facility_name: Tamarack Center

report_date: January 17, 2023

summary: State Inspection — ONGOING - ROUTINE (01/11/2023)

raw_content:
Residential Treatment Facility
Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
January 17, 2023
Tamarack Center, 2901 W Elliott Dr, Spokane, WA. 99224-5808 Tim Davis
Agency Name and Address Administrator
ONGOING - ROUTINE 01/11/2023 AAU0303
Inspection Type Inspection Onsite Dates Inspector
X2022-672 RTF.FS.00001068 Mental Health Services
Inspection Number License Number RTF Service Types
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0095 Licensing The Washington Administrative Code standard is not met as
WAC 246-337-010(8)(a) An applicant may not open evidenced by:
or operate an RTF until all requirements for licensure Based on observation and interview, Tamarack Center failed
set forth in this section are met and the department to post current RTF license in a conspicuous place on the
has issued an initial, renewed, or amended RTF premises.
license listing the service type(s) approved to be
provided in the RTF. (8) The licensee shall: (a) Failure to post license may cause individuals to not know
Maintain and post a current RTF license in a what type of treatment or services they are receiving from a
conspicuous place on the premises. licensed Residential Treatment Facility.
Findings included:
1. In an onsite survey on 1/11/2023 at 10:30 am, the licenses
posted in entryway were expired.
2. In an interview on 1/11/2023 at 12:30 pm with Staff C,
Director of Ancillary Services, he stated they had current
licenses but just had not replaced the expired ones.
0620 Management of human resources The Washington Administrative Code standard is not met as
WAC 246-337-050(5)(a) (5) The licensee must evidenced by:
document that staff receive the following training as Based on personnel record review and interview, Tamarack
applicable: (a) Initial orientation and ongoing training Center failed to document training for initial orientation and
to address the safety and health care needs of the ongoing training to address the safety and health care needs
residents served for all staff. of residents served for all staff in 3 of 5(#2, #4, #5) personnel
records reviewed.
Failure to orient staff to resident needs can result in harm for
residents and staff by not having information to serve
residents appropriately.
Finding included:
1. In a review of personnel records on 01/11/2023 at
12:00 pm, there was no documentation of orientation
training in personnel files (#2, #4, #5).
2. In an interview on 01/11/2023 with Staff B, Human
Resource Director, at 12:00pm, she said that they are
doing this training but it unable to locate
documentation at this time.
0625 Management of human resources The Washington Administrative Code standard is not met as
WAC 246-337-050(5)(b) (5) The licensee must evidenced by:
document that staff receive the following training as Based on personnel record review and interview, Tamarack
applicable: (b) Bloodborne pathogen training Center failed to document training for Bloodborne pathogen
inclusive of HIV/AIDS training for staff involved in in 2 out of 5(#4, #5) personnel files reviewed.
direct resident care or potential for having contact
with blood or body fluids. Failure to train staff for required trainings could exposed staff
and patients to blood or bodily fluids.
Findings included:
1. In a review of personnel records on 01/11/2023 at
12:00 pm, there was no documentation of blood borne
pathogen training in personnel files (#4, #5).
2. In an interview on 01/11/2023 with Staff B, Human
Resource Director, at 12:00pm, she said that they are
doing this training but it unable to locate documentation
at this time.
0780 Management of human resources The Washington Administrative Code standard is not met as
WAC 246-337-050(7)(d) (7) The licensee shall have evidenced by:
written documentation for each staff member Based on personnel record review and interview, Tamarack
including: (d) Current signed job description. Center failed to have written documentation for each staff
member including: 10(d) Current signed job description in 1
of 5 (#5) personnel records reviewed.
Failure to have job descriptions for an employee places
agency at risk for employee to not know what duties they are
expected to perform.
Finding included:
1. In a review of personnel records on 01/11/2023 at
12:00 pm, there was no documentation of blood borne
pathogen training in personnel file #5.
2. In an interview on 01/11/2023 with Staff B, Human
Resource Director, at 12:00pm, she said that they are
doing this training but it unable to locate
documentation at this time.
0785 Management of human resources The Washington Administrative Code is not met as evidenced
WAC 246-337-050(7)(e) (7) The licensee shall have by:
written documentation for each staff member Based on interview and record review, Tamarack Center
including: (e) Criminal history disclosure statement failed to have written documentation for each staff member
and results of a background check, according to WAC including a criminal history disclosure consistent with RCW
246-337-055, completed within the previous three 43.43.842 (1)(b) in 5 of 5 (#1, #2, #3, #4, #5) personnel
months of hire date and annually thereafter. records reviewed.
Failure to have criminal disclosure statements from
employees can place agency at risk for providing substandard
care.
Finding included:
1. In a review of personnel records on 01/11/2023 at
12:00 pm, there was no documentation of a criminal
disclosure in personnel files #1, #2, #3, #4, and #5.
2. In an interview on 01/11/2023 with Staff B, Human
Resource Director, at 12:00pm, she said that they are
part of process but was unable to locate
documentation at this time.
0790 Management of human resources The Washington Administrative Code standard is not met as
WAC 246-337-050(7)(f) (7) The licensee shall have evidenced by:
written documentation for each staff member Based on interview and record review, Tamarack Center
including: (f) Current license, certification, or failed to have current licenses for 2 of 6 (#4, #5) personnel
registration, if applicable. records reviewed.
Failure to ensure professional staff is currently licensed places
agency at risk to provide unlicensed care.
Findings included:
1. In a review of personnel records on 01/11/2023 at
12:00 pm, there was no documentation of current
license in personnel files #4 and #5.
2. In an interview on 01/11/2023 with Staff B, Human
Resource Director, at 12:00pm, she said that they are
doing this but was unable to locate documentation at
this time.
0810 Management of human resources The Washington Administrative Code standard is not met as
WAC 246-337-050(7)(j) (7) The licensee shall have evidenced by:
written documentation for each staff member
including: (j) Initial and ongoing tuberculosis Based on interview and record review, Tamarack Center
screening according to the facility risk assessment failed to have an initial Tuberculosis (TB) screening in 3 of
and tuberculosis written plan according to WAC 246- 5(#2, #3, #5) personnel records reviewed.
337-060.
Failure to ensure professional staff is screened for
Tuberculosis places agency at risk to spread an infectious
disease within facility.
Findings included:
1. In a review of personnel records on 01/11/2023 at
12:00 pm, there was no documentation of TB screening
in personnel files #2, #3, and #5.
2. In an interview on 01/11/2023 with Staff B, Human
Resource Director, at 12:00pm, she said that they are
doing this but was unable to locate documentation at
this time.
1060 Resident care services The Washington Administrative Code standard is not met as
WAC 246-337-080 (2)(b) (2) The licensee must:(b) evidenced by:
Conduct or accept a current health care screening of Based on record review and interview, Tamarack Center failed
each resident upon admission including a to have a Tuberculosis (TB) risk assessment for residents upon
tuberculosis risk assessment and symptom screening; admission in 1 of 3 resident records (#2) reviewed.
Failure to screen residents for Tuberculosis could place
residents at risk to be exposed to a communicable disease
within facility.
Findings included:
1. In a review of resident records on 1/11/23 at 1:30
pm, there was not a TB screen present in resident
record #2.
2. In an interview on 01/11/2023 at 1:30pm with Staff C,
Director of Ancillary Services, stated that they do TB
screenings sometimes the form may not be scanned
correctly into the record.
2145 Medication management The Washington Administrative Code standard is not met as
WAC 246-337-105(5)(b) The licensee is responsible evidenced by:
for implementing policies and procedures for the Based on patient record review and interview, Tamarack
control and appropriate use of all drugs within the Center failed to document in the medication administration
RTF in accordance with all applicable state and record the parameters of use of all medications in 3 of 3 (#1,
federal regulations. The policies and procedures to #2, #3) patient records reviewed.
implement this section must be developed,
approved, and reviewed by a health care prescriber Failure to document required elements in patient records
and the RTF administrator, and must be consistent could cause patients to receive substandard care.
with this chapter. (5) Documentation. All medications
administered, observed being self-administered, or Findings included:
involuntarily administered must be documented on 1. In a patient record review on 01/11/2023 at 1:30pm,
the medication administration record, including: (b) the Medication Administration Record (MAR) did not
Parameters of use. have parameters of drug use for all medications for
each patient record reviewed (#1, #2, #3).
2. In an interview on 01/11/2023 at 1:30pm with Staff C,
Director of Ancillary Services, stated he observed in
the MAR some of the medications had the
parameters of use but not for all of them.
2440 Food and nutrition services The Washington Administrative Code standard is not met as
WAC 246-337-111(2) Meals must meet resident evidenced by:
nutritional needs, and are stored, prepared and Based on observation, Tamarack Center failed to post current
served in accordance with chapter 246-215 WAC. The food handlers permits in the kitchen.
licensee shall: (2) Post current food handlers permits
in the kitchen. Failure to have current and/or up-to-date food worker cards
may result in unqualified/unauthorized food worker(s)
preparing/handling food.
Findings included:
1. In an observation on 01/11/2023 at 11:15am, the
facility did not have current kitchen workers food
handlers card posted in kitchen.
2495 Food and nutrition services The Washington Administrative Code standard is not met as
WAC 246-337-111(13) Meals must meet resident evidenced by:
nutritional needs, and are stored, prepared and
served in accordance with chapter 246-215 WAC. The Based on observation and interview, Tamarack Center failed
licensee shall: (13) Use commercial appliances if the to have a working commercial Warewashing equipment
kitchen provides meals for more than sixteen present in their facility because the kitchen provides meals
residents. A licensed RTF with sixteen or fewer for sixteen residents.
residents may use domestic or home-type kitchen
appliances. Domestic and home-type equipment Failure to not have working equipment present in facility can
must meet sanitation requirements of chapter 246- cause harm to residents by not properly washing or sanitizing
