report_date: September 20, 2021

summary: State Inspection

raw_content:
Residential Treatment Facility
Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
September 20, 2021
Newport Academy - Seattle, 12029 113th Ave NE, Kirkland, WA. 98034-6901 Annie Gendaszek
Agency Name and Address Administrator
NEW LICENSURE - OPERATIONAL 09/08/2021 Jennifer M Ross LMHC
Inspection Type Inspection Onsite Dates Inspector
X2021-254 RTF.FS.61015924 Co-occurring 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
1385 Resident's individual service plan The Washington Administrative Code STANDARD was NOT
WAC 246-337-100(1)(a-b) (1) The licensee must MET as evidenced by:
develop and implement an individual service plan for
each resident based on the resident's: (a) Initial Based on clinical record review and interview with staff, it
health on admission; and (b) Health assessment(s). was determined that the clinical record did not document an
individual service plan that addressed the initial health on
admission and the health assessment.
Findings include:
1. In a review of clinical records, it was determined that
4 of the 4 files did not have an individual service plan
that addressed the initial health on admission and the
health assessment.
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.
EMPLOYEE AND CONTRACTOR SCREENING TOOL
• Has the individual had known contact with a confirmed or suspected case of COVID-19?
• Does the individual live with someone who is under investigation or awaiting testing for COVID-19?
• Is the individual experiencing any of the following symptoms?
o Fever
o Sore throat
o Cough
o Muscle pain
o New loss of taste or smell
o Shortness of breath
o Nausea, vomiting, diarrhea
Vaccinated individuals do not need to quarantine following exposure to a confirmed case of COVID-19 as
long as they remain asymptomatic since current exposure.
A. Excluding fully vaccinated people and those who have had COVID-19 in the past 3 months and
recovered and do not develop new symptoms, the following individuals must quarantine following
close contact and exposure to COVID-19:
1. Any individual who lives with someone who is under investigation or awaiting testing for
COVID-19 must remain at home until the test results come back negative. If test results come
back positive, follow guidance under next point.
2. Any individual who has been directly exposed to someone who has tested positive with
COVID-19 within the past 14 days, with whom the employee has been living, been an
intimate partner, or provided care, or with whom the employee has had prolonged contact
(defined by the public health department as within 6 feet for 15 cumulative minutes or more
over 24 hours), should quarantine and monitor symptoms daily. Quarantine can end after
day 10 if there are no symptoms or after day 7 if the individual has a negative test between
day 5 and day 7. The individual should self-monitor and practice masking through day 14.
More details are outlined in Section VI.
3. Employees who are showing symptoms of COVID-19 (e.g.: sore throat, cough, fever, chills,
muscle pain, new loss of taste or smell, or shortness of breath) must refrain from coming to
work until they have been symptom-free for a period of 24 hours (no fever without taking
fever-reducing medicine) and have had at least 10 days since their symptoms appeared,
whichever is later.
4. Employees who have been diagnosed with COVID-19 must refrain from coming to work until
they have been symptom-free for a period of 24 hours (no fever without taking fever-
reducing medicine) and have had at least 10 days since their symptoms appeared, whichever
is later.
The company will follow the guidance of the local health department and the CDC regarding notification,
management, and reporting of positive employee cases.
9
NEWPORT HEALTHCARE COVID-19 MANAGEMENT GUIDELINES AND PROTOCOLS
ISSUED: 4/2/2020 REVISED: 4/7/2021
PURPOSE: The purpose of this guidance is to ensure Newport Healthcare employees are informed
about COVID-19 and are prepared to respond as needed. This document coalesces previous
distributed guidance and supersedes all previous distributions on the topic.
POLICY: Newport Healthcare follows the guidance of the Centers for Disease Control and
Prevention (CDC), federal, state and local governments, related to prevention, treatment, and
response to COVID-19. The following guidance, drafted by Newport Healthcare’s COVID-19
Response Task Force in consultation with Dr. Rachel Fortune, is informed by CDC guidelines as well
as federal, state, and local guidance.
During the COVID-19 outbreak, increased attention is being given to assessment, training, and
management of symptomatic clients. As prevention is the key strategy to lessen the impact of
COVID-19 broadly and on the organization, Newport Healthcare provides education to clients and
employees, as well as supplies, to increase compliance with preventative measures. This document
supplements the existing Infection Control policies and Policy and Procedure Manual and
supersedes prior versions of the Respiratory Virus Protocol and supporting documents.
GUIDANCE: The following document provides guidance on
• Screening and assessment
• Management of symptomatic clients
• Personal Protective Equipment (PPE)
• Employee policies
• Communication, reporting, and notification
• Ongoing assessment and management
• On-site testing
• Clarification about exposure and return to work/programming guidance
• Vaccination
I. SCREENING
A. Clients are screened at time of Clinical Screening Questionnaire and again within 24 hours of
scheduled arrival with the following questions:
1. Has the potential client been vaccinated for COVID-19? If yes, provide verified COVID-19
vaccine card with dates and vaccine type.
2. Has the potential client had a fever in the past 14 days (temperature 100.4 degrees or
above)?
3. Does the potential client currently have a fever? (100.4 degrees or above)
4. Has the potential client or a close contact (someone with whom the potential client has been
within 6 feet for 15 cumulative minutes or more over 24 hours) tested positive for COVID-
19 (Coronavirus) or influenza within the past 14 days?
1
5. Has the potential client had contact with a confirmed case of COVID-19 in the community? If
yes, refer to this CDC guidance for evaluation.
6. Is the potential client currently experiencing any of the following COVID-19 related
symptoms?
a. Fever
b. Chills
c. Muscle pain
d. Cough
e. Sore throat
f. Shortness of breath or difficulty breathing
g. New loss of taste or smell
h. Nausea, vomiting, diarrhea
If YES to any of the above questions 2-6, client must receive clearance from the Medical
Director. For cases that need clearance from an outside physician prior to admission, utilize
Medical Clearance Form for Admission to Behavioral Health Treatment Facility rev 3.31.2019.
Clients arriving from congregate settings including psychiatric hospitals, other group homes, or
correctional facilities may be required to provide proof of a negative PCR test within 72 hours
of arrival to a Newport Healthcare facility.
Newport Healthcare may, under the guidance of the CDC and local health agencies, elect to
require clients from areas with a high number of COVID-19 cases to undergo quarantine prior
to admission to one of Newport’s residential treatment programs.
Newport Healthcare’s Admissions Department is provided with regularly updated
guidance related to geographic areas or other conditions of admissions during the
COVID-19 pandemic. This guidance is subject to change.
B. Onsite Screening at Residential and Outpatient Facilities: Upon arrival to a facility, clients are
screened with the following procedure:
1. Temperature taken by staff
2. Is the potential client currently experiencing any of the following symptoms:
a. Fever
b. Chills
c. Muscle pain
d. Cough
e. Sore throat
f. Shortness of breath or difficulty breathing
g. New loss of taste or smell
h. Nausea, vomiting, diarrhea
Any client who answers YES to any symptom A through H should be discussed with the
Medical Director at Residential or Director at Outpatient.
C. Onsite Testing: A facility may offer testing to clients as indicated for clinical assessment and
