Every finding on record at Harbors Home Health/Hospice

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: X2025-150 Dates Onsite: 04/08/25, 04/09/25, 04/10/25 This survey was conducted by: Surveyor #1 Surveyor #5 DOH staff found the facility NOT IN COMPLIANCE with the following Conditions of Participation: 42 CFR 484.55 Conditions of Participation for Comprehensive Assessment for Patients. 42 CFR 484.60 Care planning coordination, quality of care During the course of the survey, the surveyors investigated issues related to the State Complaints 2025-3117 and 2025-2394. There were findings related to the complaints. .

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: . Based on document review, record reviews and interviews, the agency failed to provide proper written notice of the Medicare-covered care prior to discharge for 4 of 19 patients (Patients # 115, #116, #119, and #518). Failure to provide proper written notice prior discharge prevent patients from exercising their rights to dispute early discharge from services. . Findings included: 1. Document review of agency's policy titled, "Discharge Criteria and Process," (Policy No-HOS-PCTS-2-071.1, Dated: March 2025) showed the agency will issue a Notice of Medicare Non-Coverage (NOMNC) form at least 48 hours prior to termination of services. 2. Record review of patient records Patients # 115, #116, #119, and #518 showed: a. Patient #115 was admitted on 08/20/24 with a primary diagnosis of Joint Replacement Surgery. On 10/18/24 the patient was discharged from the agency. The patient’s records had no documentation to indicate a NOMNC form was given to the patient prior to termination of services. b. Patient #116 was admitted on 06/24/24 with a primary diagnosis of Sepsis. On 10/17/24 the patient was discharged from the agency. The patient’s records had no documentation to indicate a NOMNC form was given to the patient prior to termination of services. c. Patient #119’s SOC date was 01/16/25. The patient was admitted for primary diagnosis of Chronic Kidney Disease with Heart Failure-Stage 4. On 01/21/25 the patient was discharged from the agency. The patient’s records had no documentation to indicate a NOMNC was given to the patient prior to termination of services.. d. Patient #518’s SOC date was 11/23/20. The patient was admitted for primary diagnosis of Pressure Ulcer of Right Heel-Stage 2. On 12/31/24 the patient was discharged from the agency. i. The patient’s discharge summary dated 12/31/24 showed that the patient’s goals were unattainable, and the patient was being discharged due to non-compliance resulting in danger to self. The post discharge goals included to seek appropriate level of care due to the patient’s medical complexity. ii. A communication note dated 12/20/24 and created on 01/01/25 showed that a Registered Nurse spoke to the patient on the telephone and explained that the patient was being discharged due to extreme self-destructive behaviors observed by agency staff in addition to reports from caregivers and Emergency medical Technicians that visited the home. iii. The patient’s records had no documentation to indicate a NOMNC form was given to the patient prior to termination of services. 3. On 04/10/25 at 10:30 AM, Surveyors #1 and #5 interviewed the agency’s Chief Operations Officer (Staff#111) regarding the lack of documentation of providing the NOMNC form prior to termination of services. Staff #111 acknowledged the findings and stated that they were not able to provide any documentation regarding the NOMNC forms. .