215 WAC. dishes for residents.
Finding included:
1. In an observation on 01/11/2023 at 11:15 am, the
kitchen sinks did not have a commercial dishwasher
present or working.
2. In an interview on 01/11/2023 with Staff A, Food
Employee, stated the dishwasher had broken a few
months ago but the facility was in process of getting a
new one soon.
U2405 Utensils, temperature measuring devices, and The Washington Administrative Code standard is not met as
testing devices-Sanitizing solutions, testing devices evidenced by:
(FDA Food Code 4-302-14) Based on observation and interview, Tamarack Center failed
WAC 246-215-04345 A test kit or other device that to provide a test kit or other device to accurately measure the
concentration of sanitizing solutions used in the kitchen and
accurately measures the concentration in mg/L of
dining room.
SANITIZING solutions must be provided.
Failure to properly sanitize food and nonfood-contact
surfaces can result in adverse impacts to residents and staff.
Findings included:
1. In an observation on 01/11/2023 at 11:15am, the facility
staff did not have chlorine and/or quaternary ammonia
test strips or a test kit available for measuring the
concentration of sanitizing solutions.
2. In an interview 1/11/2023 at 11:15 am, Staff A, Food
Employee, stated that they did not have a test kit or
other device to measure the concentration of sanitizing
solutions.
U2805 Objective-Food contact surfaces and utensils The Washington Administrative Code standard is not met as
(FDA Food Code 4-701.10) evidenced by:
WAC 246-215-04700 EQUIPMENT, FOOD-CONTACT Based on observation, Tamarack Center failed to provide a
SURFACES, and UTENSILS must be SANITIZED. means to sanitize food contact surfaces and utensils.
Failure to sanitize food contact surfaces and utensils may
result in a foodborne illness and/or adverse outcomes for
staff and residents.
Findings included:
1. In an observation on 01/11/2023 at 11:15am, the
facility did not have any sanitizing means.
2. In an interview 1/11/2023 at 11:15 am, Staff A, Food
Employee, stated that they did not have a test kit or
other device to measure the concentration of
sanitizing solutions.
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
You are required to respond to the Inspection Report with Noted Deficiencies by submitting a plan of correction (POC). Be sure to refer to the
deficiency number. If you include exhibits, identify them and refer to them as such in your POC.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in
compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction must
include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the deficiency.
Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to accomplish total
correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to accomplish correction; the target
completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the correction of
the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page number to
which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your inspection report you
will be sent a letter detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification, or have questions about deficiencies you must contact the inspector who
conducted the onsite inspection, or you may contact the supervisor.
Department of Health – Written Plan of Correction – January, 2023
The following items will list the regulation number; identify how the deficiency
was corrected, who is responsible for the correction, when the correction will be
completed, and how we will assure the deficiency has been successfully
corrected.
Regulation Number – 0095 – Licensing
How corrected – Current license was posted in the front of the office building
Who is responsible – Tim Davis
Completed – 1/18/2023
Successfully completed – Yes, posted
Regulation Number – 0620 – Management of Human Resources
How corrected – Tamarack has designated Sarah Kopp, Therapy Director to
design, implement, and follow up on a comprehensive on boarding orientation
program for all new employees. This program will apply to all new employees and
will be conducted by several senior employees, including the Board of Directors.
This program has been previously designed but was not implemented across all
employees and the documentation of completion has been inconsistent.
Who is responsible – Sarah Kopp
Completed – No –no new employees have been hired in the last three months.
Current employees that have training deficiencies have been identified and have
individually addressed.
Successfully completed – Tim Davis and Stephanie Weitman will monitor the on
boarding process. Tim will see who is initially scheduled for what part of their
orientation. Stephanie will monitor personnel files to see they are complete.
Regulation Number – 0625 – Management of Human Resources
How corrected – All employee personnel files have been reviewed to see that
current Blood Borne pathogen training has been completed. Those files that are
incomplete and notified the training needs to be completed. The training is a
computer-based training with a pre and posttest. Employees are given two weeks
to complete the training.
Who is responsible – Initially, each employees immediate supervisor. That list is
Tim Davis, Mark Holmes, Sarah Kopp, and Tammy Carruthers.
Stephanie Weitman, business assistant will compile the test and report any
employee who has not completed the training.
Completed – Five employees have not completed the training.
Successfully completed – Stephanie will monitor personnel files, with a check list,
to ensure all training are complete. She will do this twice a year.
Regulation Number – 0780 – Management of Human Resources
How corrected – All personnel files will be reviewed to ensure current job
descriptions are placed in each file. Our annual performance evaluation system
uses the job description as a document to measure performance.
Who is responsible – Each employees immediate supervisor (see above list).
Stephanie Weitman will do a comprehensive review of each file to ensure all
documents are present.
Completed- All personnel files have a copy of the job description
Successfully completed – After hire, Stephanie will ensure all new employees have
a job description in their file.
Regulation Number- 0785 – Management of Human Resources
How corrected – All employees have had a criminal background check completed
and placed in their file.
Who is responsible – Stephanie Weitman, business associate will conduct a
criminal background check on each new employee and place it in their file.
Completed – Yes, all employees and volunteers have had a criminal background
check and it is placed in their file.
Successfully completed – Stephanie will do twice a year audits to ensure all files
are complete.
Regulation Number – 0790 – Management of Human Resources
How Corrected – All licensed employees are currently licensed. This has been
verified by the State of Washington web site. Current licenses are then placed in
the personnel file.
Who is responsible – Immediate supervisors are responsible to see that their
employees are currently licensed (see above list).
Stephanie will send out a reminder to all licensed employees two months before
expiration that their license is due.
Completed – Yes, all licensed employees are currently licensed.
Successful completion – Stephanie will monitor each file monthly to ensure
current licensure is maintained.
Regulation Number – 0810 – Management of Human Resources
How corrected – All staff have been reviewed to ensure current TB testing. Those
staff that have not been recently tested are scheduled for a test. Documentation
will be placed in the personnel file.
Who is responsible –Tammy Carruthers, Director of Nursing
Completed - No some employees need current TB test
Successful completion – Tammy will ensure all employees are tested and then will
test all new employees.
Stephanie will send out monthly reminders for people who need to be tested.
Stephanie will then audit personnel files to ensure documentation is in the files.
Regulation Number – 1060 – Resident Care Services
How corrected – All newly admitted resident will have a TB test upon admission.
Who is responsible – Tammy Carruthers, Director of Nursing
Completed – Yes, all residents have current testing
Successful completion – Tammy will monitor the resident’s record to ensure
documentation of TB teat is in the record. She will do this for each new admission.
Regulation Number – 2145 – Medication Management
How Corrected – Medical Director, Dr. Lavy, was informed, that “mood” was
insufficient as a parameter for drug use. He immediately started using a more
descriptive description for the parameters for drug use.
Who is responsible – Dr. Lavy
Completed – Yes. He changed his parameters on the day he was notified and has
remained consistent with that pattern.
Successful completion – Tammy Carruthers, Director of Nursing will review and
ensure all documentation is correct.
Regulation Number – 2440 – Food and Nutrition Services
How Corrected – Current food handlers cards are posted in the kitchen.
Who is responsible – Mark Holmes, Ancillary Services Director
Completed – Yes, they are posted
Successful Completion – Mark will ensure they are posted. If a new person is
hired, he will ensure their card is posted as well.
Regulation Number – 2495 – Food and Nutrition Services
How Corrected – A new dishwasher was installed on 1/26/23. This is a new,
commercial dishwasher.
Who is responsible – Tracy Evans, Facility Director
Tim Davis, Executive Director
Completed – Yes – on 1/26/23
Successful Completion – Tamarack kitchen staff will monitor the equipment daily
and inform Tracy if something is not working and needs repair.
Regulation Number – U2405 – Utensils, temperature, measuring devices, and
testing devices
How Corrected – Test strips were purchased and now available in the kitchen.
Who is responsible – Mark Holmes, Ancillary Director
Completed – Yes, completed on 1/11/23.
Successful Completion – Tamarack kitchen staff will use the test strips daily. They
will inform Mark when they are running low so he can purchase new strips.
Regulation Number – U2805 – Objective Food contact surface and utensils
How Corrected – Test strips were purchased to measure the cleaning solution
used to clean surfaces. The strips will be used each time the solution is used.
Who is responsible – Mark Holmes, Ancillary Director
Completed – Yes, strips are used daily with the cleaning solution.
Successful Completion – Tamarack kitchen staff will clean the surfaces several
times a day. They will use the testing stripes to ensure safety. When running low
on stripes, they will contact Mark to buy more stripes.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
February 15, 2023
Tim Davis
Tamarack Center Inc
2901 W Elliot Dr
Spokane, WA 99224-5808
Subject: Inspection Number X2022-672
Dear Mr. Davis,
The Washington State Department of Health conducted an inspection of Tamarack Center
Inc, 2901 W Elliot Dr., Spokane, WA 99224-5808. Your state licensing on-site inspection was
completed on 01/11/2023. The Plan of Correction that was submitted on 01/26/2023 was
approved on 02/15/2023. No further action is required.
I sincerely appreciate your cooperation and hard work during the inspection process and
look forward to working with you again in the future.
Sincerely,
Amy Umberger, LICSW
Behavioral Health Reviewer
Office of Health System Oversight
Health Systems Quality Assurance
Washington State Department of Health

