Every finding on record at Kittitas Valley Home Health & Hospice

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 Part 484 conducted this health and safety survey. Examination number: X2026-483 Dates Onsite: 04/20/26, 04/21/26, & 04/22/26 Date: 04/23/26 This survey was conducted by: Surveyor #1 DOH staff found the facility NOT IN COMPLIANCE with the following Conditions of Participation: 42 CFR 484.55 Conditions of Participation for Comprehensive Assessment for Patients. 42 CFR 484.60 Care planning coordination, quality of care. Condition level findings will require a revisit to put them back into compliance. .

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: . Based on record reviews and interviews, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0102 and M0104 for 4 of 10 patients (Patient #102, Patient #105, Patient #107, and Patient #110). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Record review of patients' records for Patient #102, Patient #105, Patient #107, and Patient #110 showed: a. Patient #102 was admitted on 03/27/26 with the primary diagnosis of Right Femur Fracture. Physician orders were received for the M0102 Start of Care (SOC) for 03/27/26. Documentation showed a data of referral (M0104) date of 03/24/26, rather than the specific physician-ordered start of care (M0102) date of 03/27/26. b. Patient #105 was admitted on 04/09/26 with the primary diagnosis of Right Shoulder Osteoarthritis. Physician orders were received for the M0102 SOC for 04/13/26. Documentation showed a date of 04/09/26, rather than the specific physician-ordered start of care (M0102) date of 04/13/26. c. Patient #107 was admitted on 04/09/26 with a primary diagnosis of Left and Right Buttocks Stage 1 pressure ulcers. The referral was completed on 04/08/26 for a Skilled Nursing (SN) assessment. Documentation showed a data of specific physician-ordered start of care (M0102) date of 04/09/26, rather that the accurate data of referral (M0104) date of 04/08/26. d. Patient #110 was admitted on 04/07/25 with a primary diagnosis of Right Lower Leg Wound. The referral was completed on 04/03/25 for a SN initial assessment. Documentation showed a data of specific physician-ordered start of care (M0102) date of 04/03/25, rather than the accurate data of referral (M0104) date of 04/03/25. 2. On 04/22/26 at 9:30 AM, the Surveyor interviewed the agency’s Clinical Director (Staff #111) about lack of accuracy in OASIS Data entry for M0102 and M0104. Staff #11 acknowledged the OASIS data error findings and stated that they were not able to provide documentation as to why the OASIS M0102 and M0104 were inaccurate and stated that they were unable to provide documentation on OASIS accuracy policy. .

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: . Based on document review, record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral. Failure to conduct initial assessments within 48 hours of completing the referral puts patients at risk of physical harm due to not receiving services in a timely manner. Findings Included: 1. Failure to conduct the initial assessment visit within 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 5 of 10 patients. 2. Repeated non-compliance identified in recertification survey conducted on 10/12/23. The agency was previously cited under Tag G0514, Initial Assessment Visit, 42.CFR 484.55(a)(1), for failure to complete the initial assessment within forty-eight hours of referral, or forty-eight hours of the patient’s return home, or on the physician-ordered start of care date. Based on the scope and severity of deficiencies identified under 42 CFR 484.55 Condition of Participation: Comprehensive assessment of patients is NOT MET. Cross Reference: G0514 .

