Every finding on record at Northeast Washington Home Health, Inc.

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: X2024-570 Dates Onsite: 07/08-11/24 This survey was conducted by: Surveyor #4 Surveyor #5 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. . . . . . . .

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 review and interview the agency failed to transmit patient data to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for 360 of 1674 records transmitted between 04/01/23 and 03/31/24. Failure to transmit discharged patient data in a timely manner could result in patients not receiving full benefits. Findings included: 1. As part of the pre-survey preparation, Surveyor #5 reviewed the "HHA Error Summary by Agency" report from 04/01/23 to 03/31/24 generated from the iqies.com.gov site. The review showed that the agency had 360 of 1674 patient assessments that were not submitted in a timely manner. This resulted in a 21.5% late submission error rate. 2. On 07/09/24 at 10:00 AM and on 07/10/24 at 11:00 AM, Surveyor #5 interviewed the agency Executive Director (Staff #501) about the error rate. Staff #501 stated that the agency recently changed the manner in which assessments are reviewed for quality. Staff #501 stated that in the new system the staff that complete the reviews were backlogged therefore the assessments were submitted late. Staff #501 stated that they also learned that the assessments were only being transmitted on Tuesdays which would have contributed to the late submissions.

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 a record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of receiving a referral for 6 of 13 patients (#504, #405, #406, #408, #510 and #512). Failure to meet this requirement places patients at risk for physical harm due to not receiving needed services in a timely manner. Findings included: 1. Record review of the patient charts for Patients (#504, #405, #406, #408, #510, #512) showed: a. Patient #504's Start of Care (SOC) date was 12/23/23. The agency completed the referral on 12/20/23 but the initial assessment was not completed until 12/23/24. There was no documentation to explain why the initial assessment did not occur within 48 hours of the referral or documentation to show that the delay was based on patient request. b. Patient #405's SOC date was 04/11/24. The patient discharged to home on 04/06/24 but the initial assessment was not completed until 04/11/24. There was no documentation to explain why the initial assessment did not occur within 48 hours of the referral or documentation to show that the delay was based on patient request. c. Patient #406's SOC date was 05/24/24. The patient discharged to home on 05/21/24 but the initial assessment was not completed until 05/24/24. There was no documentation to explain why the initial assessment did not occur within 48 hours of the referral or documentation to show that the delay was based on patient request. d. Patient #408's SOC date was 05/07/24. The patient was discharged to home on 04/29/24. There was no documentation to show why the agency could not meet timely initiation of care. e. Patient #510's SOC date was 03/11/24. The agency completed the referral on 03/07/24 but the initial assessment was not completed until 03/11/24. There was no documentation to explain why the initial assessment did not occur within 48 hours of the referral or documentation to show that the delay was based on patient request. f. Patient #512's SOC date was 01/10/24. The agency completed the referral on 01/02/24 but the initial assessment was not completed until 10/10/24. There was documentation to show that the agency could not meet timely initiation of care. 2. Surveyor #5 interviewed the Executive Director (Staff #501) on 07/10/24 at 11:30 AM about the delayed initial assessments for Patients #504, #510 and #512. Staff #501 verified that for Patient #504 and #510 the documentation did not indicate that the delay was requested by the patient. Staff #501 stated that the delay for Patient #512 was agency driven. Surveyor #4 interviewed the Executive Director (Staff #501) on 07/11/24 at 9:00 AM about the delayed initial assessments for Patients #405, #406 and #408. Staff #401 verified that for Patients #405 and #406 the documentation did not indicate that the delay was requested by the patient. Staff #401 stated that the delay for Patient #408 was agency driven.