Every finding on record at Sea Mar Community Health Center

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: X2024-628 Dates Onsite: 07/22-24/24 This survey was conducted by: Surveyor #4 Surveyor #2 DOH staff found the facility NOT in compliance with the following Conditions of Participations: 42 CFR 484.55 Comprehensive Assessment of Patients 42 CFR 484.100 Compliance with Federal, State, Local Law .

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 95 of 395 records transmitted between 05/01/23 and 04/01/24. Failure to transmit 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 #4 reviewed the "HHA Error Summary by Agency" report from 05/01/23 to 04/01/24 generated from the Website address iqies.com.gov site. The review showed that the agency had 95 of 395 patient assessments that were not submitted in a timely manner. This resulted in a 24.05% late submission error rate. 2. On 07/23/24 at 10:30 AM, Surveyor #4 interviewed the agency Program Manager (Staff #401) about the error rate. Staff #401 stated that delays in documentation and the need for corrections has resulted in late submissions.

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 and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral (repeated non-compliance from previous surveys) and failed to complete the comprehensive assessment within 5 calendar days of the patients' start of care (repeated non-compliance from previous survey). Failure to conduct initial assessments within 48 hours of completing the referral and failure to complete a comprehensive assessment within 5 calendar days of the patient's start of care 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 7 patients. 2. Repeated non-compliance identified in recertification surveys completed on 12/08/17 (under Tag 0332) AND 10/01/21 for completion of the initial assessment visit within 48 hours of completing the referral: a. The agency was previously cited on the survey dated 12/08/17 under Tag G0332, Initial Assessment Visit, 42.CFR 484.55(a)(1), the agency failed to conduct the initial visit within 48 hours of receiving a referral for 4 of 12 patients in the sample. b. The agency was previously cited on the survey dated 10/01/21 under Tag G0514, RN Performs Assessment, 42 CFR 484.55(a)(1), for 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 4 of 7 patients in the sample. 3. Failure to complete a comprehensive assessment within 5 calendar days of the patients' start of care for 3 of 7 patients. 4. Repeated non-compliance identified in the recertification survey completed on 10/01/21 for failure to complete a comprehensive assessment within 5 calendar days of the patient's start of care for 1 of 7 patients. Based on the scope and severity of deficiencies under 42 CFR 484.55; the Condition of Participation: Comprehensive assessment of patients is NOT MET. Cross Reference: G0514, G0520

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 review and interview, the agency failed to conduct the initial assessment visit within 48 hours of receiving a referral for 5 of 7 patients (#201, #202, #405, #406, #407). 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. Review of patient records for Patients (#201, #202, #405, #406, #407) showed: a. Patient #405's Start of Care (SOC) date was 05/13/24. The agency completed the referral on 05/09/24 but the initial assessment was not started until 05/13/24. 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 #406's SOC date was 02/06/24. The agency completed the referral on 02/02/24 but the initial assessment was not started until 02/06/24. 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 #407's SOC date was 03/27/22. The agency completed the referral on 03/27/24 but the initial assessment was not started until 04/03/24. 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 #201's SOC date was 05/17/24. The agency completed the referral on 05/13/24, but the initial assessment was not started until 05/17/24. 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. e. Patient #202's SOC date was 09/02/22. The agency completed the referral on 08/26/22, but the initial assessment was not completed until 09/02/22. 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. 2. Surveyor #4 interviewed the Agency Director (Staff #401) on 07/24/24 at 2:25 PM about the delayed initial assessments. Staff #401 acknowledged the delay in initial assessments. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 12/08/17 AND 10/01/21.

