Every finding on record at Mountainview Home Health LLC

. MEDICARE FOCUSED INFECTION CONTROL SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR Part 484 for Home Health conducted a Medicare COVID-19 Focused Infection Control Survey for acute care. Onsite dates: 07/12/21 to 07/15/21 This survey was conducted by: Surveyor #1 Surveyor #6 DOH found the agency in substantial compliance with the infection control standards as they relate to the response the COVID-19 pandemic, except for those standard level deficiencies listed below. .

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 document scope and frequency of provider-ordered services for 6 of 17 patient records reviewed (Patient # 110, # 112, #113, #114, #116, & #117). Failure to document services and visit frequencies for provider-ordered care puts patients at risk of harm from lack of informed consent and expected outcomes from the provided services. Findings included: 1. Record review of the agency's Admission Consent form (Form #105, Rev. 9/18) showed that consent for treatment for the initial services and visit frequencies will be documented under each of the agency's provided services. 2. Surveyor #1 reviewed 17 patient records. Review of 6 of 17 records showed: a. Patient #110 was admitted on 06/30/20. Nursing and Physical therapy services were ordered, but only the nursing services were documented on the patient's consent form. b. Patient #112 was admitted on 09/25/20. Nursing, Physical therapy, Occupational therapy, and Speech therapy were ordered, but only the nursing services were documented on the patient's consent form. c. Patient #113 was admitted on 12/01/20. Nursing, Physical therapy, and Occupational therapy were ordered, but no services were documented on the patient's consent form. d. Patient #114 was admitted on 08/24/20. Nursing, Physical therapy, and Occupational therapy were ordered, but only nursing services were documented on the patient's consent form. e. Patient #116 was admitted on 02/04/21. Nursing, Physical therapy, and Occupational therapy were ordered, but no services were documented on the patient's consent form. f. Patient #117 was admitted on 06/16/21. Nursing, Social work, and Home Health aide services were ordered, but only nursing and the home health aide services were documented on the patient's consent form. 3. On 07/14/21 at 4:00 PM, Surveyor #1 interviewed the agency's Executive Director (Staff #109) and the agency's Nurse Clinical Director (Staff #110) about the lack of documentation of provider-ordered services on the consent form. Staff #109 and Staff #110 acknowledged the findings and stated that they were taking steps to make corrections. .

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 properly prevent COVID-19 by not ensuring staff received a fit test prior to N-95 face mask use consistent with Washington State regulations for 7 of 7 Staff (Staff #104, #106, #601, #602, #603, #607, and Staff #608). Failure to develop and implement a method of performing N-95 mask fit tests for staff risks staff and patients' exposure to respiratory infections including COVID-19. References: WAC 246-335-525(15) personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment; WAC 296-842-12005(1) Develop a complete worksite-specific written respiratory protection program that includes the applicable elements listed in Table 3. The program must cover each employee required by this section to use a respirator. Note: Pay for respirators, medical evaluations, fit testing, training, maintenance, travel costs, and wages. . Findings included: 1. Document review of the guidance document issued by the Department of Health (DOH) and Labor & Industries (L&I) titled, "L&I and DOH Respirator and PPE for In-Home Care Agencies: Employer responsibilities for respiratory protection program and provision of personal protective equipment (PPE)," (DOH 420-329) issued March 30, 2021, showed In-Home care agencies are required to develop and maintain a Respiratory Protection Program (RPP) under WAC 296-842-12005. The document showed that an agency should complete a RPP before fit testing for respirators. A "fit test" is a procedure that tests the seal between the respirator's facepiece and the health care worker's (HCW) face. It includes a medical evaluation and must be performed by someone who is trained in fit testing. The document also showed that In-Home care agencies are required to provide initial fit tests for each HCW with the same model, style, and size respirator that the HCW will be required to wear for protection against COVID-19 and other airborne hazards. Document review of the agency's policy titled, "Airborne Pathogen Program COVID-19 (revised 04/20)," showed that the agency is to provide all employees education on appropriate PPE and instruction on required guidelines on a regular basis. The policy also showed that the agency is to provide appropriate PPE including masks and eye protection as needed. 