Every finding on record at Wenatchee 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 CFR 484, conducted this health and safety survey. Onsite dates: 10/18/22 - 10/20/22 Examination number: X2022-822 The survey was conducted by: Surveyor #3 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.

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 missed visits resulting in changes to the patient’s plan of care in 3 of 8 patients (Patient #304, #305, and #307). Failure to complete the visit frequency as ordered by the physician and failure to notify the physician of the missed visits may put the patient at risk for unmet needs and/or a decline in condition. Findings included: 1. Document review of the agency's policy titled, "Missed Visits," dated 4/2021, showed that if a visit is missed and not rescheduled, the clinician will notify the physician and clinical supervisor of the missed visit and reason for the missed visit. The policy also showed that if a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician. 2. Record review of 3 of 8 patient records showed the following: a. Patient #304 was admitted on 09/01/22 for Skilled Nursing (SN), Physical Therapy (PT), and Social Work (MSW) services. SN services were ordered on 09/01/22 with a frequency of 1 visit per week for 9 weeks. During the weeks of 09/04/22 and 09/11/22, the agency failed to complete any SN visits. On 10/10/22, the SN service frequency was increased to 2 visits per week for 3 weeks for wound care. The agency failed to complete any SN visits the week of 10/09/22 through the date of survey. PT services were ordered on 09/11/22 with a frequency of 1 visit per week for 9 weeks. During the week of 10/09/22, the agency failed to complete a PT visit. The record contained clinician documentation of patient refusing SN and PT visits. There was no evidence of physician notification of the missed visits or evaluation of the appropriateness of the plan of care given the patient repeatedly refused visits. b. Patient #305 was admitted on 01/26/22 for Skilled Nursing (SN) and Physical Therapy (PT) services. The Surveyor reviewed the certification period from 07/25/22 through 09/22/22 and 09/22/22 to 11/21/22. SN services were ordered at a frequency of 1 visit per week for 9 weeks for wound care. During the week of 07/25/22, the agency failed to complete a SN visit. PT services were ordered at a frequency of 1 visit per week for 8 weeks. During the week of 09/18/22, the agency failed to complete a PT visit. There was no evidence of physician notification of the missed visits. c. Patient #307 was admitted on 08/11/22 for Skilled Nursing (SN), Physical Therapy (PT), and Social Worker (MSW) services. PT services were ordered at a frequency of 1 visit per week for 9 weeks on 08/11/22. During the week of 09/05/22, the agency completed no PT visit. The patient refused services on 09/15/22 and was discharged from the agency. The agency notified the physician of the patient's discharge on 09/15/22. There was no evidence of physician notification of the missed visit. 3. On 10/19/22 at 10:00 AM, the Surveyor interviewed the agency's Clinical Director (Staff #302) about the missed visit documentation. Staff #302 stated that it is the agency's policy that the clinicians notify the physician of all missed visits and document notification on the missed visit form. Staff #302 acknowledged the findings of the physician not being notified of the missed visits.

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 5 of 6 staff, through failure to complete annual performance evaluations (Staff #302 and Staff #304) (Item 1), failure to ensure staff have current CPR certification (Staff #304 and Staff #307) (Item 2), failure to renew annual TB risk assessments (Staff #302, Staff #304 and Staff #305) (Item 3), and failure to ensure contracted staff received agency-specific orientation, policy and procedure training including abuse and neglect, emergency preparedness, TB education and infection control (Staff #306) (Item 4). Failure to implement policies and procedures consistent with state licensing requirements may place patients at risk of receiving poor quality care from unqualified or untrained staff. References: (Item 1) Washington Administrative Code (WAC) 246-335-525 (16) Personnel, contractor and volunteer policies. The licensee must develop and operationalize personnel, contractor and volunteer policies and procedures that describe: (16) Annual performance evaluations of all personnel and volunteers providing direct patient care, including on-site observation of care and skills specific to the care needs of patients; and (17) Annual evaluations of services provided by contractors providing direct patient care. (Item 2) Washington Administrative Code (WAC) 246-335-530 (9) 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: (9) Current CPR training for direct care personnel and contractors (Item 3) Washington Administrative Code (WAC) 246-335-525 (15)(c)(i)(ii) Personnel, contractor and volunteer policies. The 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: (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. (Item 4) Washington Administrative Code (WAC) 246-335-525 (9) Personnel, contractor and volunteer policies. The licensee must develop and operationalize personnel, contractor and volunteer policies and procedures that describe: (9) In-person orientation to current agency policies and procedures and verification of skills or training prior to independently providing patient care. Findings included: Item 1 - Annual Performance Evaluations 1. Document review of the agency's policy titled, "Performance Evaluations" dated 04/2021, showed that the performance evaluations will be completed and dated on all personnel annually, based on personnel's annual evaluation date. The policy lacked the required component of onsite observation of care and skills specific to the needs of the patient. 