administrator: Tim Davis

service_types: Mental Health Services


state: WA

summary: State Inspection — ONGOING - ROUTINE (05/18/2021)

raw_content:
Residential Treatment Facility
Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
May 26, 2021
Tamarack Center, 2901 W Elliott Dr, Spokane, WA. 99224-5808 Tim Davis
Agency Name and Address Administrator
ONGOING - ROUTINE 05/18/2021 AAU0303
Inspection Type Inspection Onsite Dates Inspector
X2021-366 RTF.FS.00001068 Mental Health Services
Inspection Number License Number RTF Services Types
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0605 Management of human resources The Washington Administrative Code standard is not met as
WAC 246-337-050(5)(b) (5) The licensee must evidenced by:
document that staff receive the following training as Based on personnel record review and interview, Tamarack
applicable:(b) Bloodborne pathogen training inclusive Center failed to document training for Bloodborne pathogen
of HIV/AIDS training for staff involved in direct in 6 out of 6 (#1, #2, #3, #4, #5, #6) personnel files reviewed.
resident care or potential for having contact with
blood or body fluids; Failure to train staff for required trainings could exposed staff
and patients to blood or bodily fluids.
Findings included:
1. In a review of personnel records on 05/18/2021 at 1:30
pm, there was no documentation of blood borne
pathogen training in personnel files (#1, #2, #3, #4, #5,
#6).
2. In an interview on 05/18/2021 with Staff B, Director of
Nursing, at 2:00pm, he said that they stopped doing
this training because they did not think it was required
any longer.
1540 Medication management The Washington Administrative Code standard is not met as
WAC 246-337-105(5)(b) The licensee is responsible evidenced by:
for implementing policies and procedures for the Based on patient record review and interview, Tamarack
control and appropriate use of all drugs within the Center failed to document in the medication administration
RTF in accordance with all applicable state and record the parameters of use of all medications in 5 of 6 (#1,
federal regulations. The policies and procedures to #3, #4, #5, #6) patient records reviewed.
implement this section must be developed,
approved, and reviewed by a health care prescriber Failure to document required elements in patient records
and the RTF administrator, and must be consistent could cause patients to receive substandard care.
with this chapter.(5) Documentation. All medications
administered, observed being self-administered, or Findings included:
involuntarily administered must be documented on 1. In a patient record review on 05/18/2021 at 10:00am,
the medication administration record, including:;(b) the Medication Administration Record (MAR) did not
Parameters of use; have parameters of drug use for all medications for
each patient record reviewed (#1, #3, #4, #5, #6).
2. In an interview on 04/08/2021 at 11:00am with Staff
B, Director of Nursing, stated he observed in the MAR
some of the medications had the parameters of use,
PRN Medications, but not for all of them.
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
You are required to respond to the Inspection Report with Noted Deficiencies by submitting a plan of correction (POC). Be sure to refer to the
deficiency number. If you include exhibits, identify them and refer to them as such in your POC.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in
compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction must
include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the deficiency.
Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to accomplish total
correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to accomplish correction; the target
completion date, however, should be within a reasonable and mutually agreeable time-frame.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the correction of
the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page number to
which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your inspection report you
will be sent a letter detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification, or have questions about deficiencies you must contact the inspector who
conducted the onsite inspection, or you may contact the supervisor.
Umberger, Amy (DOH)
From: Tim Davis <TDavis@TAMARACK.ORG>
Sent: Tuesday, June 22, 2021 2:10 PM
To: Umberger, Amy (DOH)
Subject: Tamarack Plan for recent Inspection
External Email
Amy – Please allow this to stand as Tamarack’s response to our recent inspection. I apologize for the late response.
1 – Regulation number – 0650 Management of Human resources
Correction – A agency wide training/education model has been designed for all employees to participate on line. This
training includes a pre and posttest. It includes all required material.
Person responsible – Jason Longshore, R.N. – Director of Nursing
Chris DalPra – Assistant Director will track and monitor its completion for the individuals
personnel file.
When completed – June 9, 2021
Monitoring – Chris will do this through our HR electronic program.
2 – Regulation Number – 1540 Medication management
Correction – All medications prescribed will be documented with the purpose of the medication. The parameters for
use of each medication will be documented.
Person responsible – Both physicians, Dr. Emch and DR. Lavy will state the purpose of the medication. Jason
Longshore will oversee that all documentation is correct.
When completed – This practice went into effect on June 1, 2021
Monitoring – Jason will review Dr.s orders weekly to ensure proper documentation is listed. Overnight staff monitor
daily for correct/incorrect orders.
3 – Regulation number – 0960 – Personnel Agency record
Correction – The duty to warn will be added to all new employees formal orientation form. This will be discussed
during their orientation.
Person Responsible – Orientation is done by a person’s immediate supervisor. Each supervisor covers some basic
material as well as job specific material. Currently, these supervisors include – Dr. DalPra. Jason Longshore, Mark
Holmes, and Chris DalPra.
When completed – The orientation forms have been changed to include this new material. We have not hired new
personnel since the review.
Monitoring – This will be part of Human Resources (Chris) responsibility to ensure all requirements are met for
someone to come off orientation.
4 – Regulation Number – 1415 – Clinical Add record content
Correction – A list has been developed of all direct care staff (Counselors, R.N., Licensed Therapist, and Certified
Recreation Specialists) credentials and other disclosure requirements. This list is given to residents upon admission.
Person Responsible – Chris DalPra, Assistant Director
When completed – This list was finalized on June 11, 2021.
Monitoring – The list will be included in the intake package given to all new residents.
5 – Regulation Number – 1430 Clinical Add Record content
Correction – Added to the psychosocial, conducted upon admission, is a box to check if the resident is currently
under the Department of Corrections supervision.
Person Responsible – Dr. Ellen DalPra adjusted the form
When completed – June 15,2021
Monitoring – All psychosocials are reviewed for content (Dr. DalPra) and timeliness (overnight staff).
1
6 – Regulation Number – 1435 – Clinical Add record content
Correction – Added to the psychsocial, conducted upon admission, is a box to check if the resident is under civil or
criminal court commitment.
Person responsible – Dr. DalPra adjusted the form
When completed – June 15, 2021
Monitoring – All psychosocials are reviewed for content (Dr. DalPra) and timeliness (overnight staff).
7 – Regulation Number – 1440 – Clinical Add record content
Correction – Added to psychsocial, conducted upon admission, is a box to check if the resident has a court order
exempting the individual participant from reporting requirements.
Person Responsible – Dr. DalPra adjusted the form
When completed – June 15, 2021
Monitoring – All psychosocials are reviewed for content( Dr. DalPra) and timeliness (overnight staff).
I trust you find this complete. Please don’t hesitate to contact me if I can provide further assistance.
Tim Davis
This e-mail and any files transmitted with it are intended only for the addressee. It may contain information that is
privileged, confidential, or otherwise protected from disclosure under terms of State and/or Federal law. You may not
disclose any of this information to any other party without first obtaining the consumer’s consent or the proper judicial
order. Any review, dissemination or use of this e-mail transmission or its contents by persons other than the addressee is
strictly prohibited. If you have received this e-mail transmission in error, please notify the sender immediately by replying
to the e-mail. Violation may result in civil and/or criminal penalties.
2
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
June 22, 2021
Tim Davis
Tamarack Center Inc
2901 W Elliot Dr
Spokane, WA 99224-5808
Subject: Inspection Number X2021-366
Dear Mr. Davis,
The Washington State Department of Health conducted an inspection of Tamarack Center
Inc, 2901 W Elliot Dr., Spokane, WA 99224-5808. Your state licensing on-site inspection was
completed on 05/18/2021. The Plan of Correction that was submitted on 06/22/2021 was
approved on 06/22/2021. No further action is required.
I sincerely appreciate your cooperation and hard work during the inspection process and
look forward to working with you again in the future.
Sincerely,
Amy Umberger, LICSW
Behavioral Health Reviewer
Office of Health System Oversight
Health Systems Quality Assurance
Washington State Department of Health

