Every finding on record at Iron Bridge 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: X2026-479 Dates Onsite: 04/07-09/26 This survey was conducted by: Surveyor #5 Surveyor #2 (Orientation) Surveyor #4 (Orientation) DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. . . . . . .

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 document review, 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 3 of 5 sample discharge records reviewed (Patients #417, #514 and #515). Failure to provide the discharge summary to the patient’s attending physician prevents timely continuity of care and care coordination of patients' needs. Findings included: 1. Document review of agency’s policy titled, “Discharge Summary", (Policy No. 4-046.1, Last revised: May 2022) showed that a discharge summary will be submitted to the primary care provider within 72 hours of patient’s discharge. 2. Record review of patient records for Patients #417 and #515 and #517 showed: a. Patient ##417’s Start of Care date was 10/02/25 and the patient was discharged on 10/31/25. The discharge summary was submitted to the patient’s attending physician on 11/25/25. b. Patient #514’s Start of care date was 09/29/25 and patient was discharged on 11/08/25. The discharge summary was submitted to the patient’s attending physician on 12/09/25. c. Patient #516’s Start of care date was 09/23/25 and patient was discharged on 11/26/25. The discharge summary was submitted to the patient’s attending physician on 12/08/25. 3. On 04/09/26 at 12:45 PM, Surveyor #5 interviewed the agency’s Director of Clinical Services (Staff #502) regarding the agency's delay in sending the discharge summary to the patients' physicians within 72 hours of when patients are discharged. Staff #502 stated that the staff member responsible for sending out the discharge summaries was out of the office for a period of time and that the discharge summaries were not sent timely. This is a repeat uncorrected deficiency cited on 11/09/23.

