Every finding on record at Emerald Healthcare, Inc.

. MEDICARE FOCUSED INFECTION CONTROL SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR Part 484 for Home Health, conducted a Medicare COVID-19 Focused Infection Control Survey for Non-Long-Term Care. Onsite date(s): 06/01/21 - 06/04/21, and 06/07/21 Examination number: X2021-437 This survey was conducted by: Surveyor # 6 DOH found the facility in substantial compliance with the infection control standards as they relate to the response to the Covid-19 pandemic except those standard-level deficiencies listed below. .

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 the referral date for 4 of 12 patient records (Patient #604, #605, #606, and #610). 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 undated policy titled, "Initial and Comprehensive Assessment (Policy No. 2-007.1)." The policy showed that the agency must complete an initial assessment either within 48 hours of the referral, within 48 hours of the patient's return home, on the start of care date ordered by the physician, or at the patient/family request with the approval of the physician. 2. Surveyor #6 reviewed the record of Patient #604. The record showed: a. The agency received a physician signed referral for home health services on 03/19/21 for Patient #604. b. On 03/24/21, the agency received a physician ordered start of care date for 03/29/21. 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 03/23/21. 3. Surveyor #6 interviewed the Director of Clinical Services, (Staff #602) about the missing documentation on 06/04/21 at 8:55 AM. Staff #602 was unable to locate documentation that justified the delay in the initial assessments and acknowledged the missing information for Patient #604. Staff #602 agreed that there was no physician communication prior to 03/23/21. 4. Surveyor #6 reviewed the record of Patient #605. The record showed: a. The home health services referral date for Patient #605 was 10/29/20. b. On 10/30/20 at 12:00 PM, a Registered Nurse (Staff #609), called Patient #605 and left a voice message to schedule the start of care on Monday (11/02/20). c. Staff left voice messages for the patient on 11/03/20 and on 11/04/20. d. On 11/04/20, an RN (Staff #606) drove to the patient's home. Staff #606 noted in the record that the family said they did not want services and that the patient's son would call tomorrow. e. The patient's son called on 11/13/20 and the agency scheduled the admission for 11/16/20. f. The agency completed the initial assessment on 11/16/20, 18 days after the referral date. Documentation as to the reason for the delay in start of care (SOC) to 11/02/20 and physician notification was absent from the record. Documentation of physician notification of the patient declining services on 11/04/21 and then requesting services again on 11/13/21 were absent from the record. 5. Surveyor #6 interviewed Staff #602 on 06/04/21 at 10:05 AM about the missing documentation. Staff #602 was unable to locate documentation that justified the delay in the initial assessment request for 11/02/20 and acknowledged the missing information for Patient #605. 6. Surveyor #6 reviewed the record of Patient #606. The record showed: a. The home health services referral date for Patient #606 was 02/27/21. b. On 02/27/21, the agency notified the referring provider via voice message that the date on their referral was 12/10/20. c. On 03/02/21 the agency received a new referral from the provider. d. On 03/08/21, the agency spoke with the patient's spouse and scheduled the admission for 03/10/21. e. The agency completed the initial assessment on 03/10/21, 11 days after the referral date. Documentation as to the reason for the delay and physician notification was absent from the record. 7. Surveyor #6 interviewed Staff #602 about the missing documentation on 06/04/21 at 10:45 AM. Staff #602 was unable to locate documentation that justified the delay in the initial assessments and acknowledged the missing information for Patient #606. 8. Surveyor #6 reviewed the record of Patient #610. The record showed: a. The home health services referral date for Patient #610 was 03/30/21. b. The agency spoke with the patient on 04/03/21 and scheduled the SOC for 04/06/21. c. The agency completed the initial assessment on 04/08/21, 9 days after the referral date. Documentation as to the reason for the delay and physician notification was absent from the record. 9. Surveyor #6 interviewed Staff #602 about the missing documentation on 06/04/21 at 12:28 PM. Staff #602 was unable to locate documentation that justified the delay in the initial assessments and acknowledged the missing information for Patient #610.