report_type: Inspection Report

inspection_type: ONGOING - ROUTINE


report_date: December 14, 2020

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
December 14, 2020
Tamarack Center
2901W. Elliot Dr.
Spokane, WA. 99224-5808
Re: Complaint Investigation
Case Number: 2020-14888 and 2020-14889
License Number: BHA.FS.60873239, RTF.FS.00001068
Date(s) of Investigation: 11/19/20
Dear Administrator:
The State of Washington Department of Health recently completed an investigation of Twnarack
Center on November 19, 2020.
No current deficiencies were identified during this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: 42124
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


facility_name: Two Rivers Landing

report_date: January 30, 2025

summary: State Inspection

raw_content:
Residential Treatment Facility
Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
January 30, 2025
Two Rivers Landing, 504 S 3rd Ave, Yakima, WA. 98902-3543 Edie Dibble
Agency Name and Address Administrator
ONGOING - ROUTINE 10/14/24 GLD03/ DEC13
Inspection Type Inspection Onsite Dates Inspector
X2024-799 RTF.FS.60068796 Mental Health Services,
Inspection Number License Number RTF Service Types
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0630 Management of human resources Based on personnel record review, and interview, it was How the Deficiency Will Be
WAC 246-337-050(5)(c)(i) (5) The licensee must determined the agency failed to ensure staff completed Corrected:
document that staff receive the following initial training that included proper and safe use of • All Residential and Inpatient
training as applicable: (c) If restraint or seclusion restraint or seclusion including techniques to identify staff receive an initial ProACT
is used in the facility, initial and annual training in staff and resident behaviors, events, and environmental training as well as annual
the proper and safe use of restraint or seclusion factors that may trigger circumstances that require the boosters.
for staff required to perform restraint or use of restraint or seclusion. • The ProACT training covers all
seclusion procedures inclusive of: (i) Techniques elements of WAC 246-337-
to identify staff and resident behaviors, events, Failure to ensure staff are competent by training, 050(5)(c).
and environmental factors that may trigger experience and capability places the client at risk • HR will ensure that the initial
circumstances that require the use of restraint or significant of harm. ProACT training is scheduled on
seclusion. date of hire, to be completed
Findings included: within 90-days of hire.
1. Review of P&Ps submitted failed to address • New evening ProACT training
orientation training and staff training plans. times have been established to
accommodate night shift staff.
2. Review of the personnel record for Staff A, RN, date • ProACT training is now offered
of hire 06/05/23, showed no techniques to identify staff more frequently.
and resident behaviors, events, and environmental
factors that may trigger circumstances that require the Who is responsible:
use of restraint or seclusion training completed until • Senior Vice President for
ProACT training on 10/11/24, 16 months after hire. Human Resources
• VP for Residential and Inpatient
3. Review of the personnel record for Staff, B, BHA, date Services and acting Program
of hire 07/10/23, showed no techniques to identify staff Manager for Two Rivers Landing
and resident behaviors, events, and environmental
factors that may trigger circumstances that require the Date of Correction:
use of restraint or seclusion until ProACT training on • Completed as of 2/10/25.
12/20/23, five months after hire.
Monitors put in place to assure
4. During an interview on 10/14/24 at 10:26 AM with
continuing compliance:
Staff, H, HR, they indicated they do not know why the • Relias (our online training
training would not have been completed. They did
system) will automatically send
indicate the staff may have had to wait until the agency
supervisors pending and
had a trainer scheduled to provide the training.
overdue training reminders on a
weekly basis.
0635 Management of human resources Based on personnel record review, and interview, it was See correction plan above.
WAC 246-337-050(5)(c)(ii) (5) The licensee must determined the agency failed to ensure staff completed
document that staff receive the following initial training that include proper and safe use of
training as applicable: (c) If restraint or seclusion restraint or seclusion, including the use of nonphysical
is used in the facility, initial and annual training in intervention skills.
the proper and safe use of restraint or seclusion
for staff required to perform restraint or Failure to ensure staff are competent by training,
seclusion procedures inclusive of: (ii) The use of experience and capability places the client at risk
nonphysical intervention skills. significant of harm.
Findings included:
1. Review of P&Ps submitted failed to address
orientation training and staff training plans.
2. Review of the personnel record for Staff A, RN, date
of hire 06/05/23, showed no use of nonphysical
intervention skills training completed until ProACT
training on 10/11/24, 16 months after hire.
3. Review of the personnel record for Staff B, BHA, date
of hire 07/10/23, showed no use of nonphysical
intervention skills until ProACT training on 12/20/23,
five months after hire.
4. During an interview on 10/14/24 at 10:26 AM with
Staff H, HR, they indicated they do not know why the
training would not have been completed. They did
indicate the staff may have had to wait until the agency
had a trainer scheduled to provide the training.
0640 Management of human resources Based on personnel record review, and interview, it was See correction plan above.
WAC 246-337-050(5)(c)(iii) (5) The licensee must determined the agency failed to ensure staff completed
document that staff receive the following initial training that included proper and safe use of
training as applicable: (c) If restraint or seclusion restraint or seclusion, including choosing the least
is used in the facility, initial and annual training in restrictive intervention based on an individualized
the proper and safe use of restraint or seclusion assessment of the resident's medical or behavioral
for staff required to perform restraint or status or condition.
seclusion procedures inclusive of: (iii) Choosing
the least restrictive intervention based on an Failure to ensure staff are competent by training,
individualized assessment of the resident's experience and capability places the client at risk
medical or behavioral status or condition. significant of harm.
Findings included:
1. Review of P&Ps submitted failed to address
orientation training and staff training plans.
2. Review of the personnel record for Staff A, RN, date
of hire 06/05/23, showed no training that included,
choosing the least restrictive intervention based on an
individualized assessment of the resident's medical or
behavioral status or condition until ProACT training on
10/11/24, 16 months after hire.
3. Review of the personnel record for Staff B, BHA, date
of hire 07/10/23, showed no training that included
choosing the least restrictive intervention based on an
individualized assessment of the resident's medical or
behavioral status or condition until ProACT training on
12/20/23, five months after hire.
4. During an interview on 10/14/24 at 10:26 AM with
Staff H, HR, they indicated they do not know why the
training would not have been completed. They did
indicate the staff may have had to wait until the agency
had a trainer scheduled to provide the training.
0645 Management of human resources Based on personnel record review, and interview, it was See correction plan above.
WAC 246-337-050(5)(c)(iv) (5) The licensee must determined the agency failed to ensure staff complete
document that staff receive the following initial training that included the safe application and use
training as applicable: (c) If restraint or seclusion of all types of restraint or seclusion used in the RTF,
is used in the facility, initial and annual training in including training in how to recognize and respond to
the proper and safe use of restraint or seclusion signs of physical and psychological distress.
for staff required to perform restraint or
seclusion procedures inclusive of: (iv) The safe Failure to ensure staff are competent by training,
application and use of all types of restraint or experience and capability places the client at risk
seclusion used in the RTF, including training in significant of harm.
how to recognize and respond to signs of
physical and psychological distress. Findings included:
1. Review of P&Ps submitted failed to address
orientation training and staff training plans.
2. Review of the personnel record for Staff A, RN, date
of hire 06/05/23, showed no training that included the
safe application and use of all types of restraint or
seclusion used in the RTF, including training in how to
recognize and respond to signs of physical and
psychological distress until ProACT training on 10/11/24,
16 months after hire.
3. Review of the personnel record for Staff B, BHA, date
of hire 07/10/23, showed no training that included the
safe application and use of all types of restraint or
seclusion used in the RTF, including training in how to
recognize and respond to signs of physical and
psychological distress until ProACT training on 12/20/23,
five months after hire.
4. During an interview on 10/14/24 at 10:26 AM with
Staff H, HR, they indicated they do not know why the
training would not have been completed. They did
indicate the staff may have had to wait until the agency
had a trainer scheduled to provide the training.
0650 Management of human resources Based on personnel record review, and interview, it was See correction plan above.
WAC 246-337-050(5)(c)(v) (5) The licensee must determined the agency failed to ensure staff completed
document that staff receive the following initial training that included clinical identification of
training as applicable: (c) If restraint or seclusion specific behavioral changes that indicate that restraint
is used in the facility, initial and annual training in or seclusion is no longer necessary.
the proper and safe use of restraint or seclusion
for staff required to perform restraint or Failure to ensure staff are competent by training,
seclusion procedures inclusive of: (v) Clinical experience and capability places the client at risk
identification of specific behavioral changes that significant of harm.
indicate that restraint or seclusion is no longer
necessary. Findings included:
1. Review of P&Ps submitted failed to address
orientation training and staff training plans.
2. Review of the personnel record for Staff A, RN, date
of hire 06/05/23, showed no training that included
clinical identification of specific behavioral changes that
indicate that restraint or seclusion is no longer
necessary until ProACT training on 10/11/24, 16 months
after hire.
3. Review of the personnel record for Staff B, BHA, date
of hire 07/10/23, showed no training that included
clinical identification of specific behavioral changes that
indicate that restraint or seclusion is no longer
necessary until ProACT training on 12/20/23, five
months after hire.
4. During an interview on 10/14/24 at 10:26 AM with
Staff H, HR, they indicated they do not know why the
training would not have been completed. They did
indicate the staff may have had to wait until the agency
had a trainer scheduled to provide the training.
0655 Management of human resources Based on personnel record review, and interview, it was See correction plan above.
WAC 246-337-050(5)(c)(vi) (5) The licensee must determined the agency failed to ensure staff completed
document that staff receive the following initial training that included monitoring the physical and
training as applicable: (c) If restraint or seclusion psychological well-being of the resident who is
is used in the facility, initial and annual training in restrained or secluded including, but not limited to,
the proper and safe use of restraint or seclusion respiratory and circulatory status, skin integrity, and
for staff required to perform restraint or vital signs.
seclusion procedures inclusive of: (vi) Monitoring
the physical and psychological well-being of the Failure to ensure staff are competent by training,
resident who is restrained or secluded including, experience and capability places the client at risk
but not limited to, respiratory and circulatory significant of harm.
status, skin integrity, and vital signs.
Findings included:
1. Review of P&Ps submitted failed to address
orientation training and staff training plans.
2. Review of the personnel record for Staff A, RN, date
of hire 06/05/23, showed no training that included
monitoring the physical and psychological well-being of
the resident who is restrained or secluded including, but
not limited to, respiratory and circulatory status, skin
integrity, and vital signs until ProACT training on
10/11/24, 16 months after hire.
3. Review of the personnel record for Staff B, BHA, date
of hire 07/10/23, showed no training that included
monitoring the physical and psychological well-being of
the resident who is restrained or secluded including, but
not limited to, respiratory and circulatory status, skin
integrity, and vital signs until ProACT training on
12/20/23, five months after hire.
4. During an interview on 10/14/24 at 10:26 AM with
Staff H, HR, they indicated they do not know why the
training would not have been completed. They did
indicate the staff may have had to wait until the agency
had a trainer scheduled to provide the training.
0800 Management of human resources Based on personnel record review and interviews, it was How the Deficiency Will Be
WAC 246-337-050(7)(h) (7) The licensee shall determined that the agency failed to ensure all staff Corrected:
have written documentation for each staff required by position description to have a current Our policy on “Food Preparation in
member including: (h) Current Washington state Washington state food and beverage permit was kept Comprehensive Healthcare
food and beverage service worker permit, if current. Residential Facilities” (PC-058) will
applicable. be updated to indicate that a food
Failure to ensure staff permits are current places clients and beverage permit will be up to
at risk of harm due to staff providing food and beverage date and posted for all staff
service they are not credentialed to provide. involved in food preparation.
Findings included: During onboarding, food and
beverage permits will be collected
from the employee. If an employee
1. No P&P was submitted for review at the time of this does not have a current permit, the
writing. employee will have 7 days to
complete the training and present
2. Review of personnel records for Staff C, BHA showed the current permit.
a food handlers card that expired as of 06/17/24.
Who is responsible:
3. During an interview on 10/14/24 at 10:26 AM with • Senior Vice President for
Staff H, HR, they stated they were unable to find a Human Resources
current card for the staff member and there is a system • VP for Residential and Inpatient
in place to remind and receive the current card. services and acting Program
Manager for Two Rivers Landing
Date of Correction:
• Policy updated: By 2/28/2025
• Relias reminder changed from
30 days to 7 days: By
2/14/2025
Monitors put in place to assure
continuing compliance:
• All current staff records will be
reviewed to confirm food and
beverage permit is in personnel
file and current.
• Copies of the current permits
will be posted in the kitchen.
• Relias (our online training
system) will automatically send
supervisors pending and
overdue permits notification on
a weekly basis.
0805 Management of human resources Based on personnel record review and interviews, it was How the Deficiency Will Be
WAC 246-337-050(7)(i) (7) The licensee shall determined that the agency failed to ensure all staff Corrected:
have written documentation for each staff required by position description to have a current A copy of our current Vehicle Use
Washington driver’s license was kept current. Policy (HR-023) that covers when
member including: (i) Current driver's license, if employees must submit a driver’s
applicable. Failure to ensure staff licenses are current places clients license is included with this
at risk of harm due to staff providing transportation submission.
services with no valid driver’s license.
The submission of updated driver’s
Findings included: licenses is tracked in Relias (our
online reporting system).
1. No P&P was submitted for review at the time of this
writing. Who is responsible:
• Senior Vice President for
2. Review of personnel records for Staff B, BHA showed Human Resources
a food handlers card that expired as of 06/17/24.
Date of Correction:
3. During an interview on 10/14/24 at 10:26 AM with Completed as of 2/10/25.
Staff H, HR, they stated they were unable to find a
current card for the staff member and there is a system Monitors put in place to assure
in place to remind and receive the current card. continuing compliance:
• Relias (our online training
system) will automatically send
supervisors pending and
overdue notices when
employees are required to
submit a current driver’s license
on a weekly basis.
NOTE: The findings described in the
column to the left refer to food
handler’s cards, not missing driver’s
licenses. See the corrective action
plan above regarding the corrective
action plan for food handlers
permits.
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
You are required to respond to the Inspection Report with Noted Deficiencies by submitting a plan of correction (POC). Be sure to refer to the
deficiency number. If you include exhibits, identify them and refer to them as such in your POC.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency.
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited.
• The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in
compliance with the regulatory requirements.
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction must
include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coinciding with the amount of time your facility will need to correct the deficiency.
Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to accomplish total
correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to accomplish correction; the target
completion date, however, should be within a reasonable and mutually agreeable timeframe.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the correction of
the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page number to
which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your inspection report,
you will be sent a letter detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification or have questions about deficiencies you must contact the inspector who
conducted the onsite inspection, or you may contact the supervisor.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
2/18/2025
Edie Dibble
Two Rivers Landing
PO Box 959
Yakima, WA 98907-0959
Re: Exam Number: X2024-799
License Number: RTF.FS.60068796
Approved Plan of Correction
Date(s) of Inspection: 10/2/24-11/26/24
Dear Administrator:
This letter is to inform you that after careful review of the Plan of Correction (POC) you
submitted for the exam recently conducted at your facility, the Department has determined that
the POC is approved.
Based on the scope and severity of the deficiencies listed in your statement of deficiency report,
the Department will not conduct an announced follow-up compliance visit to verify that all
deficiencies have been corrected.
Reviewer:
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874

