Every finding on record at Wesley Homes at Home

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 CFR Part 484 conducted this health and safety survey. Examination number: X2023-485 Dates Onsite: 06/26/23, 06/27/23, 06/28/23, 06/29/23 This survey was conducted by: Surveyor #1 Surveyor #6 DOH staff found the facility NOT IN COMPLIANCE with the following Conditions of Participation: 42 CFR 484.102 Conditions of Participation for Emergency preparedness. 42 CFR 484.65 Conditions of Participation for Quality assessment and performance improvement. 42 CFR 484.70 Conditions of Participation for Infection prevention and control. .

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on document review and interview, the agency failed to maintain and update an Emergency preparedness (EP) plan at least every two years. Failure to maintain an active emergency preparedness plan puts staff and patients at risk of harm from being unprepared during disaster events. Findings included: 1. Failure to update and review an agency EP plan at least every two years, puts the agency at risk for emergency disasters that would affect the agency’s ability to provided care to patients. Cross-reference: E-0006 2. Failure to update and review an agency EP policies and procedures at least every two years, puts the agency at risk for emergency disasters that would affect the agency’s ability to provide care to patients. Cross-reference: E-0013 Due to the scope of deficiencies cited under 42 CFR 484.102, the Condition of Participation for Emergency Preparedness was NOT MET. .

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: . Based on document review and interview, the agency failed to review and update at least every two years an emergency preparedness (EP) plan. Failure to update and review an agency EP plan at least every two years, puts the agency at risk for emergency disasters that would affect the agency’s ability to provide care to patients. Findings included: 1. Document review of agency’s EP plan indicated that the agency had no EP plan for their home health agency. 2. On 06/29/23 at 10:00 AM, Surveyors #1 and #6 interviewed the agency’s Executive Director (Staff #110) about the missing EP Plan findings. Staff #110 acknowledged the findings and stated that the agency did have an EP Plan but the EP plan given was dated 2020.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: . Based on document review and interview, the agency failed to update and implement at least every two years an emergency preparedness (EP) policies and procedures (P&P). Failure to update and implement an agency EP P&P at least every two years, puts the agency at risk for emergency disasters that would affect the agency’s ability to provided care to patients. Findings included: 1. Document review of the agency’s EP P&P indicated that the EP P&P was last review in 2020. 2. On 06/29/23 at 10:00 AM, Surveyors #1 and #6 interviewed the agency’s Executive Director (Staff #110) about the agency's lack of a current EP plan. Staff #110 acknowledged the findings and was only able to provide documentation of the EP P&P dated 2020. .

