Every finding on record at Cp Snohomish County Wa, LLC

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: X2023-463 Dates Onsite: 09/18/23, 09/19/23, 09/20/23, 09/21/23 This survey was conducted by: Surveyor #1 Surveyor #6 Surveyor #2 (participated as an orientee) 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.

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 M0104 that indicates the completed referral date for 11 of 20 patients (Patients #101, #102, #104, #106, #107, #108, #112, #113, #117, #118 and #120). 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, “HH Oasis Data Transmission 500-14,” (Last Review Date: 05/20/22) showed that the organization must transmit accurate, complete OASIS data for patients. 2. Record review of patient records for Patients #101, #102, #104, #106, #107, #108, #112, #113, #117, #118 and #120 showed: a. Patient #101 was admitted for primary diagnoses of Radiculopathy in Lumbar region and Cellulitis of Left Toe—not a complete list. The referral was completed on 09/03/23 for Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) services. The OASIS M0104 data showed a date of 09/04/23 rather than the accurate data of the referral date of 09/03/23. There was no documentation to indicate how the admitting clinician determined the M0104 date of 09/04/23. b. Patient #102 was admitted for primary diagnoses of Cellulitis of the Right Lower Extremity—not a complete list. The referral was completed on 07/19/22 for SN services. The OASIS M0104 data showed a date of 07/20/22 rather than the accurate data of the referral date of 07/19/22. There was no documentation to indicate how the admitting clinician determined the M0104 date of 07/20/22. c. Patient #104 was admitted for primary diagnoses of Diabetes Mellites and Right foot Pressure wound—not a complete list. The referral was completed on 07/01/23 for SN, PT, and OT services. The OASIS M0104 data showed a date of 07/06/23 rather than the accurate data of the referral date of 07/01/23. There was no documentation to indicate how the admitting clinician determined the M0104 date of 07/06/23. d. Patient #106 was admitted for primary diagnoses of Radiculopathy in Lumbar region—not a complete list. The referral was completed on 05/16/23 for PT services. The OASIS M0104 data showed a date of 05/17/23 rather than the accurate data of the referral date of 05/16/23. There was no documentation to indicate how the admitting clinician determined the M0104 date of 05/17/23. e. Patient #107 was admitted for primary diagnoses of Hypertension and Congestive Heart Failure—not a complete list. The referral was completed on 08/25/23 for SN, PT, and OT services. The OASIS M0104 data showed a date of 08/26/23 rather than the accurate data of the referral date of 08/25/2023. There was no documentation to indicate how the admitting clinician determined the M0104 date of 08/26/23. f. Patient #108 was admitted for primary diagnoses of Hemiplegia and Hemiparesis—not a complete list. The referral was completed on 08/28/23 for PT and OT services. The OASIS M0104 data showed a date of 08/29/23 rather than the accurate data of the referral date of 08/28/23. There was no documentation to indicate how the admitting clinician determined the M0104 date of 08/29/23. g. Patient #112 was admitted for primary diagnoses of Dysphagia and Cerebral Infarction—not a complete list. The referral was completed on 06/02/23 for SN, PT, OT, HHA and SLP services. The OASIS M0104 data showed a date of 06/10/23 rather than the accurate data of the referral date of 06/02/23. There was no documentation to indicate how the admitting clinician determined the M0104 date of 06/10/23. h. Patient #113 was admitted for primary diagnoses of Dementia and Pain on Lower Left Extremities—not a complete list. The referral was completed on 12/04/22 for SN, PT, OT, HHA and SLP services. The OASIS M0104 data showed a date of 12/15/22 rather than the accurate data of the referral date of 12/04/22. There was no documentation to indicate how the admitting clinician determined the M0104 date of 12/15/22. i. Patient #117 was admitted for primary diagnoses of Right sided Sciatica Pain and Urinary Tract Infection—not a complete list. The referral was completed on 12/13/22 for SN, PT, and OT services. The OASIS M0104 data showed a date of 12/14/22 rather than the accurate data of the referral date of 12/13/22. There was no documentation to indicate how the admitting clinician determined the M0104 date of 12/14/22. j. Patient #118 was admitted for primary diagnoses of Hypothyroidism and Sleep Apnea—not a complete list. The referral was completed on 01/24/23 for PT services. The OASIS M0104 data showed a date of 01/27/23 rather than the accurate data of the referral date of 01/24/23. There was no documentation to indicate how the admitting clinician determined the M0104 date of 01/27/23. k. Patient #120 was admitted for primary diagnoses of Cerebral Infarction and Hemiplegia—not a complete list. The referral was completed on 08/22/23 for SN, PT, and OT services. The OASIS M0104 data showed a date of 08/26/23 rather than the accurate data of the referral date of 08/22/23. There was no documentation to indicate how the admitting clinician determined the M0104 date of 08/26/23. 