administrator: Edie Dibble


summary: State Inspection


summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
July 11, 2024
Comprehensive Healthcare
504 3rd Ave
Yakima, WA 98902
Re: Complaint Investigation
Case Number: 2023-13265 BHA & 2023-13266
License Number: BHA.FS.60873007 & RTF.FS.60068796
To Whom It May Concern:
The State of Washington Department of Health recently completed an investigation of
Comprehensive Healthcare on May 3, 2024.
No current deficiencies were identified, and a Statement of Deficiency report will not be issued.
Please retain a copy of this letter of no deficiency for your files.
Thank you for your time and assistance during this investigation.
Investigator: BTS03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


report_date: September 25, 2020

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
September 25, 2020
Two Rivers Landing
504 South 3Fd Avenue
Yakima,WA 98902-3543
Re: Complaint Investigation
Case Number: 2020-2252
License Number: RTF.FS.60068796
Dafe(s) of Investigation: 09/08/2020
Dear Administrator:
The State of Washington Department of Health recently completed an investigation of Two
Rivers Landing on September 8, 2020.
No current deficiencies were identified during this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: JAMC03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

deficiencies: WAC 246-337-075(2)(a) Resident Based on record review, policy and Staff members at Two Rivers Rights. The licensee must establish a procedure review,and interview, the Landing were trained on process to ensure resident rights are facility failed to ensure the resident supervision of clients while on protected in compliance with was free of abuse. outings and outside of the unit chapter 7312 RCW/ this chapter, and to include while being other applicable laws, and are based Failure to ensure the resident is free of transported in the van. Staff on the service types provided in the abuse may result in patient harm. members were trained by

deficiencies: WAC 246-341-0200 (see Definitions below) or as otherwise specified in the MCO or ASO contract. • The Risk Manager/ or designee/ will report to the Department of Health within one business day the death/ not on Comprehensive Healfchcare s premises/ of any mdividual enrolled in Opiate Treatment Program services within one day of receiving notice of the individuals death using the BHA Critical Incident Reportmg webpage: https://forti'ess.wa.gov/doh/opuTio/s?s=OTPDeathReportmg • The Risk Manager/ supervising Director or VP/ or designee of Residential or E&T Services will report to

deficiencies: WAC 246-341-0200) Refers to any of the following events to be reported to the department/ MCO or ASO/ as applicable/ within one busmess day of the critical incident: (1) Any death/ serious injury/ or sexual assault that occurs at an agency that is licensed by the deparhnent; (2) Alleged abuse or neglect of an individual receivmg services/ that is of a serious or emergency nature/ by an employee/ volunteer/ licensee/ contractor/ or another individual receiving services;


