Every finding on record at Washington Homecare and Hospice of Central Basin, 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 conducted this health and safety survey. Examination number: X2023-755 Dates Onsite: 10/23/23, 10/24/23, 10/25/23, 10/26/23 This survey was conducted by: Surveyor #4 Surveyor #6 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. .

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to provide the Notice of Medicare Non-Coverage (NOMNC) on patients being considered for discharge for cause on 2 of 5 discharged patient records (Patients #615 and #616). Failure to provide 48-hour notification of impending discharge and the Notice of Medicare Non-Coverage to patients being considered for discharge prevents timely continuity of care and coordination and puts patients at risk of abandonment. . Findings included: 1. Document review of the agency policy titled, “Notice of Non-Coverage, Expedited Determination and Reconsideration for Discharge,” (Policy No. 1.003, Revised Date 12/01/21), showed that patients should be notified at least 48 hours prior to discharge. 2. Record review of discharged patient records for Patients # 615 and #616 showed: a. Patient #615’s start of care was 09/02/22 and their discharge date occurred on 12/27/22. There was no documentation in the records to show that the agency provided the NOMNC to the patient prior to discharge. b. Patient #616’s start of care was 10/26/22 and their discharge date occurred on 03/29/23. There was no documentation in the records to show that the agency provided the NOMNC to the patient prior to discharge. 3. On 10/25/23 at 2:30 PM, Surveyor #6 interviewed the agency’s Executive Director (Staff #601) about the missing documentation of NOMNC in the discharged patients’ records. Staff #601 acknowledged the findings and stated that the agency was unable to find the documentation in the records. .

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 operationalize its policies and procedures to remain compliant with state licensing requirements for 11 of 11 personnel files reviewed (Staff # 603 Staff #604, Staff #605, Staff #606, Staff #607, Staff #608, Staff #609, Staff #610, Staff #611, Staff #612, and Staff #613). Failure to maintain and implement policies and procedures consistent with state home health regulations puts patients at risk of physical and/or psychological harm from inadequate or substandard care. . Findings included: Item #1- TB Program Reference: Washington Administrative Code (WAC) 246-335-525 (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; (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 1. The document review of the agency policy titled, “Staff Screening, New Hire And Annual,” (Policy No. 6.002, Revised Dated 06/01/23), showed the agency will conduct TB risk assessments using the state Department of Health TB risk assessment form upon hire and annually. 2. On 10/25/23, Surveyor #6 reviewed the personnel files for 11 of 11 staff members (Staff # 603 Staff #604, Staff #605, Staff #606, Staff #607, Staff #608, Staff #609, Staff #610, Staff #611, Staff #612, and Staff #613). The record review showed: a. Staff #603 was hired on 09/17/18. The record contained no evidence that the agency conducted a TB risk assessment using the state-approved form in 2018, 2020, and 2022. b. Staff #604 was hired on 07/24/17. The record contained no evidence that the agency conducted a TB risk assessment using the state-approved form in 2020, and 2022. c. Staff #605 was hired as a contracted employee on 04/04/22. The record contained no evidence that the agency conducted a TB risk assessment using the state-approved form in 2023. d. Staff #606 was hired as a contracted employee on 08/21/23. The record contained no evidence that the agency conducted a TB risk assessment using the state-approved form on hire. e. Staff #607 was hired on 04/22/21. The record contained no evidence that the agency conducted a TB risk assessment using the state-approved form in 2021 and 2022. f. Staff #608 was hired on 05/20/19. The record contained no evidence that the agency conducted a TB risk assessment using the state-approved form in 2020. g. Staff #610 was hired on 08/26/13. The record contained no evidence that the agency conducted a TB risk assessment using the state-approved form in 2020 and 2022. h. Staff #611 was hired on 12/03/12. The record contained no evidence that the agency conducted a TB risk assessment using the state-approved form in 2018, 2020, and 2022. i. Staff #612 was hired on 03/29/21. The record contained no evidence that the agency conducted a TB risk assessment using the state-approved form in 2022. 3. On 10/25/23 at 2:00 PM, Surveyor #6 interviewed the agency’s Business Manager (Staff #602) about the missing state-approved TB risk assessment forms in the staff files. Staff #602 acknowledged the findings and stated that the agency was unable to provide TB-related documentation for the staff listed above. Item #2-Criminal History Background Checks and Disclosure Statements 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. 1. Document review of the agency policy titled, "Background Checks," (Policy No. 2.3.001, Revised Date 10/01/2023) showed that all criminal background checks and disclosure statements using the state-mandated form must be renewed within two years from the previous check. 2. On 01/25/23, Surveyor #6 reviewed the personnel files for 11 of 11 staff members (Staff # 603 Staff #604, Staff #605, Staff #606, Staff #607, Staff #608, Staff #609, Staff #610, Staff #611, Staff #612, and Staff #613). The record review showed: a. Staff #603 was hired on 09/17/18. The record contained no evidence that the agency completed a state criminal background check in 2022 and the state-approved disclosure statements in 2020 and 2022. b. Staff #604 was hired on 07/24/17. The record contained no evidence that the agency completed a state criminal background check in 2021 and 2023 and the state-approved disclosure statement in 2023. c. Staff #605 was hired as a contracted employee on 04/04/22. The record contained no evidence that the agency completed the state-approved disclosure statement on hire. d. Staff #606 was hired as a contracted employee on 08/21/23. The record contained no evidence that the agency completed the state-approved disclosure statement on hire. e. Staff #608 was hired on 05/20/19. The record contained no evidence that the agency completed the state-approved disclosure statement in 2021. 3. On 10/25/23 at 2:00 PM, Surveyor #6 interviewed the agency’s Business Manager (Staff #602) about the missing criminal background checks and the state-approved disclosure statements in the staff files. Staff #602 acknowledged the findings and stated that the agency was unable to provide the documentation for the staff listed above. .