screening. Each facility should follow their site-specific protocols for managing COVID-19. Any
client pending test results should remain in isolation until results are received and course of
action can be determined.
2
II. MANAGEMENT OF ILLNESS
A. Current Clients Presenting with COVID-19 Like Symptoms
If a client becomes symptomatic, measures are taken to evaluate, quarantine, and discharge
when appropriate. All cases are evaluated individually and under the guidance of medical
professionals. In general, sick clients should interact with only essential staff necessary for their
safe and effective care during their time in isolation. Personal Protective Equipment (PPE)
should be worn when a staff member is interacting with a client who is in quarantine for known
or suspected COVID-19. When droplet precautions are in place, Droplet Precaution Signage
must be posted.
B. Positive Client(s)
In the event of a positive test, the facility will contact Compliance, and Compliance will
contact the local health department and follow their guidance on specific actions steps related
to the situation.
Generally, best practice is for a COVID-positive resident to stay at the residential facility as long
as symptoms remain mild and manageable at this level of care. Each facility has a site-specific
protocol for managing illness and a sick client.
When possible, a quarantined client should be the only person with access to his/her bathroom
and should receive all meals and medications in their space. Clients in isolation will use
designated indoor and outdoor spaces separate from other clients to contain spread of the virus
and utilize technology for virtual therapy to supplement programing. Staff bringing the clients
meals and medications should wear CDC-approved PPE.
Discharge due to suspected or confirmed COVID-19 is determined by the Medical Director and
logistical variables related to parent pick-up are taken into consideration. Parents are informed
prior to admission of the possibility that their child may need to be picked up due to illness.
C. Each location has a site-specific protocol for managing a sick client. The Executive Director is
responsible for oversight.
III. PERSONAL PROTECTIVE EQUIPMENT (PPE) & OTHER SAFETY MEASURES
A. Availability and Required Use
1. Every effort will be made to have PPE available at all facilities and the supply is to be
distributed and monitored by the Executive Director or designee. The CDC is advising all
facilities to implement strategies to conserve supplies during the COVID-19 pandemic.
2. During the COVID-19 pandemic, it is recommended that PPE is worn in the following
circumstances:
a. When droplet precautions are in place. Droplet Precaution Signage must also be
posted.
3
b. When a staff member is interacting with a client who is in quarantine for known or
suspected COVID-19.
3. PPE should also be worn in accordance with normal infection control plan.
4. PPE will be prioritized for healthcare workers who are coming into direct contact with
individuals with known or suspected COVID-19.
5. Medical staff that are hands-on with patients and for medical reasons need to violate social
distancing practices to do their jobs can be provided a mask daily.
6. Staff involved in the care of clients with known or suspected COVID-19 should adhere to the
CDC’s Standard, Contact, and Airborne precautions including eye protection, surgical masks,
gowns, gloves, etc. These materials will be provided by Newport Academy to appropriate
staff.
7. Clients with known or suspected COVID-19 should wear a surgical facemask when being
evaluated medically and in the presence of others.
8. Items available: Gloves, masks, gowns, and goggles. N95 Respirators, which are needed for
aerosol generating procedures that are not performed at Newport Healthcare, can be worn
by staff but are not necessary in our environment.
9. Effective 2/2/2021, all staff providing direct care at sites with positive cases, confirmed
Covid-19+ clients, and clients who are known to be exposed are encouraged to “double
mask” and wear a disposable medical mask under a cloth mask.
10. Frequently Asked Questions about Personal Protective Equipment from CDC
B. Face Coverings
The CDC recommends that people wear masks in public settings, at events and gatherings, and
anywhere around other people. Effective 2/2/2021, masks are required on planes, trains,
buses, and other forms of public transportation in the United States.1 Newport Healthcare staff
wear face coverings while at work even when this is not mandated by a state or local mandate.
Exceptions to this include when working alone in an office, taking a break for eating or drinking
when alone, and performing duties outdoors when social distancing (maintaining 6 feet of
distance between one another) is possible. Failure to comply with this guidance will result in
appropriate action including verbal and written warnings.
C. Physical Distancing
All Newport staff and clients will strive to maintain 6 foot distancing whenever possible during
the course of treatment and work day, especially during high risker periods such as meals when
masks must be removed. In controlled environments such as the classroom, group room, and
van transport, a 3 foot distance (shoulder to shoulder) is permitted to enhance access to
treatment and academics during Covid-19 per CDC guidance2 under the following conditions:
- All staff and clients ensure 100% mask compliance
- All chairs and seating is oriented to prevent direct face to face exposure
- Clients and staff are screened for symptoms each day prior to programming
- Structured or assigned seating to mitigate exposure risk
- Parental approval and advance screening measures required for van
transport
1 Your Guide to Masks, 2/2/2021 and Understanding the Difference Between Surgical Masks and
Respirators
2 https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools.html
4
IV. COMMUNICATION AND REPORTING POLICIES
The Newport Healthcare COVID-19 Task Force convenes daily to review protocols, plans, and
communication. Determinations are made for how to effectively communicate internally and
externally. Newport’s Senior Director of Communications oversees outgoing messaging and
communication. The Task Force works with local operators to review the effectiveness of this
protocol and make adjustments as necessary. The Director of Compliance will log test results
(negative or positive) from clients and the local HR representative will log test results for
employees.
The Compliance department will oversee communication with all local health departments.
The Compliance Officer will monitor the CDC and other official sources regularly for updated
guidelines and recommendations. The Leadership Team will discuss allocation of resources and
finances to deal with prevention and response, messaging to stakeholders, and contingency plans.
V. EMPLOYEE EXPOSURE PROTOCOL
A. PURPOSE:
Our goal is to provide a safe work environment for our employees while providing continuing
care for our clients for whom we are responsible. The purpose of this policy is to communicate
the appropriate protocols so that we can implement them in a fair and consistent manner while
working to keep everyone safe.
B. POLICY:
We follow current CDC guidance and considerations related to exposure to COVID-19.
1. Fully vaccinated individuals are not required to quarantine following exposure to
COVID-193. Vaccinated persons should continue to follow current guidance including
wearing a face covering, avoiding crowds, practicing social distancing, and washing
hands frequently.
2. Excluding fully vaccinated people and those who have had COVID-19 in the past 3
months and recovered and do not develop new symptoms, the following individuals
must quarantine following close contact and exposure to COVID-19:
• Any individual who lives with someone who is under investigation or
awaiting testing for COVID-19 must remain at home until the test results
come back negative. If test results come back positive, follow guidance under
next point.
• Any individual who has been directly exposed to someone who has tested
positive with COVID-19 within the past 14 days, with whom the employee
has been living, been an intimate partner, or provided care, or with whom
