Every finding on record at Tri-Cities Home Health, LLC

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. Service Category: Home Health Examination number: X2025-719 Dates Onsite: 08/11-15/25 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. DOH recommends recertification based on an acceptable plan of correction. . . .

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 follow state requirements to perform annual Tuberculosis (TB) assessment forms for 6 of 7 clinicians that provided patient care (Staff #503, #504, #505, #506, #507 and #508). Failure to perform annual TB Screening on staff places patients and staff at risk for exposure to TB. 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: (14) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (c) Tuberculosis infection control program. Key elements include but are not limited to: (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 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. Findings included: 1. Document review of agency’s document titled, “Tuberculosis Screening and Testing,” (Dated 03/26/24) showed that all employees will be screened annually using the Washington State Department of Health Adult Tuberculosis Risk Assessment form. 2. The personnel record reviews for the 6 clinicians showed: a. Staff #503 was hired on 01/09/23. The record showed a completed [DOH]-approved annual TB risk assessment dated 01/10/23. There was no signed assessment form in the record since this time. b. Staff #504 was hired on 12/18/10. The record showed a completed [DOH]-approved annual TB risk assessment dated 12/20/23. There was no signed assessment from in the record since this time. c. Staff #505 was hired on 09/19/22. The record showed a completed [DOH]-approved annual TB risk assessment dated 12/05/23. There was no signed assessment from in the record since this time. d. Staff #506 was hired on 06/27/16. The record showed a completed [DOH]-approved annual TB risk assessment dated 12/21/23. There was no signed assessment from in the record since this time. e. Staff #507 was hired on 06/26/23. The record showed a completed [DOH]-approved annual TB risk assessment dated 12/05/23. There was no signed assessment from in the record since this time. f. Staff #508 was hired on 05/02/22. The record showed a completed [DOH]-approved annual TB risk assessment dated 12/04/23. There was no signed assessment from in the record since this time. 3. On 08/13/25 at 9:30 AM, the surveyor interviewed the agency's Office Manager (Staff #502) about the lack of signed annual assessments. Staff #502 stated that they were unaware of the requirement to have signed assessments. THIS IS A REPEAT UNCORRECTED DEFICIENCY CITED ON 11/29/22.

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. Offsite Dates: 11/21/22-11/23/22 Onsite dates: 11/28/22-11/29/22 Examination number: X2022-922 The survey was conducted by: Surveyor #1 Surveyor #6 DOH staff found the agency 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. .

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data of the referral date (M0104) for 8 of 17 patients (Patients #101, #104, #106, #107, #109, #110, #111, and #115). 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. Document review of agency’s policy titled, “Oasis Outcome and Information Set,” (Last Review Date: 05/31/22) showed that the encoded OASIS date must accurately reflect the patient’s status at the time of assessment. 2. Record review of patient records for Patient #101, #104, #106, #107, #109, #110, #111, #115 showed: a. Patient #101 was admitted for primary diagnoses of Chronic Obstructive Pulmonary Disease and Congestive Heart Failure—not a complete list. The referral date was 08/16/22 for Skilled Nursing (SN), Physical Therapy (PT), and Home Health Aide (HHA) services. The OASIS M0104 data showed the Start of Care (SOC) date of 08/17/22 rather than the accurate data of the referral date of 08/16/22. b. Patient #104 was admitted for primary diagnoses of Hypertension and Weakness—not a complete list. The referral date was 10/28/22 for PT and Occupational Therapy (OT) services. The OASIS M0104 data showed the SOC date of 10/31/22 rather than the accurate data of the referral date of 10/28/22. c. Patient #106 was admitted for primary diagnoses of Dementia and Diabetes Mellitus—not a complete list. The referral date was 10/20/22 for PT and Speech Therapy (ST) services. The OASIS M0104 data showed the SOC date of 10/25/22 rather than the accurate data of the referral date of 10/20/22. d. Patient #107 was admitted for primary diagnoses of Venous Insufficiency and Skin ulcers on Bilateral Lower Extremities—not a complete list. The referral date was 08/06/22 for SN, PT, and OT services. The OASIS M0104 data showed the SOC date of 08/09/22 rather than the accurate date of the referral date of 08/06/22. e. Patient #109 was admitted for primary diagnoses of Osteomyelitis and Multiple Sclerosis—not a complete list. The referral date was 05/02/22 for SN and PT services. The OASIS M0104 data showed the SOC date of 05/11/22 rather than the accurate date of the referral date of 05/02/22. f. Patient #110 was admitted for primary diagnoses of Emphysema and Chronic Obstructive Pulmonary Disease (COPD)—not a complete list. The referral date was 09/09/22 for SN, PT, and OT services. The OASIS M0104 data showed the SOC date of 09/23/22 rather than the accurate date of the referral date of 09/09/22. g. Patient #111 was admitted for primary diagnoses of COPD and Pneumonia—not a complete list. The referral date was 10/08/21 for a SN, HHA, PT, and OT services. The OASIS M0104 data showed the SOC date of 10/12/22 rather than the accurate date of the referral date of 10/08/21. h. Patient #115 was admitted for primary diagnoses of Chronic Obstructive Pulmonary Disease and Pneumonia—not a complete list. The referral date was 10/21/21 for a SN, PT, OT, ST, and Social Worker (SW) services. The OASIS M0104 data showed the SOC date of 11/29/21 rather than the accurate date of the referral date of 10/21/21. 3. On 11/28/22 at 3:00 PM, Surveyors #1 and #6 interviewed the agency’s Director of Clinical Operations (Staff #109) about the inaccurate documentation of the OASIS M0104. Staff #109 acknowledged the findings and stated that the clinical managers needed re-education on completing the OASIS data. .

