Every finding on record at Kaiser Foundation Health Plan of Washington

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR Part 484 conducted this health and safety survey. Examination number: X2023-938 Dates Onsite: 01/08/24, 01/09/24, 01/10/24, 01/11/24 Dates Offsite: 01/12/24, 01/16/24 This survey was conducted by: Surveyor #1 Surveyor #6 During the course of the survey, surveyors investigated issues related to the State Complaint 2023-15044. There were findings related to the complaint. .

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 reviews, and interview, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0104 that indicates the completed referral dates for 9 of 14 patients (Patients #102, #103, #104, #105, #107, #111, #112, #113, and #117) (Item #1); and failed to accurately complete the OASIS data for M0102 that indicates the date of the Physician-ordered start of care for 4 of 4 patients (Patients #101, #106, #109, and #116) (Items #2). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Reference: OASIS-E Guidance Manual Dated: 01/01/23 Centers For Medicare & Medicaid Services. M0104 is the Date of Referral that specifies the most recent date that verbal, written, or electronic authorization to begin or resume home care was received by the home health agency (HHA). M0102 is the Date of Physician-ordered Start of Care: If the physician indicated a specific start of care date when the patient was referred for home health services, record the date specified. Findings included: Item #1 - OASIS M0104 Referral Date 1. Document review of the agency’s job aide titled, “OASIS-E SOC/ROC,” (Dated: 10/10/2023) showed the encoded OASIS data M0104 is the Date of Referral that the written or verbal referral for initiation was received by the HHA. 2. Record review of patient records for Patients #102, #103, #104, #105, #106, #107, #111, #112, #113, and #117 showed: a. Patient #102 was admitted for the primary diagnosis of Pressure Ulcers on Buttocks—not a complete list. The OASIS M0104 data showed a date of 08/19/23 rather than the accurate referral date of 08/18/23. Documentation showed the referral was completed on 08/18/23 for Skilled Nursing (SN) Services. b. Patient #103 was admitted for the primary diagnosis of Chronic Venous Hypertension with an Ulcer of the Left Lower extremity—not a complete list. The OASIS M0104 data showed a date of 06/17/23 rather than the accurate referral date of 06/16/23. Documentation showed the referral was completed on 06/16/23 for SN Services. c. Patient #104 was admitted for the primary diagnosis of Age-related Osteoporosis with current Pathological Fracture of the Left Femur—not a complete list. The OASIS M0104 data showed a date of 12/11/23 rather than the accurate referral date of 12/08/23. Documentation showed the referral was completed on 12/08/23 for SN Services. d. Patient #105 was admitted for the primary diagnosis of Nonrheumatic Aortic Stenosis—not a complete list. The OASIS M0104 data showed a date of 12/11/23 rather than the accurate referral date of 12/10/23. Documentation showed the referral was completed on 12/10/23 for SN Services. e. Patient #107 was admitted for the primary diagnosis of Osteoporosis—not a complete list. The OASIS M0104 data showed a date of 01/01/24 rather than the accurate referral date of 12/29/23. Documentation showed the referral was completed on 12/29/23 for Physical Therapy Services. f. Patient #111 was admitted for the primary diagnosis of Encounter for Fitting and Adjustment of Urinary Device—not a complete list. The OASIS M0104 data showed a date of 07/23/23 rather than the accurate referral date of 07/21/23. Documentation showed the referral was completed on 07/21/23 for SN services. g. Patient #112 was admitted for the primary diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer—not a complete list. The OASIS M0104 data showed a date of 10/17/23 rather than the accurate referral date of 10/16/23. Documentation showed the referral was completed on 10/16/23 for SN services. h. Patient #113 was admitted for the primary diagnosis of Unspecified Open Wound on the Left Lower Leg—not a complete list. The OASIS M0104 data showed a date of 12/23/23 rather than the accurate referral date of 12/22/23. Documentation showed the referral was completed on 12/22/23 for SN services. i. Patient #117 was admitted for the primary diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure—not a complete list. The OASIS M0104 data showed a date of 04/07/23 rather than the accurate referral date of 04/06/23. Documentation showed the referral was completed on 04/06/23 for SN services. 3. On 01/09/24 at 8:30 AM, Surveyor #1 interviewed the agency’s Compliance Consultant III (Staff #114) about the inaccurate data entered for OASIS M0104. Staff #114 acknowledged the inaccurate documentation of the OASIS data and stated that clinicians are trained in completing the OASIS M0104 data. . Item #2 – OASIS M0102 Physician-Ordered Start of care date. 1. Document review of the agency’s job aide titled, “OASIS-E SOC/ROC,” (Dated: 10/10/2023) showed that the encoded OASIS data M0102 is the date of Physician-ordered start of care that the physician indicated a specific start of care date. 2. Record review of patient records for Patients #101, #106, #109, and #116 showed: a. Patient #101 was admitted on 12/05/23 with the primary diagnoses of Acute Respiratory Failure and Hypoxia. The referral was completed on 12/01/23 for a Physical Therapy (PT) initial assessment. The agency received a Physician-ordered start of care date for 12/05/23. The Physician-ordered start of care date data element (M0102) was incorrectly entered as the M0104 referral date data element in the OASIS data set. b. Patient #106 was admitted on 11/20/23 with the primary diagnoses of Hypertensive Heart and Chronic Kidney Disease. The referral was completed on 11/17/23 for a Skilled Nursing (SN) initial assessment. The agency received a Physician-ordered start of care date for 11/20/23. The Physician-ordered start of care date data element (M0102) was incorrectly entered as the M0104 referral date data element in the OASIS data set. c. Patient #109 was admitted on 12/21/23 with a primary diagnosis of Parkinson’s. The referral was completed on 12/18/23 for a PT initial assessment. The agency received a Physician-ordered start of care date for 12/22/23. The Physician-ordered start of care date data element (M0102) was incorrectly entered as the M0104 referral date data element in the OASIS data set. d. Patient #116 was admitted on 04/01/23 with a primary diagnosis of Malignant Neoplasm of the Left Lung. The referral was completed on 03/28/23 for a SN initial assessment. The Physician-ordered start of care date data element (M0102) was incorrectly entered as the M0104 referral date data element in the OASIS data set. 3. On 01/09/24 at 8:30 AM, Surveyor #1 interviewed the agency’s Compliance Consultant III (Staff #114) about the inaccurate data of the OASIS M0102. Staff #114 acknowledged the inaccurate documentation of the OASIS data and stated that clinicians are trained in completing the OASIS M0102 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 reviews, and interview, the agency failed to inform the patient or their legal representative of the therapy services and the frequencies of the proposed therapy services for 10 of 10 patient records with Physical Therapy (PT) services (Patient # 101, #104, #105, #107, #109, #110, #112, #114, #115, and #116). Failure to inform the patient and their representatives of the frequencies of the proposed care and services prevent the patient or their legal representative from participating in the patient’s care. Findings included: 1. Document review of agency’s policy titled, “Home Health and Hospice Service Care and Standards,” (Policy # HHHP 1-043, Last Reviewed 08/04/23) showed the agency verifies and reinforces the patient’s understanding of home health services and receives information to facilitate in safe and continuous patient care. 2. Record review of patient records for Patient # 101, #104, #105, #107, #109, #110, #112, #114, #115, and #116 showed: a. Patient #101 was admitted on 12/05/23. Physical Therapy (PT) was ordered on 12/05/23 with frequency of visits of 4 times for 1 month, but no documentation that the patient or their representative were informed of the PT frequencies. b. Patient #104 was admitted on 12/12/23. PT was ordered on 12/14/23 with frequency of visits of 5 times for 1 month, but no documentation that the patient or their representative were informed of the the PT frequencies. c. Patient #107 was admitted on 01/03/24. PT was ordered on 01/03/24 with frequency of visits of 5 times for 1 month, but no documentation that the patient or their representative were informed of the PT frequencies. d. Patient #109 was admitted on 12/21/23. PT was ordered on 12/21/23 with frequency of visits of 2 times for 1 month, but no documentation that the patient or their representative were informed of the PT frequencies. e. Patient #110 was admitted on 10/25/23. PT was ordered on 10/27/23 with frequency of visits of 4 times for 1 month, but no documentation that the patient or their representative were informed of the PT frequencies. f. Patient #112 was admitted on 10/19/23. PT was ordered on 10/23/23 with frequency of visits of 4 every 4 weeks for 4, but no documentation that the patient or their representative were informed of the PT frequencies. g. Patient #114 was admitted on 01/29/23. PT was ordered on 02/01/23 with frequency of visits of 3 times for 1 month, but no documentation that the patient or their representative were informed of the PT frequencies. h. Patient #115 was admitted on 05/12/23. PT was ordered on 05/12/23 with frequency of visits of 4 times for 1 month, but no documentation that the patient or their representative were informed of the PT frequencies. i. Patient #116 was admitted on 04/01/23. PT was ordered on 04/05/23 with frequency of visits of 3 times for 1 month, but no documentation that the patient or their representative were informed of the PT frequencies. 3. On 01/10/24 at 1:00 PM, Surveyor #1 interviewed the agency's Compliance Consultant III (Staff #114) regarding the lack of documentation that PT frequencies are discussed with the patient or their legal representative. Staff #114 acknowledged the findings and stated that the PT frequencies are discussed during the initial visit, however they were not able to provide documentation to support this. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 09/17/21. .