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: . Based on document review, record reviews, and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral for 5 of 10 patients (Patient #102, Patient #103, Patient #105, Patient #109, and Patient #110). Furthermore, the agency failed to develop and implement policies and procedures to ensure compliance with the 48-hour initial assessment requirements as mandated by CFR 454.55(a). 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 policies showed no policy or procedure indicating the timeframe for the initial assessment visit and instructions for intake staff regarding the 48-hour requirements or the exceptions such a specific physician-ordered date. 2. Record review of patient’s records for Patient #102, Patient #103, Patient #105, Patient #109, and Patient #110 showed: a. Patient #102’s Start of Care (SOC) date was 03/27/26. The patient was admitted for primary diagnosis of Right Femur Fracture. The agency completed the referral on 03/17/26 for the Physical Therapy (PT) initial assessment, but the SOC for the PT services did not occur until 03/27/26. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the patient or their legal representative and the physician were notified of the delayed of the PT admission. b. Patient #103’s SOC date was 03/19/26. The patient was admitted for primary diagnosis of Venous Insufficiency. The agency completed the referral on 03/11/26 for the Skilled Nursing (SN) initial assessment, but the SOC for the SN services did not occur until 03/19/26. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the patient or their legal representative were notified of the delayed of the SN admission. c. Patient #105’s SOC date was 03/19/26. The patient was admitted for primary diagnosis of Right Shoulder Osteoarthritis. The agency completed the referral on 03/18/26 for the PT initial assessment, but the SOC for the PT services did not occur until 04/09/26. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the patient or their legal representative and the physician were notified of the delayed of the PT admission. d. Patient #109’s SOC date was 01/14/25. The patient was admitted for primary diagnosis of Cerebrovascular Accident. The agency completed the referral on 01/09/25 for the PT initial assessment, but the SOC for the PT services did not occur until 01/14/25. The record showed that on 01/09/25 the agency delayed the SOC due to staffing and weekend issues. In addition, there was no documentation that the patient or their legal representative and the physician were notified of the delayed of the SN admission. e. Patient #110’s SOC date was 04/07/25. The patient was admitted for primary diagnosis of Right Lower Leg Wound. The agency completed the referral on 04/03/25 for the SN initial assessment, but the SOC for the SN services did not occur until 04/07/25. The record showed that on 04/03/25 the agency delayed the SOC due to staffing and weekend issues. In addition, there was no documentation that the patient or their legal representative and the physician were notified of the delayed of the SN admission. 3. On 04/22/26 at 9:30 AM, the Surveyor interviewed the agency’s Clinical Director (Staff #111) regarding the lack of documentation that explains why the services did not occur within 48 hours of the referral and the notification of the patient and their physician of the delayed SOC. Staff #111 acknowledged the findings and stated that they could not provide documentation as to why the services were delayed. This is a REPEAT CITATION, previously cited in the last CMS survey completed on 10/12/23. .

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: . Based on document review, record review and interview, the agency failed to ensure that services are provided in the plan of care are provided for 4 of 10 patients. Failure to follow the plan of care could place the patient at risk of worsening symptoms of existing diagnoses. Findings Included: 1. Failure to ensure that there was reasonable determination for each of the missed visits in the plan of care for 4 of 10 patients. 2. Repeated non-compliance identified in the recertification survey conducted on 10/12/23. The agency was previously cited under Tag G0572, Plan of Care, 42.CFR 484.60.(a)(1), for failure to communicate with the patient's physician of missed visits resulting in changes to the patient plan of care. Based on the scope and severity of deficiencies identified under 42 CFR 484.60 Condition of Participation: Care planning, coordination of services, and quality of care is NOT MET. Cross Reference: G0572 .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: . Based on document review, record review, and interview, the agency failed to ensure that there was reasonable determination for each of the missed visits in the plan of care and that the physician was notified of the missed visits for 4 of 10 patients (Patient #101, Patient #103, Patient #104, and Patient #109). Furthermore, the agency failed to update their policy to ensure that missed visits are based on a reasonable determination of the patient’s needs. Failure to follow the plan of care could place the patient at risk of worsening symptoms of existing diagnoses. Findings included: 1. Document review of agency’s policy titled, “Missed Visits,” (Document ID: 17276, Dated: 04/21/26) showed that all missed visits will be documented and the patient’s physician is notified of the reason and date of the missed visit. In addition, there was no evidence in the policy requiring a clinical assessment of the impact of a missed visit. 