Sails Washington INC (clark)

Provider failed to implement Plan of Correction regarding medication service, health service plans, and health service refusal plans; untrained staff failed to provide supports identified in clients' PCSP.

Facility failed to notify the case manager of a client's (Client 6) refusal of services that adversely affected health, failed to document refusal events properly, and failed to inform the client of potential risks.

Facility failed to ensure staff were nurse delegated prior to performing nursing tasks for 6 clients, placing them at risk of severe adverse medical events. Multiple untrained staff administered medications and provided medical care without required training or credentials.

Facility failed to ensure systems were in place to safeguard health and safety; unlicensed/untrained staff were observed altering medications (mixing liquid meds into milk) without provider orders.

Provider failed to implement Plan of Correction regarding reporting client refusals to case managers, informing clients of risks, and documenting events; Client 6 remained at risk.

Provider failed to implement their Plan of Correction to ensure support was provided as identified in the clients' Person-Centered Support Plan (PCSP). This is an uncorrected deficiency from October 1, 2025.

Provider failed to implement their Plan of Correction to ensure staff was reporting to the case manager, informing the client of risks, and documenting efforts to provide care. This is an uncorrected deficiency from October 1, 2025.

Provider failed to ensure a system was in place to safeguard clients' health and safety regarding medication. Six clients were placed at immediate risk as medications were not given in a safe manner, and unlicensed/untrained staff altered medications without orders.

Provider failed to ensure a system was in place to safeguard clients' health and safety in service plans, resulting in six clients at immediate risk and unauthorized medication changes by untrained staff.

Provider failed to follow medication administration systems and manage medications as prescribed for 1 client, resulting in multiple medication errors, missed doses, and unauthorized administration of PRN medication.

Provider failed to follow mandated reporting policies and internal incident reporting procedures regarding medication errors, resulting in delayed medical care and delayed notifications to guardian and DSHS.

Deficiency previously identified was corrected.

Provider failed to provide requested client records for two sample clients to the Department, resulting in an inability to complete the investigation and potentially placing clients at risk due to lack of current written instructions for staff.