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT 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 for 4 of 17 patients (Patients #110, #113, #115, and #116). 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, “Plan of care (POC)/Care Planning Process,” (last reviewed 05/09/22) showed that changes to the POC are communicated to the patient and/or caregiver prior to the initiation of changes and are coordinated with the physician/allowed practitioners. 2. Record review of patient records for Patient #110, #113, #115, #116 showed: a. Patient #110 was admitted on 09/23/22 for primary diagnoses of Emphysema and Chronic Obstructive Pulmonary Disease—not a complete list. The physician ordered Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) services. On 09/25/22, the physician ordered OT services for the patient 2 times per week for 7 weeks. The weeks of 10/16/22 and 10/30/22, the patient received only 1 of 2 OT visits for each week. The record had no documentation to indicate the missed OT visits was reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed OT visits. b. Patient #113 was admitted on 11/06/21 for primary diagnoses of Diabetes Mellitus and Pulmonary Edema—not a complete list. The physician ordered SN, PT, and Social Worker (SW) services. On 12/26/21, the physician ordered PT services for 1 time per 1 week, the patient received no PT visit as ordered. The record had no documentation to indicate the missed PT visits was reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed PT visit. On 01/02/22, the physician ordered SW services for 1 time per 1 week, the patient received no SW visit as ordered. The record had no documentation to indicate the missed SW visits was reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed SW visit. c. Patient #115 was admitted on 11/29/21 for primary diagnoses of Chronic Obstructive Pulmonary Disease and Pneumonia—not a complete list. On 12/05/21, the physician ordered PT services for the patient for 1 time per week for 3 weeks and 2 times per week for 4 weeks. The week of 01/02/22 and 01/09/22, the patient received no PT visits. The record had no documentation to indicate the missed PT visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed PT visits. d. Patient #116 was admitted on 02/23/22 for primary diagnoses of Coronary Heart Disease, Congestive Heart Failure, and Chronic Kidney Disease – not a complete list. The physician ordered SN, OT, and PT services. On 02/27/22, the physician ordered PT services for the patient 2 times per week for 5 weeks. The week of 03/06/22, the patient received 1 of 2 PT visits. The record had no documentation to indicate the missed PT visit was reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed PT visit. 3. On 11/23/22 at 9:00 AM, Surveyors #1 and #6 interviewed the agency’s Director of Clinical Operations (Staff #109) about the lack of documentation of the missed visits. Staff #109 acknowledged the findings and was unable to provide any documentation of the missed visits.