2. Record review of the patients' records for Patient #101, Patient #103, Patient #104, and Patient #109 showed: a. Patient #101 was admitted on 01/06/26. The patient’s physician ordered Home Health Aide (HHA) services with a frequency of 1 visit weekly, then 2 visits weekly for 8 weeks starting 01/08/26. During the Medicare weeks of 01/11/26 and 02/08/26, the record showed HHA missed visits due to a staff illness. In addition, there was no documentation to indicate that the patient or their legal representative and the physician were notified of the missed HHA visits. b. Patient #103 was admitted on 03/19/26. The patient’s physician ordered HHA services with a frequency of 1 visit weekly, then 2 visits weekly for 2 weeks, then 2 visits every 2 weeks for 2 weeks, and then 2 visits weekly for 3 weeks starting 03/22/26. During the Medicare weeks of 03/29/26, 04/05/26, and 04/12/26, the record showed HHA missed visits due to staff vacation, no call back, and no documentation as to why the third HHA visits were missed. In addition, there was no documentation to indicate that the patient or their legal representative and the physician were notified of the missed HHA visits. c. Patient #104 was admitted on 02/03/26. The patient’s physician ordered Physical Therapy (PT) services with a frequency of 2 visits weekly for 9 weeks starting 02/09/26. During the Medicare weeks of 02/22/26 and 03/22/26, the record showed PT missed visits due to PT unable to see patient due to case load, and no documentation as to why the second PT visits were missed. The patient’s physician ordered HHA services with a frequency of 1 visit weekly, and then 2 visits weekly for 8 weeks starting 02/03/26. During the Medicare weeks of 03/01/26, 03/08/26, 03/15/26, and 03/22/26 there was no documentation as to why the HHA visits were missed. The patient’s physician ordered Occupational Therapy services with a frequency of 1 visit weekly, then 2 visits weekly for 7 weeks starting 02/08/26. During the Medicare week of 03/15/26 there was no documentation as to why the OT visits were missed. In addition, there was no documentation to indicate that the patient or their legal representative and the physician were notified of the missed PT, HHA, and OT visits. d. Patient #109 was admitted on 01/14/25. The patient’s physician ordered Skilled Nursing (SN) services with a frequency of 1 visit weekly, then 2 visits weekly, and then 1 visit weekly for 5 weeks starting 01/19/25. During the Medicare week of 01/19/25, the record showed SN missed visit due to SN was unaware of the visit. The patient’s physician ordered HHA services with a frequency of 1 visit weekly for 8 weeks starting 01/19/25. During the Medicare week of 02/09/25, the record showed HHA missed visit due to HHA out on leave. The patient’s physician ordered OT services with a frequency of 1 visit weekly, then 2 visits weekly for 8 weeks starting 01/14/25. During the Medicare weeks of 02/16/25 and 02/23/25, the record showed OT missed visits due to no staffing. In addition, there was no documentation to indicate that the patient or their legal representative and the physician were notified of the missed SN, HHA, and OT visits. 3. On 04/22/26 at 9:30 AM, the Surveyor interviewed the agency’s Clinical Director (Staff #111) regarding the missed visits. Staff #111 acknowledged the findings and stated that they were unable to provide documentation to show reasonable determination for each of the missed visits. Also, Staff #111 stated that it is the agency’s policy is to notify the physician of the missed visits and that reasons for missed visits should be patient focused. This is a REPEAT CITATION, previously cited in the last CMS survey completed on 10/12/23.

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 Part 484 for Home Health Services conducted this health and safety survey. Examination number: X2023-747 Dates Onsite: 10/10/23, 10/11/23, 10/12/23 This survey was conducted by: Surveyor #3 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard- level deficiencies listed below. DOH recommends recertification based on an acceptable plan of correction.

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 record review and interview, the agency failed to ensure the patient's right to consent to services in advance of receiving treatment for 1 of 10 patient records reviewed. Failure to provide patients with their consent for services and care could potentially deny patients the expectation and assurance of receiving quality care and services. Findings included: 1. Record review for Patient #310 showed a start of care of 05/30/23. The record showed that Patient #310 received skilled nursing, physical therapy and occupational therapy from 05/30/23 to 07/31/23. The record showed no evidence that Patient #310 provided consent for services in advance of receiving care from the agency. 2. On 10/12/23 at 12:30 PM, the Surveyor interviewed the agency's Clinical Manager (Staff #301) and Business Office Manager (Staff #302) about the missing consent. Staff #301 and Staff #302 acknowledged the finding and stated that they were unable to locate a consent for services for Patient #310.