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: . Based on document review, record review and interviews, the agency failed to show that the patient’s behaviors and circumstances to the extent that delivery of care to the patient or the ability of the agency to operate effectively was seriously impaired that warranted the patient’s discharge for cause for patient #119. Failure to determine appropriate discharge for cause of a patient may potentially cause patient abandonment and neglect. . Findings included: 1. Document review of agency's policy titled, "Discharge Criteria and Process," (Policy No-HOS-PCTS-2-071.1, Date: March 2025) showed that if the agency terminates services due to the patient’s behavior, the behavior of other persons in the patient’s home, or situation, the clinical record must identify the problems encountered, assess the situation, communicate with organization management, notify the responsible physician responsible, establish a plan to resolve the issues, and document results of the plan implemented. 2. Record review of Patients #119’s medical records showed the following: a. The start of care was on 01/16/25 and the initial comprehensive assessment was completed by a Registered Nurse. The physician ordered Skilled Nursing (SN) services for wound care 2 times a week for 2 weeks and 4 as needed (PRN) visits, and Physical Therapy (PT) services for therapy for 1 time a week for 3 weeks, and then 2 times a week for 1 week. b. Record review showed that the patient lived in a housing unit for paroled sex offenders. c. Record review of the agency’s SN visit note titled, “Prep Notes Communication,” (Dated 01/21/25) showed a routine SN was completed where the patient received wound care per care plan. In addition, the nurse documented that the patient was respectful and cooperative with the nurse, and that the nurse wrote, “…at no point in time did the SN feel unsafe”, during the visit. There was no documentation to show that there was any issues with the patient’s behavior, the behaviors of other people in the patient’s home, or the situation. d. Record review of the agency’s PT visit note titled, “Prep Notes Communication, “(Dated 01/21/25) showed a PT evaluation was completed. Further documentation showed that the patient agreed and understood the home exercise instructions and that the next visit was planned. There was no documentation to show that there was any issues with the patient’s behavior, the behaviors of other people in the patient’s home, or the situation. e. A Physician Communication note dated 01/22/25 showed that the agency discharged the patient from Home Health services due to the unsafe environment for staff due to living location. f. There is no documentation to show that the agency identified the specific problems encountered, established a plan to resolve the issues, and document the results of the implemented plan. 3. On 03/10/25 at 1:00 PM, the Surveyor #1 interviewed the agency’s Chief of Operations Officer (Staff #111) and the agency’s Chief Executive Officer (Staff #113) regarding the discharge situation of Patient #119. Staff #113 stated that the safety concerns were addressed by one clinician who stated that they did not feel safe because it was a halfway house for paroled sex offenders. In addition, Staff #113 stated that documentation could have been better and that there was room for improvements with this situation. .

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: . Based on document review, record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral (repeated non-compliance from previous survey). Failure to conduct initial assessments within 48 hours of completing the referral puts patients at risk of physical harm due to to not receiving services in a timely manner. Findings Included: 1. Failure to conduct the initial assessment visit within 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 8 of 19 patients. 2. Repeated non-compliance identified in recertification survey conducted on 04/13/22. The agency was previously cited under Tag G0514, Initial Assessment Visit, 42.CFR 484.55(a)(1), for failure to do the initial assessment within forty-eight hours of referral, or forty-eight hours of the patient’s return home, or on the physician-ordered start of care date. Based on the scope and severity of deficiencies identified under 42 CFR 484.55 Condition of Participation: Comprehensive assessment of patients is NOT MET. Cross Reference: G0514 .

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 reviews, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 8 of 19 patients (Patients #103, #106, #108, #109, #113, #114, #116 and #118) Failure to meet this requirement 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, "Initial and Comprehensive Assessment," (Policy No-HH-PCTS-2-007, Date: October 2024) showed the initial assessment will be conducted within 48 hours of the referral. 2. Record review of patient records Patients #103, #106, #108, #109, #113, #114, #116 and #118 showed: a. Patient #103’s Start of Care (SOC) date was 10/23/23. The patient was admitted for primary diagnosis of Infection of skin and tissue. The referral was dated 10/18/23 for a Skilled Nursing (SN) initial assessment, and the SOC for the SN services did not occur until 10/23/23. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. b. Patient #106’s SOC date was 01/29/20. The patient was admitted for primary diagnosis of Pressure Ulcer of Sacral Region-Stage 4. The referral was dated 01/24/20 for a SN initial assessment, and the SOC for SN services did not occur until 01/29/20. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. c. Patient #108’s SOC date was 11/04/24. The patient was admitted for primary diagnosis of Burn of First Degree of Buttocks. The referral was dated 10/30/24 for a SN initial assessment, and the SOC for SN services did not occur until 11/04/24. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. d. Patient #109’s SOC date was 12/10/24. The patient was admitted for primary diagnosis of Juvenile Osteochondrosis of head of Left Femur. The referral was dated 10/30/24 for a Physical Therapist (PT) initial assessment, and the SOC for PT services did not occur until 12/10/24. There was no documentation as to why PT services were not conducted within the 48 hours of the referral date e. Patient #113’s SOC date was 11/20/23. The patient was admitted for primary diagnosis of Pneumonia. The referral was dated 11/17/23 for a SN initial assessment, and the SOC for SN services did not occur until 11/20/23. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. f. Patient #114’s SOC date was 12/02/24. The patient was admitted for primary diagnosis of Sepsis. The referral was dated 11/27/24 for a SN initial assessment, and the SOC for SN services did not occur until 12/02/24. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. g. Patient #116’s SOC date was 06/24/24. The patient was admitted for primary diagnosis of Cellulitis of the Lower Left Extremities. The referral was dated 06/21/24 for a SN initial assessment, and the SOC for SN services did not occur until 06/24/24. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. h. Patient #118’s SOC date was 11/23/20. The patient was admitted for primary diagnosis of Pressure Ulcer of Right Heel-Stage 2. The referral was dated 11/20/20 for a SN initial assessment, and the SOC for SN services did not occur until 11/23/20. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. 3. On 04/10/24 at 10:30 AM, Surveyor #1 interviewed the agency’s Chief Operations Officer (Staff#111) regarding the lack of documentation of the delayed SOC services. Staff #111 acknowledged the findings and stated that the agency conducts the SOCs within the 48 hours of the referral but stated that they were not able to provide documentation of the delayed SOC services. This is a REPEAT CITATION, previously cited in the last CMS survey completed on 04/13/22. .