3. On 09/20/23 at 9:00 AM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #113) and the agency’s Executive Director (Staff #114) of the inaccurate documentation of the OASIS M0104. Both Staff #113 and #114 acknowledged the findings and stated that they were not aware of how clinicians determined the M0104 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 20 of 20 patient records (Patient #101, #102, #103, #104, #105, #106, 107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, and #120). Failure to inform patients and their representatives of the frequency of visits of the proposed care and review changes to their plan of care prevent patients from participating in their care. 1. Document review of agency’s document titled, “Rights/Responsibilities 1-001” (Policy ID #8927048, Last Reviewed 02/2021) showed that at the time of admission the patient has the right to be informed of revisions of the plan of care that includes frequency of visits as well as any changes in the care to be furnished. 2. Record review for Patient #101, #102, #103, #104, #105, #106, 107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, and #120 showed: a. Patient #101 was admitted on 09/05/23. Documentation showed Physical Therapy (PT) frequency of visits for 1 to 3 visits every week for 7 weeks, Skilled Nursing (SN) frequency of visits for 1 to 3 visits every week for 7 weeks, and Occupational Therapist (OT) frequency of visits for 1 to 3 visits every week for 2 weeks starting 09/17/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT, SN, and OT services. b. Patient #102 was admitted on 07/21/22. Documentation showed SN frequency of visits for 1 to 3 visits every week for 2 weeks then 1 to 2 visits every week for 9 weeks starting 07/31/22. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN services. c. Patient #103 was admitted on 01/22/23. Documentation showed SN frequency of visits for 1 to 3 visits every week for 7 weeks starting 02/05/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN services. d. Patient #104 was admitted on 07/08/23. Documentation showed SN frequency of visits for 1 to 3 visits every week for 8 weeks starting 07/16/23, PT frequency of visits for 1 to 3 visits every week for 7 weeks starting 07/23/23, and OT frequency of visits for 1 to 3 visits every week for 3 weeks starting 07/25/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, and OT services. e. Patient #105 was admitted on 07/25/23. Documentation showed PT frequency of visits for 1 to 3 visits every week for 7 weeks starting 08/06/23, OT frequency of visits for 1 to 3 visits every week for 3 weeks starting 08/13/23, and Speech Language Therapy (SLP) frequency of visits for 1 to 3 visits every week for 3 weeks starting 08/08/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT, OT, and SLP services. f. Patient #106 was admitted on 05/18/23. Documentation showed PT frequency of visits for 1 to 3 visits every week for 7 weeks starting 05/28/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT services. g. Patient #107 was admitted on 08/27/23. Documentation showed SN frequency of visits for 1 to 3 visits every week for 9 weeks starting 09/11/23, PT frequency of visits for 1 to 3 visits every week for 7 weeks starting 09/10/23, and OT frequency of visits for 1 to 3 visits every week for 2 weeks starting 08/27/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, and OT services. h. Patient #108 was admitted on 08/31/23. Documentation showed PT frequency of visits for 1 to 3 visits every week for 7 weeks starting 09/10/23 and OT frequency of visits for 1 to 3 visits every week for 2 weeks starting 09/03/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT and OT services. i. Patient #109 was admitted on 07/25/23. Documentation showed SN frequency of visits for 1 to 3 visits every week for 8 weeks starting 07/25/23, PT frequency of visits for 1 to 3 visits every week for 4 weeks starting 08/13/23, and OT frequency of visits for 1 to 3 visits every week for 2 weeks starting 07/26/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, and OT services. j. Patient #110 was admitted on 06/27/23. Documentation showed SN frequency of visits for 1 to 3 visits every week for 5 weeks starting 07/09/23 and then 1 to 3 visits for 4 weeks starting 07/31/23, PT frequency of visits for 1 to 3 weeks every week for 7 weeks starting 07/09/23 and then 1 to 3 visits every week for 2 weeks starting 07/28/23, OT frequency of visits for 1 to 3 visits every week for 2 weeks starting 07/11/23, and SLP frequency of visits for 1 to 3 visits every week for 2 weeks. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, OT, and SLP services. k. Patient #111 was admitted on 09/02/23. Documentation showed SN frequency of visits for 1 to 3 visits every week for 4 weeks starting 09/10/23, PT frequency of visits for 1 to 3 visits every week for 7 weeks starting 09/17/23, and OT frequency of visits for 1 to 3 visits every week for 2 weeks starting 09/13/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, and OT services. l. Patient #112 was admitted on 06/12/23. Documentation showed SN frequency of visits for 1 to 3 visits every week for 4 weeks starting 06/25/23, PT frequency of visits for 1 to 3 visits every week for 7 weeks starting 06/25/23, OT frequency of visits for 1 to 3 visits every week for 5 weeks starting 07/09/23, and SLP frequency of visits for 1 to 3 visits every week for 8 weeks starting 06/20/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, OT, and SLP services. m. Patient #113 was admitted on 12/16/22. Documentation showed SN frequency of visits for 1 to 3 visits every week for 2 weeks starting 12/18/22, PT frequency of visits for 1 to 3 visits every week for 2 weeks starting 12/18/22, OT frequency of visits for 1 to 3 visits every week for 2 weeks starting 12/18/22, and SLP frequency of visits for 1 to 3 visits every week for 2 weeks starting 12/18/22. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, OT, and SLP services. n. Patient #114 was admitted on 05/24/22. Documentation showed PT frequency of visits for 1 to 3 visits every week for 2 weeks, SN frequency of visits for 1 to 3 visits every week for 2 weeks, and OT frequency of visits for 1 to 3 visits every week for 2 weeks starting 05/24/22. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT, SN, and OT services. o. Patient #115 was admitted on 05/24/22. Documentation showed SN frequency of visits for 1 to 3 visits every week for 2 weeks, PT frequency of visits for 1 to 3 visits every week for 2 weeks, and OT frequency of visits for 1 to 3 visits every week for 2 weeks starting 05/24/22. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, and OT services. p. Patient #116 was admitted on 09/19/22. Documentation showed SN frequency of visits for 1 to 3 visits every week for 2 weeks and PT frequency of visits for 1 to 3 visits every week for 2 weeks starting 10/04/22. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN and PT services. q. Patient #117 was admitted on 12/15/22. Documentation showed SN frequency of visits for 1 to 3 visits every week for 8 weeks starting 12/255/22, PT frequency of visits for 1 to 3 visits every week for 2 weeks starting 01/01/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN and PT services. r. Patient #118 was admitted on 01/28/23. Documentation showed PT frequency of visits for 1 to 3 visits every week for 2 weeks starting 01/28/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT services. s. Patient #119 was admitted on 08/21/23. Documentation showed SN frequency of visits for 1 to 3 visits every week for 2 weeks starting 08/24/23, PT frequency of visits for 1 to 3 visits every week for 2 weeks starting 08/24/23, OT frequency of visits for 1 to 3 visits every week for 2 weeks starting 08/23/22, and SLP frequency of visits for 1 to 3 visits every week for 2 weeks starting 08/24/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, OT, and SLP services. t. Patient #120 was admitted on 08/28/23. Documentation showed SN frequency of visits for 1 to 3 visits every week for 6 weeks starting 09/11/23, PT frequency of visits for 1 to 3 visits every week for 7 weeks starting 09/11/23, OT frequency of visits for 1 to 3 visits every week for 7 weeks starting 09/10/23, and SLP frequency of visits for 1 to 3 visits every week for 7 weeks starting 09/10/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN, PT, OT, and SLP services. 3. On 09/20/23 at 9:00 AM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #113) and the agency’s Executive Director (Staff #114) regarding the findings. Both Staff #113 and Staff #114 acknowledged the varying frequencies findings, and stated that they were unable to provide documentation of communication and coordination between the clinicians and the patients of the frequency visits and changes in the patients’ plan of care. .