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 record reviews, and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral for 3 of 10 patients (Patients #308, #309, and #310). Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Record review of 3 discharged patient records showed the following: a. Patient #308 had a Start of Care (SOC) date of 12/30/22. The patient was admitted for primary diagnoses of emphysema, COPD and hypertension. The agency completed the referral on 12/20/22 for a physical therapy and occupational therapy evaluation, however the SOC for physical therapy did not occur until 12/30/22. The record showed that the agency faxed the provider for an alternate start of care date on 12/23/22 and 12/26/22 but received no response. There was no documentation of why the services did not occur within 48 hours of the referral. b. Patient #309 had a SOC date of 08/24/23. The patient was admitted for primary diagnoses of rotator cuff syndrome and COPD. The agency received an order on 08/10/23 for a physical therapy evaluation on 08/16/23, however the SOC for physical therapy did not occur until 08/24/23. The record showed that on 08/18/23 the agency changed the order to include the statement that the patient will only see a certain physical therapist with the first available start date of 08/24/23. The record showed no documentation of the provider responding to the order for the SOC date to be 08/24/23. The record showed the M0102 (Physician Ordered Start of Care date) on the OASIS was entered as 08/24/23 without documentation in the clinical record of a physician's order. The record also showed no evidence of Patient #309 requesting a SOC date of 08/24/23. c. Patient #310 had a SOC date of 05/30/23. The patient was admitted for primary diagnoses of pressure ulcer sacral region and urinary tract infection. The agency completed the referral on 05/19/23 for a skilled nursing (SN) assessment, however the SOC for SN services did not occur until 05/30/23. The record also showed the clinician documented the M0104 (Date of Referral) on the OASIS as 05/23/23. 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 10/12/23 at 12:00 PM, the Surveyor interviewed the agency's Clinical Manager (Staff #301) and the agency's Business Office Manager (Staff #302) about the delays in the start of care for patients. Staff #301 and Staff #302 acknowledged the findings and stated that they were unable to locate additional documentation that explains why the services did not occur within 48 hours of the referral. Staff #301 also stated that the agency has developed a performance improvement project focused on timely initiation of care.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the patient comprehensive assessments were completed within 5 days from the start of care for 2 of 10 patient (Patient #302 and #310). Failure to complete the comprehensive assessment within 5 days may place patients at risk of receiving care that does not adequately address the patient's needs. Findings included: 1. Record review of 2 patient records showed the following: a. Patient #302 had a start of care of 07/17/23. The patient's primary diagnoses were acute respiratory failure, COPD and anxiety. The record showed that skilled nursing, physical therapy and occupational therapy were ordered on 07/12/23. The physical therapist completed their evaluation on 07/25/23. The occupational therapist completed their evaluation on 08/04/23. The record showed no documentation why the physical therapy and occupational therapy evaluations were completed more than 5 days after the start of care. b. Patient #310 had a start of care of 05/30/23. The patient's primary diagnoses were pressure ulcer sacral region and urinary tract infection. The record showed that skilled nursing, physical therapy and occupational therapy were ordered on 05/19/23. The physical therapist completed their evaluation on 06/05/23. The occupational therapist completed their evaluation on 06/07/23. The record showed no documentation why the physical therapy and occupational therapy evaluations were completed more than 5 days after the start of care. 2. On 10/12/23 at 11:30 AM, the Surveyor interviewed the agency's Chief Ancillary Officer (Staff #303) about the agency's policy for completing the comprehensive assessment within 5 days of the start of care to include therapy evaluations if ordered at start of care. Staff #303 stated that the agency does not have a written policy that states when the evaluations must be completed by following a start of care.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to communicate with the patient’s provider of missed visits resulting in changes to the patient’s plan of care in 5 of 10 patients (Patient #302, #305, #306, #307 and #308). Failure to complete the visit frequency as ordered by the provider and failure to notify the provider of the missed visits may put the patient at risk for unmet needs and/or a decline in condition. Findings included: 1. Record review of the agency's document titled, "Standard Work Documenting Missed Visit in McKesson," showed that printing the missed visit note and sending the note to the provider is part of the agency's missed visit procedure. 