report_date: January 29, 2025

summary: State Inspection — ONGOING - ROUTINE (10/14/24)

raw_content:
Behavioral Health Agency Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
January 29, 2025
Comprehensive Healthcare - Two Rivers Landing, 504 S 3rd Ave, Yakima, WA.
98902-3543 Edie Dibble
Agency Name and Address Administrator
ONGOING - ROUTINE 10/14/24-11/14/24 GLD03/DEC13
Inspection Type Inspection Onsite Dates Inspector
X2024-800 BHA.FS.60873007
Inspection Number License Number
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
0695 Personnel-Agency record requirements Based on personnel record review, policy, and How the Deficiency Will Be
WAC 246-341-0510(1)(iii) A behavioral health procedure (P&P) review, and interview it was Corrected:
agency must maintain a personnel record for determined the agency failed to maintain a personnel • The Client Right attestation
each person employed by the agency. (1) The record for each employee that contained a record of form has been updated to
personnel record must contain all of the orientation within 90 days of hire that included the reflect current client rights as
following: (c) A record of an orientation to the process for resolving client complaints and grievances. well as additional references
agency within 90 days of hire that includes all of and information regarding the
the following: (iii) The process for resolving client Failure to meet this WAC standard places clients at risk following policies:
concerns. due to staff not having an understanding of client’s Client Advocate (RI-007)
o
rights to file a complaint or grievance or the steps to Client Concerns &
o
follow in the case of a complaint or grievance filed by Grievances (RI-001)
the client. • All new employees will sign this
updated form to attest that
Findings included: they understand the client
rights and where to access
additional information about
1. Review of the agency P&Ps submitted with various the Client Advocate's role if
titles and policy numbers for “HR”, failed to address needed.
orientation, specific required trainings including the • The Quality Improvement
process for resolving client concerns. onboarding training has been
updated to include more
2.Review of the personnel training records for Staff, A, detailed information on the
Registered Nurse (RN), Staff B, Behavioral Health Client Advocate and their role
Associate (BHA) and Staff C, Behavioral Health Associate within the organization in
(BHA) showed no orientation training of the process for addressing client concerns,
resolving client concerns. complaints, or questions. This
training is conducted during the
3. During an interview on 10/14/24 at 10:26 AM with first week of the employee’s
Staff H, Human Resources (HR), they indicated this topic onboarding.
may be a part of the “employee attestation checklist” • An article on the Client
completed when they attend orientation training. Advocate will appear in our
internal Connections employee
eNewsletter in February to
remind all staff of the
Advocate’s role and functions
within the organization.
Who is responsible:
• Senior Vice President of Human
Resources
• Quality Improvement
Coordinator
• Director of Marketing
Date of Correction:
• Onboarding Training:
Completed as of 2/10/25.
• Form implementation: By
2/28/25.
• Article: By 2/28/25.
Monitors put in place to assure
continuing compliance:
• Onboarding checklist for each
new hire is audited daily until all
items are completed, which
includes the review and
signature of the updated Client
Rights Attestation Form.
3535 Residential and inpatient mental health Based on personnel record review and interview it was How the Deficiency Will Be
services determined the agency failed to implement an annual Corrected:
WAC 246-341-1118(1)(a) (1) An agency individualized training plan for agency staff members • Onboarding and annual training
providing residential and inpatient mental health that included the least restrictive options available in plans are in place for all clinical
services must develop and implement an the community and how to access them. and non-clinical staff. These
individualized annual training plan for agency “Training Plans” in Relias, our
staff members, to include at least: (a) Least Failure to meet this WAC standard may harm clients and online training platform, contain
restrictive alternative options available in the places the client at a disadvantage, creating barriers for multiple individual trainings.
community and how to access them. knowing and accessing the least restrictive options in Training plans exist with specific
the community that could assist in recovery goals. categories for staff including
RNs and BHA.
Findings included: • The current LRA training in
Relias is not in the current
1. Review of P&Ps submitted failed to address Training Plans.
orientation training and staff training plans. • A custom training on LRAs that
focuses specifically on the
2. Review of the personnel record for Staff A, RN, date needs of residential and
of hire 06/05/23, showed no LRA training completed inpatient staff will be developed
until ProACT training on 10/11/24 and showed no and added to the current
annual training plan in the record. applicable Training Plans in
Relias.
3. Review of the personnel record for Staff B, BHA, date
of hire 07/10/23, showed no LRA completed until Who is responsible:
ProACT training on 12/20/23. • Senior Vice President of Human
Resources
• Senior Director for Quality
Improvement
4. Review of the personnel record for Staff B, BHA, date
of hire 03/06/23, showed completed ProACT training on Date of Correction:
06/04/23, with no annual training plan. • The custom LRA training will be
added to the applicable Training
5. During an interview on 10/14/24 at 10:26 AM with Plans by 3/31/25.
Staff H, HR, they indicated they do not know why the
training or annual evaluation would not have been Monitors put in place to assure
completed. They did indicate the staff may have had to continuing compliance:
wait until the agency had a trainer scheduled to provide Relias (our online training system)
the training. will automatically send supervisors
pending and late training
completions.
3540 Residential and inpatient mental health Based on personnel record review and interview it was How the Deficiency Will Be
services determined the agency failed to implement an annual Corrected:
WAC 246-341-1118(1)(b) (1) An agency individualized training plan for agency staff members • Individualized training plans are
providing residential and inpatient mental health that included methods of providing individualized in place for inpatient &
services must develop and implement an treatment. residential positions.
individualized annual training plan for agency Failure to provide staff with an annual training plan • Inpatient & Residential nurses,
staff members, to include at least: (b) Methods including how to provide a more specific individualized and other medical providers,
of providing individualized treatment. treatment may create a barrier for the client’s recovery complete the following trainings
and cause harm. during onboarding:
Boundaries in the
o
Findings included: Treatment Relationship
Legal and Ethical
o
1. Review of P&Ps submitted failed to address Standards for Behavioral
orientation training and staff training plans. Health Professionals
Recovery Principles and
o
2. Review of the personnel record for Staff A, RN, date Practices in Behavioral
of hire 06/05/23, showed no LRA training completed Health Treatment
until ProACT training on 10/11/24 and showed no Integration of Primary
o
annual training plan in the record. and Behavioral
Healthcare
3. Review of the personnel record for Staff B, BHA, date Strategies for Behavioral
o
of hire 07/10/23, showed no LRA completed until Health Professionals to
ProACT training on 12/20/23. Manage Chronic Stress
4. Review of the personnel record for Staff B, BHA, date The Biopsychosocial
o
of hire 03/06/23, showed completed ProACT training on Model of Substance-
06/04/23, with no annual training plan. Related and Addictive
Disorders
5. During an interview on 10/14/24 at 10:26 AM with • The BHA Training Plan includes
Staff H, HR, they indicated they do not know why the all the courses listed above plus:
training or annual evaluation would not have been Supporting Integrated
o
completed. They did indicate the staff may have had to Care through Case and
wait until the agency had a trainer scheduled to provide Care Management
the training Psychiatric Medications:
o
An Overview for
Paraprofessionals
• A customized training for
Inpatient & Residential staff on
LRAs and LRA Management will
be added to all Residential and
Inpatient Training Plans in
Relias.
• Annual training plans include
training on the following topics:
cultural competence and
humility, infection control and
prevention, bloodborne
pathogens, trauma informed
treatment principles, abuse and
neglect prevention and
intervention, suicide prevention
and intervention, ethics and the
law, corporate compliance,
essentials of HIPSS, harassment
in the workplace, and ensuring
a safe work environment.
• Timely completion of ProACT
training is addressed below.
Who is responsible:
• Senior Vice President for
Human Resources
• Senior Director for Quality
Improvement
Date of Correction:
• Training plans with the new
customized LRA training added
will be updated by 3/31/25.
Monitors put in place to assure
continuing compliance:
• Relias (online training/reporting
system) will automatically send
to the Directors/Supervisors
prior to annual due date
3545 Residential and inpatient mental health Based on personnel record review and interview it was How the Deficiency Will Be
services determined the agency failed to implement an annual Corrected:
WAC 246-341-1118(1)(c) (1) An agency providing individualized training plan for agency staff members • Training for all staff includes an
residential and inpatient mental health services that included de-escalation training and management of Annual Training on “Ensuring a
must develop and implement an individualized assaultive and self-destructive behaviors, including Safe Work Environment.” This
annual training plan for agency staff members, to proper and safe use of seclusion and restraint training meets the
include at least: (c) De-escalation training and procedures. requirements of RCW 49.19.030
management of assaultive and self-destructive for health care workers and
behaviors, including proper and safe use of Failure to meet this WAC standard and provide training always includes information on
seclusion and restraint procedures. to staff on de-escalation and assaultive and self- de-escalation skills.
destructive behaviors, including proper and safe use of • All new employees complete a
seclusion and restraint procedures may violate client “Preventing and De-Escalating
civil rights and have a potential for increased harm to Crisis Situations” training within
the client. 30 days of employment.
• In addition, Residential and
Findings included: Inpatient staff receive initial
ProACT training as well as
1. Review of P&Ps submitted failed to address annual boosters.
orientation training and staff training plans.
• HR will ensure that the initial
2. Review of the personnel record for Staff A, RN, date ProACT training is scheduled on
of hire 06/05/23, showed no LRA training completed date of hire, to be completed
until ProACT training on 10/11/24 and showed no within 90-days of hire.
annual training plan in the record. • New evening time ProACT
trainings have been established
3. Review of the personnel record for Staff B, BHA, date to accommodate night shift
of hire 07/10/23, showed no LRA completed until staff.
ProACT training on 12/20/23. • ProACT training is now on a
regular calendar and is offered
4. Review of the personnel record for Staff B, BHA, date more frequently.
of hire 03/06/23, showed completed ProACT training on
06/04/23, with no annual training plan. Who is responsible:
• Senior Vice President for
5. During an interview on 10/14/24 at 10:26 AM with Human Resources
Staff H, HR, they indicated they do not know why the • VP for Residential and Inpatient
training or annual evaluation would not have been
services and acting Program
completed. They did indicate the staff may have had to
Manager for Two Rivers Landing
wait until the agency had a trainer scheduled to provide
the training.
Date of Correction:
• Completed as of 2/10/25.
Monitors put in place to assure
continuing compliance:
• Relias (our online training
system) will automatically send
supervisors pending and
overdue training reminders on a
weekly basis.
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency.
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited.
• The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in
compliance with the regulatory requirements.
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction must
include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
The POC must include a completion date that is realistic and coincides with the amount of time your facility will need to correct the deficiency.
Direct care issues must be corrected immediately and monitored appropriately. Some deficiencies may require a staged plan to accomplish total
correction. Deficiencies that require bids, remodeling, replacement of equipment, etc., may need more time to accomplish correction; the target
completion date, however, should be within a reasonable and mutually agreeable timeframe.
Continued Monitoring
Each plan of correction must indicate the appropriate person, either by position or title, who will be responsible for monitoring the correction of
the deficiency to prevent recurrence.
Checklist:
• Before submitting your plan of correction, please use the checklist below to prevent delays.
• Have you provided a plan of correction for each deficiency listed?
• Does each plan of correction show a completion date of when the deficiency will be corrected?
• Is each plan descriptive as to how the correction will be accomplished?
• Have you indicated what staff position will monitor the correction of each deficiency?
• If you included any attachments, have they been identified with the corresponding deficiency number or identified with the page number to
which they are associated?
Your plan of correction will be returned to you for proper completion if not filled out according to these guidelines.
Note: Failure to submit an acceptable plan of correction may result in enforcement action.
Approval of POC
Your submitted POC will be reviewed for adequacy by DOH. If your POC does not adequately address the deficiencies in your inspection report,
you will be sent a letter detailing why your POC was not accepted.
Questions?
Please review the cited regulation first. If you need clarification or have questions about deficiencies you must contact the inspector who
conducted the onsite inspection, or you may contact the supervisor.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
2/18/2025
Edie Dibble
Two Rivers Landing
PO Box 959
Yakima, WA 98907-0959
Re: Exam Number: X2024-800
License Number: BHA.FS.60873007
Approved Plan of Correction
Date(s) of Inspection: 10/2/24-11/26/24
Dear Administrator:
This letter is to inform you that after careful review of the Plan of Correction (POC) you
submitted for the exam recently conducted at your facility, the Department has determined that
the POC is approved.
Based on the scope and severity of the deficiencies listed in your statement of deficiency report,
the Department will not conduct an announced follow-up compliance visit to verify that all
deficiencies have been corrected.
Reviewer:
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Inspection

