Centerwell Home Health

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: . Based on observation, record review, and interview, the agency failed to ensure that 1 of 1 active home health aides successfully completed a competency evaluation as described in agency policy (Staff #306). Failure to ensure that home health aides have completed the required competency evaluation may place patients at risk of harm from receiving care for unqualified staff. Findings included: 1. Document review of the agency’s policy titled, “07-08 Competency Testing/Skills Demonstration,” (Date Revised: 03/26), showed that competency must be established and documented at hire, prior to any independent patient assignments that require the skill. Observation validation is required for defined skills. Assignments are contingent upon documented competency, appropriate to the patient’s needs, and within the individual’s scope of practice. Home Health Aide competency evaluation is performed by a Registered Nurse (RN). All new hires complete initial competency assessments during orientation which includes a self-reported proficiency inventory and scheduled observed skills demonstrations. For Home Health Aides, competency evaluation addresses the required subject areas, and specific tasks are evaluated through observation with a patient or pseudo-patient. 2. Record review for a Nursing Assistant Certified (Staff #306) showed a hire date of 11/10/25. The record showed no evidence that Staff #306 completed a competency evaluation for the following skills; tub bath, nail care, shampoo (bed, sink, tub), bedpan, urinal and catheter care. Record review of the visit note for the first patient care assignment completed by Staff #306 showed that on 11/20/25 they completed the following skills; vital signs, perineal care, foot care, dressing, shower, and oral care. The competency evaluation form showed that Staff #306 was evaluated by an RN on 11/21/25 for vital signs, 11/26/25 for shower, 01/9/26 for oral care and there is no evidence of competency evaluation for perineal care, foot care or dressing. The record showed no evidence that the visit was a joint visit with an RN for competency evaluation. The record showed that Staff #306 completed tasks independently prior to the competency evaluation. 3. On 07/28/26 at 10:00 AM, Surveyor #3 observed a home visit with Home Health Aide (Staff #306). During the home visit, Staff #306 aided with shampooing hair for Patient #303. The record showed no evidence that Staff #306 had completed a competency evaluation for shampoo prior to providing the care. 4. On 07/29/26 at 2:00 PM, Surveyor #3 interviewed the Branch Director (Staff #313) and the Clinical Manager (Staff #314) about the missing competency evaluations for Staff #306. Staff #314 stated that the shift on 11/20/25 was a joint visit with an RN to evaluate competency. Staff #314 stated that the RN did not document the preceptor visit in the out-of-visit activity note because they are salary and did not think they needed to since it did not impact their pay. Staff #314 also stated that the RN completing the evaluation had the incorrect form with them at the time of the visit and completed the correct form after the visit but entered the incorrect date for the observation. On 07/30/26 at 8:30 AM, Staff #313 stated that the agency was removing Staff #306 from the field and completing all the missing competency evaluations before they provided additional patient care. Staff #313 acknowledged that their documented competencies were incomplete. .”

“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 document review, record reviews, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of the referral for 4 of 17 patients (Patient #104, Patient #105, Patient #115, and Patient #116). Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency’s policy titled, “03-05: Patient Assessments,” (Policy No. 03-05, Revised Date: 01/2026) showed that the initial assessment must be conducted within forty-eight hours of the referral unless otherwise ordered by the physician. 2. Record review of the patients records for 4 of 17 patients (Patient #104, Patient #105, Patient #115, and Patient #116) showed: a. Patient #104’s Start of Care (SOC) date was 02/27/26. The referral was dated 02/20/26 for Speech Therapy (ST) services. The ST initial assessment did not occur until 02/27/26. There was no documentation as to why the ST Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed SOC. b. Patient #105’s SOC date was 06/15/26. The referral was dated 06/10/26 for Physical Therapy (PT) services. The PT initial assessment did not occur until 06/15/26. There was no documentation as to why the PT Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed SOC. c. Patient #115’s SOC date was 05/20/25. The referral was dated 05/15/25 Skilled Nursing (SN), services. The SN initial assessment did not occur until 05/20/25. There was no documentation as to why the SN initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed SOC. d. Patient #116’s SOC date was 11/19/25. The referral was dated 11/14/25 for SN services. The SN initial assessment did not occur until 11/19/25. There was no documentation as to why the SN initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed SOC. 3. On 07/29/26 at 3:00 PM, Surveyor #1 interviewed the agency’s Branch Director (Staff #113) of the lack of documentation on the delayed initial assessments. Staff #113 acknowledged the findings and stated they were not able to provide documentation for the timely issues with the referral and the SOC admissions.