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 reviews, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral for 15 of 19 patients (Patients #101, #102, #103, #104, #105, #106, #108, #110, #111, #112, #114, #116, #117, #118, and #119). 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, “Home Health Plan of Care,” (date of origin: 05/01/03) showed that for services to be provided as soon as possible, the agency will accept verbal or faxed orders and written, signed and dated health care professional orders of services. 2. Record review of the patients charts for 15 of 19 patients (Patients #101, #102, #103, #104, #105, #106, #108, #110, #111, #112, #114, #116, #117, #118, and #119) showed: a. Patient #101’s Start of Care (SOC) date was 09/16/22. The agency completed the referral on 09/13/22 for Physical Therapist (PT), Registered Nurse (RN), and Home Health aide (HHA). The SOC for PT services did not occur until 09/16/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. b. Patient #102’s SOC date was 02/22/23. The agency completed the referral on 02/17/22 for PT, RN, and Occupational Therapy (OT) services. The SOC for PT services did not occur until 02/22/23. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. c. Patient #103’s SOC date was 04/19/23. The agency completed the referral on 04/10/23 for PT and OT services. The SOC for PT services did not occur until 04/19/23. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. d. Patient #104’s SOC date was 04/20/23. The agency completed the referral on 04/10/23 for PT and OT services. The patient was discharged from a skilled nursing facility on 04/17/23. The SOC for PT services did not occur until 04/20/23. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. e. Patient #105’s SOC date was 06/19/23. The agency completed the referral on 06/14/23 for RN and HHA services. The SOC for RN services did not occur until 06/19/23. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. f. Patient #106’s SOC date was 06/20/23. The agency completed the referral on 06/15/23 for RN, PT, and HHA services. The SOC for RN services did not occur until 06/20/23. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. g. Patient #108’s SOC date was 03/11/23. The agency completed the referral on 03/08/23 for RN services. The SOC for RN services did not occur until 03/11/23. There was no documentation of why the services 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 02/14/23. The agency completed the referral on 02/07/23 for RN and PT services. The SOC for RN services did not occur until 02/14/23. There was no documentation of why the services 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 05/23/23. The agency completed the referral on 05/18/23 for PT and OT services. The patient was discharged from a skilled nursing facility on 05/20/23. The SOC for PT services did not occur until 05/23/23. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. j. Patient #112’s SOC date was 06/09/20. The agency completed the referral on 06/05/20 for RN and PT services. The SOC for RN services did not occur until 06/09/23. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. k. Patient #114’s SOC date was 05/06/23. The agency completed the referral on 05/02/23 for RN services. The SOC for RN services did not occur until 05/06/23. There was no documentation of why the services 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 05/01/23. The agency completed the referral on 04/25/23 for PT services. The SOC for PT services did not occur until 05/01/23. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. m. Patient #117’s SOC date was 12/06/22. The agency completed the referral on 11/29/22 for RN, PT, and HHA services. The SOC for RN services did not occur until 12/06/22. There was documentation that the patient’s family requested the SOC on 12/06/22, but no documentation that the physician was notified of the delayed admission. n. Patient #118’s SOC date was 04/25/22. The agency completed the referral on 04/14/22 for PT and RN services. The patient was discharged from a skilled nursing facility on 04/15/22. The SOC for PT services did not occur until 04/25/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. o. Patient #119’s SOC date was 05/03/22. The agency completed the referral on 04/28/22 for PT, OT, and Social Worker services. The patient was discharged from a skilled nursing facility on 04/27/22. The SOC for PT services did not occur until 04/25/22. There was no documentation of why the services did not occur within the 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. 3. On 06/29/23 at 9:00 AM, Surveyor #1 interviewed the agency’s Nurse case manager (Staff #109) and the Executive director (Staff #110) of the lack of documentation on the delayed admission. Staff #110 and Staff #111 acknowledged the findings and stated they were not aware of the timely initiation issues with the referral and the start of care dates. .

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 establish patient-specific goals that are individualized to the patient’s medical diagnosis, physician’s orders, comprehensive assessment and patient input for 9 of 19 patients (Patients #101, #103, #105, #106, #109, #110, #111, #115 and #116). Failure to address the patient-specific goals puts patients at risk of harm from improper care and inadequate services. Findings included: 1. Document review of agency’s policy titled, “Home Health Plan of Care,” (date of origin: 05/01/03) showed that the plan of care shall include goals or outcomes measures. 2. Record review of the patients charts for 9 of 19 patients (Patients #101, #103, #105, #106, #109, #110, #111, #115 and #116) showed: a. Patient #101 was admitted on 09/16/22 with a diagnosis of Cerebral Vascular Attack (CVA) and Diabetes Mellitus. The initial assessment showed no documentation of patient-specific goals or measurable outcomes. b. Patient #103 was admitted on 06/27/23 with a diagnosis of CVA and Hemiplegia. The initial assessment showed no documentation of patient-specific goals or measurable outcomes. c. Patient #105 was admitted on 06/19/23 with a diagnosis of Venous Insufficiency and Hypotension. The initial assessment showed no documentation of patient-specific goals or measurable outcomes. d. Patient #106 was admitted on 06/20/23 with a diagnosis of Congestive Heart Failure (CHF) and Hypertension. The initial assessment showed no documentation of patient-specific goals or measurable outcomes. e. Patient #109 was admitted on 04/20/23 with a diagnosis of Left Humerus fracture and Pain on Left Shoulder. The initial assessment showed no documentation of patient-specific goals or measurable outcomes. f. Patient #110 was admitted on 02/14/23 with a diagnosis of Pressure ulcer of the sacral region and Peripheral Vascular Disease (PVD). The initial assessment showed no documentation of patient-specific goals or measurable outcomes. g. Patient #111 was admitted on 05/23/23 with a diagnosis of Cerebral Infarction and PVD. The initial assessment showed no documentation of patient-specific goals or measurable outcomes. h. Patient #115 was admitted on 08/17/22 with a diagnosis of Multiple wounds on bilateral upper extremities. The initial assessment showed no documentation of patient-specific goals or measurable outcomes. i. Patient #116 was admitted on 05/01/23 with a diagnosis of HTN and PVD. The initial assessment showed no documentation of patient-specific goals or measurable outcomes. 3. On 06/29/23 at 9:00 AM, Surveyors #1 and #6 interviewed the agency’s Nurse case manager (Staff #109) about the lack of documentation on patient-specific goals or measurable outcomes. Staff #110 acknowledged the findings and stated that when completing the initial assessment clinicians should always ask the question, “What would the patient like to be able to do again that they cannot do now?”. This question determines patient-specific goals. However, admitting clinicians were not consistent in asking this question during the initial assessments. .

