Every finding on record at Gentiva Certified Healthcare Corp

MEDICARE RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR 484, conducted this health and safety survey. Examination number: X2023 - 466 Dates Onsite: 09/25/23 - 09/28/23 This survey was conducted by: Surveyor #3 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.

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 implement policies and procedures consistent with state licensing requirements related to providing each patient with a written bill of rights affirming each patient's right to be informed of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults. Failure to include the DSHS end harm number in the agency's Bill of Rights denies patients access to the state abuse hotline number and increases their risk of harm from unreported abuse. Reference: WAC 246-335-535 (19) A home health agency at the time of admission must provide each patient, designated family member, or legal representative with a written bill of rights affirming each patient's right to: (19) Be informed of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults. Findings included: 1. Record review of "Section 2: Patient Rights and Responsibilities" in the agency's admission packet and "Patient's Guidebook for Home Healthcare," showed no evidence of the patient's right to be informed of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults. 2. Record review of an additional document titled "Patient Bill of Rights," effective 07/01/19, located in the agency's admission packet, also showed no evidence of the patient's right to be informed of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults. 3. Record review of an additional undated document titled "Patient Bill of Rights Addendum Washington," located in the agency's admission packet, also showed no evidence of the patient's right to be informed of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults. 4. Record review of the agency's "Patient Guidebook for Home Healthcare," showed that the agency adheres to all guidelines regarding reporting acts of abuse, neglect or exploitation of patients and reportable conduct by an employee, volunteer or contractor of the agency. If the agency has cause to believe that a patient has been abused, neglected or exploited, the agency must report this information as soon as possible. Reports of abuse, neglect or exploitation may be reported by anyone to the local office. The "Patient Guidebook for Home Healthcare" showed no evidence of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults. 5. Record review of the agency's admission packet showed a copy of the agency's policy titled; "WA 03-06 Abuse Policy" revised 11/08/18. The policy stated that instead of company policy when there is reasonable cause to believe that abuse, financial exploitation, neglect, or abandonment of a vulnerable adult has occurred mandatory reporters must immediately report to DSHS. All employees are mandated reporters and are responsible to contact DSHS directly. Reports of abuse or neglect must be made by calling the DSHS End Harm number at 1-866-363-4276. The policy addresses the responsibilities of mandatory reporters for reporting suspected abuse and neglect. The policy does not include information for the patient on reporting suspected abuse and neglect through the DSHS End-Harm number. 6. On 09/26/23 at 3:00 PM, Surveyor #3 interviewed the agency' s Branch Director (Staff #301) about the Patient Bill of Rights. Staff #301 stated that the agency has a Washington state specific Patient Bill of Rights policy in the agency's policy and procedure manual that includes all required elements of the Washington state patient Bill of Rights. Staff #301 provided Surveyor #3 with a copy of the policy titled, "State of Washington Patient Bill of Rights Addendum." The policy was not included in the admission packet. Staff #301 stated that they were unaware that the addendums included in the admission packet did not include the DSHS End-Harm number. Staff #301 also stated that the agency provides the patients with a copy of the agency's abuse policy that includes the DSHS End-Harm number in the admission packet.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: . Based on document review, inspection, and interview, the home health agency failed to implement policies and procedures for removing expired supplies and devices from the patient inventory supply room. Failure of the agency to monitor and ensure that products and devices do not go beyond the manufacturer’s expiration date may put patients at risk of bodily harm. . 1. Document review of the agency policy titled, “Medical Supply Management and Bundled Supplies,” (Policy No. 05-11, Revised 05/2023) showed that the clinical manager will inspect supplies every 30 days for expiration dates. It also showed that expired or damaged supplies will be removed from the inventory by the clinical manager. 2. On 09/27/23 at 2:00 PM, Surveyor #6 conducted an inspection of the agency’s patient supply room. The Surveyor found several boxes of expired catheter irrigation kits, urinary catheters, povidone iodine swabs, and a set of blood culture bottles. The Surveyor separated the expired supplies and devices from the inventory and showed them to the agency’s Branch Director (Staff #301). 3. On 09/27/23 at 3:00 PM, Surveyor #6 interviewed the agency’s Branch Director (Staff #301) about the expired supplies and devices found in the supply room. Staff #301 stated that the agency clinical manager inspects the supply room every month and acknowledged the findings. .