2. Record review for 5 patient records showed the following: a. Patient #302 had a start of care of 07/17/23. The provider ordered skilled nursing (SN) visits weekly for 9 weeks starting 07/17/23, physical therapy (PT) visits twice weekly starting 07/30/23, and occupational therapy (OT) visits weekly starting 08/04/23. The record showed that Patient #302 refused the SN visits on 07/19/23, 08/16/23, and 09/06/23. The record also showed a missed visit for PT on 09/19/23 and 10/06/23 and missed OT visits the week of 08/30/23 and 09/20/23.There was no evidence in the record that the missed visit notes were sent to the provider. b. Patient #305 had a start of care of 07/10/23. The provider ordered speech therapy (ST) visits weekly starting 08/03/23. The record showed a missed ST visit the week of 09/17/23. There was no evidence in the record that the missed visit notes were sent to the provider. c. Patient #306 had a start of care of 04/03/23. The provider ordered skilled nursing (SN) visits weekly starting 04/13/23 and home health aides (HHA) visits weekly for 1 week then twice per week for 1 week then weekly for 1 additional week starting 05/18/23. The record showed missed SN visits the week of 04/16/23, 05/07/23 and 05/14/23. The record also showed missed HHA visits the week of 05/18/23 and 05/28/23. There was no evidence in the record that the missed visit notes were sent to the provider. d. Patient #307 had a start of care of 05/04/23. For the certification period starting on 09/01/23, the provider ordered skilled nursing (SN) visits daily for 9 days then 5 visits for 1 week then three visits per week for 7 weeks starting 09/01/23 for wound care. The record showed missed SN daily visits on 09/02/23, 09/03/23, 09/04/23, and 09/05/23. There was no evidence in the record that the missed visit notes were sent to the provider. e. Patient #308 had a start of care of 12/30/22. The provider ordered physical therapy (PT) visits twice weekly for 8 weeks starting 01/02/23. The record showed missed PT visits the week of 02/12/23 and 02/19/23. There was no evidence in the record that the missed visit notes were sent to the provider. 3. On 10/12/23 at 12:30 PM, the Surveyor interviewed the agency's Clinical Manager (Staff #301) and Business Office Manager (Staff #302) about the missed visits. Staff #302 confirmed that the agency's policy is to fax missed visit notes to the provider. Staff #301 and Staff #302 stated that they were unable to locate evidence that the missed visit notes were sent to the provider.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document Home Health Aide (HHA) supervision visits by a skilled professional every 14 days for 2 of 2 patients (Patient #305 and #306) who were receiving HHA services for longer than 14 days. Failure to supervise Home Health Aides every 14 days places the patients at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patient's changing needs. Findings included: 1. Record review of the agency's policy titled, "Home Health and Hospice Aide Services and Supervision," revised 04/22/22, showed that the agency RN makes an onsite visit to the patient's home no less than every 14 days to ensure that the services ordered by the IDG and provided by the aide are meeting the patient's needs. 2. Record review for 2 patient's receiving home health aide service showed the following: a. Patient #305 had a start of care of 07/10/23. The patient's primary diagnoses were hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage affecting the right side. The provider ordered home health aides (HHA) 1 time a week for 9 weeks starting 07/10/23. The record showed that the patient received weekly HHA visits from 07/18/23 to 09/05/23. The record showed no evidence of a skilled professional completing a home health aide supervisory visit. b. Patient #306 had a start of care of 04/03/23. The patient's primary diagnoses were attention cystostomy, urinary retention, compression fractures T11-T12 and chronic pain. The Surveyor reviewed the patient care episodes from 04/03/23 to 06/02/23 and 08/02/23 to current. The provider ordered home health aide (HHA) visits starting 05/18/23. Record review of the patient's care episode starting 08/02/23 showed that the provider ordered home health aide (HHA) visits weekly for 9 weeks. The record also showed that the patient received HHA visits from 08/03/23 through 09/21/23. The record showed no evidence of a skilled professional completing a home health aide supervisory visit every 14 days. 3. On 10/12/23 at 12:30 PM, the Surveyor interviewed the agency's Clinical Manager (Staff #301) and Business Office Manager (Staff #302) about the missing home health aide supervisory visits. Staff #302 stated that the agency schedules the supervisory visits in the agency's EMR system for clinicians to complete. The agency is currently onboarding a new EMR system that will assist the agency in compliance with the supervisory visit requirement. Staff #301 and Staff #302 also stated that they were unable to locate any additional documentation for home health aide supervisory visits.