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: . Based on document review and interview, the home health agency failed to maintain a quality improvement program designed to ensure patient safety and reduce adverse events. Failure to maintain an active quality improvement program that collects and analyses data, and implements changes related to patient safety and reduction of adverse events puts patients at risk of harm from lack of monitoring and substandard care. Findings included: 1. Failure to identify and develop improvement projects for health indicators designed to address adverse outcomes puts patients at risk for safety issues and poor quality of care. Cross-Reference: G-642 2. Failure to collect and utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program puts staff and patients at risk for safety issues and poor quality of care. Cross-Reference: G-644 3. Failure to integrate the agency's infection control activities including surveillance, identification, prevention, control, and investigation of infectious and communicable diseases with the overall quality assessment and performance improvement (QAPI) program. Cross-Reference: G-680 Due to the scope of deficiencies cited under 42 CFR 484.65, the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) was NOT MET. .

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: . Based on document review and interview, the agency failed to identify and develop improvement projects for health indicators designed to address adverse outcomes, patient safety or improved quality of care. Failure to identify and develop improvement projects for health indicators designed to address adverse outcomes puts patients at risk for safety issues and poor quality of care. Findings included: 1. Document review of the agency's Quality Assessment Plan Improvement (QAPI) program showed the program contained no measurable indicators pertaining to adverse events and infection control. Review of the program showed that the agency did not measure, analyze, and track quality indicators related to processes of care, home health services, home health operations, and adverse events. 2. On 06/29/23 at 10:00 AM, Surveyors #1 and #6 interviewed the agency's Executive Director (Staff #110) regarding the lack of measurable indicators in the agency QAPI program. Staff #110 acknowledged the findings and stated that they will make updates to the agency's QAPI program. .

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: . Based on document review and interview, the agency failed to use the data derived from OASIS to monitor the effectiveness and safety of services and develop and prioritize opportunities for quality improvement based on the collected data. Failure to monitor and document the effectiveness and safety of services designed to address infection control and patient safety related to adverse events puts staff and patients at risk for safety issues and poor quality of care. Findings included: 1. Document review of agency's QAPI program, showed no documentation of the agency monitoring the effectiveness and safety of services designed to address infection control and patient safety related to adverse events and quality of care. In addition, there is no documentation that the agency identified opportunities and priorities for improvement. 2. On 06/29/23 at 10:00 AM, Surveyors #1 and #6 interviewed the agency's Executive Director (Staff #110) about the agency’s QAPI program and the lack of analysis of the program data. Staff #110 stated that they were unaware of the need to analyze collected program data to support the agency's quality program. .

