Wesley Homes Hospice, LLC

“Based on document review, record review, observation and interview, the agency failed to complete the initial bereavement assessment as part of the comprehensive assessment. 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. Failure to complete the initial bereavement assessment as part of the initial comprehensive assessment for 7 of 14 active patients and 1 of 2 bereaved patients. 2. Repeated non-compliance identified in recertification survey conducted on 05/19/21 and 08/13/23. The agency was previously cited under Tag L0531, Content of the Comprehensive Assessment - Bereavement, §418.54(c)(7), for failure to complete the initial bereavement assessment as part of the initial comprehensive assessment. Based on the scope and severity of deficiencies identified under §418.54 Condition of participation: Initial and Comprehensive assessment of the patient is NOT MET. Cross Reference: L0531”

“Based on document review, record review, and interview, the agency failed to complete the annual tuberculosis (TB) risk assessment for 3 of 5 direct care staff and 2 of 2 volunteers. Failure of the agency to complete the annual TB risk assessment places the patients and the people who provide support at risk of exposure to TB from the agency staff. Findings included: 1. The document review of the agency’s policy number HO-445 titled, “Occupational Exposure to Tuberculosis”, dated 09/06/26, showed that all staff will complete the TB risk assessment annually. 2. The record review showed that 3 of 5 direct care staff (Staff #305, Staff #308, and Staff #309) and 2 of 2 volunteer staff (Staff #311 and #312) did not complete the TB risk assessment annually since the last survey. Repeated non-compliance identified in recertification survey conducted on 08/13/23. The agency was previously cited under Tag L0579. §418.60(a) Standard: Prevention, for failure to complete Tuberculosis Risk Assessments upon hire and annually. Based on the scope and severity of deficiencies identified under §418.60 Condition of participation: Infection control is NOT MET. Cross Reference: LO579”

“Based on record review and interview, the agency failed to document Hospice Aide supervision by a Registered Nurse no less frequently than every 14 days. Failure to supervise 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 patient’s changing needs. Findings included: 1. Failure to document supervision of the Hospice Aide services by a Registered Nurse no less frequently than every 14 days for 4 of 14 patients. 2. Repeated non-compliance identified in recertification survey conducted on 08/13/23. The agency was previously cited under Tag L0629, Supervision of Hospice Aides, §418.76(h)(1)(i), for failure to document Hospice Aide supervision no less frequently than every 14 days. Based on the scope and severity of deficiencies identified under §418.76 Condition of participation: Hospice aide and homemaker services is NOT MET. Cross Reference: L0629”

“Based on record review and interview, the agency failed to implement its policies and procedures to remain compliant with state licensing requirements for personnel. 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. Findings included: 1. Record review of personnel records showed that the agency failed to complete annual performance evaluations with onsite observation of care for 5 of 7 direct care staff. 2. Record review of personnel records showed that the agency failed to renew department-approved disclosure statements for 3 of 5 direct care staff and 1 of 2 volunteers. Repeated non-compliance identified in recertification survey conducted on 08/13/23. The agency was cited under Tag L0784, §418.114(a): General qualification requirements, for failure to complete annual performance evaluations with onsite observation of skills for staff.The agency was also cited under Tag L0796, §418.114(d)(2) - Criminal background checks must be obtained in accordance with State requirements, for failure to complete department-approved disclosure statements upon hire and every 2 years from the previous check. Based on the scope and severity of deficiencies identified under §418.114 Condition of participation: Personnel qualifications is NOT MET. Cross Reference: L0784”

“Based on document review and interview, the agency failed to implement their emergency preparedness communication plan that included a method of providing information about the general condition and location of patients receiving hospice care. Failure to provide accurate information about the general condition and location of hospice patients may result in harm to patients during an emergency if the agency cannot provide necessary care. Findings included: 1. Document review of the agency’s emergency preparedness plan showed that upon initial assessment, the agency will classify patients into 4 categories based on their individual needs in the event of an emergency. The patient ratings will be maintained in a disaster logbook with phone numbers, addresses, next of kin or person to be notified. The patient ratings and critical information are entered into the electronic medical record (EMR). Document review of the agency’s admission packet showed that the agency completes an “Emergency Classification System” form that documents the patient’s emergency classification at the time of admission. Document review of the agency’s disaster logbook showed an incomplete patient list with home health and hospice patients. The list also only identified patients requiring oxygen or electrical equipment. 2. On 05/27/26 at 11:00 AM, Surveyor #2 interviewed the Senior Director of Health and Home Care (Staff #302) about the patient list in the disaster logbook. Staff #302 acknowledged that the list is incomplete and stated that the Administrator has the Standardized Operational Procedure for printing the patient disaster report. The report is pulled from the agency’s Electronic Medical Record (EMR) MatrixCare and imported into Excel. Staff #302 was unable to explain why the report did not include all patients.”

