Tahoma Hills

Based on observation, interview, and record review, provider failed to ensure one of four sampled clients (Client 2) received assistance with establishing and implementing necessary healthcare supports. This failure resulted in an unclear bowel-movement protocol and no instructions available to staff for food-preparation protocol. This failure placed clients at potential risk of health concerns that could have been preventable.

Based on interview and record review, provider failed to ensure all requirements for nurse delegation were in place for two of four sampled clients (Client 1 and Client 2). This failure resulted in written, route-specific instructions from delegating nurse, not available to staff in home for delegated medication administration tasks and no consent by clients' legal representative to delegate nursing services, and placed clients served by provider in similar situations at potential risk of harm.

Based on observation, interview, and record review, provider failed to ensure one of four sampled clients (Client 2) was treated with dignity and consideration. This failure resulted in locked thermostats in Client 2's home without Client 2's consent, or their legal representative's consent, and placed clients at potential risk of infringement of their rights.