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 complete initial assessments within 5 calendar days of the start of care for 3 of 7 patients (#404, #406, #407). 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 patient charts for Patients (#404, #406, #407) showed: a. Patient #404's initial assessment was started on 03/28/24 and completed on 04/10/24. There was no documentation in the record to show why the assessment was not completed within 5 days. b. Patient #406's initial assessment was started on 02/06/24 and completed on 02/27/24. There was no documentation in the record to show why the assessment was not completed within 5 days. c. Patient #407's initial assessment was started on 04/03/24 and completed on 04/23/24. There was no documentation in the record to show why the assessment was not completed within 5 days. 2. Surveyor #4 interviewed the Program Manager (Staff #401) on 07/24/24 at 2:25 PM about the delay in completing the initial assessments. Staff #401 stated that the assessments had been delayed in the review process. THIS IS A REPEAT CITATION PREVIOUSLY CITED 10/01/21.

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 physician of Skilled Nursing (SN) missed visits resulting in changes to patient's plan of care in 2 of 3 patients (Patient #201 and #202). Failure to communicate changes in the plan of care to the patient's physician may potentially have a clinical impact on the patient's well-being. Findings included: 1. Record review of care plans for Patients #201 and #202 showed: a. Patient #201’s Start of Care (SOC) was 05/17/24. The plan of care included SN services with the frequency of 2 visits every week for 9 weeks and 2 as needed (PRN) starting 05/17/24. During the Medicare week of 05/26/24 to 06/01/24, the patient received 1 SN visit. In addition, there was no documentation as to why the 2nd SN visit was not made and no physician notification of the missed visit. b. Patient #202’ SOC was 09/02/22. The plan of care included SN services with the frequency of 2 visits every week for 8 weeks, 2 as needed (PRN) for the wound care, and once a month for 3 months for the catheter. During the Medicare weeks of 09/11/22 to 09/17/22 and 10/23/22 to 10/29/22, the patient received 1 SN visit. In addition, there was no documentation as to why the 2nd SN visit was not made and no physician notification of the missed visit. Patient #202’s current certification period of 06/23/24 to 08/21/24 showed a plan of care that included SN services with the frequency of 2 visits every week for 9 weeks. During the Medicare week of 06/30/24/ to 07/05/24, the patient received 1 SN visit. In addition, there was no documentation as to why the 2nd SN visit was not made and no physician of the missed visit. 2. On 07/24/24 at 2:00 PM, Surveyor #2 interviewed the agency Director of Home and Community Services (Staff #401) regarding missed visits. Staff #401 stated that she was not aware of why the SN did not document the missed visits. Staff #401 also stated that documented missed visits automatically notify the patient's physician.

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 ensure that staff received Tuberculosis (TB)- related training and education at the time of hire or during new employee orientation. The agency also failed to conduct the TB risk assessment screening using the Department of Health (DOH)- approved TB risk assessment form annually on three staff members (Staff #402, #403, and #404). Failure of the agency to comply with implementing the required TB education, training, and screening may place the patients and staff at risk of TB exposure. Findings included: Reference: Washington Administrative Code (WAC) 246-335-525 (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 (iii) 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 and procedure titled “ Health Screening,” (Policy # 100.29) showed that all employees and volunteers must complete a health screening at time of hire or initial volunteer date and then annually thereafter. The annual health screening requires a tuberculosis screening, fit-for-duty attestation for licensed employees, and flu vaccination. Annual health screenings are conducted during the flu season. Document review of the agency's policy and procedure titled "TB-Employee Prevention and Control," (Policy # 1100.221.4) showed that all employees will be screened annually which will include Skin testing with Protein Purified Derivative (PPD) for those with prior negative results to allow for early detection and treatment of conversions. Annual TB screening occurs each year in the month of July and is incorporated into the agency-wide Quality Improvement Program. 2. Record review of 3 of 3 personnel files showed: a. Staff #402 was hired on 02/03/16. There was no evidence in the record that the agency provided TB-related training and education at the time of hire or during new employee orientation. There was also no documentation that the agency conducted annual skin testing with PPD and an annual TB risk assessment using a DOH-approved form in 2022, 2023, and 2024. b. Staff #403 was hired on 03/08/24. There was no evidence in the record that the agency provided TB-related training and education at the time of hire or during new employee orientation. There was also no documentation that the agency conducted skin testing with PPD and an initial TB risk assessment using a DOH-approved form upon hire. c. Staff #404 was hired on 02/15/21. There was no evidence in the record that the agency provided TB-related training and education at the time of hire or during new employee orientation. There was also no documentation that the agency conducted annual skin testing with PPD and an annual TB risk assessment using a DOH-approved form in 2022 and 2024. 3. On 07/24/24 at 2:00 PM, Surveyor #2 interviewed the agency Director of Home and Community Services (Staff #401) about the lack of documentation on TB-related training and education and TB risk assessments using the DOH-approved form. Staff #401 stated that the agency’s Human Resources (HR) department conducts Annual Health Screenings for employees and was unaware why the annual TB risk assessment was not included in the personnel records. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 10/01/21.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on document review and interview, the agency had repeated non-compliance with all applicable state regulations related to the health and safety of patients, by failing to complete and/or renew criminal history background checks and complete department-approved disclosure statements consistent with state regulations for both the current survey and the survey completed on 10/01/21. Repeated non-compliance with state regulations for completion of criminal background checks puts patients at risk of harm from unvetted caregivers. Findings included: The agency received a citation for failure to complete criminal background checks and disclosure statements every two years as required by state regulations. The agency received the same citation on their previous survey completed on 10/01/21. Based on the scope and severity of deficiencies identified under 42 CFR 484.100; the Condition of Participation for Compliance with Federal, State, Local Law, is NOT met. Cross Reference: G860

