Every finding on record at Cp Snohomish County Wa, LLC

Based on record review and interview, the agency failed to follow the plan of care (POC) relative to hospice aides (HA) visit frequencies and failed to notify the patient and/or their representatives of HA missed visits for 14 of 42 patients (Patient #119, Patient #128, Patient #130, Patient #131, Patient #132, Patient #133, Patient #134, Patient #135, Patient #137, Patient #138, Patient #139, Patient #140, Patient #141, and Patient #142). Failure to follow the POC and communicate with the patient and/or their representatives of changes to the POC may potentially have a clinical impact on the patients wellbeing. --- Findings included: 1. Document review of the agencys policy titled, ";Plan of Care", (Date Revision: 07/2023) showed that the POC specifies the hospice care and services necessary to meet the patient and family-specific needs. 2. Record review of patient records for 14 of 42 patients (Patient #119, Patient #128, Patient #130, Patient #131, Patient #132, Patient #133, Patient #134, Patient #135, Patient #137, Patient #138, Patient #139, Patient #140, Patient #141, and Patient #142) showed: a. Patient #119s election date was on 07/11/24. Hospice aide (HA) services were ordered with frequencies of 1 visit every week for 12 weeks starting 07/14/24. On 07/24/24, a missed visit note showed visit discrepancy. There was no other documentation to show that the HA missed visit was communicated to the patient and/or their representative. b. Patient #128s election date was 07/08/20. HA services were ordered with frequencies of 2 visits every week for 5 weeks starting 07/07/20. The records showed the following HA missed visit showed: i. On 07/30/20, a missed visit note showed visit was declined. ii. On 09/03/24, a missed visit note showed visit was declined. There was no other documentation to show who declined the missed visits and that the HA missed visits were communicated to the patient and/or their representative. c. Patient #130s election date was 12/16/23. HA services were ordered with frequencies of 1 visit every week for 8 weeks starting 08/11/23. On 07/02/23, a missed visit note showed a missed HA visit. There was no other documentation to show that the HA missed visit was communicated to the patient and/or their representative. d. Patient #131s election date was 08/27/24. HA services were ordered with frequencies of 1 visit every week for 13 weeks starting 08/27/24. On 09/06/24, a missed visit note showed scheduling conflict, visit not made. There was no other documentation to show the HA missed visit was communicated to the patient and/or their representative. e. Patient #132s election date was 07/30/24. HA services were ordered with frequencies of 1 visit every week for 10 weeks starting 08/18/24. The record showed the following missed visits: i. On 08/27/24, a missed visit note showed scheduling conflict, visit was not made. ii. On 09/03/24, a missed visit note showed scheduling conflict. There was no other documentation to show the HA missed visits were communicated to the patient and/or their representative. f. Patient #133s election date was 07/01/24. HA services were ordered with frequencies of 1 visit every week for 12 weeks starting 07/02/24. On 08/02/24, a missed visit note showed regular hospice aide day off. There was no other documentation to show the HA missed visit was communicated to the patient and/or their representative. g. Patient #134s election date was 06/09/24. HA services were ordered with frequencies of 1 visit every week for 12 weeks starting 06/10/24. On 07/24/24, a missed visit note showed visit discrepancy. There was no other documentation to show the HA missed visit was communicated to the patient and/or their representative. h. Patient #135s election date was 06/13/24. HA services were ordered with frequencies of 1 visit every week for 13 weeks starting 06/14/24. The record showed the following missed visits: i. On 07/25/24, a missed visit note showed visit discrepancy. ii. On 08/26/24, a missed visit note showed visit discrepancy. iii. On 09/06/24, a missed visit note showed visit discrepancy. iv. On 09/11/24, a missed visit note showed scheduling conflict There was no other documentation to show the HA missed visits were communicated to the patient and/or their representative. i. Patient #137s election date was 03/16/24. HA services were ordered with frequencies of 1 visit every week for 9 weeks starting 03/18/24. The record showed the following missed visits: i. On 05/05/24, a missed visit note showed scheduling conflict. ii. On 07/03/24, a missed visit note showed scheduling conflict. iii. On 07/24/24, a missed visit note showed scheduling conflict. iv. On 08/28/24, a missed visit note showed scheduling conflict There was no other documentation to show the HA missed visits were communicated to the patient and/or their representative. j. Patient #138s election date was 04/30/24. HA services were ordered with frequencies of 2 visits every week for 7 weeks starting 05/15/24. The record showed the following missed visits: i. On 05/07/24, a missed visit note showed visit declined. ii. On 05/16/24, a missed visit note showed visit declined. iii. On 05/20/24, a missed visit note showed visit declined. iv. On 05/23/24, a missed visit note showed visit declined. v. On 05/27/24, a missed visit note showed visit declined. vi. On 07/22/24, a missed visit note showed visit discrepancy. There was no other documentation to show who declined the missed visits and that the HA missed visits were communicated to the patient and/or their representative. k. Patient #139s election date was 08/6/23. HA services were ordered with frequencies of 2 visits every week for 8 weeks starting 06/02/24. The record showed the following missed visits: i. On 07/05/24, a missed visit note showed visit declined. ii. On 07/30/24, a missed visit note showed visit declined. There was no other documentation to show who declined the missed visits and that the HA missed visits were communicated to the patient and/or their representative. l. Patient #140s election date was 06/17/24. HA services were ordered with frequencies of 1 visit every week for 12 weeks starting 06/18/24. The record showed the following missed visits: i. On 07/24/24, a missed visit note showed visit discrepancy. ii. On 07/30/24, a missed visit note showed visit declined. There was no other documentation to show who declined the missed visit and that the HA missed visits were communicated to the patient and/or their representative. m. Patient #141s election date was 03/07/24. HA services were ordered with frequencies of 1 visit every week for 13 weeks starting 06/25/24. On 07/24/24, a missed visit note showed scheduling conflict. There was no other documentation to show the HA missed visit was communicated to the patient and/or their representative. n. Patient #142s election date was 08/17/24. HA services were ordered with frequencies of 1 visit every week for 13 weeks starting 08/18/24. On 09/04/24, a missed visit note showed scheduling conflict, visit was not made. There was no other documentation to show the HA missed visit was communicated to the patient and/or their representative. 3. On 09/26/24 at 11:00 AM, Surveyor #1 interviewed the agencys Hospice Director (Staff #104) regarding the HA missed visit notes. Staff #104 acknowledged the findings and was unable to provide documentation to show that the patient and/or their representative were contacted regarding their missed visits.