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 facility failed to properly prevent COVID-19.The agency failed to provide health screenings of Home Health staff prior to issuing N-95 masks, and failed to ensure staff received a fit test prior to N-95 face mask use, consistent with Washington State regulations for 2 of 4 Staff ( Staff #606 and Staff #607). Failure to develop a method of performing health screenings and fit testing for proper N-95 mask use for staff may result in the risk of staff and patients' exposure to respiratory infections including COVID-19. Reference: 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 RPP should be completed before fit testing for respirators. A "fit test" is a procedure that tests the seal between the respirator's facepiece and the health care workers (HCW) face. It includes a medical evaluation and 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, "COVID-19 Preparedness Plan - Corona Virus Action Plan (Addendum 7-001.A)," showed that staff will don appropriate PPE prior to entering home. Document review of the agency's undated policy titled, "Tuberculosis Exposure Plan (Policy No. 9-002.1)" showed that "home health personnel will attend an in-service on the use of a NIOSH-certified N95 mask and will undergo fit testing based on organization's risk assessment or when a patient has been identified with known or suspected TB. 2. Surveyor #6 interviewed a Physical Therapy Assistant (Staff #607) on 06/03/21 at 1:10 PM about the agency's COVID-19 response plan and PPE they had received. Staff #607 stated that, they had received an N-95 face mask, but that they had not been fit tested. 3. Surveyor #6 interviewed a Registered Nurse (Staff #606) on 06/03/21 at 2:45 PM about the agency's COVID-19 response plan and PPE they had received. Staff #606 stated that, they had received an N-95 face mask, but that they were not fit tested. 4. Surveyor #6 interviewed the agency's Director of Clinical Services (Staff #602) on 06/04/21 at 11:20 AM about the agency's N-95 fit testing process. Staff #602 stated, "We do not fit test." At the time of the interview, Surveyor #6 asked Staff #602 to provide the agency policy on fit testing. Staff #602 provided Surveyor #6 the agency's undated policy, "Tuberculosis Exposure Plan (Policy No. 9-002.1)". 5. Surveyor# 6 interviewed the Director of Quality Improvement (Staff #604) on 6/07/11 at 2:15 PM about the agency's COVID-19 Action plan and N-95 mask fit testing procedures. Staff #604 provided Surveyor #6 with the agency's undated policy, "COVID-19 Preparedness Plan - Corona Virus Action Plan (Addendum 7-001.A)" and the agency's undated policy, "Tuberculosis Exposure Plan (Policy No. 9-002.1). Staff #604 stated that, they do not have a process in place for fit testing or medical evaluations of staff for N-95 mask use. Staff #604 acknowledged that, fit testing and medical evaluations for N-95 face mask use, are not a part of the agency's current COVID-19 response plan.