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: . Based on record review and interview, the agency failed to develop and implement an infection control program which has as its goal the prevention and control of infections and communicable disease. Failure to have an infection prevention and control program puts patients and staff at risk for infectious disease. Findings included: 1. Failure to have an agency-wide infection control program puts patients and staff at risk for infectious diseases. Cross-Reference: G-684 2. Failure to provide an agency-wide education on infection control puts patients and staff at risk for infectious diseases. Cross-Reference: G-686 Due to the scope of deficiencies cited under 42 CFR 484.70, the Condition of Participation for Infection Prevention and Control was NOT MET. .

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 develop and implement an agency-wide program for infection control that included surveillance, identification, prevention, control and investigation of infectious and communicable disease as part of its overall quality assessment and performance improvement (QAPI) program. Failure to address infection prevention and control as part of an agency wide QAPI program puts patients and staff at risk of harm from communicable diseases. Findings included: 1. Document review of the agency’s QAPI program showed that the agency had not implemented an infection control and prevention program. 2. On 06/29/23 at 10:00 AM, Surveyors #1 and #6 interviewed the agency’s Executive Director (Staff #110) about the agency’s lack of infection control and prevention program. Staff #110 acknowledged the findings and stated that they were unable to provide documentation on the agency’s infection control program. .

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: . Based on record review and interview, the agency failed to develop and implement an agency-wide program to provide infection control education to patients and caregivers specific to the patient's plan of care caregivers that are specific to a patient’s plan of care, health, conditions, and individual learning needs (Item #1); and failed to provide infection control and prevention education training to 8 of 8 staff (Staff #601, #602, #603, #604, #605, #606, #607, and #608) (Item #2). Failure to provide agency-wide education on infection control puts patients and staff at risk of harm from infectious diseases. Findings included: Item #1-Infection Control and Prevention Education for Patients and Caregivers 1. Document review of the agency’s policies and procedures showed the agency had not implemented an education program specific to infection control, for patients and caregivers. 2. On 06/29/23 at 10:00 AM, Surveyors #1 and #6 interviewed the agency’s Executive Director (Staff #110) about the agency’s lack of education on infection control and prevention programs. Staff #110 acknowledged the findings and stated that they were unable to provide documentation on the education provided to patients and caregivers about infection control. Items #2-Personnel Education. 1. On 06/28/23, Surveyor #6 reviewed the personnel records for 8 of 8 staff (Staff #601, #602, #603, ^04, #605, #606, #607, and #608). The review showed: a. Staff #601 was hired on 02/13/23. The staff record contained no evidence the agency provided infection prevention training. b. Staff #602 was hired on 07/01/19. The staff record contained no evidence the agency provided infection prevention training. c. Staff #603 was hired on 09/28/16. The staff record contained no evidence the agency provided infection prevention training. d. Staff #604 was hired on 04/09/23. The staff record contained no evidence the agency provided infection prevention training. e. Staff #605 was hired on 12/01/15. The staff record contained no evidence the agency provided infection prevention training. f. Staff #606 was hired on 07/08/19. The staff record contained no evidence the agency provided infection prevention training. g. Staff #607 was hired on 04/01/15. The staff record contained no evidence the agency provided infection prevention training. h. Staff #608 was hired on 02/01/10. The staff record contained no evidence the agency provided infection prevention training. 2. On 06/28/23 at 11:00 AM, Surveyor #6 asked the agency’s Human Resource Manager (Staff #111) about the missing documentation of infection prevention education and training in the staff files. Staff #111 acknowledged the findings and stated that they were unable to provide the infection prevention education and training records for the staff listed above. .

