Every finding on record at King County Public Hospital District #2

. 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: 2024-572 Dates Onsite: 07/15/24 - 07/18/24 This survey was conducted by: Surveyor #1 Surveyor #6 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. .

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 dates for 10 of 17 patients (Patients #601, #602, #603, #604, #605, #606, #608, #611, #616, and #617). 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: 01/01/24 Centers for Medicare & Medicaid Services (CMS). 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). Findings included: 1. Document review of the agency’s job aide titled, “EPIC OASIS auditing,” (Updated 11/16/23) showed that the encoded OASIS data M0104 is the Date of Referral. 2. Record review for Patients #601, #602, #603, #604, #605, #606, #608, #611, #616, and #617 showed the following: a. Patient #601was admitted for the primary diagnosis of chronic venous hypertension with ulcer and inflammation of the left lower extremity - not a complete list. The OASIS M0104 data showed a date of 04/04/24 rather than the accurate referral date of 04/03/24. Documentation showed the referral was completed on 04/03/24 for Skilled Nursing (SN) Services. b. Patient #602 was admitted for the primary diagnosis of other symptoms and signs involving cognitive functions following cerebral infarction - not a complete list. The OASIS M0104 data showed a date of 05/28/24 rather than the accurate referral date of 05/24/24. Documentation showed the referral was completed on 05/24/24 for Physical Therapy (PT) Services. c. Patient #603 was admitted for the primary diagnosis of amyotrophic lateral sclerosis – not a complete list. The OASIS M0104 data showed a date of 05/20/24 rather than the accurate referral date of 05/17/24. Documentation showed the referral was completed on 05/17/24 for SN Services. d. Patient #604 was admitted for the primary diagnosis of chronic combined systolic and diastolic heart failure – not a complete list. The OASIS M0104 data showed a date of 06/26/24 rather than the accurate referral date of 06/25/24. Documentation showed the referral was completed on 06/25/24 for SN Services. e. Patient #605 was admitted for the primary diagnosis of Parkinson’s Disease with dyskinesia – not a complete list. The OASIS M0104 data showed a date of 05/25/24 rather than the accurate referral date of 05/24/24. Documentation showed the referral was completed on 05/24/24 for SN Services. f. Patient #606 was admitted for the primary diagnosis of hypertension – not a complete list. The OASIS M0104 data showed a date of 07/06/24 rather than the accurate referral date of 07/05/24. Documentation showed the referral was completed on 07/05/24 for SN Services. g. Patient #608 was admitted for the primary diagnosis of Parkinson’s Disease – not a complete list. The OASIS M0104 data showed a date of 01/01/24 rather than the accurate referral date of 12/21/23. Documentation showed the referral was completed on 12/21/23 for SN Services. h. Patient #611 was admitted for the primary diagnosis of Alzheimer’s Disease – not a complete list. The OASIS M0104 data showed a date of 05/12/24 rather than the accurate referral date of 05/10/24. Documentation showed the referral was completed on 05/10/24 for PT Services. i. Patient #616 was admitted for the primary diagnosis of encounter for surgical aftercare following surgery of circulatory system – not a complete list. The OASIS M0104 data showed a date of 11/29/23 rather than the accurate referral date of 11/28/23. Documentation showed the referral was completed on 11/28/23 for PT Services. j. Patient #617 was admitted for the primary diagnosis of fracture of left femur – not a complete list. The OASIS M0104 data showed a date of 02/02/24 rather than the accurate referral date of 02/01/24. Documentation showed the referral was completed on 02/01/24 for SN Services. 3. On 07/17/24 at 2:30 PM, the Surveyors interviewed the agency’s Director of Home Care Services (Staff #601) about the inaccurate data entered for OASIS M0104. Staff #601 acknowledged the inaccurate documentation of the OASIS data and stated that clinicians are trained in completing the OASIS M0104 data.

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 notify the patient’s physician when therapy services were not provided as written in the plan of care for 3 of 17 patients (Patients #102, Patient #105, and Patient #111). Failure to communicate with the patient’s physician of changes to the plan of care may potentially have a clinical impact on the patient’s wellbeing. Findings included: 1. Document review of the agency’s policy titled, “EHCS PC HH 2-018 Care Planning Process,” (Date Revision: 03/15/24) showed that the plan of care is based on the physician’s orders and will contain the services required to meet the patient’s needs. 2. Record review for Patients #102, #105, and #111 showed: a. Patient #102 was admitted on 05/29/24. Occupational Therapy (OT) services were ordered with frequencies of 1 visit every week for 4 weeks starting 06/03/24. During the dates from 06/03/24 through 06/29/24, the patient received 1 of the 4 OT visits. There was no documentation as to why the OT visits were not made, and no physician notification of the missed visits. b. Patient #105 was admitted on 05/26/24. OT services were ordered with frequencies of 4 visits every 30 days for 60 days starting 05/26/24. During the 30 days dated 05/26/24 to 06/25/24, the patient received 2 of the 4 OT visits. There was no documentation as to why the OT visits were not made, and no physician notification of the missed visits. c. Patient #111 was admitted on 05/13/24. Physical Therapy (PT) services were ordered with frequencies of 4 visits every 30 days for 60 days starting 05/13/24. During the 30 days dated 05/13/24 to 06/12/24, the patient received 2 of the 4 PT visits. There was no documentation as to why the PT visit was not made, and no physician notification of the missed visits. 3. On 07/17/24 at 2:00 PM, Surveyor #1 interviewed the agency’s Director of Home Care Clinical Services (Staff #101) regarding the lack of documentation and physician notification of the PT and OT missed visits. Staff #101 acknowledged the findings and stated they were unable to provide documentation as to why the missed visit did not occur and why the patients’ physician was not notified. .