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 review, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral for 12 of 17 patients (Patients #103, #104, #105, #106, #107, #108, #109, #110, #111, #113, #115, and #116) 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 policy titled, “Initial Referral/Admission Process,” (dated 08/26/21) showed that the initial assessment will be done within 48 hours of receipt of the referral and within the patient’s discharge to home. 2. Record review of patient records for Patient #103, #104, #105, #106, #107, #108, #109, #110, #111, #113, #115, #116 showed: a. Patient #103’s Start of Care (SOC) date was 08/15/22. The patient was admitted for primary diagnoses of Metabolic Encephalopathy and Diabetes Mellitus—not a complete list. The referral date was 08/12/22 for a Skilled Nursing (SN) assessment, and the SOC for the SN services did not occur until 08/15/21. There was no documentation of why the SN service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. b. Patient #104’s SOC date was 10/31/22. The patient was admitted for primary diagnoses of Hypertension and Weakness—not a complete list. The referral date was 10/28/22 for a Physical Therapy (PT) assessment, and the SOC for the PT service did not occur until 10/31/22. There was no documentation of why the PT service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. c. Patient #105’s SOC date was 11/08/22. The patient was admitted for primary diagnoses of Stroke and Ischemia—not a complete list. The referral date was 10/14/22 for a PT assessment, and the SOC for the PT service did not occur until 11/08/22. There was no documentation of why the PT service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. d. Patient #106’s SOC date was 10/25/22. The patient was admitted for primary diagnoses of Dementia and Diabetes Mellitus—not a complete list. The referral date was 10/20/22 for a PT assessment, and the SOC for the PT service did not occur until 10/25/22. There was no documentation of why the PT service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. e. Patient #107’s SOC date was 08/09/22. The patient was admitted for primary diagnoses of Venous Insufficiency and Skin ulcers on Bilateral Lower Extremities—not a complete list. The referral date was 08/06/22 for a SN assessment, and the SOC for the SN service did not occur until 08/09/22. There was no documentation of why the SN service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. f. Patient #108’s SOC date was 08/31/22. The patient was admitted for primary diagnoses of Pneumonia and Diabetes Mellitus—not a complete list. The referral date was 08/15/22 for a SN assessment, and the SOC for the SN services did not occur until 08/31/22. There was no documentation of why the SN service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. g. Patient #109’s SOC date was 05/11/22. The patient was admitted for primary diagnoses of Osteomyelitis and Multiple Sclerosis—not a complete list. The referral date was 05/02/22 for SN assessment, and the SOC for the SN service did not occur until 05/11/22. There was no documentation of why the SN service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. h. Patient #110’s SOC date was 09/23/22. The patient was admitted for primary diagnoses of Emphysema and Chronic Obstructive Pulmonary Disease—not a complete list. The referral date was 09/09/22 for SN assessment, and the SOC for the SN services did not occur until 09/23/22. There was no documentation of why the SN service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. i. Patient #111’s SOC date was 10/12/22. The patient was admitted for primary diagnoses of Hypertension and Chronic Kidney Disease—not a complete list. The referral date was 10/08/22 for SN assessment, and the SOC for the SN services did not occur until 10/12/22. There was no documentation of why the SN service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. j. Patient #113’s SOC date was 11/06/22. The patient was admitted for primary diagnoses of Diabetes Mellitus and Pulmonary Edema—not a complete list. The referral date was 11/03/21 for SN assessment, and the SOC for the SN service did not occur until 11/06/22. There was no documentation of why the SN service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. k. Patient #115’s SOC date was 11/29/21. The patient was admitted for primary diagnoses of Chronic Obstructive Pulmonary Disease and Pneumonia—not a complete list. The referral date was 10/21/21 for a SN assessment, and the SOC for the SN service did not occur until 11/29/21. There was no documentation of why the SN service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. l. Patient #116’s SOC date was 02/23/22. The patient was admitted for primary diagnoses of Myocardial Infarction and Congestive Heart Failure—not a complete list. The referral date was 02/11/22 for a SN assessment, and the SOC for the SN service did not occur until 02/23/22. There was no documentation of why the SN service did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. 3. On 11/23/22 at 9:00 AM, Surveyors #1 and #6 interviewed the agency’s Director of Clinical Operations (Staff #109) of the lack of documentation of the delayed services. Staff #109 acknowledged the findings and was unable to provide any documentation for the delayed admission. .