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: X2023-704 Dates Onsite: 11/06/23, 11/07/23, 11/08/23, 11/09/23 This survey was conducted by: Surveyor #1 Surveyor #5 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on document review, record review, and interview the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0104 that indicates the completed referral date or obtain physician orders for M0102 for 12 of 19 patients (Patients #101, #102, #103, #104, #106, #108, #109, #110, #115, #116, #117, and #118). Failure to accurately complete the OASIS data 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, “OASIS Data Transmission,” (Policy No. 3-020.1, Last Revised: May 2022) showed that the encoded OASIS data must accurately reflect the patient’s status at the time of assessment and that the agency will conduct audits to verify that collected OASIS data are consistent with reported OASIS data. 2. Record review of patient records for Patients #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #115, #116, #117, and #118 showed: a. Patient #101 was admitted for primary diagnosis of West Nile Virus Infection and Encephalitis—not a complete list. The referral was completed on 09/06/23 for Skilled Nursing (SN), Physical Therapy (PT), and Speech Therapy (ST) services. The OASIS M0104 data showed a date of 09/07/23 rather than the accurate data of the referral date of 09/06/23. There was no documentation to indicate how the admitting clinician determined the M0104 date of 09/07/23. b. Patient #102 was admitted for primary diagnosis of Status post Aortic Valve Surgery and Congestive Heart Failure—not a complete list. The referral was completed on 10/24/23 for SN, PT, and Occupational Therapy (OT) services. The OASIS M0102 data showed a date of 10/20/23 rather than the accurate data of the OASIS M0104 of 10/24/23. There was no physician's order to specify the M0102 date of 10/20/23. c. Patient #103 was admitted for primary diagnosis of Neoplasm of the anus and Hypertension—not a complete list. The referral was completed on 06/23/2023 for SN services. The OASIS M0102 data showed a date of 06/23/23 rather than the accurate data of the OASIS M0104 of 06/23/23. There was no physician's order to specify the M0102 date of 10/20/23. d. Patient #104 was admitted for primary diagnosis of Surgery aftercare of Digestion—not a complete list. The referral was completed on 09/18/23 for SN services. The OASIS M0102 data showed a date of 09/18/23 rather than the accurate data of the OASIS M0104 of 09/18/23. There was no physician's order to specify the M0102 date of 09/18/23. e. Patient #106 was admitted for primary diagnosis of Right Lower Leg wound and Diabetes Mellitus—not a complete list. The referral was completed on 10/23/23 for SN services. The OASIS M0102 data showed a date of 10/24/23 rather than the accurate data of the OASIS M0104 of 10/23/23. There was no physician's order to specify the M0102 date of 10/24/23. f. Patient #108 was admitted for primary diagnosis of Sepsis and Pneumonia—not a complete list. The referral was completed on 09/19/23 for SN, PT, and OT services. The OASIS M0102 data showed a date of 09/14/23 rather than the accurate data of the OASIS M0104 of 09/19/23. There was no physician's order to specify the M0102 date of 09/14/23. g. Patient #109 was admitted for primary diagnosis of Right Lower Leg wound—not a complete list. The referral was completed on 09/15/23 for SN services. The OASIS M0102 data showed a date of 09/15/23 rather than the accurate data of the OASIS M0104 of 09/15/23. There was no physician's order to specify the M0102 date of 09/15/23. h. Patient #110 was admitted for primary diagnosis of Cerebral Palsy—not a complete list. The referral was completed on 10/13/23 for SN and PT services. The OASIS M0102 data showed a date of 10/10/23 rather than the accurate data of the OASIS M0104 of 10/13/23. There was no physician's order to specify the M0102 date of 10/10/23. i. Patient #115 was admitted for primary diagnosis of Neoplasm of the Right Lung—not a complete list. The referral was completed on 01/11/23 for SN and PT services. The OASIS M0102 data showed a date of 01/11/23 rather than the accurate data of the OASIS M0104 of 01/11/23. There was no physician's order to specify the M0102 date of 01/11/23. j. Patient #116 was admitted for primary diagnosis of Bleeding Ulcer and Diabetes Mellitus—not a complete list. The referral was completed on 08/22/23 for SN services. The OASIS M0102 data showed a date 08/24/23 rather than the accurate data of the OASIS M0104 of 08/22/23. There was no physician's order to specify the M0102 date of 08/24/23. k. Patient #117 was admitted for primary diagnosis of Acute Renal Failure and Stage 4 Pressure ulcer on Coccyx—not a complete list. The referral was completed on 04/04/22 for SN, PT, and OT services. The OASIS M0104 data showed a date of 04/05/23 rather than the accurate data of the referral date of 04/04/23. There was no documentation to indicate how the admitting clinician determined the M0104 date of 04/04/23. l. Patient #118 was admitted for primary diagnosis of Gastrointestinal bleed and Hypertension—not a complete list. The referral was completed on 09/25/23 for SN, PT, OT, Home Health Aide services. The OASIS M0102 data showed a date 09/25/23 rather than the accurate data of the OASIS M0104 of 09/25/23. There was no physician's order to specify the M0102 date of 09/25/23. 3. On 11/08/23 at 2:00 PM, Surveyor #1 interviewed the agency’s Executive Director (Staff #112) and the agency’s Director of Clinical Services (Staff #113) about the inaccurate documentation of the OASIS M0104. Both Staff #113 and #114 acknowledged the findings and stated that clinicians are trained in how to complete the OASIS M0102 and M0104 data. .