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: 2021-443 Dates Onsite: 06/29/21-07/02/21 Dates Offsite: 07/06/21 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. DOH recommends recertification based on an acceptable plan of correction. . . .

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: . Based on record review and interviews, the agency failed to implement policies and procedures in compliance with CFR 484.50 (e)(2) and WAC 246-335-525 (8) (a-b). Personnel, contractor, and volunteer policies regarding reporting Abuse and Neglect for 2 of 7 Staff (Staff #503 and #504) interviewed during home visits. Failure to ensure reporting of abuse and neglect to the appropriate authorities in compliance with state and federal regulations may result in delayed reporting/and or potential harm related to abuse and/or neglect toward vulnerable adults. References: RCW 74.34.020 (8) defines a "Mandated reporter" as "an employee of the department; law enforcement officer; social worker; professional school personnel; individual provider; an employee of a facility; an operator of a facility; an employee of a social service, welfare, mental health, adult day health, adult day care, home health, home care, or hospice agency; county coroner or medical examiner; Christian Science practitioner; or health care provider." RCW 74.34.035(1) defines the duties of a mandated reporter: "When there is reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, mandated reporters shall immediately report to the Department". RCW 74.34.020(4) defines department as "the department of social and health services" (DSHS). Findings included: 1. Surveyor #5 reviewed the agency's policy and procedure titled "PATIENT ABUSE, EXPLOITATION, AND NEGLECT: ASSESSMENT, IDENTIFICATION, AND REPORTING," revised on 05/20/20. The policy review showed that agency staff, contractors or volunteers will immediately document the assessment of the patient's condition which might indicate abuse, neglect or exploitation, and report it to the their state agency supervisor and appropriate community agency. 2. Document review of the personnel files for a Physical Therapy Assistant (Staff #503) and a Registered Nurse(Staff #504) showed: a. Staff #503 was hired on 09/13/20, and received training for abuse/neglect/mandatory reporting on 12/20/20. b. Staff #504 was hired on 04/11/21 and received training for abuse/neglect/mandatory reporting in April 2021. 3. On 07/01/21 at 10:30 AM, Surveyor #5 interviewed Staff #503 about what they would do if patient abuse or neglect was suspected. Staff #503 stated that they would first call the supervisor to determine if the state agency should be called. 4. On 07/02/21 at 10:00 AM, Surveyor #5 interviewed Staff #504 about what they would do if patient abuse or neglect was suspected. Staff #504 stated that they would first call the supervisor to determine if the state agency should be called. 5. Surveyor #5 interviewed the Executive Director (Staff #501) on 07/06/21 at 11:00 AM about the staff competency for mandatory reporting. Staff #501 stated that a discussion took place with employees a few months ago where the agency stated that if employees did not know if they should report [suspected abuse, neglect or exploitation], they should call their supervisor. Staff #501 stated that could have led to confusion about immediately reporting suspected abuse or neglect to the state agency. .