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: . Based on document review, record review and interview, the agency failed to ensure that services in the plan of care are provided for 5 of 19 patients (repeated non-compliance from previous survey). Failure to follow the plan of care could place the patient at risk of worsening symptoms of existing diagnoses. Findings Included: 1. Failure to ensure that there was reasonable determination for each of the missed visits in the plan of care for 5 of 19 patients. 2. Repeated non-compliance identified in recertification survey conducted on 04/13/22. The agency was previously cited under Tag G0572, Plan of Care, 42.CFR 484.60.(a)(1), for failure to communicate with the patient's physician of missed visits resulting in changes to the patient plan of care. Based on the scope and severity of deficiencies identified under 42 CFR 484.60 Condition of Participation: Care planning, coordination of services, and quality of care is NOT MET. Cross Reference: G0572 .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: . Based on document review, record review and interview, the agency failed to ensure that there was reasonable determination for each of the missed visits in the plan of care for 5 of 19 patients (Patients #101, #105, #113, #115, and #116). Failure to follow the plan of care could place the patient at risk of worsening symptoms of existing diagnoses. . Findings included: 1. Document review of agency’s policy titled, “Missed Visits,” (Policy NO-HH-PCTS-2-059, Dated: March 2025) showed that all missed visits will be documented with the reasons for the missed visits, physician notification, description of any unmet needs and how the patient’s needs were met, and any other follow-up needed. 2. Record review of patient records for Patients #101, # 105, #113, #115, and #116 showed: a. Patient #101 was admitted on 01/08/25 with a primary diagnosis of Osteomyelitis of Vertebra-Thoracic Region. On 01/12/25, the physician ordered Skilled Nursing (SN) services for the patient 2 times per week for 1 week, then 1 time per week for 5 weeks. During the weeks of 01/19/25 and 02/02/24, the patient received no SN visits for each week. The record had no documentation to indicate the missed SN visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed SN visits. On 01/08/25, the physician ordered Home Health Aide (HHA) services for the patient 1 time a week for 6 weeks. During the weeks of 02/02/25 and 03/02/24, the patient received no HHA visits for each week. The record had no documentation to indicate the missed HHA visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed HHA visits. b. Patient #105 was admitted on 03/13/25 with a primary diagnosis of Hemiplegia. On 03/17/25, the physician ordered HHA services for the patient 1 time a week for 3 weeks. During the week of 03/30/25, the patient received no HHA visits for this week. The record had no documentation to indicate the missed HHA visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed HHA visits. c. Patient #113 was admitted on 11/20/23 with a primary diagnosis of Pneumonia. On 11/26/23, the physician ordered SN services for the patient 2 times per week for 2 weeks, then 1 time per week for 4 weeks. During the week of 12/03/23, the patient received 1 of 2 SN visits, and during the week of 12/24/23, the patient received no SN visits. The record had no documentation to indicate the missed SN visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed SN visits. d. Patient #115 was admitted on 08/20/24 with a primary diagnosis of Joint Replacement Surgery. On 08/25/24, the physician ordered Physical Therapy (PT) services for the patient 1 time a week for 4 weeks. During the week of 09/08/24, the patient received no PT visit for this week. The record had no documentation to indicate the missed PT visit were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed PT visit. e. Patient #116 was admitted on 06/24/24 with a primary diagnosis of Sepsis. On 08/26/24, the physician ordered SN services for the patient 2 times per week for 8 weeks. During the weeks of 09/01/24 and 09/08/24, the patient received 1 of 2 SN visits during these weeks. The record had no documentation to indicate the missed SN visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed SN visits. 3. On 04/10/25 at 10:30 AM, Surveyor #1 interviewed the agency’s Chief Operations Officer (Staff#111) regarding of the lack of documentation of the missed visits. Staff #111 acknowledged the findings and stated they were unable to provide any documentation of the missed visits. This is a REPEAT CITATION, previously cited in the last CMS survey completed on 04/13/22. .

