing needs. Findings included: 1. Record review of the agency's policy titled, "03-17 Patient Care Supervision" revised 10/2022, showed that supervision of home health aide services will be performed when the patient is receiving skilled nursing services. A RN will make on-site supervisory visits to each patient receiving home health aide services at least every 14 days. When the patient is receiving only therapy and aide services, the licensed therapist will make supervisory visits in lieu of the RN when allowed by state regulations. 2. Record review of 3 patient records showed the following: a. Patient #308 was admitted on 12/12/23 with diagnoses of strain muscle, fascia, tendon of lower back, hypertensive chronic kidney disease-not a complete list. The record showed that Patient #308 was to receive HHA services weekly for 8 weeks. The patient received HHA services on 12/22/23, 12/29/23 and 01/26/24 (35 days duration). There was no documentation of HHA supervisory visits every 14 days during the episode. b. Patient #309 was admitted on 09/14/23 with diagnoses of laceration without foreign body, essential hypertension, sciatica-not a complete list. The record showed that Patient #309 received HHA services 2 times per week for 8 weeks starting 09/17/23 through 11/12/23. The record showed documentation of HHA supervisory visits on 09/28/23 and 10/26/23. There was no documentation of HHA supervisory visits every 14 days as required. c. Patient #315 received home health services from 03/29/23 to 04/24/23 for essential hypertension and surgical aftercare-not a complete list. The record showed that Patient #315 received HHA services 2 times per week from 04/07/23 to 04/24/23 (17 days duration). There was no documentation of HHA supervisory visits every 14 days as required. 3. On 02/01/24 at 2:00 PM, the Surveyor interviewed the agency’s Branch Director (Staff #301) and the agency’s Clinical Manager (Staff #311) regarding the lack of evidence in the patient record that HHA supervisory visits were completed as required by federal law and consistent with the agency's policy. Staff #301 and #311 acknowledged the findings and stated that they were unable to provide documentation that HHA supervisory visits were conducted on the patients noted above.

. MEDICARE RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR 484 - HOME HEALTH regulations, conducted this health and safety survey. Examination number: X2021-440 Onsite date(s): 06/14/21 - 06/18/21, and 06/21/21 This survey was conducted by: Surveyor #6 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.

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to ensure patients received a copy of their Patient Rights prior to receiving services for 7 of 13 patient records (Patients #601, #602, #605, #607, #608, #609 and #610). Failure to provide/inform patients/caregivers of their rights could result in physical, psychological, or other forms of harm if patients are unaware of their rights or the agency's responsibility to promote said rights. Findings included: 1. Surveyor #6 reviewed the agency's policy titled, "Patient Rights and Notice of Privacy Practices (Policy WA 03-09, revised 11/09/18)." The policy showed that the agency must provide each patient admitted or readmitted to services with a copy of the Washington Addendum to the Patient Bill of Rights. 2. Surveyor #6 reviewed the record of Patient #601. The record showed: a. Patient #601 had a start of care (SOC) date of 11/01/20. b. Patient #601's "Home Care Consent" was dated 11/01/20. c. The consent form included an unchecked box that the patient had received the "Patient Bill of Rights Addendum Specific to the State of Washington." 3. Surveyor #6 reviewed the record of Patient #602. The record showed: a. Patient #602 had a start of care (SOC) date of 04/27/21. b. Patient #602's "Home Care Consent" was dated 04/27/21. c. The consent form included an unchecked box that the patient had received the "Patient Bill of Rights Addendum Specific to the State of Washington." 4. Surveyor #6 reviewed the record of Patient #605. The record showed: a. Patient #605 had a start of care (SOC) date of 03/29/21. b. Patient #605's "Home Care Consent" was dated 03/29/21. c. The consent form included an unchecked box that the patient had received the "Patient Bill of Rights Addendum Specific to the State of Washington." 5. Surveyor #6 reviewed the record of Patient #607. The record showed: a. Patient #607 had a start of care (SOC) date of 05/10/21. b. Patient #607's "Home Care Consent" was dated 05/10/21. c. The consent form included an unchecked box that the patient had received the "Patient Bill of Rights Addendum Specific to the State of Washington." 6. Surveyor #6 reviewed the record of Patient #608. The record showed: a. Patient #608 had a start of care (SOC) date of 03/30/21. b. Patient #608's "Home Care Consent" was dated 03/30/21. c. The consent form included an unchecked box that the patient had received the "Patient Bill of Rights Addendum Specific to the State of Washington." 7. Surveyor #6 reviewed the record of Patient #609. The record showed: a. Patient #609 had a start of care (SOC) date of 05/25/21. b. Patient #609's "Home Care Consent" was dated 05/25/21. c. The consent form included an unchecked box that the patient had received the "Patient Bill of Rights Addendum Specific to the State of Washington." 8. Surveyor #6 reviewed the record of Patient #610. The record showed: a. Patient #610 had a start of care (SOC) date of 05/29/21. b. Patient #610's "Home Care Consent" was dated 05/29/21. c. The consent form included an unchecked box that the patient had received the "Patient Bill of Rights Addendum Specific to the State of Washington." 9. Surveyor #6 interviewed the Branch Director (Staff #606) about the 7 records with an unchecked box on the client consent form on 06/17/21 between 8:30 AM and 2:35 PM. Staff #606 was unable to locate documentation that showed the patients received or had an opportunity to review their patient rights prior to receiving services. Staff #606 acknowledged the missing information in the patients' records. .

