Every finding on record at Klickitat County Public Hospital District No 1

.Based on record review and interview, the agency failed to develop and implement an emergency preparedness training and testing program based on a risk assessment, policies and procedures and a communication plan as defined by §42 CFR-Part 418.113(d). Failure to develop and implement an emergency preparedness training and testing program based on established standards puts patients and staff at increased risk of injury or untreated medical conditions in the event of an emergency event. --- Findings included: 1. Record review of the agency's emergency preparedness policy titled, "Emergency Disaster Preparedness and Procedures," last reviewed on 10/06/21, showed that all personnel will be oriented to the emergency preparedness plan and their assignments in the event of such an occurrence. The policy failed to describe how the agency will test the emergency preparedness plan in response to risks identified in the agency's hazard and vulnerability risk assessment. The policy failed to establish a process to include participation of all staff in the testing exercises. 2. On 09/11/23 at 1:49 PM, the Surveyor interviewed the integrated healthcare system's Director of Support Services (Staff #309) about the agency's emergency preparedness plan. Staff #309 provided the Surveyor a copy of the integrated health system's emergency preparedness plan for review. Staff #309 acknowledged that the integrated health system's emergency preparedness plan does not include Hospice-specific training and testing requirements. Staff #309 confirmed that hospice agency staff are required to complete the online training course titled, "Emergency Operations Plan," upon hire and annually. Staff #309 stated that the "Emergency Operations Plan" course does not include training on the hospice policy, "Emergency Disaster Preparedness and Procedures." 3. On 09/11/23 at 12:30 PM, the Surveyor interviewed the agency's Chief Nursing Officer (Staff #302) and Hospice Care Manager (Staff #301) about the agency's emergency preparedness plan. Staff #302 and Staff #301acknowledged that the agency's emergency preparedness plan does not meet the requirements for training staff and testing exercises. Staff #302 stated that the agency does not participate in the integrated health systems' emergency preparedness testing exercises. Staff #302 and Staff #301 acknowledged that the agency has developed its own emergency preparedness plan specific to the needs of the Hospice population and that the Hospice emergency preparedness plan does not include a training and testing program as described in §42 CFR-Part 418.113(d).

.Based on record review and interview, the agency failed to provide an emergency preparedness training program to train staff on the plan as identified by the risk hazard assessment on hire and every 2 years, consistent with 42 CFR §418.113(d)(1) for 6 of 6 staff and volunteer records reviewed. Failure to have staff trained on the emergency preparedness program, places staff, patients, and volunteers at risk of harm should a natural or man-made emergency occur. --- Findings included: 1. Record review for 6 of 6 staff and volunteer records showed no evidence of documentation for staff training on the agency's emergency preparedness plan (Staff #303, 304, #305, #306, #307, and #308). 2. On 09/11/23 at 12:30 PM, the Surveyor interviewed the Chief Nursing Officer (Staff #301) about the lack of documentation to support staff training. Staff #301 stated that agency staff and volunteers complete the online training course titled, "Emergency Operations Plan," upon hire and annually. Staff #301 also stated that the "Emergency Operations Plan" course does not include training on the Hospice-specific emergency preparedness plan. 3. On 09/11/23 and 09/12/23 the Surveyor interviewed 3 staff members during home visits about the agency's emergency preparedness plan (Staff #303, Staff #304 and Staff #305). Staff #303, Staff #304 and Staff #305 all stated that they have not received training on the Hospice-specific emergency preparedness plan or participated in testing exercises. .