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 6 of 18 patients (Patients #101, #104, #107, #109, #111, and #112) 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, "Patient Assessment and Recertification," (Policy HH 4-076, Last Reviewed: 08/04/23) showed the initial assessment will be conducted within 48 hours of the referral. 2. Record review of patient records Patients #101, #104, #107, #109, #111, and #112 showed: a. Patient #101’s Start of Care (SOC) date was 12/05/23. The patient was admitted for primary diagnoses of Acute Respiratory Failure and Hypoxia. The agency completed the referral on 12/01/23 for a Physical Therapy (PT) initial assessment, and the SOC for PT services did not occur until 12/05/23. There was no documentation that the patient or their legal representative were notified of the delayed of PT services within the 48 hours of the referral date. b. Patient #104’s SOC date was 12/12/23. The patient was admitted for primary diagnoses of Age-related Osteoporosis and Parkinson’s. The agency completed the referral on 12/08/23 for a Skilled Nursing (SN) initial assessment, and the SOC for SN services did not occur until 12/12/23. There was no documentation that the patient or their legal representative were notified of the delayed of SN services within the 48 hours of the referral date. c. Patient #107’s SOC date was 01/03/24. The patient was admitted for primary diagnoses of Osteoporosis and Back Fracture. The agency completed the referral on 12/29/23 for a PT initial assessment, and the SOC for PT services did not occur until 01/03/24. There was no documentation that the patient or their legal representative were notified of the delayed of PT services within the 48 hours of the referral date. d. Patient #109’s SOC date was 12/21/23. The patient was admitted for a primary diagnosis of Parkinson’s. The agency completed the referral on 12/18/23 for a PT initial assessment, and the SOC for PT services did not occur until 12/21/23. There was no documentation that the patient or their legal representative were notified of the delayed of PT services within the 48 hours of the referral date. e. Patient #111’s SOC date was 07/25/23. The patient was admitted for a primary diagnosis of Urinary Retention. The agency completed the referral on 07/21/23 for a SN initial assessment, and the SOC for SN services did not occur until 07/25/23. There was no documentation that the patient or their legal representative were notified of the delayed of SN services within the 48 hours of the referral date. f. Patient #112’s SOC date was 10/19/23. The patient was admitted for primary diagnoses of Type 2 Diabetes Mellitus. The agency completed the referral on 10/16/23 for a SN initial assessment, and the SOC for SN services did not occur until 10/19/23. There was no documentation that the patient or their legal representative were notified of the delayed of SN services within the 48 hours of the referral date. 3. On 01/11/24 at 9:00 AM, Surveyor #1 interviewed the agency’s Compliance Consultant III (Staff #114) regarding the lack of documentation that the patient or their legal representative was notified of the delayed SOC services. Staff #114 acknowledged the findings and stated that the referral department attempts to notify the patient or their legal representative of the delayed SOC but is not able to provide documentation to support this. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 09/17/21. .

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to show that the patient’s strengths and goals were assessed during the initial comprehensive assessment for 17 of 18 patients (Patient #101, #102, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, and #118). Failure to establish the patient’s strengths and goals prevent patients from achieving their individualized home health goals. . Findings included: 1. Document review of agency’s policy titled, “Patient Assessment and Recertification,” (Policy # HH 4-076, Last Reviewed 08/04/23) showed the initial assessment includes an evaluation of the patient’s strengths, and the information is used to develop the individualized and goal-oriented plan of care. 2. Record review of the patient’s initial assessment for Patient #101, #102, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, and #118 showed no documentation that the agency identified the patients' strengths and goals during the initial comprehensive assessment of the patient. 3. On 01/10/24 at 2:00 PM, Surveyor #1 interviewed the agency’s Compliance Consultant III (Staff #114) regarding the lack of patients’ strengths and goals during the initial comprehensive assessment. Staff #114 acknowledged the findings and stated that clinicians do establish the patient’s strengths and goals during the initial assessment visit but was not able to provide documentation to support this. .