“Based on document review, record review, and interview, the agency failed to provide emergency preparedness training on hire and at least annually, and failed to document staff knowledge of emergency procedures. Failure of the agency to provide emergency preparedness training upon hire and to update current staff, potentially places the patient at risk for harm due to the staff’s lack of training for an unexpected or emergency event. Findings included: 1. Document review of the agency’s policy number HO-345 titled, “Emergency Preparedness”, dated 05/01/26, showed that initial training on policies and procedures will be provided to all new and existing hospice staff, contractors, and volunteers. The staff will demonstrate knowledge of emergency procedures, and training will occur annually. 2. Record review of 7 direct care staff showed that 7 of 7 direct care staff (Staff #204, Staff #205, Staff #206, Staff #207, Staff #208, Staff #209, and Staff #210) and 1 of 2 volunteers (Volunteer #211) showed no evidence the agency provided initial or annual emergency preparedness training. a. Staff #204’s date of hire was 05/05/25. There was no evidence of emergency preparedness training found in the record. b. Staff #205’s date of hire was 10/21/19. There was no evidence of emergency preparedness training found in the record. c. Staff #206’s date of hire was 10/14/25. There was no evidence of emergency preparedness training found in the record. d. Staff #207’s date of hire was 02/10/26. There was no evidence of emergency preparedness training found in the record. e. Staff #208’s date of hire was 08/26/20. There was no evidence of emergency preparedness training found in the record. f. Staff #209’s date of hire was 09/28/16. Emergency preparedness training was completed in 2023. There was no other evidence of emergency preparedness training found in the record. g. Staff #210’s date of hire was 03/03/25. There was no evidence of emergency preparedness training found in the record. h. Volunteer #211’s date of hire was 09/14/23. There was no evidence of emergency preparedness training found in the record. 3. On 05/28/26 at 10:00 AM, Surveyor #2 interviewed the Senior Director of Health and Home Care (Staff #202) about the emergency preparedness staff training. Staff #202 stated that the training is done during orientation and should be documented on the orientation checklist. The orientation checklist titled, “Wesley Homes Health & Hospice Training” does not list emergency preparedness training as a topic that is covered for the new hire. Staff #202 stated that it is covered under “Orient to Policies and Procedures” on the list..”

“Based on record review and interview, the agency failed to complete an initial bereavement risk assessment as part of the initial comprehensive assessment for 7 of 14 active patient records (Patient #302, #304, #305, #307, #310, #311, and #313) and 1 of 2 bereaved patient records (#317). 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. Document review of the agency’s policy and procedure titled, “Bereavement services”, (Policy No. HO 368, Reviewed 07/26/23) showed that the initial bereavement risk assessment will be completed by the chaplain, social worker, or registered nurse at the time of admission to hospice. 2. Document review of the agency’s job description for Licensed Clinical Social Worker showed that the Social Worker is responsible for conducting initial and periodic psychosocial assessments, including appropriateness for Hospice admission and bereavement needs. 3. Record review of 7 active patients and 1 bereaved patient showed the following: a. Patient #302 was admitted on 05/23/26. 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. b. Patient #304 was admitted on 04/15/26. 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. c. Patient #305 was admitted on 05/15/26. 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. d. Patient #307 was admitted on 03/24/26. 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. e. Patient #310 was admitted on 03/24/26. 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. f. Patient #311 was admitted on 03/25/26. 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. g. Patient #313 was admitted on 05/20/24. 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. h. Patient #317 was admitted on 11/11/25 and expired on 02/04/26. 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. The record did show that the Bereavement Coordinator attempted to contact the patient’s family and left a detailed message regarding bereavement services. 4. On 05/26/26 at 1:20 PM, Surveyor #2 conducted a home visit for Patient #302. The home visit was an initial Master of Social Work (MSW) evaluation visit with Staff #207. During the visit, Staff #207 failed to complete the initial bereavement assessment for Patient #302. 5. On 05/28/26 at 11:00 AM, Surveyor #2 interviewed the Clinical Director (Staff #303) about the missing initial bereavement risk assessment and staff responsibility for their completion. Staff #303 acknowledged the missing initial bereavement assessment and stated that they were unable to provide documentation on the missing item. Staff #303 also stated that the MSW is responsible for completing the initial bereavement assessment. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 05/19/21 AND 08/13/23 UNDER TAG L531”