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on document review, record review, and interview, the agency failed to inform patients of all aspects of their plan of care, including the total frequency of the proposed services and the manner in which the agency will provide care and services. The agency also failed to review the plan of care with the patient on an ongoing basis as changes to their plan of care occurred for 10 of 19 patient records (Patient #101, #109, #110, #111, #112, #113, #114, #116, #118, and #119). Failure to inform patients and their representatives of variance in visit frequency for proposed care and failure to allow for review of care plan changes may prevent patients or their representatives from full participation in their care. Findings included: 1. Document review of agency’s document titled, “Patient Notification of Changes in Care” (Policy No. 4-014.1, Last Revised May 2022) showed that when a significant change in visit frequencies are anticipate, the clinical personnel will notify the patient of the change and verify acceptance. 2. Record review for Patient #101, #109, #110, #111, #112, #113, #114, #116, #118, and #119 showed: a. Patient #101 was admitted on 09/07/23. Documentation showed Skilled Nursing (SN) frequency of visits for weekly visits for 4 weeks, then 1 visit every 2 weeks for 4 weeks starting 09/07/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN services. b. Patient #109 was admitted on 09/18/23. Documentation showed Physical Therapy (PT) frequency of visits for weekly visits for 5 weeks, then 1 visit every 2 weeks for 4 weeks starting 09/18/22. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT services. c. Patient #110 was admitted on 10/13/23. Documentation showed SN frequency of visits for 1 visit every 3 weeks for 3 weeks starting 10/13/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN services. d. Patient #111 was admitted on 09/07/23. Documentation showed PT frequency of visits for 2 visits every 2 weeks for 2 weeks, then 2 visits every week for 3 weeks, and then weekly visits for 2 weeks starting 09/13/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT services. e. Patient #112 was admitted on 07/19/23. Documentation showed SN frequency of visits for weekly for 4 weeks, then 1 visits every 2 weeks for 2 weeks starting 07/19/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN services. f. Patient #113 was admitted on 09/22/22. Documentation showed PT frequency of visits for 1 visit every 3 weeks for 3 weeks, and then weekly for 4 weeks starting 09/25/22. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT services. g. Patient #114 was admitted on 09/20/22. Documentation showed Occupational Therapy (OT) frequency of visits for weekly for 5 weeks, then weekly for 1 week, and then 1 visits every 2 weeks for 2 weeks starting 09/20/22. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered OT services. h. Patient #116 was admitted on 08/24/22. Documentation showed PT frequency of visits for 2 visits for 1 week, then 1 visit for 1 week, and then 1 visit every 2 weeks for 6 weeks starting 08/24/22. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered PT services. i. Patient #118 was admitted on 09/26/23. Documentation showed SN frequency of visits for 2 visits for 1 week, and then 1 visits every 3 weeks for 6 weeks starting 09/26/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN services. j. Patient #119 was admitted on 10/02/23. Documentation showed SN frequency of visits for 3 visits for 1 week, then 1 visit every 2 weeks for 2 weeks, then 1 visit weekly for 2 weeks, and then 1 visits every 2 weeks for 4 weeks starting 10/02/23. There was no documentation in the record to show the agency informed and coordinated with the patient or their representative of the varying frequencies for the ordered SN services. 3. On 11/08/23 at 2:00 PM, Surveyor #1 interviewed the agency’s Executive Director (Staff #112) and the agency’s Director of Clinical Services (Staff #113) regarding the findings. Both Staff #112 and Staff #113 acknowledged the varying frequencies findings but were unable to provide documentation of communication and coordination between the clinicians and the patients of the frequency visits and changes in the patients’ plan of care. .

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 review, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral and notify the patient’s home health physician of the delayed admission for 3 of 19 patients (Patients #105, #109 and #114). Failure to meet this requirement places patients at risk of physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency's policy titled, "Admission Criteria and Process," (Policy No. 2-003.1, Last Revised: May 2022) showed that agency staff will conduct an initial assessment within 48 hours of acceptance of referral information. 2. Record review for Patients #105, #109 and #114 showed: a. Patient #105’s Start of Care (SOC) date was 03/28/23. The patient was admitted for primary diagnosis of Chronic Venous Insufficiency. The agency completed the referral on 03/23/23 for a Skilled Nursing (SN) assessment, but the SOC for SN services did not occur until 03/28/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. b. Patient #109’s SOC date was 09/18/23. The patient was admitted for primary diagnosis of an Open Wound to the Right Lower Leg. The agency completed the referral on 09/15/23 for a SN assessment, but the SOC for SN services did not occur until 09/18/23. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. c. Patient #114’s SOC date was 09/20/22. The patient was admitted for primary diagnosis of Lumbar Laminectomy. The agency completed the referral on 09/16/22 for a PT assessment, but the SOC for PT services did not occur until 09/20/22. There was no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. 3. On 11/08/23 at 2:00 PM, Surveyor #1 interviewed the agency’s Executive Director (Staff #112) and the agency’s Director of Clinical Services (Staff #113) regarding the delayed SOC and lack of provider notification. Both acknowledged the findings and stated that they were unable to provide documentation that the agency notified patients’ providers of the delayed SOC. .