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 reviews, and interview, the agency failed to communicate with the patient’s physician of Skilled Nursing (SN) missed visits resulting in changes to the patient’s plan of care in 4 of 18 patients (Patients #108, #110, #111, and #114). Failure to communicate changes in the plan of care to the patient's physician may potentially have a clinical impact on the patient’s well-being. Findings included: 1. Document review of the agency’s job aide, “Missed visits: Nursing and Therapy” pg. 290 (Dated 01/04/24) showed patients are contacted to determine if the visit needs to be moved and that all missed visits require a physician order. 2. Record review of patient records for Patients #108, #110, #111, and #114 showed: a. Patient #108 was admitted on 10/15/23. The plan of care included Skilled Nursing (SN) services with a frequency of 1 visit every week for 5 weeks starting 10/23/23, then 1 visit every week for 3 weeks starting 11/27/23. During the Medicare week of 11/05/23 to 11/11/23, the patient received no SN visits. In addition, there was no documentation as to why the SN visit was not made, and no physician notification of the missed visit. b. Patient #110 was admitted on 10/25/23. The plan of care included SN services with the frequency of 2 visits every week for 2 weeks starting 10/25/23, then 1 visit every week for 1 week starting 10/31/23, and then 1 visit every week for 7 weeks starting 11/05/23. During the Medicare weeks of 11/26/23 to 12/02/23 and 12/03/23 to 12/09/23, the patient received no SN visits. In addition, there was no documentation as to why the SN visit was not made, and no physician notification of the missed visit. c. Patient #111 was admitted on 07/25/23. The plan of care included SN services with the frequency of 2 visits every week for 1 week and then 1 visit every week for 1 week starting 07/25/23. During the Medicare week of 07/30/23 to 08/05/23, the patient received no SN visits. In addition, there was no documentation as to why the SN visit was not made, and no physician notification of the missed visit. d. Patient #114 was admitted on 01/29/23. The plan of care included SN services with the frequency of 2 visits every week for 2 weeks and then 1 visit every week for 8 weeks starting 01/29/23. During the Medicare week of 02/05/23 to 02/11/23, the patient received no SN visits. In addition, there was no documentation as to why the SN visit was not made, and no physician notification of the missed visit. 3. On 01/10/23 at 2 PM, Surveyor #1 interviewed the agency’s Compliance Consultant III (Staff #114) regarding the lack of documentation and physician notification of the SN missed visits. Staff #114 acknowledged the findings and was not able to provide documentation as to why the missed visit occurred and why the patients’ physicians were not notified of the missed visits. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 09/17/21. .

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to include the Medicare required goals and measurable outcomes in the individualized plan of care (CMS-485) for 17 of 18 patients (Patients #101, #102, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, and #118)(Item #1); and failed to include therapy services and therapy frequencies in the plan of care for 6 of 10 (Patients #104, #105, #110, #112, #114, and #115) (Item #2). Failure to include all required elements on the CMS-485 form may result in omissions of care and put the patient at risk for unmet needs and receiving care not ordered by a physician. Findings included: Item #1 - Measurable outcomes and goals not included in the plan of care (CMS-485) form 1. Record review of the CMS-485 form for Patients #101, #102, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, and #118 showed: a. Patient #101's Start of Care (SOC) date was 12/05/23. The CMS-485 form for the initial certification period of 12/05/23 to 02/02/24 failed to include the Medicare required goals and measurable outcomes. b. Patient #102's SOC date was 08/20/23. The CMS-485 form for the initial certification period of 08/20/23 to 10/18/23 failed to include the Medicare required goals and measurable outcomes. c. Patient #104's SOC date was 12/12/23. The CMS-485 form for the initial certification period of 12/12/23 to 02/09/24 failed to include the Medicare required goals and measurable outcomes. d. Patient #105's SOC date was 12/12/23. The CMS-485 form for the initial certification period of 12/12/23 to 02/09/24 failed to include the Medicare required goals and measurable outcomes. e. Patient #106's SOC date was 11/20/23. The CMS-485 form for the initial certification period of 11/20/23 to 01/18/24 failed to include the Medicare required goals and measurable outcomes. f. Patient #107's SOC date was 01/03/24. The CMS-485 form for the initial certification period of 01/03/24 to 03/02/24 failed to include the Medicare required goals and measurable outcomes. g. Patient #108's SOC date was 10/15/23. The CMS-485 form for the initial certification period of 10/15/23 to 12/13/23 failed to include the Medicare required goals and measurable outcomes. h. Patient #109's SOC date was 12/21/23. The CMS-485 form for the initial certification period of 12/21/23 to 02/18/24 failed to include the Medicare required goals and measurable outcomes. i. Patient #110's SOC date was 10/25/23. The CMS-485 form for the initial certification period of 10/25/23 to 12/12/23 failed to include the Medicare required goals and measurable outcomes. j. Patient #111's SOC date was 07/25/23. The CMS-485 form for the initial certification period of 07/25/23 to 09/22/23 failed to include the Medicare required goals and measurable outcomes. k. Patient #112's SOC date was 10/19/23. The CMS-485 form for the initial certification period of 10/19/23 to 12/17/23 failed to include the Medicare required goals and measurable outcomes. l. Patient #113's SOC date was 12/23/23. The CMS-485 form for the initial certification period of 12/23/23 to 02/02/24 failed to include the Medicare required goals and measurable outcomes. m. Patient #114's SOC date was 01/29/23. The CMS-485 form for the initial certification period of 01/09/23 to 03/29/23 failed to include the Medicare required goals and measurable outcomes. n. Patient #115's SOC date was 05/12/23. The CMS-485 form for the initial certification period of 05/12/23 to 07/10/23 failed to include the Medicare required goals and measurable outcomes. o. Patient #116's SOC date was 04/01/23. The CMS-485 form for the initial certification period of 04/01/23 to 05/30/23 failed to include the Medicare required goals and measurable outcomes. p. Patient #117's SOC date was 04/08/23. The CMS-485 form for the initial certification period of 04/08/23 to 06/06/23 failed to include the Medicare required goals and measurable outcomes. q. Patient #118's SOC date was 06/03/23. The CMS-485 form for the initial certification period of 06/03/23 to 08/12/23 failed to include the Medicare required goals and measurable outcomes. 2. On 01/11/23 at 9:00 AM, Surveyor #1 interviewed the agency’s Compliance Consultant III (Staff #114) regarding the lack of patients’ home health goals and measurable outcomes in the CMS-485 forms. Staff #114 acknowledged the findings and was unable to explain why the patients’ home health goals and measurable outcomes are not listed on the patients’ initial CMS-485 forms. Item #2 – Therapy services and frequencies not included in the plan of care (CMS-485) 1. Record review of the CMS-485 form for Patients #104, #105, #110, #112, #114, and #115, who were receiving therapy services, showed: a. Patient #104's SOC date was 12/12/23. The CMS-485 form for the initial certification period of 12/12/23 to 02/09/24 failed to include Physical Therapy (PT) services and frequencies for 5 visits for 1 month as ordered by the physician on 12/14/23. b. Patient #105's SOC date was 12/12/23. The CMS-485 form for the initial certification period of 12/12/23 to 02/09/24 failed to include PT and Occupational Therapy (OT) services; and the PT frequencies for 5 visits for 1 month and OT frequencies for 3 visits every 5 weeks for 5 weeks as ordered by the physician on 12/12/23. c. Patient #110's SOC date was 10/25/23. The CMS-485 form for the initial certification period of 10/25/23 to 12/12/23 failed to include PT services and frequencies for 4 visits for 1 month as ordered by the physician on 10/27/23. d. Patient #112's SOC date was 10/19/23. The CMS-485 form for the initial certification period of 10/19/23 to 12/17/23 failed to include PT services and frequencies for 4 visits every week for 4 weeks for 4 weeks as ordered by the physician on 10/23/23. e. Patient #114's SOC date was 01/29/23. The CMS-485 form for the initial certification period of 01/29/23 to 03/08/23 failed to include PT services and frequencies for 3 visits 1 month as ordered by the physician on 01/28/23. f. Patient #115's SOC date was 05/12/23. The CMS-485 form for the initial certification period of 05/12/23 to 07/10/23 failed to include PT services and frequencies for 4 visits 1 month as ordered by the physician on 05/15/23. 2. On 01/11/23 at 9:00 AM, Surveyor #1 interviewed the agency’s Compliance Consultant III (Staff #114) regarding the lack of the therapies and frequencies in the CMS-485 forms. Staff #114 acknowledged the findings and was unable to explain why the therapies and the frequencies are not listed on the patients’ initial CMS-485 forms. .

