Every finding on record at Wesley Homes Hospice, LLC

Based on record review and interview, the agency failed to include in the patients Bill of Rights, the patients right to be free from verbal, mental, sexual, and physical abuse, neglect, exploitation, discrimination, and the unlawful use of restraint or seclusion as required in the Washington Administrative Code (WAC) 246-335-635 Bill of Rights. Failure of the agency to update and implement the patients Bill of Rights place the patients at risk of being unaware of their rights pertaining to care. References: WAC 246-335-635 Bill of Rights. A hospice agency at the time of admission must provide each patient, designated family member, or legal representative with a written bill of rights affirming each patient right to: (10) Be free from verbal, mental, sexual, and physical abuse, neglect, exploitation, discrimination, and the unlawful use of restraint or seclusion. --- Findings Included: 1. On 08/14/23 at 10:00 AM, Surveyor #1 reviewed the agencys patients Bill of Rights document and the Bill of rights policy and noted the lack of information about the patients right to be free from verbal, mental, sexual, and physical abuse, neglect, exploitation, discrimination, and the unlawful use of restraint or seclusion. 2. On 08/15/23 at 11:00 AM, Surveyor #1 interviewed the agencys Hospice Director (Staff #109) on the missing Bill of Rights information. Staff #109 acknowledged the missing information and stated that they had made steps in updating the agencys patients Bill of Rights. .

Based on record review and interview, the agency failed to complete an initial bereavement risk assessment as part of the initial comprehensive assessment for 1 of 2 bereavement patient records (Patient #106). Failure to assess the family's risk for grief and loss at the beginning stages of hospice care may lead to an individual's inability to cope at a later stage. --- Findings included: 1. On 08/14/23 at 11:00 AM, Surveyor #1 reviewed the agencys policy and procedure titled, ";Bereavement services", (Policy No. HO 368, Reviewed 07/26/23) indicated the initial bereavement risk assessment will be completed by the chaplain, social worker, or registered nurse at the time of admission to hospice. 2. Record review of Patient #106 showed the patient was admitted on 09/13/22. Documentation of the initial bereavement risk assessment was not present in the patient's record. There was no documentation to explain the absence of the bereavement risk assessment. 3. On 08/16/23 at 10:00 AM, Surveyor #1 interviewed the Hospice Director (Staff #109) on the missing initial bereavement risk assessment. Staff #109 acknowledged the missing initial bereavement assessment and stated that they were unable to provide documentation on the missing item. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 05/19/21 UNDER TAG L531 .

Based on record review and interview, the agency failed to update its policies and procedures (P&Ps) to remain compliant with state licensing requirements for the Tuberculosis (TB) infection control program for 2 of 8 personnel files reviewed. Failure of the agency to comply with developing, updating, and implementing required policies and procedures (P&Ps) on TB screening may place the patients and staff at risk of TB exposure. . --- Item #1: Tuberculosis Risk Assessment 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, ";Occupational Exposure to Tuberculosis," (Policy No. HO 445, Reviewed 07/31/23) lacked the state requirements for conducting a TB risk assessment using the department-approved form for all personnel on hire and annually. 2. Record review on 2 of 8 personnel files showed: a. Staff #107 was hired as a volunteer on 11/20/18. There was no documentation in the records to show that the agency completed a TB risk assessment using the department-approved form in 2019, 2020, 2021, and 2022. b. Staff #108 was hired as a volunteer on 03/15/19. There was no documentation in the records to show that the agency completed a TB risk assessment using the department-approved form on hire in 2020, 2021, and 2022. 3. On 08/16/23 at 2:30 PM, Surveyor #6 interviewed the agencys Hospice Director (Staff #109) about the missing requirements in the agencys P&P and the department-approved disclosure statements in the personnel records. Staff #109 stated that they thought the P&Ps had been updated to meet the state requirements 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 document Hospice aide supervisory visits by a Registered Nurse (RN) no less frequently than every 14 days for 4 of 14 patients (Patient #101, #108, #109, and #113). Failure to supervise the hospice aides no less frequently than every 14 days places the patient at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patients changing needs. --- Finding included: 1. Document review of the agencys policy and procedure titled, ";Home Hospice Aide Services and Supervision," (Policy No. HO 820, Reviewed 07/31/23) indicated the supervision of Hospice aides will be done by the agencys Director of clinical services or Case manager. The supervisory visit will be on-site and no less frequently than every fourteen days. 2. Record review for 4 of 14 patients records (Patient #101, #108, #109, and #113) showed: a. Patient #101s Start of Care (SOC) was on 06/01/23. The patient was admitted to hospice with diagnoses including Cognitive decline and Atrial Fibrillation – not a complete diagnosis list. The Physician ordered Hospice aide services weekly for thirteen weeks starting on 06/08/23. There was no documentation of RN supervisory visits for the period of 06/08/23-06/24/23 (2 weeks) and 07/30/23-08/12/23 (2 weeks). b. Patient #108s SOC was on 07/25/23. The patient was admitted to hospice with diagnoses including Cognitive decline and Heart Failure – not a complete diagnosis list. The Physician ordered Hospice aide services weekly for thirteen weeks starting on 07/27/23. There was no documentation of RN supervisory visits for the period of 07/27/23-08/12/23 (2 weeks). c. Patient #109s SOC was on 05/16/23. The patient was admitted to hospice with diagnoses including Cognitive decline and Dementia – not a complete diagnosis list. The Physician ordered Hospice aide services weekly for thirteen weeks starting on 05/18/23. There was no documentation of RN supervisory visits for the period of 06/18/23-08/12/23 (8 weeks). d. Patient #113s SOC was on 05/23/23. The patient was admitted to hospice with diagnoses including Cognitive decline and spinal stenosis – not a complete diagnosis list. The Physician ordered Hospice aide services weekly for thirteen weeks starting on 05/24/23. There was no documentation of RN supervisory visits for the period of 05/24/23- 07/15/23 (7 weeks) and 07/30/23- 08/12/23 (2 weeks). 3. On 08/16/23 at 10:00 AM, Surveyor #1 interviewed the agencys Hospice Director (Staff #109) about the lack of documentation of supervisory visits on Hospice Aides by the RN no less frequently than every 14 days. Staff #109 acknowledged the findings and stated that they were unable to provide any documentation on the missing supervisory visits. .