2. Surveyor #6 interviewed the agency's Executive Director (Staff #609) on 07/14/21 at 1:00 PM about the agency's N-95 fit testing process. Staff #609 stated that they do not do fit tests in the office. At the time of the interview, Surveyor #6 asked Staff #609 to provide the agency policy on fit testing. Staff #609 stated that the agency did not have a policy on fit-testing and that the agency has been unable to find fit-testing supplies. . Based on observation, document review, and interview, the agency failed to properly prevent COVID-19 by not ensuring staff wore eye protection consistent with Washington State regulations for 7 of 7 Home Health staff (Staff #104, #106, #601, #602, #603, #607, and Staff #608). Failure to ensure staff wear eye protection when performing patient care, risks staff and patients' exposure to infectious organisms including COVID-19. References: WAC 246-335-525(15) personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment; WAC 206-800-160 You must make sure that your employees have, use, and care for the appropriate personal protective equipment (PPE). PPE is an item or items used to protect the eyes, face, head, body, arms, hands, legs, and feet such as goggles, helmets, head covers, gloves, rubber slickers, disposable coveralls, safety shoes, protective shields, and barriers. WAC 296-800-16040 You must require your employees to use necessary PPE on the job. WAC 296-800-16030(3) You must retrain an employee when you have reason to believe the understanding, motivation, and skills required to use the PPE has not been retained. Circumstances where retraining is required include: (3) Work habits or demonstrated knowledge indicate that the employee has not retained the necessary understanding, skill, or motivation to use PPE. Findings included: 1. Document review of the guidance document issued by the Department of Health (DOH) and Labor & Industries (L&I) titled, "L&I and DOH Respirator and PPE for In-Home Care Agencies: Employer responsibilities for respiratory protection program and provision of personal protective equipment (PPE)," (DOH 420-329) issued March 30, 2021 showed that In-home care agencies are required to develop and maintain a Respiratory Protection Program (RPP) under WAC 296-842-12005. The document also showed that agencies are required to provide gowns, gloves, and eye protection to staff who are entering patient's homes. The document further stated that staff must wear eye protection when there is moderate to substantial community transmission of COVID-19. The document defined eye protection as goggles or a face shield that covers the front and sides of the face. Review of the document also showed that personal eyeglasses are not PPE and do not provide adequate eye protection. Document review of the guidance document issued by the Department of Health (DOH) titled, " COVID-19 Guidance for Home Care, Home Health, and Hospice Agencies," (DOH 420-299) issued June 09, 2021 showed when COVID-19 community transmission case rate is greater than 25 per 100,000, in 2 weeks, HCWs are to wear a surgical face mask and eye protection for ALL patient care encounters, regardless of patient/client COVID-19 status. According to DOH COVID-19 cases and testing for Yakima County, the 2-week transmission rate at the time of survey was 117 per 100,000. Document review of the agency's policy titled, "Airborne Pathogen Program COVID-19 (revised 04/20)," showed that the agency is to provide all employees education on appropriate PPE and instruction on required guidelines on a regular basis. The policy also stated that the agency is to provide appropriate PPE including masks and eye protection as needed. The policy additionally stated that the agency is to inform clinicians of appropriate PPE to wear during visits and to review don/doff procedures. The policy also stated that agency staff would follow PPE guidelines to protect themselves and the patient. 2. On 07/12/21 Surveyor #6 observed the following: a. At 11:30 AM, a Licensed Practical Nurse (Staff #60)1 performed patient care within 6 feet of Patient #601 and did not wear eye protection. b. At 1:05 PM, a Physical Therapist (Staff # 602) performed patient care within 6 feet of Patient #602 and did not wear eye protection. c. At 2:35 PM, a Physical Therapy Assistant (Staff # 603) performed patient care within 6 feet of Patient #603 and did not wear eye protection. 