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 ensure patients received an initial assessment within 48 hours from their home health referral date for 4 of 13 patient records (Patient #605, #606, #607, and #609). Failure to meet this requirement places patients at risk for physical harm due to not receiving needed services in a timely manner. Findings included: 1. Surveyor #6 reviewed the agency's policy titled, "Initial and Comprehensive Assessments Policy 03-05," (revised 03/2021). The policy showed that the agency must complete an initial assessment either within 48 hours of the referral or agency discharge, unless otherwise ordered by the primary care provider (PCP). The policy also showed that if the office received a referral and were unable to visit within 48 hours, the agency should contact the PCP or refer the patient to another provider for services. 2. Surveyor #6 reviewed the record of Patient #605. The record showed: a. The agency received a physician-signed referral for home health services on 03/19/21 for Patient #605. b. The agency documented on 03/23/21, "date orders received 03/19/21" c. The record also showed the agency called the client on 03/24/21 and noted that the "Pt is agreeable to SOC on 03/29." c. The agency completed the initial assessment on 03/29/21, 10 days after the referral date. Documentation as to the reason for the delay was absent from the record. The record did not contain documentation of any physician notifications prior to 03/24/21. 3. Surveyor #6 interviewed the Branch Director, (Staff #606) about the missing documentation on 06/16/21 at 2:22 PM. Staff #606 was unable to locate documentation that justified the delay in the initial assessments and acknowledged the missing information for Patient #605. Staff #606 agreed that there was no physician communication prior to 03/24/21. 4. Surveyor #6 reviewed the record of Patient #606. The record showed: a. The home health services referral date for Patient #606 was 07/01/20. b. The agency completed the initial assessment on 07/07/20, 6 days after the referral date. Documentation as to the reason for the delay in start of care (SOC) to 07/07/20 and physician notification was absent from the record. 5. Surveyor #6 interviewed Staff #606 on 06/17/21 at 10:45 AM about the missing documentation. Staff #606 was unable to locate documentation that justified the delay in the SOC and acknowledged the missing information for Patient #606. 6. Surveyor #6 reviewed the record of Patient #607. The record showed: a. The agency received a physician-signed referral for home health services on 05/05/21 for Patient #607. b. The agency completed the initial assessment on 05/10/21, 5 days after the referral date. Documentation as to the reason for the delay was absent from the record. The record did not contain documentation of any physician notification. 7. Surveyor #6 interviewed the Branch Director, (Staff #606) about the missing documentation on 06/14/21 at 11:05 AM. Staff #606 was unable to locate documentation that justified the delay in the initial assessments and acknowledged the missing information for Patient #607. Staff #606 agreed that there was no physician communication. 8. Surveyor #6 reviewed the record of Patient #609. The record showed: a. The agency received a physician-signed referral for home health services on 05/13/21 for Patient #609. b. On 05/21/21, the agency documented a "Welcome Call", that stated, "Pt agreeable to a SOC on 05/24/21. c. The agency completed the initial assessment on 05/25/21, 12 days after the referral date. Documentation as to the reason for the delay was absent from the record. The record did not contain documentation of any physician notification. 9. Surveyor #6 interviewed the Branch Director, (Staff #606) about the missing documentation on 06/17/21 at 8:10 AM. Staff #606 stated that the process for referrals is for the sales staff to talk to patient first and provide them with a timeframe for admission. After establishment of an admission timeframe, the agency's administrative staff speaks with the patient or family, confirming the admission and the patient's start of care. Staff #606 was unable to locate documentation that justified the delay in the initial assessment and acknowledged the missing information for Patient #609. Staff #606 agreed that there was no physician communication. .