Based on observations, record review, and interview, the agency failed to ensure the supervising Registered Nurse (RN) confirmed the Hospice aide (HA) is able to follow the agencys policies and procedures (P&P) on the plan of care (POC), to use proper body mechanics, to comply with infection prevention and control practices including Hand Hygiene, and to report changes in the patients condition. Failure of the supervising RN to ensure the HA follows the agencys P&P on POC, to use proper body mechanics, to comply with infection prevention and control practices, and to report changes in the patient's condition may result in the HA providing poor and unsafe care to patients. --- Findings included: 1. On 08/15/23 at 10:00 AM, Surveyor #1 visited the Adult Family Home (AFH) of Patient #103 to interview and observe care provided by the agency Hospice aide (HA) (Staff #103). During the home visit, Surveyor #1 observed the HA as they provided patient care. The observations showed: a. Prior to entering the AFH of Patient #103, Surveyor #1 interviewed Staff #103 and asked what kind of care will be provided to the patient. Staff #101 stated, ";...I have no idea, this is my first time seeing this patient." Surveyor #1 interviewed Staff #103 about patient #103's plan of care (POC) regarding personal care. Staff #103 proceeded to look at their iPad to review Patient #103's POC, and Staff #103 stated that she will do a shower on Patient #103 as indicated in the POC. b. When Surveyor #1 and Staff #103 initially entered Patient #103's room, Patient #103 is laying on her bed. Staff #103 stated that she would perform a bed bath on Patient #103 since the patient is on her bed. c. Prior to performing a bed bath to Patient #103, Staff #103 failed to adjust the height of Patient #103s bed preventing Staff #103 from using appropriate body mechanics. d. Staff #103 donned a set of gloves prior to performing the bed bath task. On multiple occasions, she stopped the bed bath task and stepped out of the room to obtain supplies while still wearing the same gloves. Upon returning to Patient 103s room, she removed the gloves and donned a new set of gloves to continue the bed bath task. There was no hand washing or application of alcohol-based hand rub between the multiple changes in gloves. e. Surveyor #1 interviewed the AFH caregiver about Patient #103's condition during the home visit and the personal care provided by Staff #103. The AFH caregiver stated the patient always receives showers by the agency since the patient is able to sit up on a shower chair. The AFH caregiver stated that the patient seemed really tired during this home visit. 2. On 08/16/23 at 9:00 AM, Surveyor # 1 reviewed agency records. The review showed: a. Patient #103s home visit record dated 08/15/23 was completed by Staff #103. Documentation showed Staff #103 provided bed bath, shampoo, skin care, and assisted with dressing and change of adult diaper. There was no documentation that the supervising RN was notified of the change in condition of the patient. b. The agencys policy and procedure titled, ";Home Hospice Aide Services and Supervision," (Policy No. HO 820, Reviewed 07/31/23) indicated the POC is reviewed with the HA before the initial visit to the patient. The Case manager or Director of clinical services will determine that the HA understands the POC and provide training or demonstration of assigned tasks as needed. c. The Home Health/Hospice Aide onboarding checklist was completed and signed by Hospice director on 02/22/23 for Staff #103. Documentation showed Staff #103 was able to do independently use proper body mechanics, observe, report, and document patient status. d. The Home Health/Hospice Orientation checklist completed and signed by the Hospice director on 02/22/23 and 08/08/23 for Staff #103. Documentation showed Staff #103 completed training on Infection prevention and control including hand hygiene. 3. On 08/16/23 at 9:00 AM, Surveyor #1 interviewed the agency's Hospice Director (Staff #109) about Surveyor #1's home visit observations and findings. Staff #109 acknowledged the findings and stated that she had contacted Staff #103 the day before the home visit. Staff #109 stated that she discussed with Staff #103 the details of Patient #103's POC and the assigned tasks for the home visit set for 08/15/23. Staff #109 also stated that she determined that Staff #103 understood the POC and was able to demonstrate the assigned tasks for Patient #103. However, upon learning of the observations and findings from the home visit, Staff #109 stated that she was baffled by Staff #103's lack of understanding of the POC and the assigned tasks. .