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 update its policies and procedures to remain compliant with state licensing requirements for 7 of 7 personnel files reviewed and 10 of 10 patient records reviewed, including failure to complete skills verification for personnel (Item #1), failure to complete department-approved disclosure statements at the time of hire and renew every 2 years (Item #2), failure to complete annual performance evaluations (Item #3), failure to complete character, competency and suitability determinations for personnel with negative information on background checks (Item #4), and failure to provide patients with a complete bill of rights that includes information on advanced directives and Physician Orders for Life Sustaining Treatment (Item #5). 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 - Verification of Skills Reference: WAC 246-335-530 (5) The licensee must maintain records on all personnel and volunteers and have access to records on all contractors, to include: Verification of personnel, contractor, and volunteer skills or training specific to meeting the care needs of patients. Findings included: 1. Record review of 4 of 7 personnel records showed the following: a. A Registered Nurse (Staff #305) was hired on 04/15/23. The record showed no evidence of skill verification or competency specific to meeting the care needs of patients. b. A Physical Therapist (Staff #307) was hired on 06/07/23. The record showed no evidence of skill verification or competency specific to meeting the care needs of patients. c. An Occupational Therapist (Staff # 308) was hired on 09/26/22. The record showed no evidence of skill verification or competency specific to meeting the care needs of patients. d. A Social Worker (Staff # 309) was hired on 04/01/22. The record showed no evidence of skill verification or competency specific to meeting the care needs of patients. 2. On 10/11/23 at 10:40 AM, the Surveyor interviewed the agency's Clinical Manager (Staff #301) and Chief Ancillary Officer (Staff #303) about the agency's policy and procedure for verifying that staff have the skills necessary to meet the care needs of the patients. Staff #303 stated that the agency only has a policy that describes the requirement for competency testing for home health aides but does not have a policy for other home health disciplines. Staff #301 stated that staff participate in skills competencies upon hire and at an education fair annually. Staff #301 stated that they were unable to locate documentation of skills competencies for Staff #305, #307, #308 and #309. Item #2 - Disclosure Statements Reference: WAC 246-335-525 The applicant or 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. Record review of the agency's policy titled, "Recruitment Pre-Employment Screening," revised 05/20/22, showed that potential employees and volunteers will be required to complete a voluntary criminal history disclosure concerning any convictions of crimes against persons, or any civil adjudication for sexual assault, physical abuse or exploitation of a minor. This disclosure statement will be completed as part of the application process. The Home Health and Hospice departments will undergo criminal background checks every other year. The policy failed to include the department-approved disclosure statements and the renewal requirement. 2. Record review of 7 personnel files showed the following: a. A Registered Nurse (Staff #305) was hired on 04/15/20. The record showed no evidence of a department-approved disclosure statement completed upon hire or renewed every 2 years from the previous check. b. A Nursing Assistant Certified (Staff #306) was hired on 12/29/21. The record showed no evidence of a department-approved disclosure statement completed upon hire. c. A Physical Therapist (Staff #307) was hired on 06/07/23. The record showed no evidence of a department-approved disclosure statement completed upon hire. d. An Occupational Therapist (Staff #308) was hired on 09/26/22. The record showed no evidence of a department-approved disclosure statement completed upon hire. e. A Social Worker (Staff #309) was hired on 04/01/22. The record showed no evidence of a department-approved disclosure statement completed upon hire. f. A Physical Therapist (Staff #310) was hired on 07/10/17. The record showed no evidence of a department-approved disclosure statement completed every 2 years from the previous check since 2018. g. A Physical Therapy Assistant (Staff #311) was hired on 09/16/15. The record showed no evidence of a department-approved disclosure statement completed every 2 years from the previous check since 2018. 