3. On 07/13/21 Surveyors #1 and #6 observed the following: a. At 8:30 AM, Surveyor #1 observed a Certified Nursing Assistant (Staff #106) perform patient care within 6 feet of Patient #104 and did not wear eye protection. b. At 11:00 AM, Surveyor #1 observed an Occupational Therapist (Staff #104) perform patient care within 6 feet of Patient #106 and did not wear eye protection. c. At 11:48 AM, Surveyor #6 observed a Certified Occupational Therapy Assistant (Staff #608) perform patient care within 6 feet of Patient #607 and did not wear eye protection. 4. Surveyor #6 interviewed the agency's Executive Director (Staff #609) on 07/14/21 at 1:00 PM about the agency's policy on PPE and eye protection. Staff #609 stated that they do not expect staff to wear eye protection at patient visits unless the patient was COVID-19 positive. When asked for agency policies on eye protection, Staff #609 referenced the agency policy reviewed above. . Based on document review and interview, the agency failed to ensure 3 out of 8 staff (Staff #601, #607, and #608) completed M. Tuberculosis (TB) risk assessments annually. Failure to ensure staff completed required TB risk assessments may place patients and/or staff at risk of TB exposure/infection. Reference: WAC 246-335-525(15)(c)(i)(ii): The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (c) Tuberculosis (TB) infection control program. Key elements include, but are not limited to: (i) Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency's responsibility to conduct TB testing of new employees. If TB testing is required, follow the department's tuberculosis risk assessment form testing recommendations; (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; and . Findings included: 1. Document review of the agency's policy titled, "Employee Health (Policy HH-405, revised 05-13-21) showed that all employees are required to complete a TB risk assessment form as specified in WAC 246-335-525(15)(c). The policy also showed that new employees must comply with all employee health policies. 2. Surveyor #6 reviewed the personnel files for 8 home health staff members (Staff #104, #106, #601, #602, #603, #605, #607, and Staff #608). The review showed: a. Staff #601 was hired 02/09/06 and a TB risk assessment for 2020 was absent from the record. b. Staff #607 was hired 01/25/16 and a TB risk assessment for 2020 was absent from the record. c. Staff #608 was hired 08/01/94 and a TB risk assessment for 2020 was absent from the record. 3. On 07/14/21 at 4:00 PM, Surveyor #6 interviewed the agency's Executive Director (Staff #609) and about the missing TB risk assessments. Staff #609 acknowledged that the agency did not complete TB risk assessments in 2020 for the staff listed above. Staff #609 stated that the agency revised their "Employee Health" policy on 05-13-21 to include the requirement for annual TB risk assessments for all employees.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to ensure 6 out of 8 staff (Staff #104, #602, #603, #605, #607, and #608) received M. Tuberculosis (TB) related training and education at the time of hire or orientation consistent with state licensing rules and regulations for the prevention and control of TB. Failure to ensure staff complete required TB training prior to providing patient care may place patients and/or staff at risk of harm from TB exposure/infection. Reference: Washington Administrative Code (WAC) 246-335-525(15)(c)(iii) Personnel, contractor, and Volunteer Policies Ensuring workers receive TB related training and education at the time of hire or during new employee orientation. Training and education must be consistent with the department's tuberculosis program's online posted educational materials. . Findings included: 1. Document review of the agency's policy titled, "Employee Health (Policy HH-405, revised 05-13-21) showed that all employees are required to complete a TB risk assessment form and complete education "(TB-101 Test)" specified in WAC 246-335-525(15)(c). The policy also showed that, new employees must comply with all employee health policies. 2. Surveyor #6 reviewed the personnel files for 8 home health staff members (Staff #104, #106, #601, #602, #603, #605, #607, and Staff #608). The review showed: a. Staff #104 was hired 12/17/20 and evidence of TB training was absent from the record. b. Staff #602 was hired 02/18/19 and evidence of TB training was absent from the record. c. Staff #603 was hired 04/28/06 and evidence of TB training was absent from the record. d. Staff #605 was hired 12/30/19 and evidence of TB training was absent from the record. e. Staff #607 was hired 01/25/16 and evidence of TB training was absent from the record. f. Staff #608 was hired 08/01/94 and evidence of TB training was absent from the record. 3. On 07/14/21 at 4:00 PM, Surveyor #6 interviewed the agency's Executive Director (Staff #609) and about the missing TB training documentation. Staff #609 acknowledged that the agency did not complete TB training for the staff above. Staff #609 stated that the agency revised their "Employee Health" policy on 05-13-21 to include the requirement for TB training.