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 and/or renew criminal history background checks and complete department-approved disclosure statements for 3 of 3 personnel providing direct care (Staff #402, #403 and #404). Failure to renew criminal background checks and disclosure statements for personnel providing direct care puts the clients at risk of receiving care from an unvetted staff member, potentially compromising their safety and well-being. Reference: Washington Administrative Code (WAC) 246-335-525 (6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following: (c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check; Findings included: 1. Document review of the agency’s policy and procedure titled “Criminal History Information,” (Policy # 2000.23) showed that Sea Mar Community Health Centers Home Health, Home Care, and Hospice agencies must request background checks and disclosure statements every two years for all employees who provide direct care to clients or patients. Home health and hospice agencies must process background checks through the Washington State Patrol (WSP). Private duty home care agencies must process initial hiring checks through DSHS BCCU and subsequent checks through WSP. 2. Record review of 3 of 3 personnel files showed: a. Staff #402 was hired on 02/03/16. There was no evidence in the personnel record to show the subsequent criminal history background checks and completion of department-approved disclosure statements in 2023. b. Staff #403 was hired on 03/08/24. There was no evidence in the personnel record to show the completion of department-approved disclosure statements upon hire. c. Staff #404 was hired on 02/15/21. There was no evidence in the personnel record to show the subsequent criminal history background checks and completion of department-approved disclosure statements in 2023. 3. On 07/24/24 at 2:00 PM, Surveyor #2 interviewed the agency Director of Home and Community Services (Staff #401) regarding criminal history background checks and disclosure statements. Staff #401 stated that the agency’s Human Resources (HR) department handles the background checks and completion of department-approved disclosure statements and was unaware of why it was not included in the personnel records. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 10/01/21.

. 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: 09/23/21 to 10/01/21 Examination number: X2021-705 The survey was conducted by: Surveyor #6 DOH staff found the facility NOT IN COMPLIANCE with the following Conditions of Participation: 42 CFR 484.105 Organization and Administration of Services .

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: . Based on document review, and interview, the agency failed to ensure the Patient Bill of Rights (PBR) included the Washington State Department of Health's (DOH) complaint hotline number for 7 of 7 patients (Patients (#601, #602, #603, #604, #605, #606, and #607). Failure to ensure the PBR contained the DOH complaint number may result in denial of the patient's due process and access to needed information for filing a complaint. Findings included: 1. Document review of the agency's undated document titled, "Sea Mar Home Health Patient's Bill of Rights" showed that the PBR failed to contain the DOH complaint number (1-800-633-6828). 2. Document review of patient records for Patients (#601, #602, #603, #604, #605, #606, and #607) showed that the PBR for each patient failed to contain the DOH complaint number. 3. On 09/23/21 at 10:36 AM, Surveyor #6 interviewed the agency's Administrator (Staff #604) about the PBR failing to provide patients with the DOH complaint number. Staff #604 acknowledged that the patient bill of rights failed to include the DOH complaint number. .

