Every finding on record at Jefferson County Public Hospital District No 2

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: 2021-1087 Dates Onsite: 03/07/22, 03/08/22, 03/09/22 This survey was conducted by: Surveyor #1 Surveyor #4 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. .

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on document review, record reviews, and interview, the agency failed to ensure that the plan of care was followed as ordered by the physician for 3 of 10 patients (Patient #101, #103, #110). . Failure to follow the plan of care, as ordered by the physician, could place the patient at risk of worsening symptoms of existing diagnoses. . Findings included: 1. Document review of agency’s policy titled, “Home Health Assessment and Plan of Care,” (Policy #11289599, date revised 02/2022) showed that the individualized plan of care will conforms to provider orders. 2. Record review of patient records Patients #101, #103, and #110 showed: a. Patient #101 was admitted on 11/24/21 with Chronic pain syndrome, Unspecified abdominal pain, and Peritoneal adhesions –not a complete list. The physician ordered Occupational Therapy (OT) services. On 11/24/21, the physician ordered OT services for the patient 1 time per week for 6 weeks, and then 1 time per week for 1 week. The week of 12/19/21 to 12/25/21, the patient received no OT visits. There was not documentation of why there were missed visits, nor was there documentation that the physician had been notified. b. Patient #103 was admitted on 10/26/21 with Parkinson’s disease, Congestive heart failure, and Pulmonary hypertension – not a complete list. The physician ordered Skilled Nursing (SN), OT, and Physical Therapy (PT) services. On 10/26/21, the physician ordered SN services for the patient 1 time per week for 1 week, then 1 time per week for 2 weeks, and then 1 time every 2 weeks for 6 weeks. The week of 12/19/21 to 12/25/21, the patient received no SN visits. There was no documentation of why there were missed visits, nor was there documentation that the physician had been notified. c. Patient #110 was admitted on 10/23/20 with Atherosclerotic heart disease, Aortocoronary bypass graft, and Chronic kidney disease – not a complete list. The physician ordered SN and PT services. On 10/25/20, the physician ordered PT services for the patient 1 time per week for 4 weeks. The weeks of 11/01/20 to 11/07/20, 11/08/20 to 11/14/20, and 11/15/20 to 11/21/20 the patient received no PT visits. There was no documentation of why there were missed visits, nor was there documentation that the physician had been notified. 3. On 03/08/22 at 2:00 PM, Surveyor #1 interviewed the agency’s Home Health Executive Director (Staff #109) about the lack of documentation of the missed visits. Staff #109 acknowledged the findings and was not able to find any explanation for the missed visits. .

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 48 hours of completing the referral for 1 of 10 patients (Patients #102). 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, "Home Health Assessment and Plan of care," (Policy 11289599, Last Revised 02/2022) indicated that all patients are assessed within forty-eight hours of the receipt of the referral and/or 48 hours of the patient's return home or as specified by the physician. 2. Record review for Patient #102 showed: Patient #102’s Start of Care (SOC) date was 12/23/21. The patient was admitted for primary diagnoses was Chronic diastolic (congestive) heart failure, Intervertebral disc degeneration, and Acquired absence of left leg below knee . The agency completed the referral on 12/16/21 for Physical therapist (PT) assessment, but the SOC for PT services did not occur until 12/23/21. The agency failed to provide documentation to explain why PT services did not occur within 48 hours of the referral, and no documentation to indicate the agency notified the patient’s home health physician of the delayed admission. 3. On 03/08/22 at 10:00 AM, Surveyor #1 interviewed the agency’s Home Health Executive Director (Staff #109) about the delayed SOC and lack of provider notification. Staff #109 acknowledged the findings and was not able to find any explanation for the delay in services. .