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
No Deficiencies Found
August 19, 2021
Timothy Shields
Comprehensive Healthcare - Two Rivers Landing
PO Box 959
Yakima, WA 98907-0959
Subject: Inspection Number: X2021-130
License Number: BHA.FS.60873007
Inspection Type: ONGOING - ROUTINE
Dear Mr. Timothy Shields
This document contains information regarding the recent inspection of Comprehensive Healthcare -
Two Rivers Landing, 504 S 3rd Ave, Yakima, WA. 98902-3543 by the Washington State Department
of Health. Your state licensing inspection was completed on 07/27/2021.
During the inspection, no deficient practice was found.
Please contact me if there are questions regarding the inspection process. I may be reached at (360)
280-6392. I am also available by email at Gina.Dick@doh.wa.gov.
I want to extend another “thank you” to you and to everyone that assisted me during the survey.
Sincerely,
Gina L. Dick, LMHC, SUDP, MHP, MAC
Behavioral Health Reviewer
Office of Health Systems Oversight
Health Systems Quality Assurance Division


facility_name: Comprehensive Healthcare - Two Rivers Landing

summary: State Investigation


report_date: September 25,2020

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
September 25,2020
Two Rivers Landing
5 04 South 3rd Avenue
Yakima,WA 98902-3543
Re: Complaint Investigation
Case Number: 2020-2251
License Number: BHA.FS.6087007
Date(s) of Investigation: 09/08/2020
Dear Administrator:
The State of Washington Department of Health recently completed an investigation of Two
Rivers Landing on September 8, 2020.
No current deficiencies were identified during this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: JAMC03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

deficiencies: WAC 246-341-0420(15) Agency Based on record review, policy and Staff members at Two Rivers administration -Policies and procedure review, the facility failed to Landing were trained on procedures. Each agency licensed by report a critical incident within one reporting of critical incidents the department to provide any business day to the department. Failure including what to report, behavioral health service must to report a critical incident within one completing incident reports develop, implement, and maintain business day to the department may within 24 hours/ and notifying administrative policies and result in patient harm. team leader of the incident.

deficiencies: WAC 246-341-1126(l)(b) Mentai Based on record review, policy and Staff at Two Rivers Landing health inpatient services - Policies procedure review/ and interview, the were trained on supervision of and procedures "Adult. In addition facility failed to implement iine of clients while on outings and to meeting the agency licensure, sight or camera monitoring as outside of the unit to include certification/ administration, appropriate to the Individual while being transported in the personnel/ and clinical van. Staff members were requirements, in WAC 246-341-0100 Failure to implement line of sight or trained by Team Leader on

deficiencies: WAC 246-341-0200 (see Definitions below) or as otherwise specified m the MCO or ASO contract. • The Risk Manager/ or designee/ will report to the Department of Health within one business day the death/ not on Comprehensive Healthcare s premises/ of any individual enrolled m Opiate Treatment Program services within one day of receiving notice of the individuaFs death usmg the BHA Critical Incident Reportmg webpage: https://fortress.wa.gov/doh/opu'do/s?s=OTPDeathReportmg • The Risk Manager/ supervising Director or VP/ or designee of Residential or E&T Services will report to

deficiencies: WAC 246-341-0200) Refers to any of the followmg events to be reported to the department/ MCO or ASO/ as applicable/ within one busmess day of the critical mcident: (1) Any death/ serious injury/ or sexual assault that occurs at an agency that is licensed by the department; (2) Alleged abuse or neglect of an individual receiving services/ that is of a serious or emergency nature/ by an employee/ volunteer/ licensee/ contractor/ or another individual receivmg services;


report_date: January 21, 2021

summary: State Inspection — ONGOING - ROUTINE (01/14/2021)