Based on record review and interview, the agency failed to complete an initial assessment within 48 hours after the election of hospice care for 2 of 20 patient (Patients #112 and #116) Failure to meet this requirement places patients at risk of physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency's policy titled, "Initial and Comprehensive Assessments," (Policy ID # 10223312, Last reviewed 02/2021) showed that a registered nurse (RN) will complete an initial patient assessment within 48 hours after the election of hospice. 2. Record review of the patients charts for 2 patients (Patient #112 and #116) showed: a. Patient #112's notice of election of hospice was signed on 01/24/22 and hospice coverage begin as of 01/24/22. The initial and comprehensive assessment was started on 01/31/22. There was no documentation in the record that explained why hospice services did not occur within 48 hours after the election of hospice, and no documentation to indicate the agency notified the patient's hospice physician of the delayed assessment. b. Patient #116's notice of election of hospice was signed on 01/12/22 and hospice coverage begin as of 01/12/22. The initial and comprehensive assessment was started on 01/18/22. There was no documentation in the record that explained why hospice services did not occur within 48 hours after the election of hospice, and no documentation to indicate the agency notified the patient's hospice physician of the delayed assessment. 3. Surveyor #1 interviewed the Hospice Clinical Quality Improvement Manager (Staff #103) on 02/16/22 at 10:00 AM regarding the delay in completing the initial and comprehensive assessment; and Staff #103 acknowledged the findings and provided no further information. .

Based on record review and interview, the agency staff failed to complete the initial bereavement risk assessment as part of the initial comprehensive assessment for 5 of 20 patients (Patient #108, #109, #110, #112, and #114). This failure has the potential to delay or overlook the needs of the patient's family and others in their ability to cope with the patient's death. Findings included: 1. Document review of agency's policy titled, "Initial and Comprehensive Assessments," (Policy ID # 10223312, Last reviewed 02/2021) showed that a bereavement assessment will be included in the comprehensive assessment. 2. Record review of the patients' charts for 5 patients (Patient #108, #109, #110, #112, and #114) showed: a. Patient #108 was admitted on 01/21/22. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. b. Patient #109 was admitted on 01/12/22. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. c. Patient #110 was admitted on 01/07/22. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. d. Patient #112 was admitted on 01/31/22. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. e. Patient #114 was admitted on 12/31/21. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. 3. Surveyor #1 interviewed the Hospice Clinical Quality Improvement Manager (Staff #103) on 02/15/22 at 9:00 AM regarding the findings. Staff #103 acknowledged the missing initial bereavement assessments. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 02/01/19. .

