Every finding on record at Whidbey Island Public Hospital District

Based on record review and interview, the agency failed to show that patients received and understood their rights upon start of services with the agency for 14 of 14 Patients (#501, #502, #503, #504, #505, #506, #507, #508, #509, #510, #511, #512, #513, and #514) currently receiving services. Failure to ensure that patients received and understood their rights place patients at risk of failing to fully exercise their rights while under the care of the agency. Findings included: --- 1. During the survey, the Surveyor reviewed 14 active patient records. The records showed: a. Patient #501 had a start of care date of 11/21/23. There was no evidence in the record to show the patient had received and understood their patient rights. b. Patient #502 had a start of care date of 10/17/23. There was no evidence in the record to show the patient had received and understood their patient rights. c. Patient #503 had a start of care date of 11/07/23. There was no evidence in the record to show the patient had received and understood their patient rights. d. Patient #504 had a start of care date of 11/08/23. There was no evidence in the record to show the patient had received and understood their patient rights. e. Patient #505 had a start of care date of 01/16/24. There was no evidence in the record to show the patient had received and understood their patient rights. f. Patient #506 had a start of care date of 06/27/23. There was no evidence in the record to show the patient had received and understood their patient rights. g. Patient #507 had a start of care date of 01/31/24. There was no evidence in the record to show the patient had received and understood their patient rights. h. The Surveyor reviewed additional records for Patients (#508, #509, #510, #511, #512, #513 and #514). None of the patient files reviewed contained evidence that the patients had received and understood their rights. 2. On 02/06/24 at 2:15 PM, the Surveyor interviewed the Hospice Manager (Staff #501) about the lack of documentation showing patients received and understood their rights at the start of services. Staff #501 stated that although the agency previously had the patient/representative sign an acknowledgement after receipt of their rights, the agency removed that from the intake process. Staff #501 verified that the patient records did not contain documentation that patients received and understood their rights at the start of care.

Based on record review and interview, the agency failed to conduct an annual Tuberculosis (TB) screening for 5 of 5 staff that worked directly with patients (#505, #506, #507, #508, #509). Failure to perform annual TB screening on staff places patients and staff at risk for infectious diseases. Reference: 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: (14) 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:(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. Findings included: --- 1. On 02/07/24 the Surveyor reviewed the personnel records for 5 direct care workers. The review showed: a. A Registered Nurse (Staff #505) was hired on 02/07/07. A TB test was completed on 02/19/07. No further testing or annual TB risk assessments were evident. b. A Registered Nurse (Staff #506) was hired on 11/09/13. A TB test was completed on 11/15/13. No further testing or annual TB risk assessments were evident. c. A Licensed Social Worker (Staff #507) was hired on 08/23/19. A TB test was completed on 08/21/19. No further testing or annual TB risk assessments were evident. d. A Certified Nurse Aide (Staff #508) was hired on 03/18/15. A TB test was completed on 03/20/15. No further testing or annual TB risk assessments were evident. e. A Certified Nurse Aide (Staff #509) was hired on 02/08/19. A TB test was completed on 02/01/19. No further testing or annual TB risk assessments were evident. 2. On 02/07/24 at 2:45 PM, the Surveyor interviewed the Employee Health Nurse (Staff #511) about the missing annual TB risk assessment on staff. Staff #511 acknowledged the findings and stated that they were not aware of the state requirements for annual TB screening for staff. .

Based on record review and interview, the agency failed to obtain criminal history background checks every two years and Washington State Disclosure Statements according to Washington State hospice regulations for 5 of 5 direct care workers (#505, #506, #507, #508, #509). Failure to conduct criminal history background checks according to state regulations puts patients at risk from receiving unsupervised care from unvetted staff. Reference: WAC 246-335-630 Personnel, contractor, and volunteer records. The licensee must maintain records on all personnel and volunteers and have access to records on all contractors to include: (6) Evidence of initial and subsequent criminal history background checks and disclosure statements according to RCW 43.43.830 through 43.43.842 and this chapter; (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. On 02/07/24, the Surveyor completed a review of staff records. The records showed: a. A Registered Nurse (Staff #505) showed a hire date of 02/07/07. A criminal history background check was completed on 10/18/19 and a Disclosure Statement was completed on 10/23/19. There was no evidence any additional subsequent two-year background checks or Disclosure Statements had been completed. b. A Registered Nurse (Staff #506) showed a hire date of 11/19/13. A criminal history background check was completed on 10/18/19 and a Disclosure Statement was completed on 10/23/19. There was no evidence any additional subsequent two-year background checks or Disclosure Statements had been completed. c. A Licensed Social Worker (Staff #507) showed a hire date of 08/23/19. A criminal history background check was completed on 08/12/19 and a Disclosure Statements was completed on 08/08/19. There was no evidence any additional subsequent two-year background checks or Disclosure Statements had been completed. d. A Certified Nursing Aide (Staff #508) showed a hire date of 03/18/15. A criminal history background check was completed on 10/18/19 and a Disclosure Statement was completed on 10/23/19. There was no evidence any additional subsequent two-year background checks or Disclosure Statements had been completed. e. A Certified Nursing Aide (Staff #509) showed a hire date of 02/08/19. A criminal history background check was completed on 01/24/19 and a Disclosure Statement was completed on 10/23/19. There was no evidence any additional subsequent two-year background checks or Disclosure Statements had been completed. 2. On 02/07/24 at 2:45 PM the Surveyor interviewed the Human Resources Generalist (Staff #110) about the missing background checks and disclosure statements. Staff #110 verified that the background checks and Disclosure Statements were not completed. Staff #110 stated that they were not aware of the state requirements.