2. On 10/19/22, the Surveyor reviewed the personnel files of an Occupational Therapist (Staff #302) and a Physical Therapy Assistant (Staff #304). The record review showed the following: a. Staff #302 was hired on 06/12/20. The record showed no evidence of an annual performance evaluation since 05/19/21. b. Staff #304 was hired on 09/21/20. The record showed no evidence of an annual performance evaluation since 05/19/21. 3. On 10/19/22 at 1:30 PM, the Surveyor interviewed the agency Executive Director (Staff #301) about the missing performance evaluations. Staff #301 stated that the agency plans to conduct annual performance evaluations in January 2023 and continue annually thereafter. Item 2 - Current CPR certification 1. Document review of the agency's Physical Therapist and Physical Therapy Assistant Job Descriptions showed position qualifications include possessing and maintaining current CPR certification. 2. On 10/19/22, the Surveyor reviewed personnel files for a Physical Therapy Assistant (Staff #304) and a Physical Therapist (Staff #307). The record review showed the following: a. Staff #304 was hired on 09/21/20. The personnel record contained a CPR certification that expired 09/15/22. The record showed no evidence of current CPR certification. b. Staff #307 was hired on 09/23/22. The record showed no evidence of current CPR certification. 3. On 10/19/22 at 1:40 PM, the Surveyor interviewed the agency Executive Director (Staff #301) about the missing CPR certifications. Staff #301 stated that the agency does require current CPR certification for all direct care staff. Staff #301 also acknowledged the missing documentation. Item 3 - Tuberculosis (TB) risk assessment 1. Document review of the agency's policy titled, "Tuberculosis Exposure Control Plan" dated 04/2021, showed that the agency requires personnel upon hire to provide evidence of a baseline Tuberculosis (TB) skin or blood test. In addition to the TB screening test, all patient care personnel will be given an individual TB risk assessment to establish baseline. The policy also showed that the agency will conduct an annual TB risk assessment to determine the need, type and frequency of testing and assessment for all direct care personnel. 2. On 10/29/22, the Surveyor reviewed personnel records of an Occupational Therapist (Staff #302), a Physical Therapy Assistant (Staff #304) and a Registered Nurse (Staff #305). The record review showed the following: a. Staff #302 was hired on 06/12/20. The record contained two negative TB skin tests dated 04/15/20 and 05/07/21. The record showed no evidence that the agency completed a TB risk assessment upon hire or annually. b. Staff #304 was hired on 09/21/20. The record contained a negative TB skin test dated 09/28/20. The record showed no evidence that the agency completed a TB risk assessment upon hire or annually. c. Staff #307 was hired on 02/02/22. The record contained a negative TB skin test dated 06/28/21. The record showed no evidence that the agency completed a TB risk assessment upon hire. 3. On 10/19/22 at 1:45 PM, the Surveyor interviewed the agency Executive Director (Staff #301) about the missing TB risk assessments. Staff #301 stated that the agency planned to renew the TB risk assessments in January 2023 for all staff and continue renewing annually thereafter. Item 4 - Orientation for contracted staff 1. Document review of the agency's contract with Core Medical Group (CMG) dated 09/06/22 identified the agency as "Client". The contract showed that it is the responsibility of the Client to orient CMG professionals to the Client's facility and Client specific rules and regulations, all policies and procedures, all Client equipment, and to validate competency of the Client to properly utilize all relevant equipment. 2. Record review of the personnel file for a CMG contracted Physical Therapist (Staff #306) showed no evidence that the agency provided Staff #306 orientation or training on agency policies and procedures including Abuse and Neglect, Emergency Preparedness, Infection Control and Tuberculosis education. 3. On 10/19/22 at 1:50 PM, the Surveyor interviewed the agency Executive Director (Staff #301) about the missing orientation documentation for the contracted staff. Staff #301 stated that they were unaware of the requirement for contracted staff to receive the same orientation and policy and procedure training as agency personnel. Staff #301 also stated that it was their understanding that the orientation had been completed by Core Medical Group (CMG).