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on document review, record review and interview, the agency failed to assess the clinical impact of missed visits and notify the patient’s physician to changes in the patient’s condition or needs that would suggest that outcomes are not being achieved and/or that the plan of care should be updated for 3 of 10 active patients (Patient #107, Patient #108, and Patient #112). Failure to communicate with the patient’s physician of changes in the patient’s condition or needs may potentially have a clinical impact on the patient’s wellbeing. Findings included: 1. Document review of the agency’s policy titled, “EHCS PC HH 2-018 Care Planning Process,” (Date Revision: 03/15/24) showed that clinicians will promptly notify the physician to any changes in the patient’s condition or needs that suggest that outcomes were not being achieved and/or the plan of care should be changed. 2. Record review for Patient #107, #108, and #112 showed: a. Patient #107 was admitted on 07/02/24 with the diagnoses of Right Carotid Stenosis and Paget’s Disease. PT services were ordered with frequencies of 5 visits every 30 days for 60 days and OT services with frequencies of 5 visits every 30 days for 60 days starting 07/02/24. Review of Patient #107 missed visit records showed the following: i. On 07/09/24, PT documentation showed that only one visit was indicated during this week. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. ii. On 07/10/24, OT documentation showed that visits for 2 times a week were not indicated. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. b. Patient #108 was admitted on 01/02/24 with the diagnoses Stage 4 Pressure Ulcer to the sacral region, Left Knee Traumatic Wound, Parkinson’s, and Dementia. Skilled Nursing (SN) services were ordered with frequencies of 2 visits every week for 5 weeks starting 01/07/24. Review of Patient #108 missed visit records showed the following: i. 01/19/24, SN documented that there was no need for SN visit today. The Adult Family Home (AFH) caregivers will change wound dressing and that the patient’s next SN visit was on 01/22/24. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. ii. On 01/24/24, SN documented that there was no need for SN visit today. The AFH caregivers will change the wound dressing and that the Triad Cream is used now. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. iii. On 01/31/24, SN documented that there was no need for SN visit today. The caregivers will change the wound dressing on the right knee if needed. Triad cream to coccyx would. SN visit scheduled for Monday, 05/05/24. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. iv. On 02/07/24, SN documented patient was seen yesterday. There is no need for visit today. Next SN visit on Monday. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. c. Patient #112 was admitted on 05/09/24 with the diagnoses Prostate Cancer with Metastasis to the Bong, Congestive Heart Failure, Venous Insufficiency, Lymphedema, and Chronic Pain. PT services were ordered with frequencies of 4 visits every 30 days for 60 days starting 05/12/24 and OT services with frequencies of 1 visit a week for 8 weeks starting 05/15/24. Review of Patient #112 missed visit records showed the following: i. On 05/22/24, PT documented that the patient cancelled the visit due to hay fever allergy issues and to reschedule the visit for 05/27/24. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. ii. On 05/31/24, PT documented that the patient cancelled the visit due to the patient being unwell. Patient will their primary care provider. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. iii. On 06/06/24, PT documented that the patient cancelled the visit due to family issues and to reschedule for 06/10/24. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. iv. On 06/14/24, PT documented that the patient cancelled the visit and will attempt to follow up on 06/17/24. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. v. On 05/23/24, OT documented that the patient cancelled the due to not feeling well, and OT will see the patient next week. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. vi. 05/30/24, OT documented that the patient cancelled the due to a medical appointment. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. vii. On 06/06/24, OT documented that the patient cancelled the due to personal matters. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. viii. On 06/13/24, OT documented that the patient cancelled the due to not feeling well, and OT noted missed visit four times consecutively limiting progress toward OT goals. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. ix. 06/27/24, OT documented that the patient cancelled because the patient fell over the weekend. OT to check the patient next week. There was no documentation that the clinician assessed the clinical impact of the missed visit, and that the physician was notified of the change in the patient’s plan of care. 3. On 07/17/24 at 2 PM, Surveyor #1 interviewed the agency’s Director of Home Care Clinical Services (Staff #101) regarding the lack of documentation and physician notification of the PT and OT missed visits. Staff #101 acknowledged the findings and stated they were unable to provide documentation on clinical impact of the missed visits and the physician notification. .