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 properly prevent COVID-19 through their failure to ensure staff received a fit test prior to N-95 face mask use, consistent with Washington State regulations for 4 of 26 Staff ( Staff #602, #603, #608 and Staff #609). Failure to develop and implement a method of performing N-95 mask fit tests for staff risks staff and patients' exposure to respiratory infections including COVID-19. References: WAC 246-335-525(15) 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: (a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment; WAC 296-842-12005(1) Develop a complete worksite-specific written respiratory protection program that includes the applicable elements listed in Table 3. The program must cover each employee required by this section to use a respirator. Note: Pay for respirators, medical evaluations, fit testing, training, maintenance, travel costs, and wages. . Findings included: 1. Document review of the guidance document issued by the Department of Health (DOH) and Labor & Industries (L&I) titled, "L&I and DOH Respirator and PPE for In-Home Care Agencies: Employer responsibilities for respiratory protection program and provision of personal protective equipment (PPE)," (DOH 420-329) issued March 30, 2021, showed In-Home care agencies are required to develop and maintain a Respiratory Protection Program (RPP) under WAC 296-842-12005. The document showed that an agency should complete a RPP before fit testing for respirators. A "fit test" is a procedure that tests the seal between the respirator's facepiece and the health care worker's (HCW) face. It includes a medical evaluation and must be performed by someone who is trained in fit testing. The document also showed that In-Home care agencies are required to provide initial fit tests for each HCW with the same model, style, and size respirator that the HCW will be required to wear for protection against COVID-19 and other airborne hazards. Document review of the agency's undated policy titled, "Personal Protective Equipment (PPE), Policy 10-04" (revised 12/20) showed that PPE will be provided to all clinicians to protect against exposure. The policy also showed that all clinicians will use appropriate barrier precautions to prevent exposure to COVID-19 or other potentially infectious materials. Document review of the agency's fit-testing binder showed the following: a. Staff #602 had a documented fit test record completed on 08/11/20. The record showed Staff #602 passed the test. b. Staff #603 had a documented fit test record completed on 12/08/20. The record showed Staff #603 passed the test. Their record did not include documentation of the manufacturer, model or size of the respirator used for the test. c. Staff #608 had a documented fit test record completed on 09/17/20. The record showed Staff #608 passed the test. The record did not include documentation that the staff member completed any of the 7 fit test exercises on the fit test record. d. Staff #609 had a documented fit test record completed on 08/24/20. The record showed Staff #609 passed the test. The record did not include documentation that the staff member completed any of the 7 fit test exercises on the fit test record. 2. Surveyor #6 interviewed a Registered Nurse (Staff #602) on 06/15/21 at 9:45 AM about the agency's COVID-19 response plan and PPE they had received. Staff #602 stated that they had been fit tested but failed, adding they never pass fit tests because they are unable to smell or taste the test solutions. This information contradicted the documented result in the fit test record, which indicated Staff #602 passed their fit test. 3. Surveyor #6 interviewed the agency's Branch Director (Staff #606) on 06/18/21 at 10:40 AM about the agency's N-95 fit testing process. Staff #606 stated that they do fit tests in the office. At the time of the interview, Surveyor #6 asked Staff #606 to provide the agency policy on fit testing. Staff #606 provided Surveyor #6 the agency's undated policy, "Personal Protective Equipment (PPE)" (Policy 10-04 revised 12/20). . Based on observation, document review, and interview, the agency failed to properly prevent COVID-19 through failure to ensure staff wore eye protection consistent with Washington State regulations for 5 of 5 Home Health staff (Staff #601, #602, #603, #604, and #605). Failure to ensure staff wear eye protection when performing patient care, risks staff and patients' exposure to infectious organisms including COVID-19. References: WAC 246-335-525(15) 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: (a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment; WAC 206-800-160 You must make sure that your employees have, use, and care for the appropriate personal protective equipment (PPE). PPE is an item or items used to protect the eyes, face, head, body, arms, hands, legs, and feet such as goggles, helmets, head covers, gloves, rubber slickers, disposable coveralls, safety shoes, protective shields, and barriers. WAC 