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 and interview, the agency failed to conduct the initial assessment visit within 48 hours of completed referral for 4 of 7 patients (Patients #601, #602, #603, and #604). Failure to conduct an initial assessment within 48 hours places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency's policy titled, "Assessment and Re-Assessments, Policy Number: 2002.03," (Dated 05/01/21) showed that staff are to conduct a comprehensive client assessment at the start of care. The policy also showed that the agency must conduct an initial assessment 48 hours from completion of the referral. Document review of agency's policy titled, "Referral for Home Health Care, Policy Number: 2002.01," (Dated 04/2018) showed that the agency must conduct an initial visit within 48 hours of a completed referral. The policy also showed that agency staff must conduct the initial visit as a Start of Care (SOC) visit with a complete assessment. 2. Record review of patient records (Patients #601, #602, #603, and #604) showed: a. Patient #601's SOC date was 02/22/21. The agency completed the referral on 02/19/21 for Skilled Nursing (SN). The record failed to document the reason for the delay in the SOC and failed to document physician notification. b. Patient #602's SOC date was 09/15/21. The agency completed the referral on 09/10/21 for Physical Therapy (PT). The record failed to document the reason for the delay in the SOC and failed to document physician notification. c. Patient #603's SOC date was 08/12/21. The agency completed the referral on 07/29/21 for SN, PT, and Occupational Therapy (OT). The record documented communication with the patient from 07/29/21 to 08/04/21 regarding the reasons for the delayed SOC. The record failed to document the reason for the delay in the SOC between 08/05/21 to 08/12/21 and failed to document any physician notifications of the delayed SOC. d. Patient #604's SOC date was 09/14/21. The agency completed the referral on 09/07/21 for Physical Therapy (PT). The record failed to document the reason for the delay in the SOC and failed to document physician notification. 3. On 09/29/21 at 12:00 PM, Surveyor #6 interviewed the agency's Administrator (Staff #604) about the failures to conduct initial assessments within 48 hours of referral. Staff #604 acknowledged the findings. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 12/08/17 UNDER TAG G332. .

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 comprehensive assessments were completed within 5 days from the start of care (SOC) for 1 of 7 patients (Patient #605). Failure to complete timely assessments puts them at risk of harm from improper care and worsening symptoms. Findings included: 1. Document review of agency's policy titled, "Assessment and Re-Assessments, Policy Number: 2002.03," (Dated 05/01/21) showed that the agency must conduct a comprehensive client assessment at the start of care. The policy also showed that the agency must complete the comprehensive assessment no later than 5 days after the SOC. 2. Record review of the record for Patient #605 showed: a. Patient #605's SOC date was 04/22/21. The agency started the initial comprehensive assessment on 04/22/21 but completed it on 05/03/21. The record failed to document the reason for the delay in completing the assessment. 3. On 09/29/21 at 2:10 PM, Surveyor #6 interviewed the agency's Administrator (Staff #604) about the delay in completing the assessment. Staff #604 acknowledged the findings and stated that the agency policy is to complete assessments within 5 days. .