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: . Based on the document and record review, the agency failed to track the performance of corrective actions to address previously identified non-compliance that ensure quality and safe patient care and the reduction of adverse events. Failure of the agency to monitor, implement, maintain, and evaluate performance improvement projects puts patients at risk of receiving substandard care. . 1. Document review of the agency policies titled, “Improving Organizational Performance,” (Policy No. HHHP 5-001, Revised Date 04/12/23) showed Senior Management and Quality Coordinator will adopt a structured framework for performance improvement with problem-solving in the areas of practice standards, patient care and patient safety, clinical skills and competencies of personnel, and benchmarking activities current performance against past performance. 2. A review of the agency’s document titled, “Home Health Quality and Compliance Council Charter,” (Reviewed and Revised Date 01/19/23) showed that the council will maintain survey readiness that includes the standards and expectations of accrediting bodies and will review, audit, and monitor activities to ensure that management develops and implements appropriate corrective actions. 3. A review of the agency’s previous Medicare Recertification surveys from 12/11/17 and 09/17/21 showed: a. The agency was previously cited on the survey dated 09/17/21 for G0434, Participate in care, CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii), for failure to inform the patient or their legal representative of the therapy services and the frequencies of the proposed therapy services. Cross Reference: See G0434 b. The agency was previously cited on the survey dated 09/17/21 for G0514, RN performs assessment, CFR(s): 484.55(a)(1), for failure 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. Cross Reference: See G0514 c. The agency was previously cited on the survey dated 09/17/21 for G0572, Plan of care, CFR(s): 484.60(a)(1), for failure to communicate with the patient’s physician of Skilled Nursing (SN) missed visits resulting in changes to the patient’s plan of care. Cross Reference: See G0572 d. The agency was previously cited on the surveys dated 12/11/17 and 09/17/21 for G0860, Licensing, CFR(s): 484.100(b), Reference: Washington Administrative Code (WAC) 246-335-525 (6), for failure to conduct state requirements for criminal background checks and disclosure statements on hire and within two years of the previous check. Cross Reference: See G0860 e. The agency was cited on the survey dated 09/17/21 for G0860, Licensing, CFR(s): 484.100(b), Reference: Washington Administrative Code (WAC) 246-335-530 (12), for failure to show adequate documentation of personnel performance evaluations. Cross Reference: See G0860 .

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 operationalize its policies and procedures to comply with agency-wide and state licensing requirements for the Tuberculosis (TB) infection control program for 10 of 12 personnel files reviewed. (Staff #602, #603, #605, #606, #607, #608, #609, #610, #611, and #612) Failure of the agency to comply with the agency and state requirements for TB screening may place the patients and staff at risk of TB exposure. . Reference: Washington Administrative Code (WAC) 246-335-525 (15) (c): Tuberculosis (TB) infection control program. Key elements include, but are not limited to: (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. 1. Document review of the agency policies titled, “Health Care Worker Immunity and Screening Requirements,” (Policy No. D-07-005, Reviewed Date 09/22/21) and “Tuberculosis (TB) Exposure Control Plan,” (Policy No. D-07-004, Approved Date 12/06/23) showed the policy lacked the state requirements for conducting a TB risk assessment using the department-approved form for all personnel on hire and annually. 2. On 01/11/24, Surveyor #6 reviewed 12 personnel files (Staff #601, #602, #603, #604, #605, #606, #607, #608, #609, #610, #611, and #612). The review showed: a. Staff #602 was hired on 05/08/06. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. b. Staff #603 was hired on 08/13/18. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. c. Staff #605 was hired on 12/14/15. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. d. Staff #606 was hired on 01/11/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. e. Staff #607 was hired on 09/13/21. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. f. Staff #608 was hired on 08/20/18. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. g. Staff #609 was hired on 11/14/22. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. h. Staff #610 was hired on 05/22/17. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. i. Staff #611 was hired on 02/19/19. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. j. Staff #612 was hired on 12/09/19. The record contained no evidence that the agency conducted a TB risk assessment using the department-approved form in 2023. 3. On 01/11/24 at 11:30 AM, Surveyor #6 interviewed the agency’s Employee Health Nurse (Staff #620) about the missing TB risk assessments using the department-approved form in the personnel records for 2023. Staff #620 acknowledged the findings and stated that the agency was unable to provide the missing 2023 documents. .

HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to provide documentation of adequate competency training to Home Health Aides that addresses the required subject areas before providing care. Failure to provide adequate competency training to Home Health Aides puts the patients at risk of harm from untrained and unqualified caregivers. . 1. Document review of the agency policies titled, "Performance Standards," (Policy No. HHHP 7-051, Revised Date 03/09/22) and “Orientation in Home Health and Hospice,” (Policy No. HHHP 7-049, Revised Date 01/18/22) showed that clinical competencies will be assessed during orientation for personnel providing direct patient care and documentation will be retained in the personnel files. The agency’s document titled, “Home Health Aide Competency Evaluation Performance Checklist,” (Revised 02/2021) did not show the following subject areas that meet the Home Health Aide competency requirements: i. Communication skills; ii. Observation, reporting, and documentation of patient status and the care or service furnished; iii. Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor; iv. Maintenance of a clean, safe, and healthy environment; v. Recognizing emergencies and the knowledge of instituting emergency procedures and their application; vi. The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property; vii. Adequate nutrition and fluid intake. Cross Reference: G0764 2. On 01/11/24 and 01/12/24, Surveyors # 1 and #6 reviewed 3 Home Health Aide files (Staff #601, # 603, and #609). The review showed: a. Staff #603 was hired on 08/13/18. The staff record contained no evidence that the agency completed the Home Health Aide competency training before providing patient care that addresses the required subject areas as listed on CFR 484.80(b)(3)(i-xv). b. Staff #609 was hired on 11/14/22. The staff record contained no evidence that the agency completed the Home Health Aide competency training before providing patient care that addresses the required subject areas as listed on CFR 484.80(b)(3)(i-xv). 3. On 01/12/24 at 11:00 AM, Surveyors #1 and #6 interviewed the agency’s Home Health Managers (Staff #622 and Staff #623) about the missing documentation of Home Health Aide competency training with the required subject area before providing patient care. Staff #622 and Staff #623 acknowledged the findings and stated that the agency was unable to provide the missing documents for the staff listed above. .

Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to provide documentation of an annual on-site visit while the Home Health Aide performs patient care. Failure to properly supervise Home Health Aides puts the patients at risk of harm from inadequate or substandard care. . 1. Document review of the agency policy titled, "Performance Standards," (Policy No. HHHP 7-051, Revised Date 03/09/22) showed that annual observation visits will be conducted and documented by the manager or designee to assess if skilled care meets the patient’s care needs. 2. On 01/11/24 and 01/12/24, Surveyors #1 and #6 reviewed 3 Home Health Aide files (Staff #601, #603, and #609). The review showed: a. Staff #601 was hired on 09/20/07. The staff record contained no evidence that the agency completed an on-site visit in 2021 and 2023. b. Staff #603 was hired on 08/13/18. The staff record contained no evidence that the agency completed an on-site visit in 2023. 3. On 01/12/24 at 11:00 AM, Surveyors #1 and #6 interviewed the agency’s Home Health Managers (Staff #622 and Staff #623) about the missing documentation of on-site visits to the Home Health Aides. Staff #622 and Staff #623 acknowledged the findings and stated that the agency was unable to provide the missing documents for the staff listed above. .

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 operationalize its policies and procedures consistent with state licensing requirements through failure to conduct criminal background checks using the Washington State Patrol (WSP) and complete a disclosure statement for 2 of 12 clinicians (Staff #609 and #610) (Item #1); failure to show adequate documentation of performance evaluations for 9 of 12 clinicians (Staff #601, #602, #603, #604, #607, #608, #610, #611, and #612) (Item #2); failure to document verification of skills or training specific to meeting the care needs of patients for 8 of 12 clinicians (Staff #603, #605, #606, #607, #608, #609, #610, and #612) (Item #3); failure to show adequate evidence of orientation for 2 of 12 clinicians (Staff #608 and #609) (Item #4). Failure to maintain and implement policies and procedures consistent with state home health regulations puts patients at risk of physical and/or psychological harm from inadequate or substandard care. . Item #1-Criminal History Background Checks and Disclosure Statements Reference: Washington Administrative Code (WAC) 246-335-525 (6): Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following: (c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check. 1. Document review of the agency policy titled, "Human Resources," (Policy No. HHHP 7-002, Revised Date 10/08/21) showed that on hire and every two years all in-home services staff will complete and sign the department-approved disclosure statement and the agency will complete the Washington State Patrol (WSP) criminal background checks. 2. On 01/11/24 and 01/12/24, Surveyors #1 and #6 reviewed 12 personnel files (Staff #601, #602, #603, #604, #605, #606, #607, #608, #609, #610, #611, and #612). The review showed: a. Staff #609 was hired on 11/14/22. There was no evidence the agency completed the WSP criminal background check on hire. b. Staff #610 was hired on 05/22/17. There was no evidence the agency completed a department-approved disclosure statement in 2021. 3. On 01/11/24 at 1:00 PM, Surveyors #1 and #6 interviewed the agency’s Home Health Managers (Staff #622) about the missing WSP criminal background check and the department-approved disclosure statement in the personnel files. Staff #611 acknowledged the findings and stated they were unable to provide the missing documents for the staff listed above. THIS IS A REPEAT CITATION, PREVIOUSLY CITED ON THE TWO CMS SURVEYS COMPLETED ON 12/11/17, CITED UNDER TAG 0118, AND ON 09/17/21. Item #2- Performance Evaluation References: Washington Administrative Code (WAC) 246-335-530 (12): 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). Washington Administrative Code (WAC) 246-335-525 (16) and (17): The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (16) 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; and Surveyor Note: The requirement of WAC 246-335-525(16) for on-site annual observation/evaluation of staff providing care was exempted by Washington State Register (WSR) 20-10-061, signed by the Secretary of Health on April 30, 2020. Annual performance evaluations of all personnel, including observation of care and skills, were still required, but could be done remotely (instead of on-site) using various electronic resources. This exemption ended on 10/31/22. 1. Document review of the agency policies titled, “Human Resources,” (Policy No. HHHP 7-002, Revised Date 10/08/21) and “Performance Evaluations,” (Policy No. NATL.HR.034, Effective Date 12/07/23) showed that all staff will receive an annual performance evaluation and should be acknowledged by the employee via signature or eSignature. 2. On 01/11/24 and 01/12/24, Surveyors #1 and #6 reviewed 12 personnel files (Staff #601, #602, #603, #604, #605, #606, #607, #608, #609, #610, #611, and #612). The review showed: a. Staff #601 was hired on 09/20/07. The staff record contained no evidence that the agency completed an annual performance evaluation that was signed and acknowledged by the employee in 2021 and 2022. b. Staff #602 was hired on 05/08/06. The staff record contained no evidence that the agency completed the annual performance evaluation that was signed and acknowledged by the employee in 2021 and 2022. c. Staff #603 was hired on 08/13/18. The staff record contained no evidence that the agency completed the annual performance evaluation that was signed and acknowledged by the employee in 2021 and 2022. d. Staff #604 was hired on 03/25/04. The staff record contained no evidence that the agency completed the annual performance evaluation that was signed and acknowledged by the employee in 2022. e. Staff #607 was hired on 09/13/21. The staff record contained no evidence that the agency completed the annual performance evaluation that was signed and acknowledged by the employee in 2022. f. Staff #608 was hired on 08/20/18. The staff record contained no evidence that the agency completed the annual performance evaluation that was signed and acknowledged by the employee in 2021 and 2022. g. Staff #611 was hired on 02/19/19. The staff record contained no evidence that the agency completed the annual performance evaluation that was signed and acknowledged by the employee in 2022. h. Staff #612 was hired on 12/09/19. The staff record contained no evidence that the agency completed the annual performance evaluation that was signed and acknowledged by the employee in 2022. 3. On 01/12/24 at 11:00 AM, Surveyors #1 and #6 interviewed the agency’s Home Health Managers (Staff #622 and Staff #623) about the missing documentation of annual performance evaluations that was signed and acknowledged by the employee for personnel providing direct patient care. Staff #622 and Staff #623 acknowledged the findings and stated they were unable to provide the missing documents for the staff listed above. THIS IS A REPEAT CITATION, PREVIOUSLY CITED ON THE LAST CMS SURVEY COMPLETED ON 09/17/21. Item #3- Verification of Skills Reference: Washington Administrative Code (WAC) 246-335-530 (5): Verification of personnel, contractor, and volunteer skills or training specific to meeting the care needs of patients. 1. Document review of the agency policies titled, "Performance Standards," (Policy No. HHHP 7-051, Revised Date 03/09/22) and “Orientation in Home Health and Hospice,” (Policy No. HHHP 7-049, Revised Date 01/18/22) showed that clinical competencies will be assessed on hire and annually for personnel providing direct patient care and documentation will be retained in the personnel files. 2. On 01/11/24 and 01/12/24, Surveyors #1 and #6 reviewed 12 personnel files (Staff #601, #602, #603, #604, #605, #606, #607, #608, #609, #610, #611, and #612). The review showed: a. Staff #603 was hired on 08/13/18. The staff record contained no evidence that the agency verified the staff member's skills or training specific to meeting the care needs of patients. b. Staff #605 was hired on 12/14/15. The staff record contained no evidence that the agency verified the staff member's skills or training specific to meeting the care needs of patients. c. Staff #606 was hired on 01/11/21. The staff record contained no evidence that the agency verified the staff member’s skills or training specific to meeting the care needs of patients. d. Staff #607 was hired on 09/13/21. The staff record contained no evidence that the agency verified the staff member’s skills or training specific to meeting the care needs of patients. e. Staff #608 was hired on 08/20/18. The staff record contained no evidence that the agency verified the staff member’s skills or training specific to meeting the care needs of patients. f. Staff #609 was hired on 11/14/22. The staff record contained no evidence that the agency verified the staff member’s skills or training specific to meeting the care needs of patients. g. Staff #610 was hired on 05/22/17. The staff record contained no evidence that the agency verified the staff member’s skills or training specific to meeting the care needs of patients. h. Staff #612 was hired on 12/09/19. The staff record contained no evidence that the agency verified the staff member’s skills or training specific to meeting the care needs of patients. 3. On 01/12/24 at 11:00 AM, Surveyor #6 interviewed the agency’s Home Health Managers (Staff #622 and Staff #623) about the missing documentation of skills verification for staff providing direct patient care. Staff #622 and Staff #623 acknowledged the findings and stated they were unable to provide the missing documents for the staff listed above. Item #4 – Evidence of Orientation Reference: Washington Administrative Code (WAC) 246-335-530 (4) Evidence of orientation to current agency policies and procedures. 1. Document review of the agency policies titled, "Human Resources," (Policy No. HHHP 7-002, Revised Date 10/08/21) and “Orientation in Home Health and Hospice,” (Policy No. HHHP 7-049, Revised Date 01/18/22) showed that new employees will complete the orientation program and the completion of the process will be documented in the personnel files. 2. On 01/11/24 and 01/12/24, Surveyors #1 and #6 reviewed 12 personnel files (Staff #601, #602, #603, #604, #605, #606, #607, #608, #609, #610, #611, and #612). The review showed: a. Staff #608 was hired on 08/20/18. The staff record contained no evidence that the agency completed the employee’s orientation and training on policies and procedures upon hire. b. Staff #609 was hired on 11/14/22. The staff record contained no evidence that the agency completed the employee’s orientation and training on policies and procedures upon hire. 3. On 01/12/24 at 11:00 AM, Surveyor #6 interviewed the agency’s Home Health Managers (Staff #622 and Staff #623) about the missing documentation of orientation for staff providing direct patient care. Staff #622 and Staff #623 acknowledged the findings and stated they were unable to provide the missing documents for the staff listed above. .

