Every finding on record at Glacier Peak Healthcare Inc.

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: 2024-524 Dates Onsite: 06/24/24 – 06/27/24 This survey was conducted by: Surveyor #6 Surveyor #2 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 discharged patient data to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for 87 of 6290 records transmitted between 05/01/23 and 05/31/24. 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 05/01/23 and 05/31/24 generated from the iqies.cms.gov website. The review showed that the agency had 87 of 6290 patient assessments that were not submitted in a timely manner. This resulted in a 1.38% late submission error rate. 2. On 06/26/24 at 2:00 PM, Surveyor #6 interviewed the Director of Clinical Services (Staff #601) regarding the error rate. 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 notified the corporate leadership about the agency's error percentage, the new CMS requirements, and that they will make changes in their workflow processes to be in compliance.

MEDICARE HOME HEALTH 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. Onsite dates: 08/30/21 - 09/03/21 Examination number: 2021-663 The survey was conducted by: Surveyor #3 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. .

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . . Based on observation, document review and interview, the agency failed to ensure staff wore eye protection consistent with agency policy and Washington State regulations for 7 of 7 Home Health staff (Staff #301, #302, #303, #304, #305, #306, and #307). Failure to ensure staff wear eye protection when performing patient care places patients and staff at risk to exposure to infectious organisms including COVID-19. Reference: WAC 246-335-525(15) personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment; WAC 206-800-160 You must make sure that your employees have, use, and care for the appropriate personal protective equipment (PPE). PPE is an item or items used to protect the eyes, face, head, body, arms, hands, legs, and feet such as goggles, helmets, head covers, gloves, rubber slickers, disposable coveralls, safety shoes, protective shields, and barriers. DOH 420-299 (issued 06/09/21) Covid -19 Guidance for Home Care, Home Health, and Hospice agencies: When community transmission is moderate or high (>25/100,000 cases in 2 weeks according to DOH COVID-19 cases and testing by County), healthcare providers should wear a surgical face mask and eye protection for ALL patient care encounters, regardless of patient/client COVID-19 status. WAC 296-800-16040 You must require your employees to use necessary PPE on the job. 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 ( updated 07/07/2021) showed that In-home care agencies are required to develop and maintain a Respiratory Protection Program (RPP) under WAC 296-842-12005. The document also showed that agencies are required to provide gowns, gloves, and eye protection to staff who are entering patient's homes. The document further stated that staff must wear eye protection when there is moderate to substantial community transmission of COVID-19. The document defined eye protection as, goggles or a face shield that covers the front and sides of the face. The document stated that personal eyeglasses are not PPE and do not provide adequate eye protection. Document review of the guidance document issued by the Department of Health( DOH) titled, Covid -19 Guidance for Home Care, Home Health, and Hospice agencies DOH 420-299 (issued 06/09/21)" States, "When community transmission is moderate or high (>25/100,000 cases in 2 weeks according to DOH COVID-19 cases and testing by County), healthcare providers should wear a surgical face mask and eye protection for ALL patient care encounters, regardless of patient/client COVID-19 status". Document review of the agency policy titled, "Covid-19 Exposure Control Plan policy no. 6-028.1 (no revision date)", showed staff are required to wear a facemask and eye protection at every visit. Document review of DOH licensing information showed this agency serves patients in San Juan, Skagit and Snohomish counties. 14-day case rate (per 100,000) data reported in the DOH Covid-19 Summary Tables at the time of the survey showed the case rate in San Juan County was 126.9, the case rate in Skagit County was 505.9 and the case rate in Snohomish County was 394.5. All the rates for counties in the agency's service areas indicated high levels of community transmission. 2. On 08/31/21 between 8:30 AM and 9:30 AM, Surveyor #3 conducted a home visit with a Licensed Practical Nurse (Staff #306). The surveyor observed that Staff #306 failed to wear approved eye protection during the home visit with Patient #306. 3. On 08/31/21 between 10:30 AM and 11:30 AM, Surveyor #3 conducted a home visit with a Physical Therapist (Staff #302). The surveyor observed that Staff #302 failed to wear approved eye protection during the home visit with Patient #307. 4. On 08/31/21 between 12:00 PM and 1:00 PM, Surveyor #3 conducted a home visit with a Registered Nurse (Staff #303). The surveyor observed that Staff #303 failed to wear approved eye protection during the home visit with Patient #308. 5. On 08/31/21 between 1:30 PM and 2:30 PM, Surveyor #3 conducted a home visit with an Occupational therapist (Staff #305). The surveyor observed that Staff #305 failed to wear approved eye protection during the home visit with Patient #309. 6. On 08/31/21 between 3:00 PM and 4:00 PM, Surveyor #3 conducted a home visit with a Certified Nurse Aid (Staff #301). The surveyor observed that Staff #301 failed to wear approved eye protection during the home visit with Patient #310. 7. On 09/01/21 between 10:30 AM and 11:30 AM, Surveyor #3 conducted a home visit with a Speech Language Pathologist (Staff #307). The surveyor observed that Staff #307 failed to wear approved eye protection during the home visit with Patient #311. 8. On 09/01/21 between 1:00 PM and 2:00 PM, Surveyor #3 conducted a home visit with an Occupational therapist (Staff #304). The surveyor observed that Staff #304 failed to wear approved eye protection during the home visit with Patient #312. 9. On 08/31/21 at 8:30 AM Surveyor #3 interviewed Staff #306 about the use of eye protection during home visits. Staff #306 stated that no shields were required at this time. 10. On 09/01/21 at 2:45 PM Surveyor #3 interviewed the Agency Executive director (Staff #308) about the staff use of eye protection during home visits. Staff # 308 stated that eye protection had been required during the height of the Covid outbreak and the agency had stopped requiring eye protection at the time of the state's economic re-opening on June 30, 2021. .

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 clients 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. Document review of the agency's Bill of Rights and Patient admission handbook (no revision date) showed the Bill of Rights did not include a statement about the right to be informed of the DSHS end harm hotline number used to report suspected abuse of children or vulnerable adults. 2. On 09/03/21 At 9:31 AM Surveyor #3 interviewed the Clinical Manager (Staff #309) about the missing elements in the Bill of Rights document. Staff #309 acknowledged the Bill of Rights did not contain this information.