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to include all the Medicare required elements in the individualized plan of care (CMS-485) for 7 of 7 patients (Patients #601, #602, #603, #604, #605, #606, and #607). Failure to include all required elements on the Form CMS-485 may result in omissions of care and puts the patient at risk for unmet needs and receiving care not ordered by a physician. Findings included: 1. Document review of agency's policy titled, "Assessment and Re-Assessments, Policy Number: 2002.03," (Dated 05/01/21) showed that the agency creates the Form CMS-485 from the comprehensive assessment. The policy also showed that the comprehensive assessment must include the prognosis, risk factors, equipment, supplies, safety measures, and functioning level of the patient. 2. Record review of patient records (Patients #601, #602, #603, #604, #605, #606, and #607) showed: a. Patient #601's SOC date was 02/22/21. The Forms (CMS-485) for certification periods 06/22/21-08/20/21 and 08/21/21-10/19/21 failed to document required patient equipment and supplies. Both Forms also failed to include risks for Emergency Department (ED) visits and failed to describe all necessary interventions to address the underlying risk of ED visits and hospitalizations. b. Patient #602's SOC date was 09/15/21. The Form CMS-485 for certification period 09/15/21-11/13/21 failed to include risks for Emergency Department (ED) visits and failed to describe all necessary interventions to address the underlying risk of ED visits and hospitalizations. c. Patient #603's SOC date was 08/12/21. The Form CMS-485 for certification period 08/22/21-10/01/21 failed to document the patient's prognosis, rehab potential, functional limitations, activities permitted, and required patient equipment and supplies. The Form CMS-485 also failed to include risks for Emergency Department (ED) visits and failed to describe all necessary interventions to address the underlying risk of ED visits and hospitalizations. d. Patient #604's SOC date was 09/14/21. The Form CMS-485 for certification period 09/14/21-11/12/21 failed to include risks for Emergency Department (ED) visits and failed to describe all necessary interventions to address the underlying risk of ED visits and hospitalizations. e. Patient #605's SOC date was 04/22/21. The Forms (CMS-485) for certification periods 04/22/21- 06/20/21, 06/21/21- 08/19/21 and 08/20/21- 10/18/21 failed to document required patient equipment and supplies. The Forms also failed to include risks for Emergency Department (ED) visits and failed to describe all necessary interventions to address the underlying risk of ED visits and hospitalizations. f. Patient #606's SOC date was 10/31/18. The Form CMS-485 for the initial certification period incorrectly listed the dates as 10/30/18- 12/28/18 and failed to document the patient's nutritional requirements and required patient equipment and supplies. The Form CMS-485 also failed to include risks for Emergency Department (ED) visits and failed to describe all necessary interventions to address the underlying risk of ED visits and hospitalizations. g. Patient #607's SOC date was 08/18/17. The Form CMS-485 for certification period 12/16/17- 02/13/18 failed to include risks for Emergency Department (ED) visits and failed to describe all necessary interventions to address the underlying risk of ED visits and hospitalizations. 3. On 10/02/21 at 2:15 PM, Surveyor #6 interviewed the agency's Administrator (Staff #604) about the missing elements from the patients' CMS-485 Forms. Staff #604 acknowledged the findings and stated that they will review with their staff the missing elements from the Form. .

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: . Based on observation, document review, and interview, the agency failed to follow physician's orders for 1 of 7 patients (Patients #601). Failure to provide care only as ordered by a physician, places patients at risk of harm due to receiving improper or contraindicated care. Findings included: 1. Document review of agency's policy titled, "Physician Orders, Policy Number: 4004.01," (Dated 08/14/21) showed that all care provided must be based on the most recent physician orders. The policy also showed that all orders on the plan of care (Form CMS-485) must be specific to the patient, and that both agency staff and the physician must review and recertify orders at least every 60 days and as warranted by changes in patient condition. The policy also showed that agency clinical staff must continuously review and determine the adequacy of the Form CMS-485. 2. On 09/24/21 at 10:24 AM, Surveyor #6 observed an agency RN (Staff #602) perform urostomy care for Patient #601. Staff #602 removed the urostomy bag, cleansed the skin, and applied a new urostomy bag. 3. At the time of the observation, Surveyor #6 asked Staff #602 how often they performed urostomy care and Staff #602 stated, "once per week". Surveyor #6 ask Staff #602 if they had orders to perform urostomy care and Staff #602 stated that they had orders, as they had been providing the care since the patient started with the agency. 4. Record review for Patient #601 showed: a. Patient #601's SOC date was 02/22/21. The initial Form CMS-485 had orders for urostomy care. The Form CMS-485 for certification periods 06/22/21-08/20/21 and 08/21/21-10/19/21 did not include orders for urostomy care. The record failed to document physician orders for urostomy care after 06/22/21. The record showed that Staff #602 performed urostomy care weekly from 06/21/21 to 09/24/21 without physician orders. 5. On 09/28/21 at 9:00 AM, Surveyor #6 interviewed the agency's Administrator (Staff #604) about the missing urostomy orders form Patient #601's Form CMS-485. Staff #604 acknowledged the findings and stated that they were unsure why the orders were not on the last two Forms. Staff # 604 stated that they would get new orders from the physician. .