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to document home health aide Supervisory visits no less frequently than every 14 days for 1 of 2 patients receiving home health aide services (Patient #119). Failure to supervise the home health aide at least every 14 days places the patients at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patient’s changing needs. Findings included: 1. Record review for Patient #119 showed the patient had a Start of Care of 10/02/23, and was admitted with diagnoses of Hyperplasia and Diabetes Mellitus–not a complete diagnosis list. The Physician ordered Home Health aides services weekly for 4 weeks, and then 1 visit every 2 weeks for 2 weeks starting on 10/02/23. There was no documentation of supervisory visits for the 5 weeks of 10/02/23-11/04/23. 2. On 11/08/23 at 2:00 PM, Surveyor #1 interviewed the agency’s Executive Director (Staff #112) and the agency’s Director of Clinical Services (Staff #113) regarding the lack of home health aide supervisory visits. Staff #113 acknowledged the findings and state that they were unable to provide documentation that home health aide supervisory visits were conducted on the patients who had home health aide services. .

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 reviews and interview, the agency failed to implement policies and procedures consistent with state licensing requirements through failure to ensure compliance with an updated agency’s patient’s Bill of Rights (BoR) (Item #1). The agency also failed to obtain an initial department-approved disclosure statement for 1 of 10 staff providing direct care and a subsequent disclosure statement for 3 of 10 staff providing direct care every 2 years from the previous check (Item #2). Failure to maintain and implement policies and procedures consistent with state home health regulation puts patients at risk of physical and/or psychological harm from inadequate or substandard care. Findings included: Item #1-Patient’s Bill of Rights Reference: Washington Administrative Code WAC 246-335-535 Bill of rights. (1) Receive effective treatment and quality services from the home health agency for services identified in the plan of care; (2) Be cared for by appropriately trained or credentialed personnel, contractors and volunteers with coordination of services; (4) A statement advising of the right to have access to the department's listing of licensed home health agencies and to select any licensee to provide care, subject to the individual's reimbursement mechanism or other relevant contractual obligations; (5) A listing of the total services offered by the home health agency and those being provided to the patient; (9) Be free from discrimination; (10) Have property treated with respect; and (20) The home health agency must ensure that the patient rights under this section are implemented and updated as appropriate. 1. Record review of the agency’s BoR showed the document lacked the following: Receive effective treatment and quality services from the home health agency for services identified in the plan of care; Be cared for by appropriately trained or credentialed personnel, contractors and volunteers with coordination of services; A statement advising of the right to have access to the department's listing of licensed home health agencies and to select any licensee to provide care, subject to the individual's reimbursement mechanism or other relevant contractual obligations; A listing of the total services offered by the home health agency and those being provided to the patient; Be free from discrimination; Have property treated with respect; and The home health agency must ensure that the patient rights under this section are implemented and updated as appropriate. 2. On 11/08/23 at 2:00 PM, Surveyor #1 interviewed the agency’s Executive Director (Staff #112) regarding the missing BoR items. Staff #11 acknowledged the findings and stated that they are currently updating the agency’s BOR document to include the missing items. . Item #2 – Disclosure Statements Reference: WAC 246-335-530 Personnel, contractor, and volunteer records. The licensee must maintain records on all personnel and volunteers and have access to records on all contractors, to include: (7) Evidence of initial and subsequent criminal history background checks and disclosure statement(s) according to RCW 43.43.830 through 43.43.842 and this chapter. 1. Surveyor #5 completed a record review of personnel files for direct care staff that showed: a. A Physical Therapy Assistant (Staff #501) was hired on 06/05/23. The record showed no evidence the agency completed a department-approved disclosure statement since the date of hire. b. A Home Health Aide (Staff #508) was hired on 01/26/21. The record showed an initial disclosure statement was completed on 01/26/21 but there was no evidence the agency completed a department-approved disclosure statement in 2023. c. A Speech Language Pathologist (Staff #509) was hired on 03/05/20. The record showed an initial disclosure statement was completed on 03/05/20 but there was no evidence the agency completed a department-approved disclosure statement in 2022. d. A Licensed Social Worker (Staff #510) was hired on 10/16/19. The record showed that an initial disclosure statement was completed on 10/16/19 but there was no evidence the agency completed a department-approved disclosure statement in 2021 or 2023. 2. On 11/08/23 at 11:00 AM, Surveyor #5 interviewed the agency's Human Resources Representative (Staff #511) about the missing disclosure statements. Staff #511 stated that the initial disclosure statement for Staff #501 was missing and that they were unaware of the requirement to complete the disclosure statement every 2 years. .