the employee has had prolonged contact without both parties wearing a face
covering (defined by the public health department as within 6 feet for 15
cumulative minutes or more over 24 hours), should quarantine and monitor
symptoms daily. Quarantine can end after day 10 if there are no symptoms
or after day 7 if the individual has a negative test between day 5 and day 7.
3 https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html
5
The individual should self-monitor and practice masking through day 14.
More details are outlined in Section VI.
• Employees who are showing symptoms of COVID-19 (e.g.: sore throat,
cough, fever, chills, muscle pain, new loss of taste or smell, or shortness of
breath) must refrain from coming to work until they have been symptom-
free for a period of 24 hours (no fever without taking fever-reducing
medicine) and have had at least 10 days since their symptoms appeared,
whichever is later.
• Employees who have been diagnosed with COVID-19 must refrain from
coming to work until they have been symptom-free for a period of 24 hours
(no fever without taking fever-reducing medicine) and have had at least 104
days since their symptoms appeared, whichever is later.
The company will follow the guidance of the local health department and the CDC regarding
notification, management, and reporting of positive employee cases.
When new guidance from the Center for Disease Control (CDC) is provided, we will adjust this
policy as needed in alignment with this guidance. Should an issue arise within one of our
programs, we will work directly with the local department of public health to best manage the
situation. The Task Force that has been established within Newport is monitoring each program
daily and will adjust program schedules as needed.
C. PROCEDURE:
Employees exposed to COVID-19 as defined above, or who have a temperature of 100.4 or
higher, or who are showing any symptoms of COVID-19, should report to their manager or
Human Resources that they will not be coming to work.
Your manager or someone from HR may inquire whether you are experiencing COVID-19
symptoms if you report feeling ill at work or if you call in sick. The information obtained will
only be shared with HR but will allow us to know how to best protect you, our clients, and the
workplace.
To reduce COVID-19 exposure and transmission, all employees are expected to abide by current
COVID-19 safety precautions including wearing a face covering, frequent and thorough hand
washing/sanitizing, and social distancing.
Time and Attendance
As an essential business, we have clients for whom we are responsible, so your attendance on
site as an essential employee is critical during this time period in order for us to maintain a safe
and healing environment for them.
Remote Work
The majority of the company’s workforce is needed onsite to provide direct care to our clients
and therefore the option to work remotely is limited for most. If a request to work from home is
made, the position will be evaluated to determine if the individual can work remotely
4 On August 10, 2020, CDC updated return to work guidance https://www.cdc.gov/coronavirus/2019-
ncov/hcp/return-to-work.html; also see https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-
sick/quarantine.html (updated 12/2/2020)
6
(dependent upon the individual’s ability to successfully perform their essential job duties on a
remote basis, and the technical requirements associated with the role).
Travel
Non-essential business-related travel plans should be cancelled. All other travel should be
reviewed with your supervisor to determine if it is mission critical.
D. EMPLOYEE SCREENING
Employee screening may be implemented at the facility level utilizing the plan identified at each
facility. The Employee Screening Tool should be used (see page 9).
VI. EXPOSURE AND RETURN TO WORK OR PROGRAMMING GUIDANCE
A. See above Employee Exposure Protocol (V, B, 1) for criteria related to employee quarantine.
B. For individuals who do not meet the criteria listed above following exposure to COVID-19,
the CDC approves the following alternatives to shorten the recommended 14-day
quarantine5:
1. 10 days - If no symptoms have been reported during daily monitoring, quarantine can
end after 10 days
2. 7 days – If no symptoms have been reported during daily monitoring, and a negative
test is performed within 48 hours of the anticipated end of quarantine, then quarantine
can end at 7 days. Quarantine cannot end sooner than 7 days.
In both scenarios, masking and symptom monitoring through day 14 are required. Should any
symptoms appear at any point, the individual should self-isolate and notify their health care
provider. Additional research appears here: Scientific Brief: Options to Reduce Quarantine
VII. ADDITIONAL RESOURCES
Interim Infection Control and Prevention Recommendations from CDC
Interim Guidance for Management of Influenza Outbreak in LTC Facilities
Strategies to Mitigate Staffing Shortages
Interim Public Health Recommendations for Fully Vaccinated People updated 3.8.2021
Updated Healthcare Infection Prevention and Control Recommendations in Response to
COVID-19 Vaccination Updated 3.10.21
5 Full text appears here: When to Quarantine Guidance
7
Medical Clearance Form for Residential Admission to Behavioral Health Treatment Facility
Client Name: ______________________________________ DOB: ________________________
I confirm that I have evaluated the above client and attest to the following two statements:
Yes No
__ __ Does not require quarantine as part of disease management.
__ __ Is cleared for admission to a residential treatment facility where he/she will be
living in close contact with others.
General comments:
__________________________________ _______________
Signature and Credentials Date
__________________________________
Printed Name
___________________________________
Phone Number
8
Wednesday, April 14, 2021
Crystal Goodwin, M.S.
Manager, Licensing and Compliance
Newport Academy | Newport Institute | Center for Families
Dear Ms. Goodwin:
Your agency Residential Treatment Facility and Behavioral Health Agency review is scheduled for
Thursday, May 20, 2021. In an effort to ensure agencies are following social distancing guidelines
and to meet your facilities needs during the COVID pandemic, we are asking that you provide our
office additional information so we can best accommodate your facility during this remote review.
Since the COVID-19 pandemic may have temporarily changed schedules and suspended normal
operations, please fill out the following questionnaire about scheduling your remote review:
There is no change to our daily operation.
Our days of operation have temporarily changed. During the pandemic we are operating
on the following week days:
Monday Tuesday Wednesday Thursday Friday
Our hours of operation have changed. During the pandemic our new hours are:
_______________ to _______________
Our office is closed until __________________
What social distancing or other facility infection control requirements does your facility
have in place? (Examples: masks or other PPE requirements, limiting the number of
people in your facility, etc.) Enter response here
Other comments or concerns? Enter response here
The Department of Health is committed to state social distancing measures to prevent the spread
of COVID-19. We ask that we only have one facility point of contact, and that any entrance and
exit conferences either be conducted electronically or that the facility’s point of contact
communicate results to the facility leadership.
Please email your response to your Reviewer by Friday, May 7, 2021 so we can determine
when would be the best time to schedule your remote review.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
November 15, 2021
Annie Gendaszek
Washington Health Operations LLC
12029 113th Ave NE
Kirkland, WA 98034-6901
Subject: Inspection Number X2019-1112 and x2021-254
Dear Ms. Gendaszek,
The Washington State Department of Health conducted an inspection at Newport
Academy on 9/8/2021 for both the RTF and BHA license. The Plan of Correction
that was submitted was received on 11/8/2021 and approved on 11/15/2021. 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,
Jennifer Ross, LMHC
Behavioral Health Reviewer