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 regulation for 3 of 3 staff (Staff #601, #602, and #603). Failure to conduct an initial and annual TB risk assessment for current staff puts patients and staff at risk of harm from exposure to TB. References: Washington Administrative (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) 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; (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; and Adult Tuberculosis Risk Assessment (Form #DOH 343-144), March 2019. Use this tool to identify asymptomatic adults for latent TB infection (LTBI) testing. Do not repeat testing unless there are new risks factors since last test. Do not treat for LTBI until active TB disease has been excluded. Findings included: 1. Document review of the agency's undated policy titled, "Annual Employee TB Screening," showed that the agency was to complete an annual TB screening for every employee. The policy also showed that the personnel record of each employee must contain the TB screening and any test results. 2. On 09/28/21, Surveyor #6 reviewed 3 personnel files (Staff #601, Staff #602, and Staff #603). The review showed: a. Staff #601's hire date was 02/15/21. The record failed to document a completed TB risk assessment form. b. Staff #602's hire date was 02/23/16. The record failed to document a completed TB risk assessment form. c. Staff #603's hire date was 02/15/21. The record failed to document a completed TB risk assessment form. 3. Surveyor #6 interviewed the agency's Human Resources Manager (Staff #605) and the agency's Administrator (Staff 604) on 09/28/21 at 2:15 PM, about the missing TB risk assessments for staff. Staff #605 acknowledged the agency has not completed DOH TB risk assessment forms. Staff #605 also stated that they had been in their role for a few months and had no previous knowledge of the need to complete a TB risk assessment form. Staff #604 and Staff 605 stated that they do not have records of any TB tests or screenings for the reviewed employee's files. Staff #604 verified that the agency's policies require an annual employee TB screening for all staff. .