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 provide Occupational Therapy (OT) services as ordered in the referral by the physician for 8 of 19 patients (Patient #101, #102, #103, #104, #107, #109, #111, and #119). Failure to provide services as ordered by the physician place patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency’s document titled, “Admission Criteria” (reviewed: 01/21/08) showed that services must be ordered by a physician and must be considered to be reasonable and necessary for the treatment of the illness or injury of the patient. 2. Record review of the patient charts for 8 of 19 patients (Patient #101, #102, #103, #104, #107, #109, #111, and #119) showed: a. Patient #101 was admitted on 09/16/22 with diagnoses of Cerebral Vascular Attack (CVA) and Diabetes Mellitus. There was a referral order for OT services to assess and evaluate, but there was no documentation to indicate an OT evaluation was initiated. b. Patient #102 was admitted on 02/22/23 with diagnoses of Bilateral lower extremities of Cellulitis and Chronic pain. There was a referral order for OT services to assess and evaluate, but there was no documentation to indicate an OT evaluation was initiated. c. Patient #103 was admitted on 06/27/23 with diagnoses of CVA and Hemiplegia. There was a referral order for OT services to assess and evaluate, but there was no documentation to indicate an OT evaluation was initiated. d. Patient #104 was admitted on 04/20/23 with diagnoses of Congestive Heart Failure and Acute Kidney Failure. There was a referral order for OT services to assess and evaluate, but there was no documentation to indicate an OT evaluation was initiated. e. Patient #107 was admitted on 12/15/22 with diagnoses of Chronic Obstructive Pulmonary Disease and Weakness. There was a referral order for OT services to assess and evaluate, but there was no documentation to indicate an OT evaluation was initiated. f. Patient #109 was admitted on 04/20/23 with diagnos3s of Left Humerus fracture and Pain on left Shoulder. There was a referral order for OT services to assess and evaluate, but there was no documentation to indicate an OT evaluation was initiated. g. Patient #111 was admitted on 05/23/23 with diagnoses of CVA and Right Femur Fracture. There was a referral order for OT services to assess and evaluate, but there was no documentation to indicate an OT evaluation was initiated. h. Patient #119 was admitted on 05/03/23 with diagnoses of Cerebral Infarction and Peripheral Vascular Disease. There was a referral order for OT services to assess and evaluate, but there was no documentation to indicate an OT evaluation was initiated. 3. On 06/29/23 at 9:00 AM, Surveyors #1 and #6 interviewed the agency’s Nurse case manager (Staff #109) about the lack of documentation related to patients that failed to receive an initial OT evaluation, as ordered by their physician. Staff #109 acknowledged the findings and and stated that they were unable to provide documentation of the reasons OT services were discontinued. .