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: . Based on record review and interview, the agency failed to ensure that all home health staff met the personnel qualifications described in agency policies and procedures to include; criminal background checks and disclosure statements (Item #1) for 4 of 12 staff (Staff #302, #305, #311, and #312), and evidence of skills competencies (Item #2) for 2 of 2 contracted staff (Staff #311 and #312). Failure to ensure that staff are qualified as described in agency policy and procedure may result in patients receiving care from unvetted staff. Findings included: Item #1 – Criminal background check and disclosure statements Reference : WAC 246-335-425 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 (WSP); (b) Disclosure statements must be approved by the department; and (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; 1. Record review of the agency’s policy and procedure titled, “WA 07-16: Background Investigations,” (Date Reviewed: 07/26), showed that all prospective employees, volunteers and any other individual who would have direct access to children under 16 years of age, developmentally disabled persons, or vulnerable adults will be required to complete and sign a disclosure statement and will have a criminal background check conducted through the Washington State Patrol. All criminal background checks and disclosures statements must be renewed within two years from the date of the previous check. Review of the agency’s policy and procedure titled, “02-19 Services Under Arrangement,” (Date Revised: 07/26), showed that contracted personnel must meet qualification requirements, follow agency policies, participate in care coordination, maintain required documentation, and be subject to the same standards of competency, oversight and compliance and employees. Review of the agency’s policy and procedure titled, “Contractor Workforce Policy,” (Date Revised: 04/26), showed that background checks are required for all contractors and are completed by the contractor’s employer and not the agency prior to starting the assignment. The suppliers are required to complete the background check based on the requirements in the agency’s standard package for all contractors required by the agency’s background check policy. The standard package for all contractors listed in the policy does not include the department-approved disclosure statement for Washington state. 2. Record review of 4 of 12 staff showed that the agency failed to complete criminal background checks and disclosure statements as described in agency policy. The record review showed the following: a. A Certified Occupational Therapy Assistant (Staff #302) was hired on 04/08/19. The record showed a disclosure statement completed on 06/17/24 and criminal background check completed 06/11/24. The record showed no evidence that the agency renewed the disclosure statement or criminal background check within two years from the previous check. b. A Speech Language Pathologist (Staff #305) was hired on 07/20/20. The record showed a disclosure statement completed on 06/20/24. The record showed no evidence that the agency renewed the disclosure statement within two years from the previous check. c. A contracted Physical Therapist (Staff #311) initiated their assignment on 07/13/26. The record showed a disclosure statement signed during the survey on 07/29/26. The record showed no evidence of a disclosure statement signed upon the contract date. d. A contracted Certified Occupational Therapy Assistant (Staff #312) initiated their assignment on 06/16/26. The record showed no evidence of a disclosure statement. 3. On 07/29/26 at 2:00 PM, Surveyor #3 interviewed the agency’s Branch Director (Staff #313) about the missing criminal background checks and disclosure statements. Staff #313 acknowledged that the criminal background check and disclosure statements due in June 2026 have not been completed for Staff #302 and #305. Staff #313 stated that Staff #302 is currently out on maternity leave and set to return in August 2026. Staff #313 stated that they were aware of the requirement for contracted staff to complete the disclosure statement, but that they believed that they were being completed by the contracting agency prior to the contractor’s assignment along with the background checks. Item #2 – Skills Verification and Competencies 1. Record review of the agency’s policy titled, “07-08 Competency Testing/Skills Demonstration,” (Date Revised: 03/26), showed that competency must be established and documented at hire, prior to any independent patient assignments that require the skill. Observation validation is required for defined skills. Assignments are contingent upon documented competency appropriate to the patient’s needs and within the individual’s scope of practice. Review of the agency’s policy and procedure titled, “02-19 Services Under Arrangement,” revised 072026, showed that contracted personnel must meet qualification requirements, follow agency policies, participate in care coordination, maintain required documentation, and be subject to the same standards of competency, oversight and compliance and employees. Contract associates are trained, and skills are validated prior to participating in the development of care plans. 2. Record review for 2 of 2 contracted staff showed the following: a. A contracted Physical Therapist (Staff #311) initiated their assignment on 07/13/26. The record showed a self-assessment skills checklist completed by the contractor’s employer. The record showed no evidence that the agency completed a skills competency evaluation. b. A contracted Certified Occupational Therapy Assistant (Staff #312) initiated their assignment on 06/16/26. The records showed a self-assessment skills checklist completed by the contractor’s employer. The record showed no evidence that the agency completed a skills competency evaluation. The record showed no evidence that Staff #312 received an evaluation from the supervising Occupational Therapist prior to providing care to patients. 3. On 07/29/26 at 2:00 PM, Surveyor #3 interviewed the Branch Director (Staff #313) about the missing skills competencies for the contracted staff. Staff #313 stated that they believed the skills competencies were completed by the contracting agency prior to assignment. On 07/30/26 at 8:30 AM, Staff #313 stated that they were removing the Staff #311 and #312 from the field to complete skills competencies.”