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to schedule skilled nursing or professional services visits as ordered by the physician for 5 of 7 patients (Patients #602, #603, #605, #606, and #607), including failure to schedule skilled nursing (SN) visits, failure to schedule Physical Therapy (PT) visits, and failure to schedule Occupational Therapist (OT) visits. Failure to schedule skilled nursing and professional service visits as ordered by the physician puts patients at risk of harm from unmet needs and/or a decline in condition. Findings included: 1. Document review of the agency's policy titled, "Missed Visits Number: 2002.01.18)," (Dated 07/15/21) showed that when a patient has a missed visit, a Missed Visit Form is completed and faxed to the primary care provider and the missed visit is documented in the patient record. The policy also showed that agency staff must contact the physician when missed visits are recurring to coordinate a solution. 2. Record review of patient records (Patients #601, #602, #603, #604, #605, #606, and #607) showed: a. Patient #602's SOC date was 09/15/21. On 09/14/21 the physician ordered PT 2 times per week for 4 weeks. There was a missed PT visit on 09/17/21. Absent from the record were a missed visit form and evidence of physician notification. b. Patient #603's SOC date was 08/12/21. On 8/12/21, the physician ordered SN 1 time per week for one week, PT 2 times per week for 4 weeks, and OT 1 time per week for 1 week. The agency RN completed a SN evaluation on 09/03/21 and the OT completed the OT evaluation on 08/24/21. The record failed to document the reason for the SN and OT visit delays and physician notifications were absent from the record. On 08/24/21 the physician ordered OT 2 times per week for 6 weeks. The agency failed to complete missed visit forms and to notify the physician for the following missed visits: 08/14/21 PT visit, 08/20/21 OT and PT visits, 08/27/21 OT visit, 08/31/21 OT visit, 09/07/21 OT visit, 09/14/21 OT visit, 09/16/21 OT visit, 09/20/21 PT visit, 09/21/21 OT visit, 09/22/21 OT and PT visits, 09/23/21 OT visit, and 10/01/21 PT Assistant visit. c. Patient #605's SOC date was 04/22/21. On 08/20/21 the physician ordered SN 1 time per week for one week, then 2 times per week for 8 weeks and 2 as needed SN visits. The agency failed to complete missed visit forms and notify the physician for the following missed visits: 08/31/21, 09/07/21, 09/21/21, 09/25/21, and 09/28/21. d. Patient #606's SOC date was 10/31/18. On 10/31/18 the physician ordered PT 1 time per week for one week, then 2 times per week for 8 weeks. The record also showed that on 12/14/18 the patient asked the PT to put services on hold due to their hernia. The physician had ordered PT through 12/29/18. The record showed that, the agency did not complete PT visits for the weeks of 12/16/18 to 12/22/18 and 12/23/18 to 12/29/18. The agency PT discharged Patient #606 on 12/27/18. The record failed to document missed visit forms and physician notifications of missed visits and that the patient declined services due to a hernia. e. Patient #607's SOC date was 08/18/17. On 12/14/17 the physician ordered 1 as needed Speech Language Pathology (SLP) visit, then as of 12/18/17 SLP visits 2 times per week for 1, week, then 1 time per week for 3 weeks. On 12/16/17 the physician ordered SN visits 1 time per month for 2 months. On 12/17/17 they physician ordered PT 2 times per week for 3 weeks, then as of 01/07/18 PT 2 times per week for 1 week. The record showed the agency failed to complete a missed visit form and notify the physician for the missed PT on 12/26/17. The record also showed that the agency failed to notify the physician of the missed SLP visit on 12/28/17. 3. On 10/01/21 at 10:15 AM, Surveyor #6 interviewed the agency's Administrator (Staff #604) about the failures to provide visits as ordered by the physician. Staff #604 acknowledged the findings. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 12/08/17 UNDER TAG G158. .