3. On 10/12/23 at 10:00 AM, the Surveyor interviewed the agency's Human Resources Business Partner (Staff #304) about the missing department-approved disclosure statements. Staff #304 stated that the agency's disclosure statement was included in the pre-employment application packet until 2019. In 2019 the agency stopped requiring staff to complete the agency disclosure statement pre-employment. Staff #304 stated that the agency is currently in the process of changing the criminal background check and disclosure statement policy to be compliant with the state requirements. Item #3 - Annual Performance Evaluations 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: (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 (17) Annual evaluations of services provided by contractors providing direct patient care. WAC 246-335-530 Personnel, Contractor, and Volunteer Records: The licensee must maintain records on all personnel and volunteers and have access to records on all contractors, to include: (12) 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. Record review of the agency's policy titled, "Performance Evaluations," revised 05/20/22, showed that the agency will conduct written performance evaluations on every employee upon completion of their ninety-day introductory period, and once annually thereafter on their hire date anniversary. The policy does not include the requirement for onsite observation of care and skills specific to the care needs of patients. 2. Record review of 3 personnel records showed the following: a. A Nursing Assistant Certified (Staff #306) was hired on 12/29/21. The record showed a 90-day performance evaluation dated 04/12/22. The record showed no evidence of an annual performance evaluation with onsite observation of care and skills specific to the care needs of patients. b. An Occupational Therapist (Staff #308) was hired on 09/26/22. The record showed no evidence of an annual performance evaluation with onsite observation of care and skills specific to the care needs of patients. c. A Physical Therapist (Staff #311) was hired on 09/16/15. The record showed a performance evaluation dated 10/25/21. The record showed no evidence of an annual performance evaluation with onsite observation of care and skills specific to the care needs of patients since 2021. 3. On 10/12/23 at 10:30 AM, the Surveyor interviewed the agency's Clinical Manager (Staff #301) about the missing performance evaluations. Staff #301 stated that they are behind on completing annual performance evaluations for staff. Staff #301 also stated that the performance evaluation process does include onsite observation from ride-along visits with staff. Item #4 - Character, Competency and Suitability 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: (7) Character, competence, and suitability determination conducted for personnel, contractors, volunteers, and students whose background check results reveal nondisqualifying convictions, pending charges, or negative actions. Factors to consider when making a determination include, but are not limited to: (a) Whether there is a reasonable, good faith belief that they would be unable to meet the care needs of the patient; (b) Level of vulnerability of the patient under their care; (c) Behaviors since the convictions, charges, negative actions or other adverse behaviors; (d) Pattern of offenses or other behaviors that may put the patient at risk; (e) Number of years since the conviction, negative action, or other issue; (f) Whether they self-disclosed the conviction(s), pending charge(s) and/or negative action(s); (g) Other health and safety concerns; and (h) Although a licensee may determine, based on their assessment process, that an employee is suitable to work with vulnerable patients, the department has the final authority to deny, revoke, modify, or suspend any professional credential it issues based on application and criminal background check information. Findings included: 1. Record review of the agency's policy titled, "Recruitment Pre-Employment Screening," revised 05/20/22, showed that the following factors will be considered for those applicants with a criminal history in determining whether to hire the external applicant: any convictions for any crimes or civil adjudication for sexual assault, physical abuse, or exploitation of a minor or vulnerable adult; the nature of the crime and its relationship to the position; the time since conviction, the number (if more than one) of convictions; and whether hiring applicant would pose an unreasonable risk to the patients, organization, employees or vendors. The policy does not include the complete list of factors to consider according to WAC 246-335-525 (7) (a-h). 2. A Registered Nurse (Staff #305) was hired on 04/15/20. The record showed non-disqualifying convictions on background checks dated 03/27/20 and 02/14/22. The record showed no evidence that the agency completed a Character, Competency and Suitability Assessment considering all the required factors. 3. A Physical Therapy Assistant (Staff #311) was hired on 09/16/15. The record showed non-disqualifying convictions on a background check dated 10/02/23. The record showed no evidence that the agency completed a Character, Competency and Suitability Assessment considering all the required factors. 