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: . Based on document review, record review and interview, the agency failed to conduct supervisory visits no less frequently than every 14 days on home health aides (HHA) for 2 of 4 patients receiving HHA services (Patient #101 and #511). Failure to conduct supervisory visits place patients at risk for physical harm due to receiving services from unvetted HHAs. Findings included: 1. Document review of agency’s policy titled, “Bath Aide Supervisory Visits,” (Policy NO-HHA-PA-1-013, Date: May 2024) showed the registered nurse or therapist must conduct supervisory visits at least every 14 days. 2. Record review of the patient charts for 2 of 4 patients receiving HHA services (Patient #101 and #511) showed: a. Patient #101 had a Start of Care (SOC) on 01/08/25. The physician orders showed HHA services 1 time a week for 6 weeks. There was no documentation in the record to show that agency staff completed a supervisory visit between 01/08/25 and 02/15/25. b. Patient #511 had a SOC date on 01/10/25. The physician orders showed HHA services 2 times a week for 9 weeks. There was no documentation in the record to show that agency staff completed a supervisory visit between 03/06/25 to 04/10/25. 3. On 04/10/25 at 11:00 AM, Surveyors #1 and #5 interviewed the agency’s Chief Operations Officer (Staff#111) regarding of the lack of documentation of supervisory visits on the HHAs. Staff #111 acknowledged the findings and stated that they were unable to obtain documentation on supervisory visits on the HHAs.

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 emergency preparedness survey. Examination number: 2022-245 Dates Onsite: 04/11/22, 04/12/22, 04/13/22 This survey was conducted by: Surveyor #1 Surveyor #3 DOH staff found the facility NOT IN COMPLIANCE with the following Conditions of Participation: 42 CFR 484.102 Conditions of Participation for Emergency preparedness. For condition level findings - we are going to have to do a 45-day revisit to put them back into compliance. .

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on document review and interview, the home health agency failed to maintain and update an Emergency preparedness (EP) plan that must be reviewed, and updated at least every 2 years. Failure to maintain an active emergency preparedness plan puts staff and patients at risk of harm from being unprepared during disaster events. Findings included: 1. Failure to update and review an agency EP plan at least every 2 years, puts the agency at risk for emergency disasters that would affect the agency's ability to provide care to patients. Cross-Reference: E-0006 2. Failure to update and review an agency EP policies and procedures at least every 2 years, puts the agency at risk for emergency disasters that would affect the agency's ability to provide care to patients. Cross-Reference: E-0013 Due to the scope of the deficiencies cited under §484.102, the Condition of Participation: Emergency preparedness was NOT MET. .