“Based on record review and interview, the agency failed to ensure that each patient and primary caregiver receives education and training provided by the hospice appropriate to the care provided and services identified in the patient’s plan of care for 13 of 14 patients (Patient #301, #303, #304, #305, #306, #307, #308, #309, #310, #311, #312, #313, #314). Failure to ensure that patients and caregivers receive the education and training identified as a patient need on the plan of care may result in poor quality of care and inadequate symptom management. Findings included: 1. Record review of 13 of 14 active patient records (Patient #301, #303, #304, #305, #306, #307, #308, #309, #310, #311, #312, #313, #314) failed to include documentation that Skilled Nurses addressed the teaching and education interventions identified in the plan of care. The follow up Skilled Nurse visit notes showed consistent pain assessments, medication reconciliation and intermittent review of systems assessments but no documentation that indicated that the Skilled Nurse performed teaching and education interventions identified on the physician ordered plan of care. The follow up Skilled Nurse visit notes consistently showed Care Plan Documentation regarding pain assessments and state “Please refer to intervention documentation”. There is no field on the follow up Skilled Nurse visit note that documents interventions. 2. On 06/01/26 at 10:30 AM, Surveyor #3 interviewed the Clinical Director (Staff #303) about the lack of documentation related to teaching and eduction interventions. Staff #303 stated that Skilled Nurses document education and interventions in the narrative note section of the visit note. Staff #303 also stated that Skilled Nurses can chose from multiple different visit note templates in the agency’s electronic medical record (EMR). Depending upon which template is selected in the EMR, that will determine what fields are available for staff to chart and the templates selected do not provide a field to document education and training.”

“Based on record review and interview, the agency failed to ensure that the revised plan of care includes information about the patient’s progress towards outcomes and goals specified in the plan of care. Failure to document progress towards goals and outcomes may place patients at risk of not receiving the appropriate level of care. Findings included: 1. Patient record review for 13 of 14 active patients (Patient #301, #303, #304, #305, #306, #307, #308, #309, #310, #311, #312, #313, #314) showed no documentation of the patient’s progress towards Skilled Nursing outcome and goals. The records showed Interdisciplinary Group (IDG) notes with interventions and goals not individualized to the patients and not included on the physician ordered plan of care. The record showed a field for documenting progress towards goals that was blank. 2. On 06/01/26 at 10:30 AM, Surveyor #3 interviewed the Clinical Director (Staff #303) about the lack of documentation of progress towards goals on the revised plan of care completed during IDG. Staff #303 stated that goals are discussed during IDG and acknowledged that they are not updated on the revised plan of care IDG notes, particularly for Skilled Nursing. Staff #303 provided a written statement that stated that the IDG note interventions and goals cannot be changed within the Electronic Medical Record (EMR) IDG note. They stated that the interventions and goals on the IDG note are templates based off the selected problem identified in the note. They stated that they document individualized goals on the physician ordered Plan of Care and that those are the interventions and goals that clinicians use to provide care.”

“Based on document review, record review, and interview, the agency failed to complete the annual tuberculosis (TB) risk assessment for 3 of 5 direct care staff (Staff #202, Staff #205, and Staff #206) and 2 of 2 volunteers (Volunteer #201 and Volunteer #202). Failure of the agency to complete the annual TB risk assessment places the patients and the people who provide support at risk of exposure to TB from the agency staff. Reference: 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: (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; Findings included: 1. The document review of the agency’s policy number HO-445 titled, “Occupational Exposure to Tuberculosis”, dated 09/06/23, showed that all staff will complete the TB risk assessment annually. 2. The record review of 7 direct care staff and 2 volunteers showed that 3 of 5 direct care staff (Staff #205, Staff #208, and Staff #209) and 2 of 2 volunteer staff (Volunteer #201 and Volunteer #202) did not complete an annual TB risk assessment. a. Staff #205’s record showed no evidence of a TB risk assessment for 2023 and 2024. b. Staff #208’s record showed no evidence of a TB risk assessment for 2023 and 2024. c. Staff #209’s record showed no evidence of a TB risk assessment for 2023 and 2024. d. Volunteer #211’s record showed no evidence of a TB risk assessment for 2024 and 2025. e. Volunteer #212’s record showed no evidence of a TB risk assessment for 2025. 3. On 05/28/26 at 10:00 AM, Surveyor #2 interviewed the Senior Director of Health and Home Care (Staff #202) about the TB risk assessment. Staff #202 stated that the TB risk assessments are managed by Human Resources (HR) and stored on Dayforce, a relatively new online HR management system. Staff #203 stated that they will ask HR to look for the missing TB risk assessments in their physical records, noting that the missing TB risk assessments are for staff who have been with the agency longer than 2 years. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 08/13/23 UNDER TAG L0579”

