Sea Mar Home Health

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on document review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral (repeated non-compliance from previous surveys) and failed to complete the comprehensive assessment within 5 calendar days of the patients’ start of care (repeated non-compliance from previous survey). Failure to conduct initial assessments within 48 hours of completing the referral and failure to complete a comprehensive assessment within 5 calendar days of the patient’s start of care puts patients at risk of physical harm due to not receiving services in a timely manner. Findings included: 1. Failure to conduct the initial assessment visit within 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 5 of 7 patients. 2. Repeated non-compliance identified in recertification surveys completed on 12/08/17 (under Tag 0332) AND 10/01/21 for completion of the initial assessment visit within 48 hours of completing the referral: a. The agency was previously cited on the survey dated 12/08/17 under Tag G0332, Initial Assessment Visit, 42.CFR 484.55(a)(1), the agency failed to conduct the initial visit within 48 hours of receiving a referral for 4 of 12 patients in the sample. b. The agency was previously cited on the survey dated 10/01/21 under Tag G0514, RN Performs Assessment, 42 CFR 484.55(a)(1), for failure to conduct the initial assessment visit within 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 4 of 7 patients in the sample. 3. Failure to complete a comprehensive assessment within 5 calendar days of the patients’ start of care for 3 of 7 patients. 4. Repeated non-compliance identified in the recertification survey completed on 10/01/21 for failure to complete a comprehensive assessment within 5 calendar days of the patient’s start of care for 1 of 7 patients. Based on the scope and severity of deficiencies under 42 CFR 484.55; the Condition of Participation: Comprehensive assessment of patients is NOT MET. Cross Reference: G0514, G0520”

“Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This Condition is not met as evidenced by: Based on document review and interview, the agency had repeated non-compliance with all applicable state regulations related to the health and safety of patients, by failing to complete and/or renew criminal history background checks and complete department-approved disclosure statements consistent with state regulations for both the current survey and the survey completed on 10/01/21. Repeated non-compliance with state regulations for completion of criminal background checks puts patients at risk of harm from unvetted caregivers. Findings included: The agency received a citation for failure to complete criminal background checks and disclosure statements every two years as required by state regulations. The agency received the same citation on their previous survey completed on 10/01/21. Based on the scope and severity of deficiencies identified under 42 CFR 484.100; the Condition of Participation for Compliance with Federal, State, Local Law, is NOT met. Cross Reference: G860”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview the agency failed to transmit patient data to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for 95 of 395 records transmitted between 05/01/23 and 04/01/24. Failure to transmit patient data in a timely manner could result in patients not receiving full benefits. Findings included: 1. As part of the pre-survey preparation, Surveyor #4 reviewed the “HHA Error Summary by Agency” report from 05/01/23 to 04/01/24 generated from the Website address iqies.com.gov site. The review showed that the agency had 95 of 395 patient assessments that were not submitted in a timely manner. This resulted in a 24.05% late submission error rate. 2. On 07/23/24 at 10:30 AM, Surveyor #4 interviewed the agency Program Manager (Staff #401) about the error rate. Staff #401 stated that delays in documentation and the need for corrections has resulted in late submissions.”