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to review and update at least every 2 years an emergency preparedness (EP) plan. Failure to update and review an agency EP plan at least every 2 years, puts the agency at risk for emergency disasters that would affect the agency’s ability to provide care to patients. Findings included: 1. Document review of agency’s EP plan showed that the EP plan was last reviewed on 04/23/18. 2. On 04/11/22 at 2:00 PM, Surveyor #3 interviewed with the agency’s Chief Compliance Officer (Staff #309) about the agency’s failure to review their EP Plan every two years. Staff #309 stated that the agency had not updated or reviewed their EP Plan since 04/23/18. .

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to review and update at least every 2 years an emergency preparedness (EP) policies and procedures (P&P). Failure to update and review an agency EP P&P at least every 2 years, puts the agency at risk for emergency disasters that would affect the agency’s ability to provide care to patients. Findings included: 1. Document review of agency’s EP P&P indicated that the EP P&P was last reviewed on 04/23/18. 2. On 04/11/22 at 2:00 PM, Surveyor #3 interviewed with the agency’s Chief Compliance Officer (Staff #309) about the agency’s failure to review and update their EP policies and procedures every two years. Staff #309 stated that the agency had not updated or reviewed their EP P&P since 04/23/18. .

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: 2022-245 Dates Onsite: 04/11/22, 04/12/22, 04/13/22 This survey was conducted by: Surveyor #1 Surveyor #3 DOH staff found the facility NOT IN COMPLIANCE with the following Conditions of Participation: 42 CFR 484.65 Conditions of Participation for Quality assessment and performance improvement. For condition level findings- we are going to have to do a 45-day revisit to put them back into compliance. .