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 timely provide secondary services as ordered by the physician for 8 of 17 patients (Patients #103, #104, #106, #107, #109, #113, #115, and #116). Failure to provide timely services, as ordered by the physician, could place the patient at risk of worsening symptoms of existing diagnoses. 1. Document review of agency’s policy titled, “Patient Assessment/Reassessment,” (dated of last reviewed 03/03/22) showed that completion of the comprehensive assessment must be completed no later than five calendar days after the Start of Care (SOC) or a reassessment for Resumption of Care (ROC) within 48 hours of the patient's return home. 2. Record review of patient records for Patient #103, #104, #106, #107, #109, #113, #115, #116 showed: a. Patient #103’s SOC was on 08/15/22. The patient was admitted for primary diagnoses of Metabolic Encephalopathy and Diabetes Mellitus—not a complete list. The referral orders dated 08/12/22 included a Skilled Nursing (SN) assessment, a Physical Therapy (PT) evaluation, and a Speech Therapy (ST) evaluation. The PT and ST evaluations did not occur until 08/23/22. There was no documentation as to why the PT and the ST evaluations did not occur timely, and no documentation that the physician was notified of the delayed PT and ST evaluations. b. Patient #104’s SOC was on 10/31/22. The patient was admitted for primary diagnoses of Hypertension and Weakness—not a complete list. The referral orders dated 10/28/22 included a PT assessment and an OT evaluation. The OT evaluation did not occur until 11/17/22. There was no documentation as to why the OT evaluation did not occur timely, and no documentation that the physician was notified of the delayed OT evaluation. c. Patient #106’s SOC was on 10/25/22. The patient was admitted for primary diagnoses of Dementia and Diabetes Mellitus—not a complete list. The referral orders dated 10/20/22 included a PT assessment and a ST evaluation. In addition, a SN evaluation was ordered on 11/13/22. However, the SN evaluation was not completed. There was no documentation of why the SN evaluation did not occur, and no documentation that the physician was notified of the SN evaluation not being completed. d. Patient #107 was hospitalized, and the Resumption of Care (ROC) occurred on 09/05/22. The patient was admitted for primary diagnoses of Venous Insufficiency and Skin ulcers on Bilateral Lower Extremities—not a complete list. The ROC referral dated was 09/05/22 for a SN assessment, a PT evaluation, and an OT evaluation. The PT evaluation did not occur until 09/12/22, and the OT evaluation did not occur until 09/16/22. There was no documentation of why the PT and OT evaluations did not occur timely, and no documentation that the physician was notified of the delayed PT and OT evaluations. e. Patient #109’s SOC was on 05/11/22. The patient was admitted for primary diagnoses of Osteomyelitis and Multiple Sclerosis—not a complete list. The referral orders dated 05/02/22 included a SN assessment, a PT evaluation, and an OT evaluation. The OT evaluation was not completed. There was no documentation of why the OT evaluation did not occur, and no documentation that the physician was notified of the OT evaluation not being completed. f. Patient #113 was hospitalized and ROC occurred on 12/26/21. The patient was re-admitted for primary diagnoses of Diabetes Mellitus and Pulmonary Edema—not a complete list. The ROC referral date was 12/26/21 included a SN assessment, a PT evaluation, and a SW evaluation. The PT re-evaluation was completed on 01/21/22 and SW revaluation completed on 01/20/22. There was no documentation of why the PT and SW evaluations did not occur timely, and no documentation that the physician was notified of the PT and the SW evaluations not being completed. g. Patient #115’s SOC was on 11/29/21. The patient was admitted for primary diagnoses of Chronic Obstructive Pulmonary Disease and Pneumonia—not a complete list. The referral orders dated 10/21/21 included a SN assessment, a PT evaluation, an OT evaluation, a ST evaluation, and a Social Worker (SW) evaluation. The PT evaluation did not occur until 12/06/21, and the OT, the ST, and the SW evaluations did not occur. There was no documentation of why the PT evaluation did not occur timely and why the OT, ST, and SW evaluations did not occur. There was no documentation why the PT evaluation did not occur timely, and no documentation that the physician was notified of the OT, ST, and SW evaluations not being completed. h. Patient #116’s SOC was on 02/23/22. The patient was admitted for primary diagnoses of Myocardial Infarction and Congestive Heart Failure—not a complete list. The referral orders dated 02/11/22 included a SN assessment, a PT evaluation, and an OT evaluation. The OT evaluation was no completed. There was no documentation of why the OT evaluation did not occur, and no documentation that the physician was notified of the OT evaluation not being completed. 3. On 11/23/22 at 10:00 AM, Surveyors #1 and #6 interviewed the agency’s Director of Clinical Operations (Staff #109) about the lack of documentation of the delayed or missed secondary services. Staff #109 acknowledged the findings and stated that the secondary services are completed within 5 days of admission. However, Staff #109 was unable to provide any documentation of the delayed or missed secondary services. .