administrator: Annie Gendaszek

service_types: Co-occurring Services,


state: WA

facility_name: Newport Academy - Seattle

report_date: October 7, 2024

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
October 7, 2024
Newport Academy
12029 113th Ave NE Kirkland, WA 98034-6901
Re: Complaint Investigation
Case Number: 2024-9824
License Number: RTF.FS.61015924
To Whom It May Concern:
The State of Washington Department of Health recently completed an investigation of Newport
Academy on August 15, 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


facility_name: Pearl Youth Residence

report_date: September 14, 2022

summary: State Inspection — ONGOING - ROUTINE (09/09/2022)

raw_content:
Residential Treatment Facility
Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
September 14, 2022
Pearl Youth Residence, 1201 S Proctor St, Tacoma, WA. 98405-2047 April Stallings
Agency Name and Address Administrator
ONGOING - ROUTINE 09/09/2022 JMI03
Inspection Type Inspection Onsite Dates Inspector
X2022-502 RTF.FS.61067805 Co-occurring 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
0480 Governance and administration This Washington Administrative Code (WAC) is not met as
WAC 246-337-045(1)(d)(iii) The licensee must evidenced by:
establish a governing body with responsibility for
operating and maintaining the RTF. The governing Based on the agency’s Policies and Procedure (P&P) review,
body must provide organizational guidance and clinical documentation review, agency internal processes and
oversight to ensure that resources support and staff interview, it was determined the agency failed to maintain
provides safe and adequate resident care including, the monitoring of the agency’s compliance with the rules in
but not limited to: (1) Adopting, periodically this chapter, and other state and federal rules and laws that
reviewing, and updating as necessary, policies that: govern agency licensing and certification requirements.
(a) Govern the organization and functions of the RTF
including: (iii) Complied with by staff. Failure to meet the standard of the WAC places clients at risk
of not receiving the minimum standard of care.
Failure of the Administrator or their designee to maintain
monitoring of the agency’s Quality Management Plan (QMP)
according to WAC may jeopardize the RTF and BHA licenses,
may lead to investigation and fines, compromised service
processes and potentially places staff at risk for liability
claims.
Findings included:
1. The agency organizational P&Ps across all sites and
services indicate all WAC, RCW, State and Federal
regulations will be implemented, monitored, ensured
compliance and maintained for WA State Residential
Treatment Facility (RTF) 246-337 (to include Food
Code 246-215) and Behavioral Health Agency (BHA)
246-341 licensure standards.
• It is important to note that the agency has a
streamlined process across all site and
services/programs yet has displayed inconsistencies
of monitoring and ensuring compliance. Forms need
to be reviewed for WAC updates to reflect the most
current language of 5/25/2021 – example: Individual
Rights have the current WAC language, yet the form
date is 5/4/2020. Clinical charts are reviewed
internally every 2 weeks and quarterly.
- A centralized Authentication Sheet was
encouraged to identify handwritten initials and
signatures that were commonly not legible on all
handwritten forms to include the Medication
Administration Records (MARs).
WAC Reference for ensuring the Quality
Management Plan (QMP) 246-337-048, 050 and 246-
341-0410(4)(g) and legibility 246-337-095(5) and 246-
341-0640(1)(f).
2. New Human Resource (HR) record keeping platform
– Payroll and Dayforce. There were areas on the
Personnel Sheet that were missing, had overdue
components, or noted “Enrolled or 00/00/0000”.
WAC Reference 246-337-045(3)(a)(b), 246-337-
050(4) and 246-341-0510(1)(c ) – orientation within
90 days of hire, 246-341-0410(4)(e ) – up-to-date
personnel files.
- 08/31/2022 at 12:30 AM During the clinical chart
review, Staff B – Human Resource (HR)
elaborated on the agency HR restructuring
process:
a. For all pending Agency Affiliated
Registrations (CAAR) over 3months, HR has
kept record of DOH communications, has a
monthly reminder list that is sent to each
Program Director.
b. TB screening history had been managed by
HR, during the COVID 19 pandemic TB
screening was given to each Program to
address/complete for staff and to update HR.
08/01/2022 HR has taken back the
gathering/monitoring of TB screening for
staff as it was determined the screening
process was sporadic due to COVID response
took priority. *WAC Reference 246-337-
050(7)(j)
c. Newer staff within the last 18months have
delayed training specific to
Seclusion/Restraints – 23 staff for Pearl St.
The agency has an overview training part of
the New Employment Orientation (NEO)
process and a specific Handle with Care
training. Noted staff have had the basic
overview, not the specific training – this
training is delivered at each program level
and assigned by the Program Director who
informs HR. This process does not support
the agency’s identified organizational
streamlining for compliance. *WAC
Reference 246-337-050(5)(c )(i,ii,iii,iv,v,vi)
d. CPR trainings are monthly, staff are expected
to enroll at the next available date from hire.
A CPR training spreadsheet is generated
through Paycom Employee System. 7 staff for
Pearl St. *WAC Reference 246-337-050(5)(d)
U0155 Food work cards Food handlers’ cards are to be kept current and renewing 9/29/2022 at 7:17 AM email from
WAC 246-215-02120(1) (1) The PERMIT HOLDER and valid, inclusive of Washington Administrative Codes (WAC) provider confirmed the 4 expired Food
PERSON IN CHARGE of the FOOD ESTABLISHMENT WAC 246-217 and RCW 69.06 Handlers Cards have been updated
shall ensure that all FOOD EMPLOYEES Certified on with plan to send updated cards to on-
2/25/2021 Page 37 are in compliance with the Failure to have valid food handlers’ cards may lead to site Kitchen Manager and HR.
provisions of chapter 69.06 RCW and chapter 246- increased risk of contamination illnesses, poor food safety
217 WAC for obtaining and renewing valid FOOD regulation and public health risk.
WORKER CARDS.
Findings include:
1. Observation during the facility walk through, the
kitchen Food Handlers’ Card binder was not kept
current, had expired cards with staff that were no
longer employed and not monitored for compliance.
Expired cards and formerly employed staff cards
were given to Staff A – Quality Improvement &
Incident Reporting Associate.
• The kitchen manager is newly hired and onboarding
to the specifics of their role.
• The four expired Food Handlers’ Card for N. Cruz -
expo 6/5/2022, K. Wade - expo 8/3/2022, M. White-
Wofford - expo 7/16/2022 and J. Wiggins - expo
01/16/2022 are not providing kitchen services until
renewal per Staff A’s email update of 9/9/2022.
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 Residential Treatment Facility
Inspection: Plan of Correction
Facility Name: Pearl Youth Residence (PYR)
1201 S. Proctor St. Tacoma, WA. 98405-2047 RTF.FS.61067805
Date of Inspection: _9/9/2022__ Due: 10/18/2022
Regulati How the Deficiency Will Be Corrected W h o i s W hen the Monitoring, Follow up
on Responsible for Correction will be
Number Correction(s) Completed
WAC Findings included:
246-337- The agency organizational P&Ps across all sites and services indicate all WAC, 1.A) Daniel 1.A) 11/1/22 and 1.A) QI Associate will review
045 RCW, State and Federal regulations will be implemented, monitored, ensured Aldridge ongoing ten random RTF policies for
compliance and maintained for WA State Residential Treatment Facility (RTF)
Executive current WAC language and
(1)(d)(iii) 246-337 (to include Food Code 246-215) and Behavioral Health Agency (BHA)
Director of WAC citation and report to
246-341 licensure standards. ·