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 update its policies and procedures to remain compliant with state licensing requirements for 8 of 8 personnel files reviewed. 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: Items #1-Tuberculosis Program Reference: Washington Administrative Code (WAC) 246-335-525 Personnel, contractor, and volunteer policies. (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 (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. 1. Document review of the agency policy titled, “Occupational Exposure to Tuberculosis,” (Policy No. HH 445, Effective Date 04/17/06), showed the policy lacked the state requirements for conducting a TB risk assessment using the department-approved form for all personnel on hire and annually and that personnel receive TB related training and education on hire or during orientation. 2. On 06/28/23, Surveyor #6 reviewed personnel files for 7 staff members (Staff #601, #602, #604, #605, #606, #607, and #608). The review showed: a. Staff #601 was hired on 02/13/23. The record contained no documentation to show that the agency provided TB related training and education on hire. b. Staff #602 was hired on 07/01/19. The record contained no evidence that the agency conducted a TB risk assessment in 2021, and no documentation to show the agency provided TB-related training and education on hire. c. Staff #604 was hired on 04/09/23. The record contained no evidence that the agency conducted a TB risk assessment in 2021 and 2023, and no documentation to show the agency provided TB-related training and education on hire. d. Staff #605 was hired on 12/01/15. The record contained no evidence that the agency conducted a TB risk assessment in 2021 and 2022, and no documentation to show the agency provided TB-related training and education on hire. e. Staff #606 was hired as a contractor on 07/08/19. The record contained no evidence that the agency conducted a TB risk assessment in 2021 and 2022, and no documentation to show the agency provided TB-related training and education on hire. f. Staff #607 was hired as a contractor on 04/01/15. The record contained no evidence that the agency conducted a TB risk assessment in 2021, 2022, and 2023. g. Staff #608 was hired as a contractor on 02/01/10. The record contained no evidence that the agency conducted a TB risk assessment in 2021, 2022, and 2023. 3. On 06/28/23 at 11:00 AM, Surveyor #6 interviewed the agency’s Human Resource Manager (Staff #611) about the missing TB risk assessments and documentation of TB related education and training on hire in the staff files. Staff#611 acknowledged the findings and stated that they were 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: (a) Criminal history background checks must be processed through the Washington state patrol (WSP); (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. 1. Document review of the agency policy titled, "Criminal History, Disclosure and Background Inquiries," (Policy No. HH 510, Effective Date 05/01/03) showed that the policy failed to include the requirement to renew criminal background checks and the department-approved disclosure statements every two years from the date of the previous check. 2. On 06/28/23, Surveyor #6 reviewed 3 contracted staff files (Staff #606, #607, and #608). The record review showed: a. Staff #606 was hired as a contractor on 07/08/19. There was no evidence the agency completed a background check and a department-approved disclosure statement on hire and in 2021. b. Staff #607 was hired as a contractor on 04/01/15. There was no evidence the agency completed a background check and a department-approved disclosure statement in 2021 and 2023. c. Staff #608 was hired as a contractor on 02/01/10. There was no evidence the agency completed a background check and a department-approved disclosure statement in 2021 and 2023. 3. On 06/28/23 at 11:00 AM, Surveyor #6 interviewed the agency’s Human Resource Manager (Staff #611) about the missing WSP criminal background and the department-approved disclosure statements for the contracted staff. Staff #611 acknowledged the findings and stated that the agency uses a third-party company to do the background checks for contracted staff and confirmed they did not have the signed disclosure statements. This is a REPEAT CITATION, previously cited on the last CMS survey completed on 03/12/21. Item #3-Contracted Personnel References: Washington Administrative Code (WAC) 246-335-525 (4): Contracting process when using a contractor. The contract should include, at minimum, a description of the duties the contractor will perform, and a statement indicating that the contractor, not the employer, is responsible for withholding any necessary taxes. As with personnel and volunteers, contractors are subject to all applicable requirements in this chapter. Washington Administrative Code (WAC) 246-335-530: The licensee must maintain records on all personnel and volunteers and have access to records on all contractors, to include: (1) Current practice certification, credential or licensure, as applicable (2) Documentation of references (3) Contracts when using contractors (4) Evidence of orientation to current agency policies and procedures 1. Document review of the agency policy titled, “Contracted Services,” (Policy No. HH 420, Effective Date 05/01/03) showed the agency will establish written contracts with individuals or entity providing services under contract. Document review of the agency’s policy titled, “Orientation,” (Policy No. HH 425, Effective Date 05/01/23) showed that all personnel, volunteers, and contractors will complete a basic orientation program that includes review of the agency’s policies and procedures (P&P) and documentation of the completed review will be kept in the personnel file. 2. On 06/28/23, Surveyor #6 reviewed 3 contracted staff files (Staff #606, #607, and #608). The review showed: a. Staff #606 was hired as a contractor on 07/08/19. The staff record contained no documentation of a written contract with the agency and no record of orientation to current (P&P). b. Staff #607 was hired as a contractor on 04/01/15. The staff record contained no documentation of a written contract with the agency and no record of orientation to current (P&P). c. Staff #608 was hired as a contractor on 02/01/10. The staff record contained no documentation of a written contract with the agency and no record of orientation to current (P&P). 