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 follow state requirements to perform annual Tuberculosis (TB) screening in 2020 for 6 of 8 caregivers (Staff #101, #102, #103, #105, #106, #107). Failure to perform annual TB Screening on staff places patients and staff at risk for exposure to TB. 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: (14) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (c) Tuberculosis infection control program. Key elements include but are not limited to: (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. Findings included: 1. Document review of agency’s document titled, “Tuberculosis Screening and Testing,” (Dated 8/16/22) showed that an annual assessment of new TB risk factor will be conducted on all employees using the Washington State Department of Health Adult Tuberculosis Risk Assessment form. 2. The personnel record reviews for the 6 of 8 caregivers (Staff #101, #102, #103, #105, #106, #107) showed: a. Staff #101 was hired on 04/29/19. The record failed to contain a completed [DOH]-approved annual TB risk assessment in 2020. b. Staff #102 was hired on 08/10/15. The record failed to contain a completed [DOH]-approved annual TB risk assessment in 2020. c. Staff #103 was hired on 07/17/17. The record failed to contain a completed [DOH]-approved annual TB risk assessment in 2020. d. Staff #105 was hired on 10/26/15. The record failed to contain a completed [DOH]-approved annual TB risk assessment in 2020. e. Staff #106 was hired on 06/27/16. The record failed to contain a completed [DOH]-approved annual TB risk assessment in 2020. f. Staff #107 was hired on 07/16/07. The record failed to contain a completed [DOH]-approved annual TB risk assessment in 2020. 3. On 11/28/22 at 12:00 PM, Surveyors #1 and #6 interviewed the agency's Director of Clinical Operations (Staff #109) on the missing annual TB risk assessment in 2020 on caregivers. Staff #109 acknowledged the findings and was unable to provide documentation that the agency completed the annual TB assessment using the department approved form.

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 Administrator failed to operationalize the agency policy and procedure (P&P) for staff performance evaluations for 4 of 8 caregivers (Staff #101, #105, #106, #107). Failure to operationalize and conduct annual staff performance evaluations may result in unmet employee training needs. 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: (15) Annual performance evaluations of all personnel and volunteers providing direct patient care. Findings included: 1. The personnel record review for 4 caregivers (Staff #101, #105, #106, #107) showed: a. Staff #101 was hired on 04/29/19. The caregiver file lacked documentation of an annual evaluation of care and skills specific to the care needs of patients in 2020. b. Staff #105 was hired on 10/26/15. The caregiver file lacked documentation of an annual evaluation of care and skills specific to the care needs of patients in 2020 and 2021. c. Staff #106 was hired on 06/27/16. The caregiver file lacked documentation of an annual evaluation of care and skills specific to the care needs of patients in 2020, 2021, and 2022. d. Staff #107 was hired on 07/16/07. The caregiver file lacked documentation of an annual evaluation of care and skills specific to the care needs of patients in 2020 and 2022. 2. On 11/28/22 at 12:00 PM, Surveyors #1 and #6 interviewed the Director of Clinical Operations (Staff #109) on the missing staff evaluation. Staff #109 acknowledged the findings and was unable to provide documentation to show the agency completed annual evaluations of their personnel.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on document review, record review and interview, the agency failed to provide the patient’s discharge summary to the patient’s attending physician within 5 business days of the patient’s discharge for 4 of 5 sample discharge record reviews (Patients #113, #114, #115, and #117). Failure to provide the discharge summary to the patient’s attending physician prevents timely continuity of care and care coordination of patient’s needs. Findings included: 1. Document review of agency’s policy titled, “Clinical Record, Contents,” (last reviewed 06/24/21) showed that a completed discharge summary will be sent to the primary care provider within 5 business days of patient’s discharge. 2. Record review of patient records for Patient #113, #114, #115, #117 showed: a. Patient #113's Start of Care was 11/06/21 and their discharge date occurred on 02/24/22. There was no documentation to show the agency sent a discharge summary to the patient's attending physician within 5 business days of the patient's discharge, or that the physician ever received a discharge summary. b. Patient #114's Start of Care was 02/23/22 and their discharge date occurred on 04/02/22. There was no documentation to show the agency sent a discharge summary to the patient's attending physician within 5 business days of the patient's discharge. The agency sent the discharge summary on 04/14/22. c. Patient #115's Start of Care was 11/29/21 and their discharge date occurred on 03/22/22. There was no documentation to show the agency sent a discharge summary to the patient's attending physician within 5 business days of the patient's discharge. The agency sent the discharge summary on 07/08/22. d. Patient #117's Start of Care was 08/26/21 and their discharge date occurred on 10/06/21. There was no documentation to show the agency sent a discharge summary to the patient's attending physician within 5 business days of the patient's discharge. The agency sent the discharge summary on 10/20/21. 3. On 11/23/22 at 10:00 AM, Surveyors #1 and #6 interviewed the agency’s Director of Clinical Operations (Staff #109) about the agency's failure to document the date they provided a discharge summary to the patient's attending physician in the patient's record. Staff #109 acknowledged the findings and was unable to find reasons for the delay in sending discharge summaries to the patients' physicians.