Residential Exec. Dir. Of Residential
(1) (a)(iii)
Services Services by 1/20/23 (Amy)
1.A) Executive Director of Residential Services will work with Policy Specialist to
review RTF policies every 2 years and all other policies every 3 years, checking for
the most current WAC language. Hank
Balderrama,
It is important to note that the agency has a streamlined process across all site Policy Specialist
and services/programs yet has displayed inconsistencies of monitoring and
ensuring compliance. Forms need to be reviewed for WAC updates to reflect the
most current language of 5/25/2021 – example: Individual Rights have the
current WAC language, yet the form date is 5/4/2020. Clinical charts are
reviewed internally every 2 weeks and quarterly.
- A centralized Authentication Sheet was encouraged to identify handwritten
initials and signatures that were commonly not legible on all handwritten forms
to include the Medication Administration Records (MARs). WAC Reference for
ensuring the Quality Management Plan (QMP) 246-337-048, 050 and 246-341-
0410(4)(g) and legibility 246-337-095(5) and 246-341-0640(1)(f).
2. New Human Resource (HR) record keeping platform – Payroll and Dayforce.
There were areas on the Personnel Sheet that were missing, had overdue
components, or noted “Enrolled or 00/00/0000”. WAC Reference 246-337-
045(3)(a)(b), 246-337-050(4) and 246-341-0510(1)(c ) – orientation within 90 days
of hire, 246-341-0410(4)(e ) – up-to-date personnel files.
Department of Health Residential Treatment Facility
Inspection: Plan of Correction
Facility Name: Pearl Youth Residence (PYR)
1201 S. Proctor St. Tacoma, WA. 98405-2047 RTF.FS.61067805
Date of Inspection: _9/9/2022__ Due: 10/18/2022
- 08/31/2022 at 12:30 AM During the clinical chart review, Staff B – Human 2.A) Human 2.A) 9/10/22 and 2.A,B,C,D) Human Resources
Resource (HR) elaborated on the agency HR restructuring process: Resources: ongoing Administrator will review five
a. For all pending Agency Affiliated Registrations (CAAR) over 3months, HR has Reneishiah Davis randomly selected PYR staff
kept record of DOH communications, has a monthly reminder list that is sent to
& Madelyn Smith 2.B) 9/10/22 and for A) Agency Affiliated
each Program Director.
ongoing Registration B) TB Screen C)
b. TB screening history had been managed by HR, during the COVID 19 pandemic
2.B) Human HWC training D) CPR Training
TB screening was given to each Program to address/complete for staff and to
Resources: 2.C) 10/1/22 and by 11/15/22 and again by
update HR. 08/01/2022 HR has taken back the gathering/monitoring of TB
Reneishiah, ongoing 3/15/23 and share with the
screening for staff as it was determined the screening process was sporadic due
to COVID response took priority. *WAC Reference 246-337-050(7)(j) Madelyn PYR Director and
c. Newer staff within the last 18months have delayed training specific to PYR Medical 2.D) 9/10/22 and Development and Learning
Seclusion/Restraints – 23 staff for Pearl St. The agency has an overview training Team: Marsha ongoing Specialist to see if there
part of the New Employment Orientation (NEO) process and a specific Handle White-Wofford, Staff will become needs to be any changes
with Care training. Noted staff have had the basic overview, not the specific Michelle Henry certified to train made.
training – this training is delivered at each program level and assigned by the
PYR Admin Team: employees by
Program Director who informs HR. This process does not support the agency’s
Kymm Dozal 3/1/23
identified organizational streamlining for compliance. *WAC Reference 246-337-
050(5)(c )(i,ii,iii,iv,v,vi)
2.C) Human
d. CPR trainings are monthly, staff are expected to enroll at the next available
Resources:
date from hire. A CPR training spreadsheet is generated through Paycom
Employee System. 7 staff for Pearl St. *WAC Reference 246-337-050(5)(d) Reneishiah,
Madelyn
2.A) The Human Resources Department will make sure employees are PYR Director:
taken off the schedule on day #91 if they don’t have their Agency Kymm Dozal,
Affiliated Registration, if needed. PYR
2.B) HR works with the medical & admin team at Park Place and HR Development
tracking TB screens and Learning
2.C) HR works with The PYR Director and the PYR Development and Specialist: Brie
Learning Specialist to sign staff up for the Handle With Care training as Griffin
soon as possible during the hiring process. Staff are never to perform a
restraint without complete HWC training. 2.D) Human
2.D) HR will document CPR Trainings, monitor expirations, and take staff off Resources:
the schedule if they are not certified. Reneishiah,
Madelyn
Department of Health Residential Treatment Facility
Inspection: Plan of Correction
Facility Name: Pearl Youth Residence (PYR)
1201 S. Proctor St. Tacoma, WA. 98405-2047 RTF.FS.61067805
Date of Inspection: _9/9/2022__ Due: 10/18/2022
Several employees of CLR will go through a training to become certified to
train PYR employees in CPR/First Aide/Blood Borne Pathogens.
U0155 Food handlers’ cards are to be kept current and renewing valid, inclusive of PYR Kitchen 9/30/22 and Human Resources
Food Washington Administrative Codes (WAC) WAC 246-217 and RCW 69.06 Supervisor: ongoing Administrator will review five
work Jerinee Marshall, randomly selected PYR staff
cards Failure to have valid food handlers’ cards may lead to increased risk of HR Department: for by 11/15/22 and again by
contamination illnesses, poor food safety regulation and public health risk
Reneishiah Davis, 3/15/23 and share with the
WAC
Madelyn Smith PYR Director and the Kitchen
246-215- Findings include: 1. Observation during the facility walk through, the kitchen
Manager to see if there needs
02120(1) Food Handlers’ Card binder was not kept current, had expired cards with staff
to be any changes made.
(1) that were no longer employed and not monitored for compliance. Expired cards
and formerly employed staff cards were given to Staff A – Quality Improvement
69.06 & Incident Reporting Associate. · The kitchen manager is newly hired and The QI Associate will review
RCW and onboarding to the specifics of their role. · The four expired Food Handlers’ Card the Food Handlers’ Card
chapter for N. Cruz - expo 6/5/2022, K. Wade - expo 8/3/2022, M. White-Wofford - expo Binder to check expiration
246-217 7/16/2022 and J. Wiggins - expo 01/16/2022 are not providing kitchen services dates by 5/15/23 and give
WAC until renewal per Staff A’s email update of 9/9/2022 results to the Kitchen
Supervisor and the HR
9/29/2022 at 7:17 AM email from provider confirmed the 4 expired Food department
Handlers Cards have been updated with plan to send updated cards to on-site
Kitchen Manager and HR.
The PYR Kitchen Supervisor will monitor the Food Handlers’ Card binder for
expiration dates.
The HR Department will ensure staff have their Food Handlers’ Card if
required by their role and prompt staff to renew when expiring.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
October 17, 2022
RE: Inspection Number - X2022-502 License Number - RTF.FS. 61067805
Pearl Youth Residence
1305 Tacoma Ave S Ste 201
Tacoma, WA 98402-1903
Dear Ms. Amy Starkey c/o April Stallings
The Washington State Department of Health conducted a Residential Treatment
Facility Review of Pearl Youth Residence, 1201 S Proctor St, Tacoma, WA. 98405-
2047 on 09/09/2022.
The Plan of Correction that was submitted on 10/17/2022 has been approved with
no further action required.
I sincerely appreciate your cooperation and hard work during the review process and
look forward to working with you again in the future. Please contact me if there are
questions regarding the review process. I may be reached at (360) 480-5666. I am
also available by email at Jewelya.Ianniciello@doh.wa.gov
Sincerely,
Jewelya M Ianniciello SUDP LICSW CIYT CCTP MAC
Facility Inspector
Behavioral Health Reviewer
Office of Health Systems Oversight