Based on record review and interview, the agency failed to develop an individualized plan of care for each patient that reflected the patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessment for 7 of 10 patients. Failure to develop an individualized plan of care with specific interventions based on the problems identified in the comprehensive assessments may place patients at risk of not receiving services to manage the patient's terminal illness and associated symptoms. --- Findings included: 1. Record review of the agency's plan of care for 7 of 10 patients showed no evidence that the plan of care was individualized to meet the needs of the hospice patient. The plan of care did not include specific goals and interventions designed to manage the patient's symptoms identified in the comprehensive assessment for Patient #301, #302, #303, #304, #305, #306 and #308. 2. On 09/12/23 at 9:45 AM, the Surveyor interviewed the Chief Nursing Officer (Staff #301) and Hospice Care Manager (Staff #302) about the lack of individualized interventions based upon the comprehensive assessment with measurable goals and outcomes on the plan of care and visit notes. Staff #302 stated that the agency's EMR system, Meditech, does not allow staff to individualize the goals and interventions when creating the plan of care. The EMR system provides a drop box selection with limited narrative fields. The narrative fields do not show on the printed plan of care unless they are entered in the goal field of the care plan. Agency staff are only using the drop box selections for interventions on the plan of care. Agency staff have not received superuser training for the EMR system and frequently have questions about the functionality of the system. During the survey, Staff #301 and Staff #302 contacted an informaticist with Meditech to discuss these concerns. The agency is setting up superuser training for all staff and additional educational opportunities with Meditech.

Based on record review and interview, the agency failed to include specific interventions to manage pain and symptoms on the plan of care for 7 of 10 patients. Failure to include specific interventions to manage pain and symptoms on the plan of care may place patients at risk of not receiving services to manage the patient's terminal illness and associated symptoms. --- Findings included: 1. Record review of care plans for 7 of 10 patients (#301, #302, #303, #304, #305, #306 and #308) showed no evidence of interventions to manage pain and symptoms. 2. On 09/12/23 at 9:45 AM, the Surveyor interviewed the Chief Nursing Officer (Staff #301) and Hospice Care Manager (Staff #302) about the lack of individualized interventions on the plan of care and visit notes. Staff #302 stated that the agency's EMR system, Meditech, does not allow staff to individualize interventions when creating the plan of care. The EMR system provides a drop box selection with limited narrative fields. The narrative fields do not show on the printed plan of care unless they are entered in the goal field of the care plan. Agency staff are only using the drop box selections for interventions on the plan of care. Agency staff have not received superuser training for the EMR system and frequently have questions about the functionality of the system. During the survey, Staff #301 and Staff #302 contacted an informaticist with Meditech to discuss these concerns. The agency is setting up superuser training for all staff and additional educational opportunities with Meditech.

Based on record review and interview, the agency failed to establish measurable outcomes in the patients' plan of cares in order to determine the progression of patients' individualized hospice goals for 10 of 10 patients. Failure to establish measurable outcomes prevent patients from achieving their individualized hospice goals. --- Findings included: 1. Document review of agency's policy titled, "Documentation: Hospice Patient Clinical Record," reviewed on 10/06/21, showed that the hospice patient record will contain the patient's response to interventions and services provided, and progress towards goal achievement that is documented in appropriate and measurable terms. 2. Record review of 10 patient records showed no documentation of patients' individualized hospice goals and measurable outcomes with implementation and coordination of the patient's plan of care (Patients #301, #302, #303, #304, #305, #306, #307, #308, #309, and #310). 3. On 09/12/23 at 9:45 AM, the Surveyor interviewed the agency's Chief Nursing Officer (Staff #301) and Hospice Care Manager (Staff #302) about the lack of documentation of individualized patient goals and measurable outcomes. Staff #301 and Staff #302 acknowledged the findings and stated that the lack of documentation is related to the functionality of the agency's EMR system. See interview for Tag L545 and L546. .