“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 communicate with the patient’s physician of Skilled Nursing (SN) missed visits resulting in changes to patient’s plan of care in 2 of 3 patients (Patient #201 and #202). Failure to communicate changes in the plan of care to the patient’s physician may potentially have a clinical impact on the patient’s well-being. Findings included: 1. Record review of care plans for Patients #201 and #202 showed: a. Patient #201’s Start of Care (SOC) was 05/17/24. The plan of care included SN services with the frequency of 2 visits every week for 9 weeks and 2 as needed (PRN) starting 05/17/24. During the Medicare week of 05/26/24 to 06/01/24, the patient received 1 SN visit. In addition, there was no documentation as to why the 2nd SN visit was not made and no physician notification of the missed visit. b. Patient #202’ SOC was 09/02/22. The plan of care included SN services with the frequency of 2 visits every week for 8 weeks, 2 as needed (PRN) for the wound care, and once a month for 3 months for the catheter. During the Medicare weeks of 09/11/22 to 09/17/22 and 10/23/22 to 10/29/22, the patient received 1 SN visit. In addition, there was no documentation as to why the 2nd SN visit was not made and no physician notification of the missed visit. Patient #202’s current certification period of 06/23/24 to 08/21/24 showed a plan of care that included SN services with the frequency of 2 visits every week for 9 weeks. During the Medicare week of 06/30/24/ to 07/05/24, the patient received 1 SN visit. In addition, there was no documentation as to why the 2nd SN visit was not made and no physician of the missed visit. 2. On 07/24/24 at 2:00 PM, Surveyor #2 interviewed the agency Director of Home and Community Services (Staff #401) regarding missed visits. Staff #401 stated that she was not aware of why the SN did not document the missed visits. Staff #401 also stated that documented missed visits automatically notify the patient’s physician.”

“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 ensure that staff received Tuberculosis (TB)- related training and education at the time of hire or during new employee orientation. The agency also failed to conduct the TB risk assessment screening using the Department of Health (DOH)- approved TB risk assessment form annually on three staff members (Staff #402, #403, and #404). Failure of the agency to comply with implementing the required TB education, training, and screening may place the patients and staff at risk of TB exposure. Findings included: Reference: Washington Administrative Code (WAC) 246-335-525 (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. Findings included: 1. Document review of the agency’s policy and procedure titled “ Health Screening,” (Policy # 100.29) showed that all employees and volunteers must complete a health screening at time of hire or initial volunteer date and then annually thereafter. The annual health screening requires a tuberculosis screening, fit-for-duty attestation for licensed employees, and flu vaccination. Annual health screenings are conducted during the flu season. Document review of the agency’s policy and procedure titled “TB-Employee Prevention and Control,” (Policy # 1100.221.4) showed that all employees will be screened annually which will include Skin testing with Protein Purified Derivative (PPD) for those with prior negative results to allow for early detection and treatment of conversions. Annual TB screening occurs each year in the month of July and is incorporated into the agency-wide Quality Improvement Program. 2. Record review of 3 of 3 personnel files showed: a. Staff #402 was hired on 02/03/16. There was no evidence in the record that the agency provided TB-related training and education at the time of hire or during new employee orientation. There was also no documentation that the agency conducted annual skin testing with PPD and an annual TB risk assessment using a DOH-approved form in 2022, 2023, and 2024. b. Staff #403 was hired on 03/08/24. There was no evidence in the record that the agency provided TB-related training and education at the time of hire or during new employee orientation. There was also no documentation that the agency conducted skin testing with PPD and an initial TB risk assessment using a DOH-approved form upon hire. c. Staff #404 was hired on 02/15/21. There was no evidence in the record that the agency provided TB-related training and education at the time of hire or during new employee orientation. There was also no documentation that the agency conducted annual skin testing with PPD and an annual TB risk assessment using a DOH-approved form in 2022 and 2024. 3. On 07/24/24 at 2:00 PM, Surveyor #2 interviewed the agency Director of Home and Community Services (Staff #401) about the lack of documentation on TB-related training and education and TB risk assessments using the DOH-approved form. Staff #401 stated that the agency’s Human Resources (HR) department conducts Annual Health Screenings for employees and was unaware why the annual TB risk assessment was not included in the personnel records. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 10/01/21.”