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 the initial assessment visit within the 48 hours of completing the referral and failed to notify the patient’s home health physician of the delayed admission for 9 of 20 patients (Patients #104, #105, #108, #109, #110, #111, #115, #119, and #120). Failure to complete initial assessments within 48 hours of the referral and failure to notify the patient's home health physician if there are delays in admission 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, "HH Admission Criteria and Process 201-2," (Policy ID 10787101, Last Revised 07/2022) showed that agency staff will conduct an initial assessment within 48 hours of acceptance of a completed referral. 2. Record review for Patients #104, #105, #108, #109, #110, #111, #115, #119, and #120 showed: a. Patient #104’s Start of Care (SOC) date was 07/08/23. The patient was admitted for primary diagnoses of Diabetes Mellites and Right foot Pressure wound. The agency completed the referral on 07/01/23 for a Skilled Nursing (SN) assessment, but the SOC for SN services did not occur until 07/08/21. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. b. Patient #105’s SOC date was 07/25/23. The patient was admitted for primary diagnoses of Parkinson’s and Dysphagia. The agency completed the referral on 07/20/23 for a Physical Therapy (PT) assessment, but the SOC for PT services did not occur until 07/25/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. c. Patient #108’s SOC date was 08/31/23. The patient was admitted for primary diagnoses of Hemiplegia and Hemiparesis. The agency completed the referral on 08/28/23 for a PT assessment. The patient was discharged on 08/26/23, but the SOC for PT services did not occur until 08/31/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. d. Patient #109’s SOC date was 07/25/23. The patient was admitted for primary diagnoses of Orthopedic aftercare and Diabetes Mellites. The agency completed the referral on 07/18/23 for a SN assessment, but the SOC for SN services did not occur until 07/25/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. e. Patient #110’s SOC date was 06/27/23. The patient was admitted for primary diagnoses of Hypertension and Chronic Kidney Disease. The agency completed the referral on 06/14/23 for a SN assessment. The patient was discharged on 06/23/23, but the SOC for SN services did not occur until 06/27/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. f. Patient #111’s SOC date was 09/02/23. The patient was admitted for primary diagnoses of Right Femur Fracture and Osteoporosis. The agency completed the referral on 08/31/23 for a SN assessment, but the SOC for SN services did not occur until 09/02/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. g. Patient #115’s SOC date was 05/24/22. The patient was admitted for primary diagnoses of Multiple Sclerosis and Bilateral Pressure Ulcers on Buttocks. The agency completed the referral on 05/20/22 for a SN assessment, but the SOC for SN services did not occur until 05/24/22. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. h. Patient #119’s SOC date was 08/21/23. The patient was admitted for primary diagnoses of Multiple Sclerosis and Bilateral Pressure Ulcers on Buttocks. The agency completed the referral on 08/14/23 for a SN assessment, but the SOC for SN services did not occur until 08/21/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. i. Patient #120’s SOC date was 08/28/23. The patient was admitted for primary diagnoses of Cerebral Infarction and Hemiplegia. The agency completed the referral on 08/22/23 for a SN assessment, but the SOC for SN services did not occur until 08/28/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. 3. On 09/20/23 at 9:00 AM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #113) regarding the delayed SOC and lack of provider notification. Staff #113 acknowledged the findings and stated that they were unable to provide documentation that the agency notified patients’ providers of the delayed SOC.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on document review, 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 6 patients receiving HHA services (Patient #110, #112, and #120). Failure to supervise the HHA 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. Document review of the agency’s policy and procedure titled, “HH Home Health Aide (HHA) Services 200-9,” (Policy ID 12624960, Last Revised 10/2023) indicated there will be a supervisory visit assessment every 14 days of the care provided by the HHA. 2. Record review for 3 of 6 patient receiving HHA services (Patient #110, #112, and #120) showed: a. Patient #110’s Start of Care (SOC) was on 06/27/23 and was admitted with diagnoses of Hypertension and Chronic Kidney disease–not a complete diagnosis list. The Physician ordered Home Health aides services 2 times