Based on record review and interview, the governing body for the agency failed to ensure the system implemented to monitor corrective actions for previously identified deficiencies was robust enough to maintain a continued level of acceptable compliance. Failure of the governing body to assume responsibility for performance improvement activities in response to issues of non-compliance puts patients at risk of harm from inadequate monitoring of performance improvement projects and substandard care. --- Findings included: The hospice agency received a deficiency citation for failure to complete initial bereavement risk assessments for 3 of 11 patients during the previous survey completed on 05/19/21. The agency received a second citation for failure to document completion of an initial bereavement risk assessment during the current survey, reflecting a failure to ensure ongoing correction. Cross-Reference: L531

Based on record review and interview, the agency failed to update its policies and procedures to remain compliant with state licensing requirements for 6 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. --- . Item #1: Reference checks References: 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: (3) References for personnel, contractors, and volunteers. Findings included: 1. Record review of the agency's policy and procedure (P&P) titled, "Personnel Selection," (Policy No. HO 405, Reviewed Date 07/26/23) showed that all applicants must have two positive references verified prior to employment. 2. Record review of Staff #101 showed a hire date of 07/10/23. There was no documentation in the record to show the agency conducted the reference checks as part of the hiring process. 3. On 08/15/23 at 2:30 PM, Surveyor #6 interviewed the agency's Hospice Director (Staff #109) about the missing documentation of reference checks in the employee file. Staff #109 acknowledged the findings, and stated that the agency was unable to provide the missing document. . Item #2: Performance evaluation References: 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: (15) 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. Surveyor Note: The requirement of WAC 246-335-625(15) for on-site annual observation/evaluation of staff providing care was exempted by Washington State Register (WSR) 20-10-061, signed by the Secretary of Health on April 30, 2020. Annual performance evaluations of all personnel, including observation of care and skills, were still required, but could be done remotely (instead of on-site) using various electronic resources. This exemption ended on 10/31/22. 1. Document review of the agency policy titled, ";Annual Performance Evaluation Policy and Procedure," (Policy No. HO 105, Review Date: 05/23) showed that the formal performance evaluations are conducted at the end of the 90-day introductory period from hire date and every 12 months on all personnel, contractors, and volunteers. The evaluations may be performed as a part of the supervisory visit and the documentation will be in the personnel record. 2. Record reviews on 3 of 8 personnel files showed: a. Staff #101 was hired on 07/01/19. There was no documentation in the staff record to show that the agency completed an annual performance evaluation with on-site observation in 2023. b. Staff #102 was hired on 01/03/22. There was no documentation in the staff record to show that the agency completed an annual performance evaluation with on-site observation in 2023. c. Staff #103 was hired on 02/21/23. There was no documentation in the staff record to show that the agency completed the end of the 90-day introductory period evaluation in 2023. 3. On 08/15/23 at 2:00 PM, Surveyor #6 interviewed the agencys Hospice Director (Staff #109) about the missing performance evaluations in the personnel records. Staff #109 stated that they were unaware of the missing performance evaluations and stated that the agency was unable to provide documentation of the missing documents. .

Based on record review and interview, the agency failed to update policies and procedures on criminal background check and disclosure statements consistent with state requirements for staff and failed to complete the criminal background checks and the department-approved disclosure statements on 3 of 8 staff (Staff #101, #107, and #108). 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, "Criminal History, Disclosure and Background Inquiries," (Policy No. HO 510, Review Date 07/31/2023) showed that the policy failed to include the requirement to use the department-approved disclosure statement every two years from the date of the previous check. 2. Record review on 3 of 8 personnel files showed: a. Staff #101 was hired on 07/01/19. There was no documentation in the records to show that the agency completed a department-approved disclosure statement on hire. b. Staff #107 was hired as a volunteer on 11/20/18. There was no documentation in the records to show that the agency completed a criminal background check and the department-approved disclosure statement on hire, in 2020, and 2022. c. Staff #108 was hired as a volunteer on 03/15/19. There was no documentation in the records to show that the agency completed a criminal background and the check department-approved disclosure statement on hire and in 2021. 3. On 08/15/23 at 2:30 PM, Surveyor #6 interviewed the agencys Director of Hospice and Palliative Care (Staff #109) about the missing requirements in the agencys P&P and the missing department-approved disclosure statements in the personnel records. Staff #109 stated that the P&P should have been updated to meet the state requirements and stated that the agency was unable to provide documentation of the missing disclosure statements in the personnel files.