4. On 10/12/23 at 10:30 AM, the Surveyor interviewed the agency's Human Resources Business Partner (Staff #304) about the missing Character, Competency and Suitability (CCS) Assessments for Staff #305 and #311. Staff #304 stated that they were unaware of the required factors of consideration for the CCS Review. Staff #304 also stated that they reviewed the factors of consideration stated in the agency policy but do not document the outcome of the review in writing. Item #5 - Bill of Rights Based on record review and interview, the agency failed to include in the patient’s Bill of Rights, the patient’s right to be informed about advanced directives and POLST and the agency's scope of responsibility as required in the Washington Administrative Code (WAC) 246-335-535 Bill of Rights for 10 of 10 patient records reviewed. Failure of the agency to update and implement the patient’s Bill of Rights place the patients at risk of being unaware of their rights pertaining to care. References: WAC 246-335-535 Bill of Rights. A home health agency at the time of admission must provide each patient, designated family member, or legal representative with a written bill of rights affirming each patient right to: (14) be informed about advanced directives and POLST and the agency's scope of responsibility. Findings included: 1. Record review of the agency's Patient Rights and Responsibilities document showed no evidence of the patient's right to be informed about the POLST and the agency's scope of responsibility for 10 of 10 patients (Patient #301, #302, #303, #304, #305, #306, #307, #308, #309, and #310). 2. On 10/12/23 at 10:00 AM, the Surveyor interviewed the agency's Clinical Manager (Staff #301) about the agency's Bill of Rights not including the patient's right to be informed about the POLST form and the agency's responsibilities. Staff #301 stated that clinicians provide the patient with a copy of the POLST form at the start of care and discuss the form with them during the visit. Staff #301 stated that they were unaware of the requirement to include the patient's right to information about the POLST form on the Bill of Rights document.

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 Part 484 conducted this health and safety survey. Examination number: 2021-702 Dates Onsite: 08/9-12/21 This survey was conducted by: Surveyor #5 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. .

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 provide documentation of a signed department- approved disclosure statement for 4 of 5 employees (Staff# 501, 502, 503, and 504) and failed to ensure a system to obtain Washington State Patrol background (WSP) checks from employees every two years for 4 of 5 employees (Staff# 501, 502, 503, and 504). Failure to maintain current disclosure statements and WSP checks according to Washington State law, places patients at risk to receive care from an un-vetted caregiver. Reference: Washington Administrative Code (WAC) 246-335-525 (6) (b) and (c) (effective date, April 6, 2018). (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 43.43.843 and the following: (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. On 08/11/21, the surveyor reviewed the personnel files for 1 caregiver (Staff #501) and 3 providers (Staff# #502, #503, and #504). a. Staff #501 (a caregiver) was hired on 06/01/17. The record did not contain an updated disclosure statement after the initial date of hire. An intital WSP background check was completed at hire on 05/23/17 but the record did not contain a subsequent WSP criminal history background check after 05/19. b. Staff #502 (a physical therapist) was hired on 09/30/16. An initial disclosure statement was completed at hire. The initial WSP background check was completed on 09/30/16. There was no documentation of a signed disclosure statement or completed WSP background check after 09/18. c. Staff #503 (a registered nurse) was hired on 02/23/18. An initial disclosure statement was completed at hire. A background check was completed on 10/16/18. There was no documentation of a disclosure statement or background check completed after 10/20 as required. d. Staff #504 (a social worker) was hired on 04/01/16. An initial disclosure statement was completed at hire. A background check was completed on 03/23/16. There was no documentation of a signed disclosure statement or background check completed after 03/18 as required. 2. On 08/12/21 at 3:15 PM, the surveyor asked the agency Director (Staff# 506) to verify the lack of updated disclosure statements and background checks in the staff records. Staff #506 confirmed the agency did not have a current signed disclosure statement as required and did not have documentation of the every 2-year background checks for the above employees in the current records.