report_type: Inspection Report

inspection_type: ONGOING - ROUTINE

administrator: April Stallings


summary: State Inspection


summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
March 11, 2022
Pearl Youth Residence
1201 S Proctor St
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2021-10483
License Number: RTF.FS.61067805
Dear Mr. Aldridge:
The State of Washington Department of Health recently completed an investigation of Pearl
Youth Residence on March 2, 2022.
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


summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
March 11, 2022
Pearl Youth Residence
1201 S Proctor St
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2021-10597 RTF, 2021-10598 BHA
License Number: RTF.FS.61067805, BHA.FS.61067737
Dear Mr. Aldridge:
The State of Washington Department of Health recently completed an investigation of Pearl
Youth Residence on March 2, 2022.
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


summary: State Investigation

raw_content:
S 1A1 i.: OF WASHINdTON
DEPARTMENT OF HEALTH
May 12,2021
Comprehensive Life Resources — Pearl Youth Residence
121 South Proctor Street
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-13516
License Number: RTF.FS.6107805
Dear Melissa Olson:
The State of Washington Department of Health recently completed an investigation of
Comprehensive Life Resources -- Pearl Youth Residence on April 2, 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: JAMC03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

raw_content:
STATI-; OF WASHINGTON
DEPARTMENT OF HEALTH
March 22,2021
Comprehensive Life Resources — Pearl Youth Residence
121 South Proctor Street
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-13708 RTF
License Number: RTF.FS.6107805
DearMelissa Olson:
The State of Washington Department of Health recently completed an investigation of
Comprehensive Life Resources - Pearl Youth Residence on March 22,2021.
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: JAMC03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

raw_content:
STATI-: ()\: WAS1 fINGt'ON
DEPARTMENT OF HEALTH
March 22, 2021
Comprehensive Life Resources - Pearl Youth Residence
121 South Proctor Street
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-15174
License Number: RTF.FS.6107805
Dear Melissa Olson;
The State of Washington Department of Health recently completed an investigation of
Comprehensive Life Resources - Pearl Youth Residence on March 1 8,2021.
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: JAMC03
Department of Health
HSQA/Offlce of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


report_date: February 16, 2021

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
February 16, 2021
Pear! Youth Residence
1201 S Proctor St.
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-16052 RTF, 2020-16053 BHA
License Number: BHA.FS.61067737, RTF.FS.61067805
Dear Mr. Aldridge:
The State of Washington Department of Health recently completed an investigation of Pearl
Youth Residence on January 27, 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


report_date: February 16,2021

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
February 16,2021
Pearl Youth Residence
1201 S Proctor St
Tacoma, WA 98405-2047
Re: Complaint Investigation
Case Number: 2020-15971 BHA, 2020-15972 RTF
License Number: BHA.FS.61067737, RTF.FS.61067805
Dear Mr. Aldridge:
The State of Washington Department of Health recently completed an investigation of Pearl
Youth Residence on January 20, 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


summary: State Investigation


report_date: November 12, 2020

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
November 12, 2020
Pearl Street
1201 S. Proctor St
Tacoma, WA. 98405
Re: Complaint Investigation
Case Number: 2020-12367
License Number: RTF.FS.61067805
Date(s) of Investigation: 10/7/20
Dear Administrator:
The State of Washington Department of Health recently completed an investigation of Pearl
Street on October 7, 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: Sea Mar Renacer Treatment Center

report_date: December 02, 2021

summary: State Inspection

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
No Deficiencies Found
December 02, 2021
Kristen Prentice
Sea Mar Renacer Treatment Center
10001 17th Pl S
Seattle, WA 98168-1615
Subject: Inspection Number: X2021-690
License Number: RTF.FS.00001053
Inspection Type: ONGOING - ROUTINE
Dear Mr./Ms. Kristen Prentice
This document contains information regarding the recent inspection of Sea Mar Renacer Treatment
Center, 10001 17th Pl S, Seattle, WA. 98168-1615 by the Washington State Department of Health.
Your state licensing inspection was completed on 11/02/2021.
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)
236-4690. I am also available by email at Jennifer.Ross@doh.wa.gov.
I want to extend another “thank you” to you and to everyone that assisted me during the survey.
Sincerely,
Jennifer M Ross LMHC
Facility Inspector


