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: X2024-872 Dates Onsite: 10/21/24 – 10/23/24 This survey was conducted by: Surveyor #6 Surveyor #3 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 1834 of 4671 records transmitted between 09/01/23 and 09/30/24. Failure to transmit patient data timely could result in inaccurate data and cause delays for patients to receive full benefits. . 1. As part of the pre-survey preparation, the Surveyors reviewed the "HHA Error Summary by Agency" report from 09/01/23 and 00/30/24 generated from the iqies.cms.gov website. The review showed that the agency had 1834 of 4671 patient assessments (M090) that were not submitted in a timely manner. This resulted in a 39.26% late submission error rate. 2. On 10/22/24 at 2:30 PM, Surveyor #6 interviewed the Branch Director (Staff #601) regarding the error rate for M090. Staff #601 stated that the agency was not aware of any late submission errors and they regularly review the submission report from their electronic medical records (EMR) vendor. Staff #601 stated that they will make changes in their workflow processes to be in compliance. .

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the Notice of Medicare Non-Coverage (NOMNC) on patients being considered for discharge for cause on 2 of 5 discharged patient records (Patients #614 and #615). Failure to provide 48-hours notification of impending discharge and the Notice of Medicare Non-Coverage to patients being considered for discharge prevents timely continuity of care and coordination that may put patients at risk of abandonment. . Findings included: 1. Document review of the agency policy titled, “Discharge or Transfer Policy and Job Aid,” (Policy No. 03-25 Review Date 09/2024), showed that patients are to be provided with the Notice of Medicare Non-Coverage (NOMNC) form no less than two days prior to discharge from the agency. 2. Record review of discharged patient records for Patient # 614 and #615 showed: a. Patient #614 had a start of care date of 12/05/23 and their discharge date occurred on 01/31/24. There was no documentation in the records to show that the agency provided the NOMNC prior to discharge. b. Patient #615 had a start of care date of 09/13/23 and their discharge date occurred on 11/24/23. There was no documentation in the records to show that the agency provided the NOMNC prior to discharge. 3. On 10/23/24 at 12:30 PM, Surveyor #6 interviewed the agency Clinical Manager (Staff #612) about the missing documentation of NOMNC in the discharged patients’ records. Staff #612 acknowledged the findings and stated that they were unable to find the documentation in the records. . .

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: 2021-844 Dates Onsite: 10/25-28/21 This survey was conducted by: Surveyor #4 Surveyor #5 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. . . . . .

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to report an allegation of misappropriation of property according to agency policy and Chapter 74.34.020(8) RCW and Chapter 74.34.035(1) RCW for mandatory reporting of abuse and/or neglect involving vulnerable children and adults. Failure to ensure compliance with mandated reporter requirements could lead to on-going harm from abuse and/or neglect to vulnerable patients. Reference: Chapter 74.34.020 (8) RCW gives the following definition of a mandated reporter - "Mandated reporter" is an employee of the department; law enforcement officer; social worker; professional school personnel; individual provider; an employee of a facility; an operator of a facility; an employee of a social service, welfare, mental health, adult day health, adult day care, home health, home care, or hospice agency; county coroner or medical examiner; Christian Science practitioner; or health care provider. Chapter 74.34.035 RCW defines the duties of a mandated reporter: "When there is reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, mandated reporters shall immediately report to the department". RCW 74.34.020(4) defines department as "the department of social and health services" (DSHS). Findings included: 1. On 10/28/21, Surveyor #5 reviewed the agency policy and procedure for mandatory reporting. The review showed that the policy titled," Abuse, Neglect and Exploitation (Policy 3-6)," stated that the Clinical Manager or designee is responsible to ensure that when instances of suspected or actual violations involving misappropriation of patient's property are known, the notification to appropriate agencies are made. On 10/25/21, Surveyor #5 reviewed the agency complaint log. The log contained an allegation, dated 04/21/21, that a care provider took $300.00 from the patient during a home visit. The complaint documentation form contained the question, “Is the complaint reportable to an outside agency?”. In response to the question the document showed a “No” was checked. There was no documented evidence the agency had reported the allegation to the department. 2. On 10/28/21 at 8:30 AM, Surveyor #5 interviewed the Area Director (Staff #509) about the allegation of stolen money. Staff #509 stated that the allegation had not been reported to the Department as required by agency policy and state regulations. .

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 patient assessment within 48 hours of receiving the referral for 1 of 17 patients (#515). Failure to conduct a timely initial assessment delays the start of care and could place patients at risk for having immediate care and support needs go unmet. Findings included: 1. On 10/27/21, Surveyor #5 reviewed the record for Patient #515. The record showed a referral date of 06/25/20. The initial assessment was completed on 06/29/21. There was no documented evidence to show a reason for the delay in the assessment to begin care. 2. On 10/27/21 at 10:50A PM, Surveyor #5 interviewed the Branch Manager (Staff #501) about the timely initiation of care for Patient #515. Staff #501 verified there was a greater than 48-hour delay in completing the initial assessment. .