“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 complete and/or renew criminal history background checks and complete department-approved disclosure statements for 3 of 3 personnel providing direct care (Staff #402, #403 and #404). Failure to renew criminal background checks and disclosure statements for personnel providing direct care puts the clients at risk of receiving care from an unvetted staff member, potentially compromising their safety and well-being. 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: (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’s policy and procedure titled “Criminal History Information,” (Policy # 2000.23) showed that Sea Mar Community Health Centers Home Health, Home Care, and Hospice agencies must request background checks and disclosure statements every two years for all employees who provide direct care to clients or patients. Home health and hospice agencies must process background checks through the Washington State Patrol (WSP). Private duty home care agencies must process initial hiring checks through DSHS BCCU and subsequent checks through WSP. 2. Record review of 3 of 3 personnel files showed: a. Staff #402 was hired on 02/03/16. There was no evidence in the personnel record to show the subsequent criminal history background checks and completion of department-approved disclosure statements in 2023. b. Staff #403 was hired on 03/08/24. There was no evidence in the personnel record to show the completion of department-approved disclosure statements upon hire. c. Staff #404 was hired on 02/15/21. There was no evidence in the personnel record to show the subsequent criminal history background checks and completion of department-approved disclosure statements in 2023. 3. On 07/24/24 at 2:00 PM, Surveyor #2 interviewed the agency Director of Home and Community Services (Staff #401) regarding criminal history background checks and disclosure statements. Staff #401 stated that the agency’s Human Resources (HR) department handles the background checks and completion of department-approved disclosure statements and was unaware of why it was not included in the personnel records. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 10/01/21.”

“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 record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of receiving a referral for 5 of 7 patients (#201, #202, #405, #406, #407). Failure to meet this requirement places patients at risk for physical harm due to not receiving needed services in a timely manner. Findings included: 1. Review of patient records for Patients (#201, #202, #405, #406, #407) showed: a. Patient #405’s Start of Care (SOC) date was 05/13/24. The agency completed the referral on 05/09/24 but the initial assessment was not started until 05/13/24. There was no documentation to explain why the initial assessment did not occur within 48 hours of the referral or documentation to show that the delay was based on patient request. b. Patient #406’s SOC date was 02/06/24. The agency completed the referral on 02/02/24 but the initial assessment was not started until 02/06/24. There was no documentation to explain why the initial assessment did not occur within 48 hours of the referral or documentation to show that the delay was based on patient request. c. Patient #407’s SOC date was 03/27/22. The agency completed the referral on 03/27/24 but the initial assessment was not started until 04/03/24. There was no documentation to explain why the initial assessment did not occur within 48 hours of the referral or documentation to show that the delay was based on patient request. d. Patient #201’s SOC date was 05/17/24. The agency completed the referral on 05/13/24, but the initial assessment was not started until 05/17/24. There was no documentation to explain why the initial assessment did not occur within 48 hours of the referral or documentation to show that the delay was based on patient request. e. Patient #202’s SOC date was 09/02/22. The agency completed the referral on 08/26/22, but the initial assessment was not completed until 09/02/22. There was no documentation to explain why the initial assessment did not occur within 48 hours of the referral or documentation to show that the delay was based on patient request. 2. Surveyor #4 interviewed the Agency Director (Staff #401) on 07/24/24 at 2:25 PM about the delayed initial assessments. Staff #401 acknowledged the delay in initial assessments. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 12/08/17 AND 10/01/21.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to complete initial assessments within 5 calendar days of the start of care for 3 of 7 patients (#404, #406, #407). Failure to meet this requirement places patients at risk for physical harm due to not receiving needed services in a timely manner. Findings included: 1. Record review of patient charts for Patients (#404, #406, #407) showed: a. Patient #404’s initial assessment was started on 03/28/24 and completed on 04/10/24. There was no documentation in the record to show why the assessment was not completed within 5 days. b. Patient #406’s initial assessment was started on 02/06/24 and completed on 02/27/24. There was no documentation in the record to show why the assessment was not completed within 5 days. c. Patient #407’s initial assessment was started on 04/03/24 and completed on 04/23/24. There was no documentation in the record to show why the assessment was not completed within 5 days. 2. Surveyor #4 interviewed the Program Manager (Staff #401) on 07/24/24 at 2:25 PM about the delay in completing the initial assessments. Staff #401 stated that the assessments had been delayed in the review process. THIS IS A REPEAT CITATION PREVIOUSLY CITED 10/01/21.”