report_date: February 24, 2020

summary: State Inspection

raw_content:
Behavioral Health Agency Inspection Report
Department of Health
P.O. Box 47874, Olympia, WA 98504-7874
TEL: 360-236-4732
February 24, 2020
Sea Mar Renacer Treatment Center, 10001 17th Pl S, Seattle, WA. 98168-1615 Kristen Prentice
Agency Name and Address Administrator
ONGOING - ROUTINE 10/22/19 Jennifer M Ross LMHC
Inspection Type Inspection Onsite Dates Inspector
X2019-469 RTF.FS.00001053
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
1015 Resident rights Washington Administrative Code was not met as evidenced The clinical staff was re-trained on the
WAC 246-337-075(4)(a) The licensee must establish a by: importance of ROI, 42 CFR Part 2, and
process to ensure resident rights are protected in Based on clinical record review, the RTF did not protect the allowable exclusions for
compliance with chapter 71.12 RCW, this chapter, confidentiality of the treatment and personal information confidentiality. The staff member
and other applicable laws, and are based on the when communicating with individuals not associated or listed responsible for these charts no longer
service types provided in the RTF. This process must in the resident’s individual service plan or confidentiality works at Sea Mar. Monthly clinical
address how the RTF will:(4) Protect the disclosure chart audits will be conducted for 6
confidentiality of: (a) Treatment and personal months to ensure ongoing compliance.
information when communicating with individuals Failure to protect confidentiality of residents may result in a
not associated or listed in the resident's individual information being released without resident’s permission and
service plan or confidentiality disclosure form; /or a fine due to release of HIPPA information.
Findings include:
1. On 10/22/19, in review of clinical records it was
determined that Records #2 and 3 did not have
proper releases of information completed in the file
for the persons that the facility was speaking with.
This also includes probation reports that were being
sent without proper release of information
2. On 10/22/19, in an interview with Staff #2, Program
Director, it was confirmed that neither file had the
appropriate release of information for the
information that was being communicated
3.
1060 Resident care services Washington Administrative Code was not met as evidenced To correct this finding, all youth
WAC 246-337-080 (2)(b) (2) The licensee must:(b) by: entering treatment will complete a TB
Conduct or accept a current health care screening of symptom screening on paper (see
each resident upon admission including a Based on clinical record review the RTF did not ensure that a attached) that will be scanned into the
tuberculosis risk assessment and symptom screening; current health care screening of each resident including a TB electronic health record. If a youth
risk assessment and symptom screening was being completed screens, high-risk they will be referred
to the medical clinic for further
Failure to have this health care screening may result in the screening. Sea Mar is slated to change
facility not knowing of a resident with TB and being unable to electronic health record systems in
provide the care needed as well as putting other 2020 and in that system, the TB
staff/residents at risk of TB. screener questions are included in the
admission documentation
Findings include: requirements.
1. On 10/22/19, in a review of clinical records it was
determined that Records #1/2/3 did not have a
health care screening which included a TB risk
assessment and symptom screening was being
completed
1085 Resident care services The Washington Administrative Code was not met as Based on our records, there is no
WAC 246-337-080(2)(g) (2) The licensee must:(g) evidence by: evidence that these patients were
Provide access to tuberculosis testing if the resident symptomatic or high-risk therefore a
is high-risk or symptomatic of tuberculosis; Based on clinical record review, policy review and interview TB test was not required. A meeting
with staff, it was determined that the clinical record did not will be set up between our Adolescent
document that a TB test was complete. clinic physician/staff to determine the
best process for getting the TB testing
Failure to meet this standard may result in substandard care results transferred to Renacer
for patients and not meeting the health needs of all patients. following physical exams. Each youth
will submit to a TB blood test if high
Findings include: risk/symptomatic. The results will be
1. On 10/22/19, in a clinical record review, it was printed and provided to Renacer staff
determined that Records #1/2/3 did not have a TB at our next clinic day. The results will
test completed on residents. be kept in the MAR binder as well as
scanned into the EHR. As per policy, all
youth are required to have a physical
exam completed within 5 days of
admission.
1150 Resident care services The Washington Administrative Code was not met as The names of these patients was
WAC 246-337-080(5)(a) (5) RTFs which meet the evidence by: requested and we have not received a
conditions in subsection (3) or (4) of this section response yet. If the document is
must:(a) Perform a health assessment for each Based on clinical record review, policy review and interview available in the record, we can submit
resident. A prescriber or licensed nurse operating with staff, it was determined that the clinical record did not it for review. There is a possibility that
within their scope of practice shall conduct and document that a health assessment was performed on each record of the physical exam was in the
complete the assessment following the resident's resident. medication binder and not yet scanned
admission to the RTF unless a health assessment was into the EHR. It is Sea Mar policy that
performed within the past three months and is Failure to meet this standard may result in substandard care every youth attends a physical exam
available to the RTF upon admission; and for patients and not meeting the health needs of all patients. within the first 5 days of their stay.
Findings include:
1. On 10/22/19, in a clinical record review, it was
determined that Records #1/2/3 did not have a
health assessment performed on each resident.
1385 Resident's individual service plan The Washington Administrative Code was not met as An in depth staff training on individual
WAC 246-337-100(1)(a-b) (1) The licensee must evidence by: service plans will be conducted on
develop and implement an individual service plan for 3/11/2020 and will cover the need to
each resident based on the resident's: (a) Initial Based on clinical record review, policy review and interview have health needs included in the ISP.
health on admission; and (b) Health assessment(s). with staff, it was determined that the clinical record did not Monthly clinical chart audits will be
document that a health assessment was performed on each conducted for 6 months to prove
resident that could be included on the service plan compliance with this requirement.
Failure to meet this standard may result in substandard care
for patients and not meeting the health needs of all patients.
Findings include:
1. On 10/22/19, in a clinical record review, it was
determined that Records #1/2/3 did not have a
health assessment performed on each resident so it
could be included on each service plan.
1400 Resident's individual service plan Washington Administrative Code was not met as evidenced An in depth staff training on individual
WAC 246-337-100(2)(c) (2) Individual service plans by: service plans will be conducted on
must:(c) Include work assignments given to a resident 3/11/2020 and will cover the need to
as part of their individual service plan, if applicable; Based on clinical record review, it was determined that the include community engagement/
clinical record did not include work assignments given to cleaning tasks in the ISP. Monthly
residents as part of their individual service plan. clinical chart audits will be conducted
Failure to include work assignments as part of their service for 6 months to prove compliance with
plan may result in resident’s work not being acknowledged this requirement.
properly
Findings include:
1. On 10/22/19, in a clinical record review, it was
determined that Records #1/2/3 did not have service
plans that reflected the work assignments given to
residents including: responsible for the cleaning of
entire facility and responsible for maintaining clean
room.
2. On 10/22/19, in interview with Staff #2, Program
Director, it was determined that these items were
not put on their service plan but they were part of
the resident’s assigned duties
1405 Resident's individual service plan Washington Administrative Code was not met as evidenced An in depth staff training on individual
WAC 246-337-100(2)(d) (2) Individual service plans by: service plans will be conducted on
must:(d) Be updated as additional needs are 3/11/2020 and will cover the need to
identified during treatment; and Based on clinical record review, it was determined that include assignments assigned to clients
service plans were not updated to reflect assignments that in the ISP and the progress toward
were given to residents those assignments in the ISP review.
Monthly clinical chart audits will be
Failure to update service plans may result in residents not conducted for 6 months to prove
meeting all their service plan goals compliance with this requirement.
Findings include:
1. On 10/22/19, in a review of resident records, it was
determined that Record #3 did not reflect
assignments given to resident as part of their
treatment
1410 Resident's individual service plan Washington Administrative Code was not met as evidenced An in depth staff training on individual
WAC 246-337-100(2)(e) (2) Individual service plans by: service plans will be conducted on
must:(e) Include a discharge health care plan. 3/11/2020 and will cover the need to
Based on clinical record review, it was determined that the include discharge planning tasks in the
service plans did not include a discharge health care plan ISP. Monthly clinical chart audits will
be conducted for 6 months to prove
Failure to have discharge health care plans may result in the compliance with this requirement.
resident’s health care needs not being met
Findings include:
1. On 10/22/19, in review of clinical records, it was
determined that Records #1/2/3 did not have discharge
health care plans reflected on the service plan.
1980 Facility and environment requirements Washington Administrative Code was not met as evidenced a. The broken tile and flooring was
WAC 246-337-120(1) (1) The licensee must maintain by: corrected in November by the
the facility, exterior grounds, and component parts Based on the inspection of all areas of the facility, the RTF maintenance person at the building.
such as fences, equipment, outbuildings, and failed to ensure that the facility was safe, sanitary, and being b. The drywall patch in the bathroom
landscape items in a manner that is safe, free of maintained in good repair. was repaired on 3/4/2020.
hazards, clean, and in good repair. c. The mop boards at the base of the
Failure to keep the facility maintained in good repair may wall will be secured to the wall by
result in poor hygiene, bugs and rodents, mold growth, health 3/11/2020.
concerns to residents, overall unsanitary condition. d. We have begun construction on a
portion of our building. We are
Findings included: attempting to salvage the flooring from
1. During the survey on 10/22/19, at 11:30 am the that portion of the building to repair