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 skilled nursing or professional services visits as ordered by the physician for 5 of 12 patients (Patients #601, #602, #603, #608, and #609), including failure to schedule skilled nursing visits, failure to schedule Home Health Aide (HHA) visits, and failure to schedule Occupational Therapist (OT) visits. Failure to schedule skilled nursing and 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, "Staffing and Scheduling," (Policy NO. 2-031.1) showed the clinical supervisor or designee will consult the Clinical Director or Executive Director/Administrator regarding any daily staffing issues that cannot be resolved. The policy also showed that patient care will not be interrupted due to staff absences and that the director of nursing will ensure appropriate staff assignments and coverage. The policy showed that in the event an ordered service cannot be performed, the physician will be notified, and new order were to be obtained and the patient was to be referred to another agency which provided the needed services. Document review of the agency's undated policy titled, "Informed Consent/Refusal of Treatment," (Policy NO. 1-002.1) showed the patient will be informed of the expected consequences whenever they elect to refuse any treatment or care. The policy requires that staff document missed/refused visits and physician notifications in the clinical record and that the documentation include: the date and time of visit, the specific care or treatment that was being refused, and the physician notification date and time. 2. Surveyor #6 reviewed the record of Patient #601. The record showed: a. Patient #601 had a Start of Care (SOC) order on 04/07/20. b. The physician ordered skilled nursing 2 times per week for 2 weeks, then 1 time per week for 4 weeks. c. The patient received no nursing visits the week of 05/03/20. d. On 05/11/20 the record showed the visit as caregiver/patient refused. The staff failed to document that the patient was informed of the expected consequences from refusal of care. 3. On 06/02/21 at 2:42 PM, Surveyor #6 interviewed the agency's Director of Clinical Services (Staff #602), about the missed visit for Patient #601. Staff #602 acknowledged that there was no documentation in the record that the patient was informed of the expected consequences of their refusal of care. 4. Surveyor #6 reviewed the record of Patient #602. The record showed: a. Patient #602's physician ordered OT visits 2 times per week for 4 weeks starting on 06/01/20. b. There were two missed visits the week of 06/07/21. Documentation as to the reason for the missed visits and physician notifications were absent from the record. The staff failed to document that the patient was informed of the expected consequences from refusal of care. 5. On 06/02/21 at 3:49 PM, Surveyor #6 interviewed Staff #602, about the missed visits for Patient #602. Staff #602 acknowledged that there was no documentation in the record about the missed visits or physician notifications. Staff #602 also acknowledged that there was no documentation in the record that the patient was informed of the expected consequences of the care that was refused. 6. Surveyor #6 reviewed the record of Patient #603. The record showed: a. Patient #603 had an SOC on 11/25/20. b. On 11/18/20, the physician ordered HHA visits 1-2 times per week for 3 weeks. Documentation as to the reason for the missed visits and physician notifications were absent from the record. The staff failed to document that the patient was informed of the expected consequences from refusal of care. 7. On 06/03/21 at 8:36 AM, Surveyor #6 interviewed Staff #602, about the missed visits for Patient #603. Staff #602 stated that, there were never any HHA services provided to the patient. Staff #602 stated that their system only allows for 3 service types to be put into the SOC admission, and that any additional visits from other disciplines need to be manually added on the calendar. Staff #602 stated, "I think they did not add HHA/Bath Aide services, so it never showed up to track." Staff #602 acknowledged that there was no documentation in the record about the missed visits or physician notifications. Staff #602 also acknowledged that there was no documentation in the record that the patient was informed of the expected consequences of for refusing care. 8. Surveyor #6 reviewed the record of Patient #608. The record showed: a. Patient #608 had an SOC on 05/14/21. b. The physician ordered OT visits effective 05/23/21 occurring 2 times a week for 3 weeks. c. One OT visit occurred during the week of 05/23/21 to 05/29/21. d. The staff documented the reason for the missed visit as a failure to assign it on the calendar. 9. On 06/07/21 at 11:20 AM, Surveyor #6 interviewed Staff #602, about the missed visits for Patient #608. Staff #602 acknowledged the record did not indicate the missed visit was due to patient request/refusal. Staff #602 stated, they were not sure why it was not scheduled in the calendar. 10. Surveyor #6 reviewed the record of Patient #609. The record showed: a. Patient #609 had an SOC on 05/20/21. b. On 05/30/21, the referring physician ordered OT visits 2 times per week for 3 weeks. c. The record also showed that Patient #609 had one visit the week of 05/30/21 to 06/05/21. The staff documented the reason for the missed visit as 'schedule change.' The record did not indicate the missed visit was due to patient request/refusal nor was there a documented reason for the schedule change. 11. On 06/07/21 at 11:48 AM, Surveyor #6 interviewed Staff #602 about the missed visit for Patient #609. Staff #602 acknowledged that the record did not indicate the missed visit was due to patient request/refusal. Staff #602 agreed the record did not indicate why the schedule was changed and failed to note which staff member changed the schedule.