Based on record review and interview, the agency failed to implement policies and procedures to remain compliant with state licensing requirements for the Tuberculosis (TB) infection control program for 6 of 6 personnel files reviewed. Failure of the agency to comply with implementing required policies and procedures on TB screening may place the patients and staff at risk of TB exposure. --- References: Washington Administrative Code (WAC) 246-335-525 Personnel, contractor, and volunteer policies. (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 the agency's responsibility to conduct TB testing of employees. Retesting should only be done for persons who previously tested negative and have new risk factors since the last assessment. Findings included: 1. Document review of the agency policy titled, ";Tuberculosis Screening Hospice," dated 02/08/23, showed that the agency will use the Washington state Department of Health approved screening forms upon initial hire and annually for all employees. 2. Record review on 6 of 6 personnel files showed: a. A Nursing Assistant Certified (Staff #303) was hired on 02/12/19. The record showed evidence of a TB test on 03/18/22 and 03/01/22. The record showed no evidence of a department approved TB risk assessment upon hire or annually. b. A Registered Nurse (Staff #304) was hired on 11/02/21. The record showed an agency TB risk assessment form completed on 02/07/22. The record showed no evidence of a department approved TB risk assessment upon hire or annually. c. A Social Worker (Staff #305) was hired on 07/05/16. The record showed an agency TB risk assessment form completed on 03/21/22. The record showed no evidence of a department approved TB risk assessment renewed annually. d. A Registered Nurse (Staff #306) was hired on 01/02/18. The record showed an agency TB risk assessment form completed on 03/18/22. The record showed no evidence of a department approved TB risk assessment renewed annually. e. A Volunteer (Staff #307) was hired on 03/17/22. The record showed an agency TB risk assessment form completed on 03/17/22. The record showed no evidence of a department approved TB risk assessment upon hire or annually. f. A Volunteer (Staff #308) was hired on 05/21/21. The record showed no evidence of a department approved TB risk assessment upon hire or annually. 3. On 09/11/23 at 3:00 PM, the Surveyor interviewed the agencys Chief Nursing Officer (Staff #301) about the missing department-approved TB risk assessments in the personnel records. Staff #301 stated that they were unaware of the department-approved TB risk assessment form and the agency was unable to provide documentation of the missing TB risk assessments in the personnel files. .

Based on record review and interview, the agency failed to include direct care staff in the agency's Quality Assessment and Performance Improvement (QAPI) program. Failure to include direct care staff in the QAPI program may result in staff being unaware of the agency's performance improvement projects and may place patients at risk of insufficient care if direct care staff are not aware of the agency's quality measures. --- 1. Record review of the agency's Quality Assessment and Performance Improvement (QAPI) program showed no evidence that direct care staff are involved in the agency's QAPI program. 2. On 09/11/23 at 11:30 AM, the Surveyor interviewed the agency's Administrative Assistant (Staff #311) and Quality, Risk, Compliance Officer (Staff #312) about the agency's QAPI program. Staff #311 stated that performance improvement projects are selected based on data collected through patient surveys, adverse event reporting and data collection. Staff #311 also stated that direct care staff are not involved in the QAPI program but received pertinent education as needed based upon the agency's performance improvement projects. Staff #311 oversees the hospice QAPI program and reports to Staff #312 in the integrated healthcare system. 3. Between 09/11/23 and 09/12/23, the Surveyor interviewed 3 direct care staff during home visits about the QAPI program (Staff #303, #304, and #305). All 3 staff members stated that they are not involved in the agency's QAPI program and did not know what the agency's current performance improvement project was.

Based on record review and interview, the agency failed to provide documentation that the hospice aide completed the required competency evaluation program prior to providing care to patients. Failure to ensure that hospice aides have completed the required competency evaluation program prior to providing care to patients may result in the hospice patients receiving care from an untrained staff member. --- Findings included: 1. Record review of the agency's policy titled, "Competency Assessment Completion Prior to Interaction with Patients," dated 02/08/23, showed that competency will be determined upon initial hiring of staff prior to them seeing patients. Competencies will be reviewed annually with evaluations. The policy failed to include the required subject areas and distinguish which skills must be evaluated by observing the aide's performance of the task with a patient or pseudo-patient and which may be evaluated through other methods. 2. Record review of a hospice aide (Staff #303) showed a hire date of 02/12/19. The records showed no evidence of competency evaluation of skills prior to Staff #303 providing care to patients. 3. On 09/11/23 at 3:00 PM, Surveyor #3 interviewed the agency's Chief Nursing Officer (Staff #301) about the missing skills competencies for the agency's hospice aide. Staff #301 stated that the agency does complete a skills competency upon hire, but the agency was unable to locate the documentation.