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 reviews, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral for 12 of 17 patients (Patients #101, #102, #104, #105, #106, #107, #109, #111, #112, #114, #115, #116). Failure to complete an initial assessment within 48 hours of referral to home health 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, “Initial and Comprehensive Assessment,” (dated October 2018) showed that the initial assessment visit must be done within 48 hours of the referral, within 48 hours of the patient’s discharge to home, or the start of care date ordered by the physician, or at the patient/family request with the approval of the physician. 2. Record review of patient records for Patients #101, #102, #104, #105, #106, #107, #109, #111, #112, #114, #116, #117 showed: a. Patient #101’s Start of Care (SOC) date was 04/11/22. The patient was admitted for primary diagnosis of Gait Abnormality and Type 2 Diabetes Mellitus. The agency completed the referral on 03/30/22 for a Physical Therapist (PT) however, the SOC for PT services did not occur until 04/11/22. There was no documentation to explain why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. b. Patient #102’s SOC date was 12/22/21. The patient was admitted for primary diagnosis of Type-2 Diabetes Mellitus and Cerebral Infarction. The agency completed the referral on 12/16/21 for a Skilled Nursing (SN) assessment however, the SOC for SN services did not occur until 12/22/21. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. c. Patient #104’s SOC date was 04/03/22. The patient was admitted for primary diagnosis of Malignant Neoplasm of the right main bronchus and Type 2-Diabetes Mellitus . The agency completed the referral on 03/30/22 for an SN assessment however, the SOC for SN services did not occur until 04/03/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. d. Patient #105’s SOC date was 03/03/22. The patient was admitted for primary diagnosis of Pain in the right shoulder and Opioid use. The agency completed the referral on 02/25/22 for an SN assessment however, the SOC for SN services did not occur until 03/03/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. e. Patient #106’s SOC date was 03/21/22. The patient was admitted for primary diagnosis of Congestive heart failure and Osteoarthritis. The agency completed the referral on 03/15/22 for a PT assessment however, the SOC for PT services did not occur until 03/21/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. f. Patient #107's SOC date was 03/25/22. The patient was admitted for a primary diagnosis of Malignant neoplasm of the prostate. The agency completed the referral on 03/15/22 for an SN assessment however, the SOC for SN services did not occur until 03/25/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. g. Patient #109’s SOC date was 03/27/22. The patient was admitted for a primary diagnosis of Discitis and Type 2-Diabetes Mellitus. The agency completed the referral on 03/23/22 for an SN assessment however, the SOC for SN services did not occur until 03/27/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. h. Patient #111’s SOC date was 03/15/22. The patient was admitted for a primary diagnosis of Cellulitis of the chest wall. The agency completed the referral on 03/04/22 for a PT assessment however, the SOC for PT services did not occur until 03/15/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. i. Patient #112’s SOC date was 02/21/22. The patient was admitted for a primary diagnosis of Urinary tract infection. The agency completed the referral on 02/15/22 for an SN assessment however, the SOC for SN services did not occur until 02/21/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. j. Patient #114’s SOC date was 05/05/21. The patient was admitted for a primary diagnosis of Type-2 Diabetes Mellitus. The agency completed the referral on 04/30/21 for an SN assessment however, the SOC for SN services did not occur until 05/05/21. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. k. Patient #116’s SOC date was 10/08/21. The patient was admitted for a primary diagnosis of Fracture of the right humerus. The agency completed the referral on 10/04/21 for an SN assessment however, the SOC for SN services did not occur until 10/08/21. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. l. Patient #117’s SOC date was 08/25/21. The patient was admitted for a primary diagnosis of Chronic obstructive pulmonary disease. The agency completed the referral on 08/21/21 for an SN assessment however, the SOC for SN services did not occur until 08/25/21. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation to show that the agency notified the physician of the delayed admission. 3. On 04/12/22 at 4:00 PM, Surveyor #1 interviewed the agency’s Chief Operations Officer (Staff #110) and the Interim Chief Executive (Staff #111) about the lack of documentation on the delayed admission. Staff #110 and Staff #111 acknowledged the findings and stated they are taking steps to develop a plan of correction. .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to communicate with the patient’s physician of missed visits resulting in changes to the patient’s plan of care in 3 of 17 patients (Patient #105, #107, #112). Failure to communicate with the patient’s physician of changes to the plan of care may potentially have a clinical impact on the patient’s wellbeing. Findings included: 1. Document review of agency’s document titled, “Missed Visits,” (Dated April 2022) showed that if a visit is missed and not rescheduled, the clinician will notify the patient’s physician. 2. Record review of patient records for Patients #105, #107, #112 showed: a. Patient #105 was admitted on 03/03/22. Skilled Nursing (SN) services were ordered on 03/06/22 with a visit frequency of 2 visits every week for 3 weeks, and then 2 visits every week for 2 weeks. During the week of 03/06/22, the agency failed to complete an SN visit and during the week of 03/13/22, the agency completed only 1 of 2 SN visits. There were no documentation or physician notification of the missed SN visits. b. Patient #107 was admitted on 03/25/22. Home Health aide (HHA) services were ordered on 03/28/22 with a visit frequency of 2 visits every week for 8 weeks. During the week of 04/03/22, the agency failed to complete any HHA visits. There were no documentation or physician notification of the missed HHA visits. c. Patient #112 was admitted on 02/21/22. SN services was ordered on 02/27/22 with a visit frequency of 2 visits every week for 4 weeks. During the week of 03/13/22, the agency failed to complete 1 of 2 SN visits and during the week of 04/27/22, the agency completed only 1 of 2 SN visits. There were no documentation or physician notification of the missed SN visits. 3. On 04/12/22 at 4:00 PM, Surveyor #1 interviewed the agency’s Chief Operations Officer (Staff #110) and the Interim Chief Executive (Staff #111) about the lack of documentation on the missed visits. Staff #110 and Staff #111 acknowledged the findings and were unable to find any documentation related to the missed visits or physician notification. .