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to implement policies and procedures consistent with state licensing requirements for 7 of 7 patient files and 3 of 3 staff files reviewed, through failure to ensure the Bill of Rights (BR) informed patients of their right to the agency's policy on providing back-up care for 7 patients (Patients #601, #602, #603, #604, #605, #606, and #607) (Item 1), failure to ensure the BR informed patients of their right to the name of the individual supervising their care for 7 patients (Patients #601, #602, #603, #604, #605, #606, and #607) (Item 2), and failure to complete and provide documentation of department approved disclosure statements and criminal background checks every 2 years for 3 staff (Staff #601, Staff #602, and Staff #603) (Item 3). Failure to maintain compliance with state licensing requirements puts patients at risk of unmet needs, limits patient's ability to report concerns, and may result in receiving care from an un-vetted or unqualified caregiver. Item 1 - Policy on Back-up Care . References: WAC 246-335-520 DELIVERY OF SERVICES - The applicant or licensee must develop and operationalize delivery of services policies and procedures that describe: (11) Providing back-up care to the patient when services cannot be provided as scheduled. Back-up care which requires assistance with patient ADLs or patient health services must be provided by staff with minimum health care credentialing. Non credentialed staff may provide back-up care only when assisting a patient with IADLs or in emergency situations. 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's right to: (16) Be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled. Findings included: 1. Document review of the agency's undated document titled, 'Sea Mar Home Health Patient's Bill of Rights' showed that the PBR failed to include a statement of the client's right to be informed of the agency's policies and procedures for providing back-up care. Document review of the Department of Health's (DOH) policy and procedure checklist for home health agencies completed by the agency's Administrator (Staff 604) on 09/24/21 showed that the agency did not have a policy for back-up care. 2. On 09/24/21 at 4:27 PM, Surveyor #6 interviewed Staff #604 about the agency's policy on back-up care. Staff #604 acknowledged the agency does not have a policy on back-up care. Staff #604 stated that they were unaware of the requirement to have a policy on back-up care. Item 2 - Supervisor of Patient 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's right to: (7) The name of the individual within the home health agency responsible for supervising the patient's care and the manner in which that individual may be contacted. Findings included: 1. Document review of the agency's undated document titled, "Sea Mar Home Health Patient's Bill of Rights," showed that the PBR failed to document the name of the individual within the home health agency responsible for supervising the patient's care and the manner in which that individual may be contacted. Document review of patient records for Patients #601, #602, #603, #604, #605, #606, and #607 showed that the PBR for each patient failed to include contact information for the individual supervising their care. 2. On 09/23/21 at 10:36 AM, Surveyor #6 interviewed the agency's Administrator (Staff #604) about the PBR failing to inform patients of the individual's name who supervises their care. Staff #604 acknowledged that the PBR failed to include the right to know the individual responsible for supervising their care. Item 3 - Background Checks & Disclosure Statements . References: 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: (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; 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: (7) Evidence of initial and subsequent criminal history background checks and disclosure statement(s) according to RCW 43.43.830 through 43.43.842 and this chapter. Findings included: 1. Document review of the undated agency policy titled, "Annual Background Checks," showed that the agency was to complete an annual background check by January 31st of each year. 2. On 09/28/21, Surveyor #6 reviewed 3 personnel files (Staff #601, Staff #602, and Staff #603). The review showed: a. Staff #601's hire date was 02/15/21. The record failed to document a Washington State Department of Health (DOH) approved disclosure statement and a Washington State Patrol (WSP) background check. b. Staff #602's hire date was 02/23/16. The record failed to document DOH approved disclosure statements. The file contained a WSP background check from 07/13/17 but failed to document WSP background checks for 2019 and 2021. c. Staff #603's hire date by the agency was 06/12/18. Staff #603 transferred to the Home Health department on 02/15/21. The record contained WSP background checks completed on 05/28/18 and 02/05/20 but lacked corresponding DOH- approved disclosure statements. 3. Surveyor #6 interviewed the agency's Human Resources Manager (Staff #605) and the agency's Administrator (Staff #604) on 09/28/21 at 3:52 PM, about the missing disclosure statements and WSP background checks for staff. Staff #605 acknowledged the agency has not completed DOH-approved disclosure statements. Staff #604 verified that the agency's policies require an annual background checks for all staff. .

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: . Based on interview and document review, the agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. Failure of the agency to appropriately manage its resources puts patients at risk of not receiving optimal care to achieve the goals and outcomes identified in patient's plan of care and may result in patients receiving substandard care and experiencing adverse outcomes. Findings included: Failure to ensure drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. Failure to provide services that are ordered by the physician or allowed practitioner as indicated in the plan of care. Failure to assure the development, implementation, and updates of the patient's plan of care. Due to the scope and severity of deficiencies identified under 42 CFR 484.105 Conditions of Participation for Organization and administration of services are NOT MET Cross Reference: Tags G0580, G0710, and G0968 .

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: . Based on record review, observation, and interview, the agency failed to assure implementation of the plan of care for 6 of 7 (Patients #601, #602, #603, #605, #606, and #607). Failure to assure implementation of the Plan of Care (Form CMS-485) places patients at risk of harm from improper care, unmet needs, or worsening symptoms. Findings included: 1. The agency failed to follow physician's orders for 1 of 7 patients (Patient #601). A Registered Nurse (Staff #602) continued to perform urostomy care without current physician orders. Refer to G580 2. The agency failed to schedule skilled nursing or professional services visits as ordered by the physician for 5 of 7 patients (Patients #602, #603, #605, #606, and #607), resulting in missed visits without physician notification. Refer to G710 3. On 10/01/21 at 10:15 AM, Surveyor #6 interviewed the agency's Administrator (Staff #604) about the failure to provide care as ordered by the physician. Staff #604 acknowledged the findings. .