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR 484, conducted this health and safety survey. Onsite dates: 09/13/21 to 09/17/21 Examination number: 2021-703 The survey was conducted by: Surveyor #1 Surveyor #6 DOH recommends recertification based on an acceptable plan of correction. .

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 ensure patients' rights to be informed of the types and frequency of care, as well as be involved in the review of any changes to their ongoing care for 4 of 4 patient records with Home Health aide services (Patient # 106, #107, #108, #109). Failure to inform patients and their representatives of the frequencies of the proposed care and services prevent the patient from participating in their care. Findings included: 1. Document review of agency's Admission Criteria and Process form titled, "Policy #HH2-003," (last revised 03/19/21) showed that the patient or their representative accepts home care services by signing the agency informed consent form. 2. Surveyor #1 reviewed 4 patient records that had Home Health aide services ordered by physician. The review showed: a. Patient #106 was admitted on 08/24/21. Home Health aide was ordered on 08/24/21 with frequency of visits of 1 to 2 visit every week for 8 weeks. There was no documentation to show the patient or their representatives were informed of the varying frequencies of home health aide services. b. Patient #107 was admitted on 09/09/21. Home Health aide was ordered on 09/17/21 with frequency of visits of 1 to 2 visit every week for 4 weeks. There was no documentation to show the patient or their representatives were informed of the varying frequencies of home health aide services. c. Patient #108 was admitted on 09/02/21. Home Health aide was ordered on 09/06/21 with frequency of visits of 1 to 2 visit every week for 8 weeks. There was no documentation to show the patient or their representatives were informed of the varying frequencies of home health aide services. d. Patient #109 was admitted on 07/10/21. Home Health aide was ordered on 07/13/21 with frequency of visits of 1 to 2 visit every week for 8 weeks. There was no documentation to show the patient or their representatives were informed of the varying frequencies of home health aide services. 3. On 09/15/21 at 3:00 PM, Surveyor #1 interviewed the agency's Home Health Quality & Compliance Nurse (Staff #117) and the agency's Clinical Nurse Specialist (Staff #118) of the lack of documentation. Staff #117 and Staff #118 acknowledged the findings. .