a week for 8 weeks, then weekly for 4 weeks starting on 06/28/23. There was no documentation of supervisory visits during the 8 weeks of 07/23/23-09/16/23. b. Patient #112’s Start of Care (SOC) was on 06/12/23 and was admitted with diagnoses of Cerebral Infarction and Dysphagia–not a complete diagnosis list. The Physician ordered Home Health aides services weekly for 5 weeks starting on 06/20/23. There was no documentation of supervisory visits during the 5 weeks of 06/20/23-07/22/23. c. Patient #120’s Start of Care (SOC) was on 08/28/23 and was admitted with diagnoses of Cerebral Infarction and Hemiplegia–not a complete diagnosis list. The Physician ordered Home Health aides services 1 to 2 visits weekly for 4 weeks starting on 09/04/23. There was no documentation of supervisory visits during the 2 weeks of 09/04/23-09/17/23. 3. On 09/20/23 at 3:00 PM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #113) regarding the lack of HHA supervisory visits. Staff #113 acknowledged the findings and stated that they were unable to provide documentation that HHA supervisory visits were conducted on the patients who had HHA services. .

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 operationalize its policies and procedures to remain compliant with state licensing requirements including implementation of a TB Program (Item #1), completion of annual performance evaluations (Item #2) for 12 of 12 personnel files (Staff #101, Staff #102, Staff #103, Staff #104, Staff #105, Staff #106, Staff #107, Staff #108, Staff #109, Staff #110, Staff #111, and Staff #112). The agency also failed to comply with state licensing requirements with client/patient bill of rights (Item #3) and for mandatory reporting of suspected abuse or neglect (Item #4). Failure to maintain and implement policies and procedures consistent with state home health regulations puts patients at risk of physical and/or psychological harm from inadequate or substandard care. Findings included: Item #1- TB Program Reference: Washington Administrative Code (WAC) 246-335-525 (15) (c): Tuberculosis (TB) infection control program. Key elements include, but are not limited to: (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; and (iii) Ensuring workers receive TB-related training and education at the time of hire or during new employee orientation. Training and education must be consistent with the department's tuberculosis program's online posted educational materials. 1. Document review of the agency policy titled, “Personnel Contractor and Volunteers, Home Health,” (Policy No. 9880293, Effective Date 05/2021), showed the agency will conduct TB risk assessments for all new employees upon hire and annually. The policy also showed that the agency will ensure that workers receive TB-related training and education at the time of hire or during orientation. 2. On 08/20/23, Surveyor #6 and Surveyor #2 (Orientee) reviewed the personnel files for 12 staff members. The record review showed: a. Staff #101 was hired on 07/05/22. The record contained no documentation to show that the agency provided TB-related training and education on hire. b. Staff #103 was hired on 05/09/21. The record contained no documentation to show that the agency provided TB-related training and education on hire. c. Staff #105 was hired on 05/10/20. The record contained no evidence that the agency conducted a TB risk assessment in 2021 and no documentation to show the agency provided TB-related training and education on hire. d. Staff #106 was hired on 11/25/19. The record contained no documentation to show that the agency provided TB-related training and education on hire. e. Staff #107 was hired on 04/25/22. The record contained no documentation to show that the agency provided TB-related training and education on hire. f. Staff #108 was hired on 03/09/12. The record contained no evidence that the agency conducted a TB risk assessment in 2021. g. Staff #109 was hired on 03/24/14. The record contained no evidence that the agency conducted a TB risk assessment in 2022. h. Staff #111 was hired as a contractor on 06/05/23. The record contained no evidence that the agency conducted a TB risk assessment on hire. i. Staff #112 was hired as a contractor on 08/08/23. The record contained no evidence that the agency conducted a TB risk assessment on hire. 3. On 08/20/23 at 12:00 PM, Surveyor #6 interviewed the agency’s Executive Director (Staff #114) and the Interim Director (Staff #113) about the missing TB risk assessments and documentation of TB-related education and training on hire in the staff files. Staff #113 and Staff #114 acknowledged the findings and stated that they were unable to provide TB-related documentation for the staff listed above. . Item #2- Performance Evaluation References: Washington Administrative Code (WAC) 246-335-530 (12): The licensee must maintain records