raw_content:
Behavioral Health Agency Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
January 21, 2021
Daybreak Youth Services - Spokane Outpatient, 200 N Mullan Rd Ste 120,
Spokane Valley, WA. 99206-6827 Thomas Russell
Agency Name and Address Administrator
ONGOING - ROUTINE 01/14/2021 AAU0303
Inspection Type Inspection Onsite Dates Inspector
X2021-15 BHA.FS.60873304
Inspection Number License Number
Please note that the deficiencies/violations/observations noted in this report are not all-inclusive, but rather were deficiencies/violations/observations that were
observed or discovered during the on-site inspection.
Deficiency Number and Rule Reference Observation Findings Plan of Correction
1430 Clinical Add record content The Washington Administrative Code is not met as
WAC 246-341-0640(4)(a) Each agency licensed evidenced by:
by the department to provide any behavioral Based on record review and interview, Daybreak Youth
health service is responsible for an individual's Services - Spokane Outpatient failed to have
clinical record content. The clinical record must documentation of the individual’s response when asked
include:(4) Documentation of the individual's if under the department of corrections supervision in 2
response when asked if:(a) The individual is of 4 individual’s records reviewed (patient 2, patient 3).
under department of corrections (DOC)
supervision Failure to have required documentation in the
individual’s record places them at risk for substandard
care.
Findings included:
1. In a record review on 01/14/2021, the documentation
present in patient 2 and patient 3 files reviewed did not
meet the WAC requirement.
2. In an interview on 01/14/2021 with Staff A at 9:40
am, she stated the individual is usually asked these
questions but their electronic record should not contain
N/A as an answer to these questions.
1435 Clinical Add record content The Washington Administration Code was not met as
WAC 246-341-0640(4)(b) Each agency licensed evidenced by:
by the department to provide any behavioral Based on record review and interview, Daybreak Youth
health service is responsible for an individual's Services - Spokane Outpatient failed to include
clinical record content. The clinical record must documentation of the individuals response when asked
include:(4) Documentation of the individual's if they were under civil or criminal court order mental
response when asked if(4) Documentation of the health or substance use disorder treatment in 2 of 4
individual's response when asked if:(b) The individual’s records reviewed (patient 2, patient 3).
individual is under civil or criminal court ordered
mental health or substance use disorder Failure to have required documentation in the
treatment; and individual’s record places them at risk for substandard
care.
Findings included:
1. In a record review on 01/14/2021, the documentation
present in patient 2 and patient 3 files reviewed did not
meet the WAC requirement.
2. In an interview on 01/14/2021 with Staff A at 9:40
am, she stated the individual is usually asked these
questions but their electronic record should not contain
N/A as an answer to these questions.
1440 Clinical Add record content The Washington Administration Code was not met as
WAC 246-341-0640(4)(c) Each agency licensed evidenced by:
by the department to provide any behavioral Based on record review and interview Daybreak Youth
health service is responsible for an individual's Services - Spokane Outpatient failed to include
clinical record content. The clinical record must documentation of the individual's response when asked
include:(4) Documentation of the individual's if there is a court order exempting the individual
response when asked if:(c) There is a court order participant from reporting requirements in 2 of 4
exempting the individual participant from individual’s records reviewed (patient 2, patient 3).
reporting requirements. A copy of the court
order must be included in the record if the Failure to have required documentation in the
participant claims exemp-tion from reporting individual’s record places them at risk for substandard
requirements; care.
Findings included:
1. In a record review on 01/14/2021, the documentation
present in patient 2 and patient 3 files reviewed did not
meet the WAC requirement.
2. In an interview on 01/14/2021 with Staff A at 9:40
am, she stated the individual is usually asked these
questions but their electronic record should not contain
N/A as an answer to these questions.
Introduction
We require that you submit a plan of correction for each deficiency listed on the inspection report form. Your plan of correction must be
submitted to the DOH within ten business days of receipt of the list of deficiencies.
Descriptive Content
Your plan of correction must provide a step-by-step description of the methods to correct each deficient practice to prevent recurrence and
provide information that ensures the intent of the regulation is met.
An acceptable plan of correction must contain the following elements:
• The plan of correcting the specific deficiency;
• The procedure for implementing the acceptable plan of correction for the specific deficiency cited;
• The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in
compliance with the regulatory requirements;
• The title of the person responsible for implementing the acceptable plan of correction.
Simply stating that a deficiency has been "corrected" is not acceptable. If a deficiency has already been corrected, the plan of correction must
include the following:
• How the deficiency was corrected,
• The completion date (date the correction was accomplished),
• How the plan of correction will prevent possible recurrence of the deficiency.
Completion Dates
Plan of Correction BHA.FS.60873304
Deficiency Number and Rule Observation of Findings Plan of Correction Monitoring
Reference
1430 The Washington Administrative Code is not met as evidenced Correction: In our In clinical file reviews
Clinical Add record content WAC by: Based on record review and interview, Daybreak Youth assessment an answer of monthly, for the next 3-
246-341-0640(4)(a) Each agency Services -Spokane Outpatient failed to have documentation of n/a was an option: this months, Clinical
licensed by the department to the individual’s response when asked if under the department has been taken out of the Supervisor will review to
provide any behavioral health of corrections supervision in 2 of 4 individual’s records assessment as an option, make sure the N/A option
service is responsible for an reviewed (patient 2, patient 3). can only be answered as has not been entered back
individual's clinical record content. Failure to have required documentation in the individual’s Yes/No. This has been into the assessment and
The clinical record must include:(4) record places them at risk for substandard care. completed as of 2/1/2021. review that in all
Documentation of the individual's assessments it is answered
response when asked if:(a) The Findings included: Trained staff on changes Yes/No as per WAC
individual is under department of 1. In a record review on 01/14/2021, the documentation of the assessment Clinical Add record
corrections (DOC) supervision. present in patient 2 and patient 3 files reviewed did not meet content WAC 246-341-
the WAC requirement. 2. Inan interview on 01/14/2021 with Discharge summary: 0640(4)(a)
Staff A at 9:40 am, she stated the individual is usually asked Added text box for
these questions, but their electronic record should not contain previous or current legal
N/A as an answer to these questions. involvement at time of
discharge.
Trained staff on changes
of the assessment
Deficiency Number and Rule Observation of Findings Plan of Correction Monitoring
Reference
1435 The Washington Administration Code was not met as Correction: In our In clinical file reviews
Clinical Add record content WAC evidenced by: Based on record review and interview, assessment an answer of monthly, for the next 3-
246-341-0640(4)(b) Each agency Daybreak Youth Services -Spokane Outpatient failed to n/a was an option: this months, Clinical
licensed by the department to include documentation of the individual's response when has been taken out of the Supervisor will review to
provide any behavioral health asked if they were under civil or criminal court order mental assessment as an option, make sure the N/A option
service is responsible for an health or substance use disorder treatment in 2 of 4 can only be answered as has not been entered
individual's clinical record content. individual’s records reviewed (patient 2, patient 3). Yes/No. This has been back into the assessment
The clinical record must include:(4) Failure to have required documentation in the individual’s completed as of 2/1/2021. and review that in all
Documentation of the individual's record places them at risk for substandard care. Trained staff on changes assessments it is
response when asked if (4) of the assessment answered Yes/No as per
Documentation of the individual's Findings included: 1. In a record review on 01/14/2021, the WAC 246-341-0640(4)(b)
response when asked if:(b) The documentation present in patient 2 and patient 3 files
individual is under civil or criminal reviewed did not meet the WAC requirement. 2. In an Discharge summary:
court ordered mental health or interview on 01/14/2021 with Staff A at 9:40 am, she stated Added text box for
substance use disorder treatment; the individual is usually asked these questions, but their previous or current legal
and electronic record should not contain N/A as an answer to involvement at time of
these questions. discharge.
Deficiency Number and Rule Observation of Findings Plan of Correction Monitoring
Reference
1440 The Washington Administration Code was not met as In clinical file reviews
Clinical Add record content WAC evidenced by: Based on record review and interview Correction: In our monthly, for 3-months,
246-341-0640(4)(c) Each agency Daybreak Youth Services -Spokane Outpatient failed to assessment an answer of Clinical Supervisor will
licensed by the department to include documentation of the individual's response when n/a was an option: this review to make sure the
provide any behavioral health asked if there is a court order exempting the individual has been taken out of the N/A option has not been
service is responsible for an participant from reporting requirements in 2 of 4 individual’s assessment as an option, entered back into the
individual's clinical record content. records reviewed (patient 2, patient 3). can only be answered as assessment and review
The clinical record must include:(4) Yes/No. This has been that in all assessments it
Documentation of the individual's Failure to have required documentation in the individual’s completed as of 2/1/2021. is answered Yes/No as
response when asked if:(c) There is record places them at risk for substandard care. Trained staff on changes per WAC 246-341-
a court order exempting the of the assessment 0640(4) ©
individual participant from 1. In a record review on 01/14/2021, the documentation
reporting requirements. A copy of present in patient 2 and patient 3 files reviewed did not meet Discharge summary:
the court order must be included in the WAC requirement. 2. In an interview on 01/14/2021 with Added text box for
the record if the participant claims Staff A at 9:40 am, she stated the individual is usually asked previous or current legal
exemption from reporting these questions, but their electronic record should not contain involvement at time of
requirements. N/A as an answer to these questions. discharge.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
February 24, 2021
Thomas Russell
Daybreak Youth Services
960 E 3rd Ave
Spokane, WA 99202
Subject: Inspection Number X2021-15
Dear Mr. Russell,
The Washington State Department of Health conducted a Remote Inspection of
Daybreak Youth Services -Spokane Outpatient, 200 N Mullan Rd Ste 120 Spokane,
WA 99206-6827. Your state licensing inspection was completed on 01/14/2021.
The Plan of Correction that was submitted on 02/24/2021 was approved on
02/24/2021. No further action is required.
I sincerely appreciate your cooperation and hard work during the inspection process
and look forward to working with you again in the future.
Sincerely,
Amy Umberger, LICSW
Behavioral Health Reviewer
Office of Health System Oversight
Health Systems Quality Assurance
Washington State Department of Health

administrator: Thomas Russell


facility_name: Daybreak Youth Services – Brush Prairie

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
June 7, 2021
Daybreak Youth Services ~- Brush Prairie
11910 NE154Eh St
Brush Prairie, WA 98606-9571
Re: Complaint Investigation
Case Number: 2021-1488
License Number: BHA.FS.60873310
Dear Mr. Russell:
The State of Washington Department of Health recently completed an investigation ofDaybreak
Youth Services - Brush Prairie on May 28, 2021.
No deficiencies will be cited as a result of this investigation.
Please retain a copy of this letter for your files.
Thank you for your time and assistance during this investigation.
Investigator: 33894
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874