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 document review, 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 reviewed (Patients #113 and #116). Failure to provide the discharge summary to the patient’s attending physician prevents timely continuity of care and care coordination of patients' needs. Findings included: 1. Document review of agency’s policy titled, “Discharge Summary, (Policy No. 4-046.1, Last revised: May 2022) showed that a discharge summary will be submitted to the primary care provider within 72 hours of patient’s discharge. 2. Record review of patient records for Patients #113 and #116 showed: a. Patient #113’s Start of Care date was 09/22/22 and the patient was discharged on 11/29/22. The discharge summary was submitted to the patient’s attending physician on 12/14/22. b. Patient #116’s Start of care date was 08/24/22 and patient was discharged on 11/18/22. The discharge summary was submitted to the patient’s attending physician on 12/14/22. 3. On 11/08/23 at 2:00 PM, Surveyor #1 interviewed the agency’s Executive Director (Staff #112) and the agency’s Director of Clinical Services (Staff #113) regarding the agency's delay in sending the discharge summary to the patients' physicians within 72 hours of when patients are discharged. Both staff acknowledged the findings and stated that they were unable to find reasons for the delay in sending discharge summaries sent to the patients' physicians.

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: 2021-526 Dates Onsite: 07/12/21-07/15/21 Dates Offsite: 07/16/21 This survey was conducted by: Surveyor #4 Surveyor #5 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction. .

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 requirments through failure to complete staff performance evaluations for 2 of 2 Staff (Staff # 503 and #505) (Item 1) and failure to provide patients and their families information on the provision of back-up care and abuse reporting as part of their patients' Bill of Rights (Item 2). Failue to maintain compliance with state licensing requirements puts patients at risk of harm from poor quality of care. Item #1-Staff Performance Evaluations References: Washington Administrative WAC 246-335-530 (12) Personnel, contractor, and volunteer records.The licensee must maintain records on all personnel and volunteers and have access to records on all contractors, to include: Documentation of performance evaluations of personnel and volunteers providing direct patient care and evaluations of services provided by contractors providing direct patient care as required in WAC 246-335-525 (16) and (17). Findings included: 1. On 07/14/21 Surveyor #5 reviewed the personnel files for a Speech Therapist (Staff #503) and a Registered Nurse (Staff #505). a. Staff #503 had a hire date of 03/05/20. There was no annual evaluation documented in the personnel file. b. Staff #505 had a hire date of 10/16/19. There was no annual evaluation documented in the personnel file. 2. On 07/14/21 at 2:30 PM, the Clinical Manager, (Staff #502) confirmed the above staff did not have an annual performance evaluation completed. Item #2-Patient Bill of Rights Reference: Washington Administrative Code (WAC) 246-335-535 (16) and (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: (16) Be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled. (19) Be informed of the DSHS end harm hotline number to report suspected abuse of children and vulnerable adults. Findings included: 1. During review of the patient Bill of Rights on 07/12/21, Surveyor #4 noted the Bill of Rights was missing the following required elements: a. The patient's right to be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled. b. The patient's right to be informed of the Department of Social and Health Services (DSHS) End Harm hotline number to report suspected abuse of children and vulnerable adults. 2. Surveyor #4 interviewed the Executive Director (Staff #401) on 07/12/21 at 3:00 PM about the missing information. Staff #401 verified the Bill of Rights did not include a statement about the patients' right to the back-up plan or the end harm hotline number. Staff #401 acknowledged these findings and said the Bill of Rights would be updated to include the information.