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide documentation of Supervisory Visits every fourteen days for 2 of 6 patient records with Home Health Aide (HH Aide) orders (Patients #603 and #605). Failure to properly supervise Home Health Aides puts the patients at risk of harm from inadequate or substandard care. Findings included: 1. Document review of the agency job aide titled, "Supervisory Visit," (undated) showed supervisory visits are required to be completed every 2 weeks as long as the Certified Nursing Aide (CNA) is still taking care of patients. 2. Record review for Patients #603 and #605 showed the following: a. Patient #603 had a start of care of 05/21/24 with the primary diagnosis of amyotrophic lateral sclerosis – not a complete list. The record showed a HH Aide order of 2 visits every week for 6 weeks starting 05/26/24. There was no documentation in the record to show Supervisory Visit note from 05/27/24 to 07/16/24. b. Patient #605 had a start of care of 05/26/24 with the primary diagnosis of Parkinson’s Disease with dyskinesia – not a complete list. The record showed a HH Aide order of 1 visit for 1 week starting 05/26/24 then 1 visit every week for 8 weeks starting 06/02/24. There was no documentation in the record to show Supervisory Visit note from 05/31/24 to 07/13/24. 3. On 07/17/24 at 2:30 PM, the Surveyors interviewed the agency’s Director of Home Care Services (Staff #601) about the missing Supervisory Visit notes on Patients #603 and #605. Staff #601 acknowledged the findings and stated that the agency was not able to provide documentation of Supervisory Visits for the patients.

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: 09/27/21 to 09/30/21 Examination number: 2021-704 The survey was conducted by: Surveyor #1 Surveyor #3 DOH recommends recertification based on an acceptable plan of correction. .

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 infection control policies and procedures that included an annual Tuberculosis (TB) risk assessment screening of Home Health staff consistent with State regulations for 5 of 8 Staff ( Staff #302, #303, #304, #305, and #308). Failure to perform annual screening of staff may result in the risk of patients' exposure to tuberculosis. Reference: WAC 246-335-525 PERSONNEL, CONTRACTOR, AND VOLUNTEER POLICIES - The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15)(c)(ii) Conducting an annual assessment of new TB risk factors for all employees. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine agency's responsibility to conduct TB testing of employees. Retesting should only be done for persons who previously tested negative and have new risk factors since the last assessment. Findings included: 1. Document review of the agency's policy titled, "Immunity/Vaccination and Tuberculosis Requirements," (last revised 09/03/19) showed that staff will be evaluated for tuberculosis upon employment and screened on annual basis. The policy showed that the annual screening is due within one year of the employee's baseline screening. 2. Surveyor #3 reviewed the employee file for the agency Physical Therapist (PT) (Staff #302). The record showed the hire date for Staff #302 was 03/04/05. The review also showed that the agency conducted Tuberculosis risk screenings on 03/19/19 and 07/06/20. The record showed no further testing or screening for TB. Surveyor #3 reviewed the employee file for the agency Registered Nurse (RN) (Staff #303). The record showed the hire date for Staff #303 was 06/25/13. The review also showed that the agency conducted Tuberculosis risk screenings on 07/08/19 and 06/17/20. The record showed no further testing or screening for TB. Surveyor #3 reviewed the employee file for the agency Social Worker (MSW) (Staff #304). The record showed that the hire date for Staff #304 was 04/22/02. The review also showed that the agency conducted Tuberculosis risk screenings on 01/21/19 and 02/06/20. The record showed no further testing or screening for TB. Surveyor #3 reviewed the employee file for the agency Occupational Therapist (OT) (Staff #305). The record showed that the hire date for Staff #305 was 09/08/08. The review also showed that the agency conducted Tuberculosis risk screenings on 04/02/19 and 06/18/20. The record showed no further testing or screening for TB. Surveyor #3 reviewed the employee file for the agency Home Health Aide (HHA) (Staff #308). The record showed that the hire date for Staff #308 was 01/06/20. The review also showed that the agency conducted a Tuberculosis risk screening on 01/08/20. The record showed no further testing or screening for TB. 3. Surveyor #3 interviewed the agency Employee Health representative (Staff # 309) and the Director of Quality (Staff #310), regarding the state requirement to perform an annual TB risk assessment on staff 09/29/21 at 11:10 AM. Staff #309 stated that it was the agency practice to allowed 90 days after the annual due date to collect the Tuberculosis screening risk assessment. In addition, Staff #310 stated that they are taking steps to update their screening process.