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 48 hours of completing the referral for 11 of 17 patients (Patients #101, #106, #107, #108, #109,#110, #112, #114, #115, #116, #117). 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, "Continuum of Care and Services, Policy HHHP 4-074," (Dated 08/18/21) showed that the agency's admission process facilitates the delivery of timely care and that home health coordinates and communicates care and services to ensure appropriate continuity of care. 2. Record review of patient records Patients #101, #106, #107, #108, #109,#110, #112, #114, #115, #116, #117 showed: a. Patient #101's Start of Care (SOC) date was 06/19/21. The patient was admitted for primary diagnoses of Parkinson's and Hypertension. The agency completed the referral on 06/02/21 for a Skilled Nursing (SN) assessment, however the SOC for SN services did not occur until 06/19/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. b. Patient #106's SOC date was 08/24/21. The patient was admitted for primary diagnoses of Stage 2 Pressure Ulcer on Right Buttocks. The agency completed the referral on 08/17/21 for a SN assessment, however the SOC for SN services did not occur until 08/24/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. c. Patient #107's SOC date was 09/09/21. The patient was admitted for primary diagnoses of Pneumonia. The agency completed the referral on 09/05/21 for a SN assessment, however the SOC for SN services did not occur until 09/09/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. d. Patient #108's SOC date was 09/02/21. The patient was admitted for primary diagnoses Fracture Left Femur. The agency completed the referral on 08/29/21 for a SN assessment, however the SOC for SN services did not occur until 09/02/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. e. Patient #109 SOC date was 07/10/21. The patient was admitted for primary diagnoses of Fracture of the Right Femur. The agency completed the referral on 07/06/21 for a SN assessment, however the SOC for SN services did not occur until 07/10/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. f. Patient #110 SOC date was 08/03/21. The patient was admitted for primary diagnoses of Osteoporosis and Osteoarthritis. The agency completed the referral on 07/28/21 for a SN assessment, however the SOC for SN services did not occur until 08/03/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. g. Patient #112 SOC date was 07/10/21. The patient was admitted for primary diagnoses of Pressure Ulcer on Left Heel. The agency completed the referral on 06/25/21 for a SN assessment, however the SOC for SN services did not occur until 07/10/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. h. Patient #114 SOC date was 06/21/21. The patient was admitted for primary diagnoses of Right Below the Knee Amputation with Wound Dehiscence. The agency completed the referral on 06/14/21 for a SN assessment, however the SOC for SN services did not occur until 06/21/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. i. Patient #115 SOC date was 02/05/21. The patient was admitted for primary diagnoses of Peripheral Vascular Disease. The agency completed the referral on 02/01/21 for a SN assessment, however the SOC for SN services did not occur until 02/05/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. j. Patient #116 SOC date was 08/24/21. The patient was admitted for primary diagnoses of Severe Protein-Calorie Malnutrition. The agency completed the referral on 08/06/21 for a SN assessment, however the SOC for SN services did not occur until 08/24/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. k. Patient #117 SOC date was 08/26/21. The patient was admitted for primary diagnoses of Asthma. The agency completed the referral on 08/05/21 for a SN assessment, however the SOC for SN services did not occur until 08/26/21. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. 3. On 09/16/21 at 3:00 PM, Surveyor #1 interviewed the agency's Home Health Quality & Compliance Nurse (Staff #117) and the agency's Clinical Nurse Specialist (Staff #118) of the findings. Staff #117 and Staff #118 acknowledged the findings and stated they are taking steps to develop a plan of corrections. .

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 changes to patient's plan of care resulting from missed health aide visits to the patient's physician, for 3 of 4 patients with home health aide services (Patient # 106, #108, #109). Failure to communicate with the patient's physician of changes to the plan of care may have a clinical impact on the patient's wellbeing. Findings included: 1. Document review of agency's document titled, "Home Health/Hospice Aide Job Breakdown- Orders & Plan of Care" (Dated 08/05/21) indicated that aide visits are set in range frequencies at the higher number of ranges. In addition, the purpose for the range visits allows for documentation but without the need for physician's orders for the missed visits. 2. Surveyor #1 reviewed 4 patient records that had Home Health aide services ordered by physician. The review showed: a. Patient #106 was admitted on 08/24/21. Home Health aide was ordered on 08/24/21 with frequency of visits of 1 to 2 visit every week for 8 weeks. During the initial week of aide services, the patient received only 1 aide visit, but there was no evidence in the record that the agency recorded the missed visit and notified the physician. b. Patient #108 was admitted on 09/02/21. Home Health aide was ordered on 09/06/21 with frequency of visits of 1 to 2 visit every week for 8 weeks. During the initial week of aide services, the patient received only 1 aide visit, but there was no evidence in the record that the agency recorded the missed visit and notified the physician. c. Patient #109 was admitted on 07/10/21. Home Health aide was ordered on 07/13/21 with frequency of visits of 1 to 2 visit every week for 8 weeks. During the 3rd, 4th, and 6th weeks of aide services, the patient received no aide visits, but there was no evidence in the record that the agency recorded the missed visits and notified the physician. 3. On 09/16/21 at 3:00 PM, Surveyor #1 interviewed the agency's Home Health Quality & Compliance Nurse (Staff #117) and the agency's Clinical Nurse Specialist (Staff #118) of the lack of documentation and physician notification of the missed visits. Staff #117 and Staff #118 acknowledged the findings. .