Based on record review and interview, the agency staff failed to ensure that all members of the hospice IDG updated the comprehensive assessment for 11 of 20 patients (Patients #102, #103, #104, #107, #108, #109, #110, #113, #114, #115, and #119. Failure to review and/or update and document the comprehensive assessment as needed or no later than 15 days, may lead to patients not receiving the care and services in a timely, planned manner that could affect their comfort at the end of life. Findings included: 1. Document review of agency's policy titled, "Initial and Comprehensive Assessments," (Policy ID # 10223312, Last reviewed 02/2021) indicated that the comprehensive assessment will be documented by the hospice interdisciplinary group (IDG) in collaboration with the patient's attending provider as often as the patient's condition requires but no less often than every 15 days. In addition, document review of agency's policy titled, "Hospice Interdisciplinary Group," (Policy ID #8854629, Last reviewed 11/2020) indicated that the following required disciplines will be included in the IDG is the physician, RN, a social worker, and a pastoral or other counselor. 2. Record review of the patients charts for 11 of 20 patients (Patients #102, #103, #104, #107, #108, #109, #110, #113, #114, #115, and #119 showed: a. Patient #102's comprehensive assessment was completed on 10/16/21. The IDG meetings were held on 11/10/21, 11/24/21, 12/08/21, 12/23/21, 01/06/22, and 1/20/22 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN and Chaplain. The Chaplain did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. b. Patient #103's comprehensive assessment was completed on 11/15/21. The IDG meetings were held on 11/30/21, 12/07/21, 12/24/21, 01/17/22, 01/31/22, and 02/02/22 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN, Social Worker (MSW), Chaplain. The MSW and Chaplain did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. c. Patient #104's comprehensive assessment was completed on 02/06/22. The IDG meetings were held on 02/14/22 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN and MSW. The MSW did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. d. Patient #107's comprehensive assessment was completed on 10/11/21. The IDG meetings were held on 11/03/21, 12/07/21, 01/03/22, and 02/03/202 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN, MSW, and Chaplain. The MSW and Chaplain did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. e. Patient #108's comprehensive assessment was completed on 01/21/22. The IDG meeting was held on 02/08/22 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN and Chaplain. The Chaplain did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. f. Patient #109's comprehensive assessment was completed on 01/12/22. The IDG meetings were held on 01/13/22 and 01/31/22 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN and MSW. The MSW did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. g. Patient #110's comprehensive assessment was completed on 01/07/22. The IDG meetings were held on 01/11/22, 01/25/22, and 02/08/22 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN and Chaplain. The Chaplain did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. h. Patient #113's comprehensive assessment was completed on 12/02/21. The IDG meetings were held on 12/14/21, 12/28/21, 01/19/22, 02/1/22 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN, MSW and Chaplain. The MSW and Chaplain did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. i. Patient #116's comprehensive assessment was completed on 01/18/22. The IDG meetings were held on 01/19/22 and 02/03/22 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN and MSW. The MSW did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. j. Patient #117's comprehensive assessment was completed on 11/22/21. The IDG meetings were held on 12/02/21, 12/16/21, 01/13/22, 01/27/22, and 02/11/22 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN and MSW. The MSW did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. k. Patient #119's comprehensive assessment was completed on 05/15/21. The IDG meetings were held on 06/09/21, 06/24/21, 07/07/21, 07/20/21, and 08/05/21 with only RN IDG documentation. The core disciplines ordered by the physician and required to participate were RN and Chaplain. The Chaplain did not document an IDG note concerning the patient's progress towards goals, response to care, or even if there were no changes. There was no late entry or explanation for the omission. 3. Surveyor #1 interviewed the Hospice Clinical Quality Improvement Manager (Staff #103) on 02/16/22 at 10:00 AM regarding no IDG documentation. Staff #103 acknowledged the findings and stated that this was not the expectation for documentation by the IDG members. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 02/01/19. .

Based upon record review and staff interviews on 02/15/2022 between approximately 1015 to 1145 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment as required by NFPA 96 and 17/17A. This could result in the failure of the system to operate properly in the event of a fire, which would endanger the patients, staff and/or visitors within the facility. The findings include: The facility failed to provide documentation that the kitchen hood system has been inspected or cleaned within the last six months. NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.2.5.1, 9.2.3, 2.1, NFPA 96 (2011 ed) 1.1.1, 11.2.5, 11.6.12 The above was discussed and acknowledged by the facility engineering supervisor who said he was unaware of the missing documentation.

Based on observation and staff interview on 02/15/2022 during the physical tour of the facility between approximately 1215 and 1345 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff, and/or visitors within the facility. The findings include: The portable K-type fire extinguisher in the kitchen was stored in a lower kitchen cabinet and obstructed from view. NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010 ed) 1.1, 6.1.3.3.1 The above was discussed and acknowledged by the facility engineering supervisor who said he was unaware of the requirement.