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on document review and interview, the home health agency failed to maintain a quality improvement program designed to ensure patient safety and reduce adverse events. Failure to maintain an active quality improvement program that collects and analyses data, and implements changes related to patient safety and reduction of adverse events puts patients at risk of harm from lack of monitoring and substandard care. Reference: COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers” last updated 05/24/21, under Home Health Agencies (HHAs) and Hospice, “CMS is modifying the requirements at §418.58(a)–(d) and§484.65(a)–(d) to narrow the scope of the QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events. This modification decreases burden associated with the development and maintenance of a broad-based QAPI program, allowing the providers to focus efforts on aspects of care delivery most closely associated with COVID-19, and tracking adverse events during the PHE. The requirement that HHAs and hospices maintain an effective, ongoing, -wide, data-driven quality assessment and performance improvement program will remain”. . Findings included: 1. Failure to identify and develop improvement projects for health indicators designed to address adverse outcomes, or infection control puts patients at risk for safety issues and poor quality of care. Cross-Reference: G-642 2. Failure to monitor and document the effectiveness and safety of services designed to address infection control and patient safety related to adverse events puts staff and patients at risk for safety issues and poor quality of care. Cross-Reference: G-644 Due to the scope of the deficiencies cited under §484.65, the Condition of participation: Quality assessment and performance improvement (QAPI) was NOT MET.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to identify and develop improvement projects for health indicators designed to address adverse outcomes, patient safety or improved quality of care. Failure to identify and develop improvement projects for health indicators designed to address adverse outcomes, or infection control puts patients at risk for safety issues and poor quality of care. Findings included: 1. Document review of the agency's Quality Assessment Plan Improvement (QAPI) program contained no measurable indicators pertaining to adverse events and infection control. The QAPI program showed that the agency did not measure, analyze, and track quality indicators related to processes of care, home health services, home health operations, adverse events, and infection control. 2. On 04/13/22 at 3:00 PM. Surveyor #1 interviewed with the agency's Chief Operations Officer (Staff #110) regarding the lack of measurable indicators in the agency QAPI program. Staff #110 acknowledged the findings and stated that they will make updates to the agency's QAPI program. .

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to use the data derived from OASIS to monitor the effectiveness and safety of services and develop and prioritize opportunities for quality improvement based on the collected data. Failure to monitor and document the effectiveness and safety of services designed to address infection control and patient safety related to adverse events puts staff and patients at risk for safety issues and poor quality of care. Findings included: 1. Document review of agency's QAPI program, showed no documentation of the agency monitoring the effectiveness and safety of services designed to address infection control and patient safety related to adverse events and quality of care. In addition, there is no documentation that the agency identified opportunities and priorities for improvement. 2. On 04/13/22 at 2:00 PM, Surveyor #1 interviewed with the agency’s Chief Operations Officer (Staff #110) about the agency’s QAPI program and the lack of analysis of the program data. Staff #110 stated that they were unaware of the need to analyze collected program data to support the agency's quality program. .

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 agency failed to follow state requirements to perform an initial and annual Tuberculosis (TB) screening for 8 of 8 staff (#101, #102, #103, #104, #105, #106, #107, #108). Failure to perform annual TB Screening on staff places patients and staff at risk for infectious diseases. Reference: 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: (14) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (c) Tuberculosis infection control program. Key elements include but are not limited to: (i) Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency's responsibility to conduct TB testing of new employees. If TB testing is required, follow the department's tuberculosis risk assessment form testing recommendations; (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 Findings included: 1. Document review of agency’s document titled, “Tuberculosis Exposure Control Plan,” (Dated April 2019) indicated all personnel will be tested for TB in accordance with federal, state, and/or local regulations. 2. Surveyor #1 reviewed the personnel records for 8 of 8 staff (#101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115). The review showed: a. Staff #101 was hired on 04/04/22. The record failed to contain a completed [DOH]-approved initial or annual TB risk assessment. b. Staff #102 was hired on 02/18/21. The record failed to contain a completed [DOH]-approved initial or annual TB risk assessment. c. Staff #103 was hired on 03/31/20. The record failed to contain a completed [DOH]-approved initial or annual TB risk assessment. d. Staff #104 was hired on 04/19/17. The record failed to contain a completed [DOH]-approved initial or annual TB risk assessment. e. Staff #105 was hired on 03/10/20. The record failed to contain a completed [DOH]-approved initial or annual TB risk assessment. f. Staff #106 was hired on 06/27/07. The record failed to contain a completed [DOH]-approved initial or annual TB risk assessment. g. Staff #107 was hired on 08/20/14. The record failed to contain a completed [DOH]-approved initial or annual TB risk assessment. h. Staff #108 was hired on 06/28/00. The record failed to contain a completed [DOH]-approved initial or annual TB risk assessment. 3. Surveyor #1 interviewed the Chief Compliance Officer/Human Resources (Staff #109) on the missing initial and annual TB risk assessment on staff. Staff #109 acknowledged the findings and stated that they were not aware of the state requirements for annual TB screening on staff. .