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . Based on observation, document review, and interview, the agency failed to properly prevent COVID-19 through failure to ensure that staff wore eye protection consistent with Washington State regulations for 6 of 7 Home Health staff (Staff #405, #407, #408, #409, #503, and #504). Failure to ensure staff wear eye protection when performing patient care, risks staff and patients' exposure to infectious organisms including COVID-19. References: WAC 246-335-525(15) personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: (a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment; WAC 206-800-160 You must make sure that your employees have, use, and care for the appropriate personal protective equipment (PPE). PPE is an item or items used to protect the eyes, face, head, body, arms, hands, legs, and feet such as goggles, helmets, head covers, gloves, rubber slickers, disposable coveralls, safety shoes, protective shields, and barriers. WAC 296-800-16040 You must require your employees to use necessary PPE on the job. Findings included: 1. Document review of the guidance document issued by the Department of Health (DOH) and Labor & Industries (L&I) titled, "L&I and DOH Respirator and PPE for In-Home Care Agencies: Employer responsibilities for respiratory protection program and provision of personal protective equipment (PPE)," (DOH 420-329) issued March 30, 2021 showed that In-home care agencies are required to develop and maintain a Respiratory Protection Program (RPP) under WAC 296-842-12005. The document also showed that agencies are required to provide gowns, gloves, and eye protection to staff who are entering patient's homes. The document further stated that staff must wear eye protection when there is moderate to substantial community transmission of COVID-19. The document defined eye protection as, goggles or a face shield that covers the front and sides of the face. The document stated that personal eyeglasses are not PPE and do not provide adequate eye protection. Document review of the guidance document issued by the Department of Health (DOH) titled, "COVID-19 Guidance for Home Care, Home Health, and Hospice Agencies," (DOH 420-299) updated June 09, 2021 showed when COVID-19 community transmission case rate is greater than 25 per 100,000, in 2 weeks, HCWs are to wear a surgical face mask and eye protection for ALL patient care encounters, regardless of patient/client COVID-19 status. According to DOH COVID-19 cases and testing for Grant County, the 2-week transmission rate at the time of survey was 67 per 100,000. 2. On 06/30/21 between 8:30 AM and 5:00 PM, Surveyor #4 completed 4 home visits. The observations showed: a. A Registered Nurse (Staff #405) failed to wear eye protection while providing patient care to Patient #405. b. A Physical Therapy Assistant (Staff #407) failed to wear eye protection while providing patient care to Patient #403. c. A Registered Nurse (Staff #408) failed to wear eye protection while providing patient care to Patient #404. d. A Licensed Social Worker (Staff #409) failed to wear eye protection during the home visit with Patient #402. 3. On 07/01/21 at 10:00 AM, Surveyor #5 conducted a home visit with a Physical Therapy Assistant (Staff #503). Staff #503 failed to wear eye protection during the home visit with Patient #506. a. On 07/02/21 at 9:00 AM, Surveyor #5 conducted a home visit with a Registered Nurse (Staff #504). Staff #504 failed to wear eye protection during the home visit with Patient #507. 4. On 07/06/21 at 11:00 AM, the surveyor interviewed the Executive Director (Staff #501), about the staff use of eye protection during home visits. Staff #501 stated that the agency has the equipment and will ensure all PPE is utilized based on the guidance.