Every finding on record at Cp Spokane Wa Hh, 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: X2026-217 Dates Onsite: 03/17-19/26 This survey was conducted by: Surveyor #5 Surveyor #2 (Orientation) Surveyor #4 (Orientation) DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. . . . . . .

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement policies and procedures to complete Washington State disclosure statements on hire and every two years for 2 of 5 Clinicians (Staff #405 and Staff #411) and 2 of 2 contractors working with vulnerable adults (Contractor #408 and Contractor #410). Failure to establish clear policies on completion of disclosure statements increases the risk of employing individuals who may not meet the required standards for working with vulnerable populations. Without proper screening procedures, the agency cannot ensure compliance with state regulations, potentially compromising patient safety. References: WAC 246-335-525 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (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: (b) Disclosure statements must be approved by the department; and (c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check. Findings included: 1. Document review of the agency's policies and procedures showed that the agency lacked required policies addressing the completion of a Washington state disclosure statement on hire and every two years. 2. On 04/19/26 Surveyor #4 completed a review of personnel records that showed: a. Staff #405, a Registered Nurse, had a hire date of 01/05/26. There was no documentation in the record to show a disclosure statement was completed on hire to present. b. Staff #411, a Physical Therapist, had a hire date of 05/01/25. There was no documentation in the record to show a disclosure statement was completed on hire to present. c. Staff #408, a contracted Registered Nurse, had a hire date of 05/01/25. There was no documentation in the record to show a disclosure statement was completed on hire to present. d. Staff #410, a contracted Registered Nurse, had a hire date of 11/10/25. There was no documentation in the record to show a disclosure statement was completed on hire to present. 3. On 03/19/26 at 11:00 AM, Surveyor #4 interviewed the agency’s Executive Director (Staff #401) and the agency’s Business Office Manager (Staff #404) regarding the missing disclosure statements. Staff #401 and #404 stated that personnel records for contracted clinicians are maintained by the contractor company and cannot be accessed directly by the agency. Staff #401 stated that they were unaware the records for the direct care staff did not contain the disclosure statements. Staff #401 was unable to provide a policy that addressed the completion of disclosure statements on hire for clinicians.

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR Part 484 conducted this health and safety survey. Examination Number 2023-561 Dates Onsite: 07/17/23, 07/18/23, 07/19/23, 07/20/23 The survey was conducted by: Surveyor #4 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement policies and procedures to ensure staff disclosure statements were renewed within two years of the previous disclosure statement for 5 of 7 staff (#403, #405, #406, #407, #408). Failure to maintain compliance with state licensing requirements puts patients at risk for harm from abuse and neglect. References: Washington Administrative Code WAC 246-335-525 (6) Personnel, contractor, and volunteer policies. The 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 other individuals associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following: (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. 1. On 07/17/23 Surveyor #4 reviewed the personnel files for 5 of 7 staff (#403, #405, #406, #407, #408). The review showed: a. Staff #403 signed a disclosure form on 05/13/21. No subsequent disclosure form was found in the record. b. Staff #405 signed a disclosure form on 05/24/21. No subsequent disclosure form was found in the record. c. Staff #406 signed a disclosure form on 05/14/21. No subsequent disclosure form was found in the record. d. Staff #407 signed a disclosure form on 05/11/21. No subsequent disclosure form was found in the record. e. Staff #408 signed a disclosure form on 05/21/21. No subsequent disclosure form was found in the record. 3. Surveyor #4 interviewed the agency Director (Staff #401) about the missing disclosure forms. Staff #401 acknowledged the findings and stated that the agency had been renewing disclosures based on the calendar year rather than within two years of the previous disclosure.

MEDICARE 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: X2019-1026 Dates Onsite: 05/24/21-05/27/21 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. . .

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 a record review and interview the agency failed to conduct the initial assessment visit within 48 hours of receiving a referral for 2 of 17 patients. (Patient's # 510, 512). 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. Document review of the patients' medical records showed: a. Patient #510's record showed a referral date of 04/09/21. The Registered Nurse (RN) completed the initial assessment on 04/12/21. There was no documentation that the patient's physician received notification of the delayed assessment and start of care. b. Patient #512's record showed a referral date of 12/12/20. The RN completed the initial assessment on 12/15/20. There was no documentation that the patient's physician received notification of the delayed assessment and start of care. 2. Surveyor #5 interviewed the Clinical Manager (Staff #508) on 05/27/21 at 11:00 AM about the delayed initial assessments for Patients #510 and #512. Staff #508 verified that the assessments were not completed in the 48-hour timeframe. THIS IS A REPEAT CITATION FROM 05/11/17 TAG 332 (Eff. 11/09/2009-11/28/2019) .