296-800-16040 You must require your employees to use necessary PPE on the job. WAC 296-800-16030(3) You must retrain an employee when you have reason to believe the understanding, motivation, and skills required to use the PPE has not been retained. Circumstances where retraining is required include: (3) Work habits or demonstrated knowledge indicate that the employee has not retained the necessary understanding, skill, or motivation to use PPE. Findings included: 1. Document review of the guidance document issued by the Department of Health (DOH) and Labor & Industries (L&I) titled, "L&I and DOH Respirator and PPE for In-Home Care Agencies: Employer responsibilities for respiratory protection program and provision of personal protective equipment (PPE)," (DOH 420-329) issued March 30, 2021 showed that In-home care agencies are required to develop and maintain a Respiratory Protection Program (RPP) under WAC 296-842-12005. The document also showed that agencies are required to provide gowns, gloves, and eye protection to staff who are entering patient's homes. The document further stated that staff must wear eye protection when there is moderate to substantial community transmission of COVID-19. The document defined eye protection as, goggles or a face shield that covers the front and sides of the face. The document stated that personal eyeglasses are not PPE and do not provide adequate eye protection. Document review of the guidance document issued by the Department of Health (DOH) titled, " COVID-19 Guidance for Home Care, Home Health, and Hospice Agencies," (DOH 420-299) issued June 09, 2021 showed when COVID-19 community transmission case rate is greater than 25 per 100,000, in 2 weeks, HCWs are to wear a surgical face mask and eye protection for ALL patient care encounters, regardless of patient/client COVID-19 status. According to DOH COVID-19 cases and testing for Clark County, the 2-week transmission rate at the time of survey was 79.1 per 100,000. Document review of the agency's undated policy titled, "Personal Protective Equipment (PPE)" (revised 12/20) showed that PPE will be provided to all clinicians to protect against exposure. The policy also showed that all clinicians will use appropriate barrier precautions to prevent exposure to COVID-19 or other potentially infectious materials. 2. On 06/14/21 at 2:45 PM, Surveyor #6 observed Staff # 601 performed patient care within 6 feet of Patient #601 and did not wear eye protection. 3. On 06/15/21 Surveyor #6 observed the following: a. At 10:00 AM, Staff # 602 performed patient care within 6 feet of the Patient #602 and did not wear eye protection. b. At 11:15 AM, Staff # 603 performed patient care within 6 feet of the Patient #603 and did not wear eye protection. c. At 2:25 PM, Staff # 604 performed patient care within 6 feet of the Patient #604 and did not wear eye protection. d. At 3:20 PM, Staff # 605 performed patient care within 6 feet of the Patient #605 and did not wear eye protection. 4. Surveyor #6 interviewed the agency's Branch Manager, (Staff #606) on 06/18/21 at 10:18 AM about the agency's policy on PPE and eye protection. Staff #606 stated that they expect staff to wear eye protection at patient visits. Staff #606 also stated that staff received either a face shield or googles with a strap for use when they are within 6 feet of a patient. When asked for agency policies on eye protection, Staff#606 provided the agency policy reviewed above. . Based on observation, document review, and interview, the agency failed to properly prevent COVID-19 through failure to ensure staff used gloves and performed hand hygiene consistent with Washington State regulations and the Centers for Disease Control and Prevention (CDC) guidelines for 1 of 5 Home Health staff (Staff #602). Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, or antiseptic hand rub. Failure to ensure staff use gloves and perform hand hygiene consistent with regulations and guidelines when performing patient care, risks staff and patients' exposure to infectious organisms including COVID-19. References: WAC 246-335-525(15) 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: (a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment; WAC 206-800-160 You must make sure that your employees have, use, and care for the appropriate personal protective equipment (PPE). Findings included: 1. Document review of the guidance document issued by the Centers for Disease Control and Prevention (CDC) titled, "Guideline for Hand Hygiene in Health-Care Settings," (Morbidity and Mortality Weekly Report Vol. 51 No. RR-16) issued October 25, 2002 showed that staff are to decontaminate hands after contact with body fluids, excretions, mucous membranes, nonintact skin, and wound dressings. The document also showed that staff are to decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. The document further showed that staff are to decontaminate hands after removing gloves. Document review of the agency's undated policy titled, "Personal Protective Equipment (PPE) (Policy 10-04)," (revised 12/20) showed that PPE will be provided to all clinicians to protect against exposure. The policy also showed that all clinicians will use appropriate barrier precautions to prevent exposure to COVID-19 or other potentially infectious materials. The policy also showed that the agency would follow CDC guidelines to ensure effectiveness of equipment designed to prevent exposure to blood borne pathogens. Document review of the agency's undated policy titled, "Hand Hygiene," (revised 11/05) showed that hands are to be cleaned before and after contact with a patient, before and after all procedures and dressing changes, and after handling soiled equipment or dressings. The policy also showed that staff are to clean hands after removal of gloves. 2. On 06/15/21 at 10:00 AM, Surveyor #6 observed a Registered Nurse (Staff #602) as they provided wound care to Patient #602. The observation showed that Staff #602 wore two pairs of gloves on each hand while providing wound care and on three separate instances, removed all pairs of gloves from both hands and applied two pairs of gloves to each hand without cleaning their hands in any of these three instances. The observation also showed that following completion of wound care for Patient #602, they gathered soiled dressings and used supplies while wearing soiled gloves and discarded the items in the trash. Then Staff #602 removed all their gloves and returned supplies to the cupboard without performing hand hygiene. 3. Surveyor #6 interviewed the agency's Branch Manager (Staff #606) on 06/18/21 at 10:18 AM about the agency's policy on glove use and hand hygiene. Staff #606 stated that they expect staff to clean hands before putting gloves on and immediately after removing gloves. When asked for agency policies on glove use and hand hygiene, Staff#606 provided the two agency policies reviewed above. .

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: . Based on record review and interview, the Agency failed to schedule professional services visits as ordered by the physician for 4 of 13 patients (Patient #603, #604, #606, and #611) including failure to schedule Speech Language Pathologist (SLP) visits, failure to schedule Physical Therapy (PT) visits, and failure to schedule Occupational Therapist (OT) visits. Failure to schedule professional service visits as ordered by the physician puts patients at risk for unmet needs and/or a decline in condition. . Findings included: 1. Document review of the agency's undated policy titled, "Physician's Orders, Policy 03-12 " (revised 09/28/2018) showed that in the event an ordered service cannot be performed, the physician will be notified. The policy directs the agency to document that the physician is aware of the missed visit. The policy also showed, if orders for services included a frequency range and the agency reduces that frequency within the range, they must contact the physician prior to increasing visits again, even if within the previously ordered range. 2. Surveyor #6 reviewed the record of Patient #603. The record showed: a. Patient #603 had a Start of Care (SOC) order on 03/10/21. b. On 05/09/21 the physician ordered PT visits 1 time per week for 6 weeks. c. The patient received no PT visits the week of 05/09/21. d. On 05/16/21 the record showed a missed visit for a Physical Therapist Assistant (PTA). The staff failed to document if they notified the patient's physician of the missed visit. 3. Surveyor #6 reviewed the record of Patient #604. The record showed: a. Patient #604's physician ordered SLP visits 1 time per week for 8 weeks starting on 05/16/21. b. There was one missed visit the week of 05/23/21. Documentation of physician notification was absent from the record. 4. Surveyor #6 reviewed the record of Patient #606. The record showed: a. Patient #606's physician ordered PT visits 2 times per week for 4 weeks starting on 07/12/20. b. There was one missed visit the week of 07/17/20. Documentation as to the reason for the missed visit and physician notification were absent from the record. 5. Surveyor #6 reviewed the record of Patient #611. The record showed: a. Patient #611's physician ordered PT visits 2 times per week for 8 weeks starting on 01/03/21, OT visits 2 times per week for 8 weeks starting on 01/11/21, and SLP visits 1 time per week from 01/01/21 to 03/01/21. b. There was one missed SLP visit the week of 01/10/21, one missed PT visit the week of 01/17/21, one missed SLP visit the week of 02/07/21, two missed visits (PT and OT) the week of 02/14/21, and two missed visits (PT and OT) the week of 02/21/21. Documentation as to the reason for the missed visits and physician notifications were absent from the record. 6. On 06/17/21 between 10:36 AM and 4:50 PM, Surveyor #6 interviewed Staff #606 about the missed visits and missing documentation of physician notification in the patient records. Staff #606 acknowledged that there was no documentation in the record about the missed visits including physician notification. .