3. On 06/28/23 at 11:00 AM, Surveyor #6 interviewed the agency's Human Resources Manager (Staff #611) about the missing contracts and the lack of evidence of policy and procedure reviews in the staff files. Staff #611 acknowledged the findings and stated that they are unable to provide copies of the contracts and evidence that the contractors received orientation to current policies and procedures. Item #4- Verification of Skills Reference: Washington Administrative Code (WAC) 246-335-530 (5): Verification of personnel, contractor, and volunteer skills or training specific to meeting the care needs of patients. 1. Document review of the agency policy titled, "Personnel Requirements," (Policy No. HH 500, Effective Date 04/19/06) showed that all personnel, volunteers, and contractors will complete a skills verification and training specific to meeting the care needs of the patient. 2. On 06/28/23, Surveyor #6 reviewed the staff records for 5 of 8 staff (Staff #602, #603, #606, #607, and #608). The review showed: a. Staff #602 was hired on 07/01/19. The staff record contained no evidence that the agency verified the staff member's skills or training specific to meeting the care needs of patients. b. Staff #603 was hired on 09/28/16. The staff record contained no evidence that the agency verified the staff member's skills or training specific to meeting the care needs of patients. c. Staff #606 was hired as a contractor on 07/08/19. The staff record contained no evidence that the agency verified the contractor’s skills or training specific to meeting the care needs of patients. d. Staff #607 was hired as a contractor on 04/01/15. The staff record contained no evidence that the agency verified the contractor’s skills or training specific to meeting the care needs of patients. e. Staff #608 was hired as a contractor on 02/01/10. The staff record contained no evidence that the agency verified the contractor’s skills or training specific to meeting the care needs of patients. 3. On 06/28/23 at 11:00 AM, Surveyor #6 interviewed the agency’s Human Resource Manager (Staff #611) about the missing documentation of skills verification for both staff and contractors. Staff #611 acknowledged the findings and stated that they were unable to provide the documentation of skills verifications for the staff and contractors listed above. Item #5- Performance Evaluation References: Washington Administrative Code (WAC) 246-335-530 (12): 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). Washington Administrative Code (WAC) 246-335-525 (16) and (17): The applicant or 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. 1. Document review of the agency policy titled, “Personnel Requirements,” (Policy No. HH 500, Effective Date 04/19/06) showed that the performance of all personnel will be evaluated and recorded in the personnel file annually including on-site observation of personnel providing direct patient care. 2. On 06/28/23, Surveyor #6 reviewed staff records for 5 of 8 staff (Staff #602, #605, #606, #607, and #608). The review showed: a. Staff #602 was hired on 07/01/19. The staff record contained no evidence that the agency completed an annual evaluation. b. Staff #605 was hired on 12/01/15. The staff record contained no evidence that the agency completed the annual evaluation with in 2021 and 2022. c. Staff #606 was hired as a contractor on 07/08/19. The staff record contained no evidence that the agency completed the annual evaluation in 2022. d. Staff #607 was hired as a contractor on 04/01/15. The staff record contained no evidence that the agency completed the annual evaluation in 2021, 2022, and 2023. e. Staff #608 was hired as a contractor on 02/01/10. The staff record contained no evidence that the agency completed the annual evaluation in 2021, 2022, and 2023. 3. On 06/28/23 at 11:00 AM, Surveyor #6 interviewed the agency’s Human Resource Manager (Staff #611) about the missing documentation of annual performance evaluations for personnel providing direct patient care. Staff #611 acknowledged the findings and stated that they were unable to provide the documentation of annual performance evaluations for the staff and contractors listed above. .

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 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 6 discharged patients (Patient #115, #117, #118, and #119). 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. Surveyors #1 and #6 reviewed the records for 6 of 6 discharged patients (Patient #115, #117, #118, and #119). The review showed: a. Patient #115's Start of care was 08/17/22 and the patient was discharged on 11/22/22. Documentation showed the discharge summary was sent to the patient's attending physician on 11/30/22. b. Patient #117's Start of care was 12/06/22 and the patient was discharged on 02/01/23. Documentation showed the discharge summary was sent to the patient's attending physician on 02/16/23. c. Patient #118's Start of care was 04/25/22 and the patient was discharged on 09/01/22. Documentation showed the discharge summary was sent to the patient's attending physician on 09/15/22. d. Patient #119's Start of care was 05/03/22 and the patient was discharged on 06/15/22. Documentation showed the discharge summary was sent to the patient's attending physician on 07/24/22. 2. On 06/29/23 at 9:00 AM, Surveyors #1 and #6 interviewed the agency’s Executive director (Staff #110) on the delayed submission of discharge summaries to patients’ attending physician. Staff #110 acknowledged the findings and stated that the healthcare professional responsible for completing the discharge summaries was not aware of the five-business day submission to the physician.