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview, the agency Administrator failed to develop policies and procedures on the agency’s implementation of the COVID-19 vaccination or the exemption to the vaccination. Failure to develop policies and procedures on the implementation of COVID-19 vaccination puts patients and staff at risk of harm from the COVID-19 infection. Findings included: 1. Document review of agency's undated document titled, "Mandatory Vaccination," showed that all agency staff are required to receive vaccinations as determined by Washington Department of Health. Review of the document also showed the agency’s policy failed to include the following required elements: a. Specify the minimum requirements for full vaccination for COVID-19 b. Include a description of staff, volunteers and contractors who are subject to compliance with the policy c. Describe steps for exemption or delay of vaccine, including a statement from an authorized practitioner when COVID-19 vaccination is clinically contraindicated d. Describe the tracking system for the agency to track vaccination status (including approved exemptions) of all staff, volunteers, and contractors e Outline what contingency measures the agency will employ for all staff that not fully vaccinated for COVID-19. 2. On 04/12/22 at 4:00 PM, Surveyors #1 and #3 interviewed the agency's Chief Operations Officers (Staff #110) of the missing information regarding the COVID-19 vaccination. Staff #110 acknowledge the findings and stated that they are making attempts to update the agency's policy and procedure. .

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 Administrator failed to operationalize the agency policy and procedure (P&P) for staff performance evaluations for 5 of 8 staff (#102, #105, #106, #107, #108). Failure to operationalize and conduct annual staff performance evaluations may result in unmet employee training needs. Reference: 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: (15) 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. Findings included: 1. Surveyors #1 and #3 reviewed the personnel records for 5 of 8 staff (#102, #105, #106, #107, #108). The review showed: a. Staff #102 was hired on 02/19/21. The staff file lacked documentation of an annual evaluation with on-site observation of care and skills specific to the care needs of patients. b. Staff #105 was hired on 03/10/. The staff file lacked documentation of an annual evaluation with on-site observation of care and skills specific to the care needs of patients. c. Staff #106 was hired on 06/27/07. The staff file lacked documentation of an annual evaluation with on-site observation of care and skills specific to the care needs of patients. d. Staff #107 was hired on 08/20/14. The staff file lacked documentation of an annual evaluation with on-site observation of care and skills specific to the care needs of patients. e. Staff #108 was hired on 06/28/00. The staff file lacked documentation of an annual evaluation with on-site observation of care and skills specific to the care needs of patients. 2. Surveyors #1 interviewed the Chief Compliance Officer/Human Resources (Staff #109) on the missing staff evaluation. Staff #109 acknowledged the findings and was unable to provide documentation to show the agency completed annual evaluations of their personnel.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the patient’s discharge summary to the patient’s attending physician within 5 business days of the patient’s discharge for 2 of 5 sample discharge records review (Patients #113, #116). Failure to provide the discharge summary to the patient’s attending physician prevents timely continuity of care and care coordination of patient’s needs. Findings included: 1. Surveyors #1 and #3 reviewed the records for 2 of 5 Patients (#113, #116). The record review showed: a. Patient #113's Start of care was 10/18/21 and the patient was discharged on 12/08/21. There was no evidence in the record to show the agency sent a discharge summary to the patient's attending physician within the specified time period. b. Patient #116's Start of care was 10/08/21 and the patient was discharged on 11/03/21. There was no evidence in the record to show the agency sent a discharge summary to the patient's attending physician within the specified time period. 2. Surveyors #1 and #3 interviewed the agency’s Chief Compliance Officer/Human Resources (Staff #109) about lack of documentation of discharge summary sent to patient’s physician when they are discharged from the agency. Staff #109 acknowledge the findings and was unable to provide documentation to show the agency sent a discharge summary to the patient's attending physician. .