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to ensure 2 out of 2 Home Health Aide staff (Staff #106 and #605) completed a competency evaluation before providing home health services as required according to 484.80(c)(1). Failure to ensure staff complete required competency evaluations prior to providing patient care may place patients at risk of injury or of receiving inappropriate care. . Findings included: 1. Document review of the agency's policy titled, "New Employee Orientation (Policy HH-407, revised 02-20-12)," showed that all employees are required to complete an orientation program. The policy also showed that each discipline will be oriented to their relevant scope of practice, patient care processes, and clinical procedures. The policy showed that a position-specific orientation checklist must be completed. 2. Surveyor #6 reviewed the personnel files for 2 of 2 Home Health Aide staff (Staff #106 and #605). The review showed: a. Staff #106 was hired 04/08/21. The personnel file review showed no evidence that Staff #106 received an evaluation of their competency through direct observation related to: 1) Toileting; 2) Elimination; 3) Normal range of motion; or 4) Positioning. b. Staff #605 was hired 12/30/19. The personnel file review showed no evidence that Staff #106 received an evaluation of their competency through direct observation related to: 1) Toileting; 2) Elimination; 3) Normal range of motion; or 4) Positioning 3. On 07/14/21 at 4:00 PM, Surveyor #6 interviewed the agency's Executive Director (Staff #609) and about the missing competency documentation. Staff #609 acknowledged that the agency did not complete the competency documentation and all required elements for the staff 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 complete a Washington State Patrol (WSP) criminal history background check prior to an offer of employment for 2 of 8 home health staff files reviewed (Staff #104, and #602) and failed to obtain criminal history disclosure statements every 2 years for 5 of 8 staff (Staff #601, #602, #603, #607, #608). Failure to complete WSP criminal history background checks and obtain criminal history disclosure statements as required by state-licensing regulations, places patients at risk to receive care from un-vetted caregivers. References: Washington Administrative Code (WAC) 246-335-525(6) PERSONNEL CONTRACTOR AND VOLUNTEER POLICIES. 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 (WSP); (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; WAC 246-335-530(7) PERSONNEL, CONTRACTOR, AND VOLUNTEER RECORDS. The licensee must maintain records on all personnel and volunteers and have access to records on all contractors to include: (7) Evidence of initial and subsequent criminal history background checks and disclosure statements according to RCW 43.43.830 through 43.43.842 and this chapter; . Findings included: 1. Document review of the agency's policy titled, "Background Checks (HH-420 issued 12-01-11)," showed that all employees are required to have a WSP background check performed before hiring and annually thereafter. The policy also showed that employees must consent to background checks. 2. Surveyor #6 reviewed the personnel files for 8 home health staff members (Staff #104, #106, #601, #602, #603, #605, #607, and Staff #608). The review showed: a. Staff #104 was hired 12/17/20 and a WSP background check was not completed until 12/30/20. b. Staff #601 was hired 02/09/06 and the record did not contain a criminal history disclosure statement since 02/02/06. c. Staff #602 was hired 02/18/19 and the record did not contain a criminal history disclosure statement since 02/18/19. A WSP background check was not completed until 02/19/21. d. Staff #603 was hired 04/28/06 and the record did not contain a criminal history disclosure statement since 04/28/06. e. Staff #607 was hired 01/25/16 and the record did not contain a criminal history disclosure statement since 01/06/16. f. Staff #608 was hired 08/01/94 and the record did not contain a criminal history disclosure statement since 07/07/04. 3. On 07/14/21 at 4:00 PM, Surveyor #6 interviewed the agency's Executive Director (Staff #609) about the missing WSP criminal history background checks and criminal history disclosure statements. Staff #609 acknowledged that the agency did not complete WSP criminal history background checks for Staff #104 and #602 prior to their hiring. Staff #609 acknowledged that criminal history disclosure statements have not been completed every 2 years as required, stating that they did not know this was a requirement. .