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to implement policies and procedures consistent with state licensing requirements for 12 of 12 staff reviewed, through failure to complete and provide documentation of department approved disclosure statements and criminal background checks every 2 years for 12 staff (Staff #601, Staff #602, Staff #603, Staff #604, Staff #605, Staff #606, Staff #607, Staff #608, Staff #609, Staff #610, Staff #611 and Staff #612) (Item 1), and failure to complete annual staff performance evaluations including on-site observations for 6 of 8 Staff (Staff #601, Staff #602, Staff #603, Staff #604, Staff #605, and Staff #607) (Item 2). Failure to maintain compliance with state licensing requirements puts patients at risk of receiving care from an un-vetted or unqualified caregiver. Item 1- Disclosure Statements and Background Checks References: Washington Administrative WAC 246-335-525 (6) Personnel, contractor, and volunteer policies. The licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following: (a) Criminal history background checks must be processed through the Washington state patrol; (b) Disclosure statements must be approved by the department; and (c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check. Findings included: 1. Document review of the agency policy titled, "Human Resources Policy Number HHHP 7-002," (03/05/21 revision date) showed that the agency was to complete an ongoing criminal record checks as required by law, and that all in-home services agency staff will complete and sign a disclosure and background check every 2 years. The policy also showed that the home health personnel record for each employee must document these efforts. Document review of the agency policy titled, "Employment Screening Guidelines," (01/31/19 revision date), showed that after a conditional job offer, applicants are to complete a background check authorization form and that an offer of employment is contingent upon satisfactory results of the background screening. 2. On 09/15/21, Surveyor #6 reviewed 12 personnel files (Staff #601, Staff #602, Staff #603, Staff #604, Staff #605, Staff #606, Staff #607, Staff #608, Staff #609, Staff #610, Staff #611, and Staff #612). The review showed: a. Staff #601's hire date was 08/30/10. The record contained a disclosure statement and background check from 2010. The record failed to document Washington State Department of Health (DOH) approved disclosure statements and Washington State Patrol (WSP) background checks from 2012 through 2019. The record contained a non-DOH approved disclosure statement completed 10/08/20 but lacked a corresponding WSP background check. The record also contained a WSP background check completed on 09/14/21 but lacked a corresponding DOH approved disclosure statement. b. Staff #602's hire date was 10/02/17. The file contained a disclosure statement and a WSP background check from 2017. The record failed to document a renewed disclosure statement and background check in 2019. The record contained a non-DOH approved disclosure statement completed 10/07/20 but lacked a corresponding WSP background check. The record also contained a WSP background check completed on 09/14/21 but lacked a corresponding DOH- approved disclosure statement. c. Staff #603's hire date was 06/30/14. The file contained a WSP background check from 2014 but lacked a disclosure statement from 2014. The record failed to document DOH- approved disclosure statements and WSP background checks from 2016 through 2020. The record contained a non-DOH approved disclosure statement completed 10/08/20 but lacked a corresponding WSP background check. The record also contained a WSP background check completed on 09/14/21 but lacked a corresponding DOH- approved disclosure statement. d. Staff #604's hire date was 01/03/12. The file contained a disclosure statement and a WSP background check from 2011. The record failed to document DOH-approved disclosure statements and WSP background checks from 2013 through 2020. The record contained a non-DOH approved disclosure statement completed 10/08/20 but lacked a corresponding WSP background check. The record also contained a WSP background check completed on 09/14/21 but lacked a corresponding DOH-approved disclosure statement. e. Staff #605's hire date was 07/24/17. The record failed to document DOH- approved disclosure statements and WSP background checks from 2017 through 2020. The record contained a non-DOH approved disclosure statement completed 10/19/20 but lacked a corresponding WSP background check. The record also contained a WSP background check completed on 09/14/21 but lacked a corresponding DOH- approved disclosure statement. f. Staff #606's hire date was 05/10/21. The file contained a non-DOH approved disclosure statement. g. Staff #607's hire date was 10/19/15. The file contained a disclosure statement and background check from 2015. The record failed to document DOH-approved disclosure statements and WSP background checks from 2017 through 2020. The record contained a non-DOH approved disclosure statement completed 10/11/20 but lacked a corresponding WSP background check. The record also contained a WSP background check completed on 09/14/21 but lacked a corresponding DOH- approved disclosure statement. h. Staff #608's hire date was 03/23/20. The record contained a non-DOH approved disclosure statement and a WSP background check from 2020. The record also contained a WSP background check completed on 09/14/21 but lacked a corresponding DOH- approved disclosure statement. i. Staff #609's hire date was 12/10/18. The record failed to document a DOH-approved disclosure statement or WSP background check at the time of hiring in 2018. The file contained a non-DOH approved disclosure statement from 02/27/19 and a WSP background check from 03/05/19. The record contained a non-DOH approved disclosure statement completed 12/16/20 but lacked a corresponding WSP background check. The record also contained a WSP background check completed on 09/14/21 but lacked a corresponding DOH- approved disclosure statement. j. Staff #610's hire date was 11/30/15. The file contained a disclosure statement and WSP background check from 2015. The record failed to document DOH- approved disclosure statements and WSP background checks from 2017 through 2020. The record contained a non-DOH approved disclosure statement completed 10/20/20 but lacked a corresponding WSP background check. The record also contained a WSP background check completed on 09/14/21 but lacked a corresponding DOH- approved disclosure statement. k. Staff #611's hire date was 02/20/18. The file contained a non-DOH approved disclosure statement and WSP background check from 2018. The record contained a non-DOH approved disclosure statement completed 10/07/20 but lacked a corresponding WSP background check. The record failed to document WSP background checks from 2020 through the date of the record review on 09/15/21. l. Staff #612's hire date was 01/22/18. The file contained a non-DOH approved disclosure statement and a WSP background check from 2018. The record contained a non-DOH approved disclosure statement completed 10/26/20 but lacked a corresponding WSP background check. The record failed to document WSP background checks from 2020 through the date of the record review on 09/15/21. 3. Surveyor #6 interviewed the Human Resources Service Center Specialist (Staff #613) on 09/15/21 at 10:59 AM, about the missing disclosure statements and background checks for staff. Staff #613 acknowledged the agency has been using non-DOH approved disclosure statements for all staff. Staff #613 also stated most staff files lacked WSP background checks, and that the agency completed WSP background checks on 09/14/21 to prepare for personnel file reviews with Surveyor #6. Staff #613 also stated that they do not believe any of the Home Health staff have had WSP background checks since their date of hire to 2021, except for employee's files reviewed on 09/15/21. Staff #613 verified that the agency's policies require completed disclosure statements and background checks every 2 years for all staff. THIS IS A REPEAT CITATION FROM 12/11/17, cited under Tag 0118. . Item 2- Staff Performance Evaluations Including On-site Observations References: Washington Administrative Code (WAC) 246-335-525 (16) PERSONNEL, CONTRACTOR, AND VOLUNTEER POLICIES. The licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: 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; and (17) Annual evaluations of services provided by contractors providing direct patient care. 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. Document review of the agency policy titled, "Human Resources Policy Number HHHP 7-002," (03/05/21 revision date) showed that the agency needs to complete performance evaluations for all staff on an annual basis. The policy also showed that the home health personnel record for each employee must document the evaluation. 2. On 09/16/21, Surveyor #6 reviewed 8 personnel files (Staff #601, Staff #602, Staff #603, Staff #604, Staff #605, Staff #606, Staff #607, and Staff #608). The review showed: a. Staff #601's hire date was 08/30/10. The record showed the agency completed performance evaluations for Staff #601 from 2017 to 2020. The record also showed the agency conducted an on-site observation on 08/16/21. Absent from the record were on-site observations for 2018, 2019 and 2020. b. Staff #602's hire date was 10/02/17. The record showed the agency completed performance evaluations for Staff #602 from 2017 to 2020. The record also showed the agency conducted an on-site observation on 09/13/21. Absent from the record were on-site observations for 2018, 2019 and 2020. c. Staff #603's hire date was 06/30/14. The record showed the agency completed performance evaluations for Staff #603 for 2017, 2018, and 2020. The record also showed the agency conducted on-site observations in 2020 and 2021. Absent from the record were on-site observations for 2017, 2018 and 2019, and a performance evaluation for 2019. d. Staff #604's hire date was 01/03/12. The record showed the agency completed performance evaluations for Staff #602 from 2017 to 2020. The record also showed the agency conducted on-site observations in 2019 and 2020. Absent from the record were on-site observations for 2017 and 2018. e. Staff #605's hire date was 07/24/17. The record showed the agency completed a performance evaluation for Staff #605 in 2020. The record also showed the agency conducted on-site observations in 2019, and 2020. Absent from the record were on-site observations for 2017 and 2018, and performance evaluations for 2017 through 2019. f. Staff #607's hire date was 10/19/15. The record showed the agency completed a performance evaluation for Staff #607 in 2018. The record also showed the agency conducted an on-site observation in 2018. Absent from the record were on-site observations and performance evaluations for 2017, 2019, and 2020. 3. Surveyor #6 interviewed the Human Resources Admin Specialist (Staff #614) on 09/16/21 at 5:00 PM, about the missing performance evaluations and on-site observations for the staff above. Staff #614 acknowledged the missing performance evaluations and on-site observations for all staff noted above.