Based on record review and interview, the agency failed to verify employee competency prior to working with patients, for 2 of 4 employee files reviewed (Staff #303 and Staff #305). Failure to verify employee competency may place patients at risk of physical harm if a caregiver's skills are not sufficient to meet their patient's care needs. --- Findings included: 1. Record review of the agency's policy titled, "Competency Assessment Completion Prior to Interaction with Patients," dated 02/08/23, showed that competency will be determined upon initial hiring of staff prior to them seeing patients. Competencies will be reviewed annually with evaluations. 2. Record review of 2 of 4 direct care staff showed the following: a. A Hospice Aide (Staff #303) was hired on 02/12/19. The record showed no evidence of the agency verifying Staff #303's competencies prior to providing care to patients or annually. b. A Social Worker (Staff #305) was hired on 07/05/16. The record showed no evidence of the agency verifying Staff #305's competencies prior providing care to patients or annually. 3. On 09/11/23 at 3:00 PM, Surveyor #3 interviewed the agency's Chief Nursing Officer (Staff #301) about the missing skills competencies. Staff #301 stated that the agency completes skills competencies upon hire but was unable to locate the documentation for Staff #303 and Staff #305. THIS IS A REPEAT CITATION, PREVIOUSLY CITED ON 01/22/21.

Based on record review and interview, the agency failed to implement policies and procedures on criminal background checks and disclosure statements consistent with state requirements for staff. Failure to maintain compliance with state requirements on criminal background checks and disclosure statements put patients at risk of receiving care from un-vetted or unqualified staff. --- References: Washington Administrative Code (WAC) 246-335-625 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (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. (b) Disclosure statements must be approved by the department. (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. Findings included: 1. Document review of the agency policy titled, "Background Checks/Disclosure Statement Timeline," dated 02/08/23, showed that new employees will sign a background check and disclosure statement upon hire and every 2 years thereafter. The agency will have Washington State Patrol background checks done on initial hire and then every 2 years after that. This policy and procedure apply to all contractors and volunteers working in Hospice. 2. Record review on 3 of 6 personnel files showed the following: a. A Nursing Assistant Certified (Staff #303) was hired on 02/12/19. The record showed a criminal background check dated 01/14/19 and 02/01/21. The record also showed a department-approved disclosure statement dated 01/22/20. The record showed no evidence that the agency completed a background check two years from the previous check on 02/01/21. There was also no evidence that the agency completed a department-approved disclosure statement upon hire or two years from the previous check on 01/22/20. b. A Registered Nurse (Staff #305) was hired on 01/02/18. The record showed criminal background checks dated 12/18/17 and 02/01/21. The record also showed a department-approved disclosure statement dated 12/14/17. The record showed no evidence that the agency renewed the background check and department-approved disclosure statement every two years from the previous check. c. A Volunteer (Staff #308) was hired on 05/21/21. The record showed a department-approved disclosure statement dated 05/16/22 and a criminal background check dated 01/27/21. The record showed no evidence that the agency completed a department-approved disclosure statement upon hire. The record also showed no evidence that the agency renewed the criminal background check every two years from the previous check. 3. On 09/11/23 at 2:40 PM, the Surveyor interviewed the agencys Executive Director of Human Resources (Staff #310) about the missing department-approved disclosure statements and criminal background checks in the personnel records. Staff #310 stated that they were unaware of the requirement to renew the department-approved disclosure statements every two years from the previous check. Staff #310 also stated that the agency is set to renew background checks and department-approved disclosure statements in October 2023.