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 review of personnel records and interview with agency staff, the agency failed to document reference checks for 5 of 5 Home Health staff records reviewed (Staff #601, #602, #603, #604, and #605). Failure to document references places clients at risk of receiving services from staff who may not be qualified to provide services or who may have a history of problems associated with service to vulnerable clients. References: Washington Administrative Code (WAC) 246-335-525(3) PERSONNEL CONTRACTOR AND VOLUNTEER POLICIES. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (3) References for personnel, contractors and volunteers; WAC 246-335-530(2) PERSONNEL, CONTRACTOR, AND VOLUNTEER RECORDS. The licensee must maintain records on all personnel and volunteers and have access to records on all contractors to include: (2) Documentation of references; Findings included: 1. Document review of the agency's undated policy titled, "Reference Checking" (Policy 7-11) showed that verification of references must be completed for all applicants prior to job offer. Document review of the agency's policy titled, "Reference Checking" (Policy 07-11), effective date 01/14/20 and revised 05/21) showed that verification of references must be attempted for all applicants prior to job offer. The policy also showed, "Every attempt must be made to obtain feedback from at least two of the references provided." 2. The Surveyor #6 reviewed Staff # 601's personnel file, and the file showed: a. Staff #601 was hired on 06/01/20. b. There was no documentation to show the agency attempted or completed reference checks. 3. The Surveyor #6 reviewed Staff # 602's personnel file, and the file showed: a. Staff #602 was hired on 10/14/19. b. There was no documentation to show the agency attempted or completed reference checks. 4. The Surveyor #6 reviewed Staff # 603's personnel file, and the file showed: a. Staff #603 was hired on 12/02/20. b. There was no documentation to show the agency attempted or completed reference checks. 5. The Surveyor #6 reviewed Staff # 604's personnel file, and the file showed: a. Staff #604 was hired on 05/21/18. b. There was no documentation to show the agency attempted or completed reference checks. 6. The Surveyor #6 reviewed Staff # 605's personnel file, and the file showed: a. Staff #605 was hired on 04/27/21. b. There was no documentation to show the agency attempted or completed reference checks. 7. On 06/18/21 at 4:55 PM, Surveyor #6 interviewed the agency's Admin Specialist/HR Designee (Staff #607) about the missing references and lack of documentation of attempts to check references. Staff #607 agreed with the findings that there were no attempts to check references or completed references in the personnel files. Staff #607 stated that the agency was told they do not need to check references once they transitioned to online applications. When asked for policies on reference checks, Staff #607 provided the two policies reviewed above. . Based on record review and interview, the agency failed to provide documentation of a Washington State Patrol (WSP) criminal history background check for 3 of 5 home health staff files reviewed (Staff #601, #602, and #604). Failure to obtain the required WSP criminal history background check, places patients at risk to receive care from an un-vetted caregiver. References: Washington Administrative Code (WAC) 246-335-525(6) PERSONNEL CONTRACTOR AND VOLUNTEER POLICIES. 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 (WSP); (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; WAC 246-335-530(7) PERSONNEL, CONTRACTOR, AND VOLUNTEER RECORDS. The licensee must maintain records on all personnel and volunteers and have access to records on all contractors to include: (7) Evidence of initial and subsequent criminal history background checks and disclosure statements according to RCW 43.43.830 through 43.43.842 and this chapter; . Findings included: 1. Document review of the agency's undated policy titled, "Background Investigations" (Policy WA 07-16) showed that all employees are required to complete and sign a disclosure statement and to have a WSP background check. The policy also showed that, all background checks and disclosure statements must be renewed every two years. 2. Surveyor #6 reviewed the personnel files for 5 home health staff members (Staff #601, #602, #603, #604, and #605). The review showed: a. Staff #601 was hired 06/01/20 and the record did not contain an initial WSP criminal history background check. b. Staff #602 was hired 10/14/19 and the record did not contain an initial WSP criminal history background check. c. Staff #605 was hired 05/21/18 and the record did not contain an initial or subsequent WSP criminal history background check. 3. On 06/18/21 at 4:55 PM, Surveyor #6 interviewed the agency's Admin Specialist/HR Designee (Staff #607) about the missing WSP criminal history background checks. Staff #607 acknowledged that the agency did not complete WSP criminal history background checks for the staff above. .