“Based on record review and interview, the agency failed to document Hospice Aide supervision by a Registered Nurse no less frequently than every 14 days for 3 of 14 active patients (Patient #306, #311, and #312). Failure to supervise 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 patient’s changing needs. Findings included: 1. Document review of the agency’s policy and procedure titled, “Home Hospice Aide Services and Supervision,” (Policy No. HO 820, Reviewed 01/2026) showed that the supervision of Hospice aides will be done by the agency’s 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 3 of 14 patients showed the following: a. Patient #306 was admitted on 09/22/25 with a primary diagnosis of Sepsis due to Methicillin Resistant Staphylococcus Aureus. During the benefit period from 09/22/25 to 12/20/25, the physician ordered Hospice Aide services twice per week for 13 weeks. The record showed no documentation of Hospice Aide supervision for the period of 10/20/25 to 12/01/25. During the benefit period from 03/21/26 to 05/19/26, the physician ordered Hospice Aide services twice per week for 9 weeks. The record showed no documentation of Hospice Aide Supervision for the period of 04/08/26 to 05/06/26. b. Patient #311 was admitted on 03/25/26 with a primary diagnosis of malignant neoplasm of unspecified site of left female breast. The physician ordered Hospice Aide services twice per week for 12 weeks. The record showed no documentation of Hospice Aide supervision for the period of 04/06/26 to 05/12/26. c. Patient #312 was admitted on 02/09/26 with a primary diagnosis of chronic obstructive pulmonary disease. The physician ordered Hospice Aide services twice per week for 13 weeks. The record showed no documentation of Hospice Aide supervision for the period of 02/11/26 to 03/06/26. 3. 05/29/26 at 4:30 PM, Surveyor #3 interviewed the Clinical Director (Staff #303) about the missing Hospice Aide supervision documentation. Staff #303 stated that they were unable to locate the missing supervisory visits. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 08/13/23 UNDER TAG L0629”

“Based on record review and interview, the agency failed to implement its policies and procedures to remain compliant with state licensing requirements for personnel. The agency failed to show evidence of annual performance evaluations with onsite observation of skills (Item #1) for 5 of 7 direct care staff (Staff #304, #305, #308, #309, and #310).The agency failed to show evidence of department-approved disclosure statements upon hire and every 2 years from the previous check (Item #2) for 3 of 5 direct care staff and 1 of 2 volunteers (Staff #305, #308, #309, #312). 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. References: Item #1 - 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; Item #2 -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; 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. Findings included: Item #1 - Annual Performance Evaluations 1. Document review of the agency’s policy number HO-105 titled, “Annual Performance Evaluation Policy and Procedure”, dated 5/2023, showed that annual performance evaluations will be scheduled every 12 months and qualified staff will observe and evaluate all disciplines of direct care staff performing their job duties at the frequencies defined by federal or state regulations. 2. Personnel record review of 5 of 7 direct care staff (Staff #304, Staff #305, Staff #308, Staff #309, and Staff #310) showed no documentation that the agency complete an on-site annual performance evaluation. a. Staff #304’s date of hire is 05/05/25. No evidence was found of an on-site annual performance evaluation. b. Staff #305’s date of hire is 10/21/19. No evidence was found of an on-site annual performance evaluation. c. Staff #308’s date of hire is 08/26/20. No evidence was found of an on-site annual performance evaluation. d. Staff #309’s date of hire is 09/28/16. No evidence was found of an on-site annual performance evaluation. e. Staff #310’s date of hire is 03/03/25. No evidence was found of an on-site annual performance evaluation. 3. On 05/28/26 at 1:00 PM, Surveyor #2 interviewed the Director of Clinical Services (Staff #303) about the on-site annual performance evaluation. Staff #303 stated that they are the only one that could do the on-site performance evaluation, and they did not do it because there are too many to do. Staff #303 also stated that they may be able to do the on-site evaluations after their counterpart on the Home Health side is functioning independently. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 08/13/23 UNDER TAG L0784 Item #2 - Department- approved Disclosure Statements 1. Document review of the agency’s policy number HO-510 titled, “Criminal History, Disclosure and Background Inquiries”, dated 09/08/23, showed that criminal background checks and disclosure statements will be renewed within two years from the date of the previous check. 2. The record review showed that 3 of 5 direct care staff (Staff #305, Staff #308, and Staff #309) and 1 of 2 volunteer staff (Volunteer #312) did not have evidence that the disclosure statement had been completed within 2 years of the previous disclosure statement. a. Staff #305’s date of hire is 10/21/19. Their records did not have evidence of a signed disclosure statement since 2019. b. Staff #308’s date of hire is 8/26/20. Their records did not have evidence of a signed disclosure statement since 2020. c. Staff #309’s date of hire is 09/16/16. Their records showed no evidence of a signed disclosure statement. d. Volunteer #312’s date of hire is 07/02/24. Their records showed no evidence of a signed disclosure statement. 3. On 05/28/26 at 10:00 AM, Surveyor #2 interviewed the Senior Director of Health and Home Care (Staff #302) about the missing disclosure statements. Staff #302 stated that the records are managed by Human Resources (HR), and they will ask HR to locate the missing disclosure statements. THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 08/13/23 UNDER TAG L0796”