Every finding on record at Touchmark on South Hill, A Limited Partnership

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: X2023-646 Dates Onsite: 09/12/23, 09/13/23, 09/14/23 The survey was conducted by: Surveyor #4 DOH staff found the 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.

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 through failure to complete annual staff performance evaluations for 4 of 4 staff (Staff #402, #403, #404 and #405) (Item 1) and failure to ensure department-approved disclosure statements were completed at the time of hire and renewed within two years of the previous disclosure statement for 4 of 4 staff (Staff #402, #403, #404 and #405) (Item 2). Failure to maintain compliance with state licensing requirements puts patients at risk of harm from poor quality care. Item #1-Annual Performance Evaluations References: Washington Administrative Code WAC 246-335-530 (12) 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: 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). 2. On 09/14/23 Survey #4 reviewed the personnel files for four staff (Staff #402, #403, #404, and #405). a. Staff #402 was hired on 06/12/17 as a Registered Nurse. There was no current annual evaluation documented in the personnel file. b. Staff #403 was hired on 03/25/08 as an Occupational Therapist. There was no current annual evaluation documented in the personnel file. c. Staff #404 was hired on 12/05/18 as a Physical Therapist. There was no current annual evaluation documented in the personnel file. d. Staff #405 was hired on 04/28/20 as a Speech Therapist. There was no current annual evaluation documented in the personnel file. 2. Surveyor #4 interviewed the agency Director (Staff #401) about the missing evaluations. Staff #401 confirmed the above staff did not have an annual performance evaluation completed in 2022. Item #2-Disclosure Forms Reference: Washington Administrative Code (WAC) 246-335-525 (6)(b)(c). A home health agency 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 (b) Disclosure statements musts be approved by the department; and (c) All 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 09/14/23 Surveyor #4 reviewed the agency's policy and procedure manual last updated in December 2022. The review showed that the agency did not have a policy for the use of department-approved disclosure statements. 2. On 09/14/23 Survey #4 reviewed the personnel files for four staff (Staff #402, #403, #404, and #405). a. Staff #402 was hired on 06/12/17 as a Registered Nurse. No department-approved disclosure statements were found in the file. b. Staff #403 was hired on 03/25/08 as an Occupational Therapist. No department-approved disclosure statements were found in the file. c. Staff #404 was hired on 12/05/18 as a Physical Therapist. No department-approved disclosure statements were found in the file. d. Staff #405 was hired on 04/28/20 as a Speech Therapist. No department-approved disclosure statements were found in the file. 2. Surveyor #4 interviewed the agency Director (Staff #401) about the missing disclosures. Staff #401 acknowledged the findings and stated that the agency had not been using department-approved disclosure statements and was unaware of the requirement.

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: 2021-607 Dates Onsite: 08/03-05/21 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. .

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 interview and record review, the agency failed to implement policies and procedures consistent with state licensing requirements through failure to provide patients and/or their representatives information on the provision of back-up care as part of their Bill of Rights for 7 of 7 patients (#401, #402, #403, #404, #405, #406, #407). Failure to maintain compliance with state licensing requirements for provision of back-up care places patients at risk of harm from poor quality care. Reference: Washington Administrative Code (WAC) 246-335-535 (16). 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 be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled. Findings included: 1. During review of the patient Bill of Rights on 08/03/21, Surveyor #4 noted the Bill of Rights given to patients #401, #402, #403, #404, #405, #406, #407 was missing the patient's right to be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled. 2. Surveyor #5 interviewed the Administrator (Staff #501) on 08/03/21 at 10:30 AM. Staff #501 verified the back-up care policy was not included in the patient Bill of Rights given to patients at admission.