on all personnel and volunteers and have access to records on all contractors, to include: Documentation of performance evaluations of personnel and volunteers providing direct patient care and evaluations of services provided by contractors providing direct patient care as required in WAC 246-335-525 (16) and (17). Washington Administrative Code (WAC) 246-335-525 (16) and (17): The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (16) Annual performance evaluations of all personnel and volunteers providing direct patient care, including on-site observation of care and skills specific to the care needs of patients; and (17) Annual evaluations of services provided by contractors providing direct patient care. Surveyor Note: The requirement of WAC 246-335-525(16) for on-site annual observation/evaluation of staff providing care was exempted by Washington State Register (WSR) 20-10-061, signed by the Secretary of Health on April 30, 2020. Annual performance evaluations of all personnel, including observation of care and skills, were still required, but could be done remotely (instead of on-site) using various electronic resources. This exemption ended on 10/31/22. 1. Document review of the agency policy titled, "Personnel Contractor and Volunteers, Home Health," (Policy No. 9880293, Effective Date 05/2021) showed that the performance evaluations of all personnel and volunteers providing direct patient care will be done annually and it includes on-site observation of care and skills. 2. On 08/20/23, Surveyor #6 and Surveyor #2 (Orientee) reviewed the personnel files for 12 staff members. The record review showed: a. Staff #106 was hired on 11/25/19. The staff record contained no evidence that the agency completed an annual performance evaluation in 2022. b. Staff #107 was hired on 04/25/22. The staff record showed an incomplete performance evaluation. There was no evidence of employee input and signature. c. Staff #109 was hired on 03/24/14. The staff record contained no evidence that the agency completed the annual evaluation with on-site observation in 2023. 3. On 09/20/23 at 12:00 PM, Surveyor #6 interviewed the agency’s Executive Director (Staff #114) and the Interim Director (Staff #113) about the missing performance evaluations in the personnel files. Staff #113 and Staff #114 acknowledged the findings and stated that they were unable to provide the performance evaluations for the staff listed above. Item #3 - Patient’s Bill of Rights References: Washington Administrative Code WAC 246-335-535 (4) and (19) Bill of Rights. (4) A statement advising of the right to have access to the department's listing of licensed home health agencies and to select any licensee to provide care, subject to the individual's reimbursement mechanism or other relevant contractual obligations; and (19) Be informed of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults. 1. Record review of the agency’s BoR showed the document lacked information about the patient’s right to include the patient’s right to have access to the Department of Health’s listing of licensed home health agencies and to select any licensee to provide care, subject to the individual’s reimbursement mechanism or other relevant contractual obligations, and to be informed of the Department of Social and Health Services End Harm hotline number to report suspected abuse of children of vulnerable adults. 2. On 09/20/23 at 10:00 AM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #113) regarding the missing BoR items. Staff #113 acknowledged the findings and updated the agency’s BOR document to include the missing items at the time of the survey. Item #4 -Mandatory Reporting References: Washington Administrative Code WAC 246-335-525 (8)(a) and (b) 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; (b) Mandatory reporters shall report suspected abandonment, abuse, financial exploitation, or neglect of a person in violation of RCW 74.34.020 or 26.44.030 to the department of social and health services and the proper law enforcement agency. Reports must be submitted immediately when the reporting person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred. 1. Document review of the agency’s policy and procedure titled, “Elder or child Abuse HH 300-10,” (Policy ID 13465190, Last Revised 04/2019) indicated that any home health staff member having suspected abuse or neglect is required to report directly to Adult Protective Services and their supervisor. The document also failed to include the department's requirements for mandatory reporting consistent with state regulations. 2. On 09/20/23 at 10:00 AM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #113) regarding the agency’s missing information regarding mandatory reporting. Staff #113 acknowledged the findings and stated that they were not aware of the missing mandatory reporting information. .