surveyor observed the following; the flooring on the Inpatient wing. If
salvage is not possible, we will forgo
a) The shower room for all residents was in need of this repair as the flooring is going to be
repair, the tile was broken off the walls and flooring area replaced fully during construction. If
exposing the wood and metal material. See pictures attached possible, this work is slated to be
(#13, #18, #19). completed by 3/25/2020.
b) The shower room ceiling showed an unfinished e. The holes in resident rooms are
drywall job centered around an open light fixture with no repaired on a weekly basis. The holes
cover. See picture attached (#16). noted in the audit have been repaired.
c) Loose mop boards need to be secured to the wall in f. The bathroom identified is a single
the main hallway where resident’s rooms are located. See occupancy shower room. The
picture attached (#10). bathroom doors lock automatically and
d) The floors in the hallway to the resident’s bedrooms entry is controlled by staff. The
were damaged coming apart at the joints. The damage to the bathrooms will be demolished as part
floors created rough edges for dirt and mold to catch in and of construction.
produce mold, and bacteria. The flooring is also a health and g. The graveyard staff have begun
tripping hazard. This surveyor tripped on the floor when cleaning the bathroom nightly, in
walking in the hallway. See pictures attached (#8, #9). addition to the youth’s daily chores.
e) Large holes in walls of resident’s bedrooms. See This has ensured that the bathroom is
pictures attached (#3, #6). kept cleaner than in the past.
f) No Shower curtains for privacy in the large shower Additionally, staff is responsible for
room. touch up cleaning at least one time on
g) Small bathroom with bathtub was dirty with mold their shift.
and grime. See pictures attached (#13, #14). h. The toilet in the small bathroom
h) Two toilets for 16 male clients, one toilet was missing was replaced in February and it
the lid the other toilet had the lid in place. currently has the tank lid attached.
i) The Medication Room had ants crawling on the wall i. The exterminator had just been to
and counter top and around sink. Renacer prior to the site visit and the
ants were crawling to the bait on the
2. During an interview with staff member #A, on wall. Renacer has monthly scheduled
10/22/19, at 11:30am, in reference to the above deficiencies, extermination services as well as “as
he stated that the reason the one toilet was missing the lid needed” service. The exterminator
was due to residents using the lid as a weapon. When asked returned to the site the day after the
about the holes in the walls he stated that the residents site visit and he moved the bait
destroy things so fast that it is hard to keep up with the placement so that the ants were not
damage. During the interview the question was brought up crawling on the counter. We will
about the rope used to hold the curtains up and if he saw it as continue to monitor the pest control
a hazardous situation the staff stated that it was not a situation.
problem. When asked why a rope is used instead of a curtain
rod the staff did not have a reason for no curtain rod. This A running maintenance log will be
surveyor was concerned that the staff member stated that created that lists deficiencies, date
the reason the one toilet lid was removed was that it could be added and date completed. This will
used as a weapon, but the second toilet lid was not removed. be kept in the manager’s office to
The observation for this surveyor was the absence of ensure maintenance is being
continuous and consistent safety in the facility for residents. completed. Construction has begun to
renovate the building and keeping up
with repairs will be a priority.
2280 Resident sleeping room requirements Washington Administrative Code was not met as evidenced Bedroom doors are locked due to
WAC 246-337-129(1) (1) The licensee shall provide by: safety and supervision concerns as
residents with an accessible, clean, well-maintained Based on the survey of the resident rooms, the RTF failed to Rencer is a Level 2 secure facility.
room with sufficient space, light, and comfortable provide residents with an accessible, clean, well-maintained
furnishings for sleeping and personal activities. rooms for sleeping and personal activities and security of We will install hooks next to each
their personal belongings. bedroom door for the youth’s sweat-
clothes when they are not wearing
Failure to provide residents with accessibility to well maintain them. To be completed 3/18/2020.
residence rooms, with comfortable furnishings for sleep and
personal activities may result in residents not having a clean We have a binder rack in the hall to
and comfortable space to rest and store their personal provide a place for each youth to store
belongings in a hygienic space. their binders and papers throughout
the day.
Findings include:
1. During the survey of the RTF, the surveyor found the Their slippers and slides will be placed
residents rooms not maintained and not accessible to in the shoe closet when they are not
residents. The residents bedrooms are kept locked being used throughout the day and in
through the day and the residents were only allowed their rooms at night. Their shoes are
in their rooms to collect items, come back out and to be stored in the shoe closet at all
the doors were locked again by staff. At one point the times when not being worn.
residents were getting ready to work outside in rain
gear and boots and had to leave their tennis shoes Construction has begun to renovate
and shirts and sweatshirts on the dirty hallway floor the building and there are plans for
outside their bedrooms due to no staff availability to there to be cubbies or shelves placed
unlock their bedroom doors so they could secure next to the youth’s rooms to store
their personal belongings in their rooms. their items throughout the day.
2305 Resident sleeping room requirements Washington Administrative Code was not met as evidenced New blinds were ordered on
WAC 246-337-129(2)(e)(i) (2) Sleeping rooms must by: 2/13/2020 and were installed on
include:(e) One or more outside windows that:(i) Has Based on the survey of the resident rooms, the RTF failed to 2/27/2020. Surplus blinds have been
adjustable curtains, shades, blinds, or equivalent provide residents with adjustable curtains, shades, blinds, or procured to ensure that if damage
installed at the windows for visual privacy; equivalent installed at the windows or visual privacy. occurs to one set, there are
replacements available.
Failure to provide residents with adjustable curtains, shades,
blinds, or equivalent installed at the windows or visual
privacy may result in residents not having safe, well
maintained rooms with privacy.
Findings include:
1. During the survey of the RTF, the surveyor found the
residents rooms had curtains strung on a ropes held
up by screws used as a curtain rods in each resident’s
rooms. This reviewer asked (Staff# A Camron
Hargrove) if this was a concern for possible harm to
residents, he was unsure. I shared that it was a strong
rope secured well and could be taken apart and used
to harm self. This did not appear to be a concern to
staff #A member.
2325 Resident sleeping room requirements Washington Administrative Code was not met as evidenced Renacer washes towels and washcloths
WAC 246-337-129(3)(b) (3) Sleeping rooms must be by: after each use. The youth put the used
equipped with:(b) An individual towel and washcloth Based on the survey of the resident rooms, the RTF failed to towel in the laundry after their
rack or an equivalent method to provide clean towels provide residents with sleeping rooms equipped with an shower/hygiene routine. They are
and washcloths; and individual towel and washcloth rack or an equivalent method then washed, dried and given to the
to provide clean and dry towels and washcloths. youth at their next shower period. No
towels or washcloths are stored in the
Failure to provide resident rooms equipped with towel and bedrooms.
washcloth racks may result in residents getting bacteria,
viruses or rashes due to unclean damp towels or washcloths.
Findings include:
1. During the survey of the RTF on 10/22/19 at 12:30,
the surveyor found the resident rooms did not have a
place to hang towels and washcloths for their use.
2375 Lighting emergency light, electric outlts Washington Administrative Code was not met as evidenced 1. Light covers were obtained and
WAC 246-337-140(1) The licensee shall ensure that by: will be replaced. To be
lighting, emergency lighting, and electrical outlets are Based on the inspection of all areas of the facility, the RTF completed by 3/18/2020.
adequate and safe including:(1) Protection of bulbs failed to ensure that lighting, was adequate and safe. The RTF 2. Light fixtures in the bathroom
and tubes against breakage by using canned lights, failed to provide protected covers for bulbs and tubes will be replaced by 3/11/2020.
appropriately fitted shields, or shatter resistant appropriately fitted shields or shatter resistant materials in all
materials in all areas occupied by residents, and in areas occupied by residents. A running maintenance log will be
medication and food preparation areas. created that lists deficiencies, date
Failure to repair broken light covers and shields may result in added and date completed. This will
residents getting hurt by shattered glass from unprotected be kept in the manager’s office to
light bulbs and or electrical shock by exposed electrical light ensure maintenance is being
sockets and wires. completed. Construction has begun to
renovate the building and keeping up
Findings include: with repairs will be a priority.
1. During a survey on 10/22/19, at 11:30am, of resident
rooms throughout various parts of the facility, light
covers were missing ends that incase the fluorescent
lighting fixture. See picture (#1).
2. During a survey on 10/22/19, at 12:30pm, of the
shower room the exposed light fixture in the ceiling
above the shower head on the wall had no light cover
on the light bulb. See picture (#16).
3. During an interview on 10/22/19, at 12:30pm, (Staff#
A Camron Hargrove not have an answer for the
missing light fittings.
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874  Olympia, Washington 98504-7874
April 1, 2020
Kristen Prentice
Sea Mar Community Health Center
10001 17th Pl S
Seattle, WA 98168
Subject: Inspection Number X2019-469
Dear Ms. Prentice,
The Washington State Department of Health conducted a inspection at Sea Mar
Community Health Center. Your inspection was conducted on 10/22/2019. The
Plan of Correction that was submitted was approved on 4/1/2020.
I sincerely appreciate your cooperation and hard work during the inspection process
and look forward to working with you again in the future.
Sincerely,
Jennifer Ross, LMHC
Behavioral Health Reviewer

administrator: Kristen Prentice


report_date: December 26, 2024

summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
December 26, 2024
Sea Mar Community Health Center
10001 17th Place South
Seattle, WA 98168
Re: Complaint Investigation
Case Number: 2023-9022
License Number: RTF.FS.00001053
Dear Kristen Prentice:
The State of Washington Department of Health recently completed an investigation of Sea Mar
Community Health Center on December 5, 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: 46151
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


summary: State Investigation

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
June 12, 2023
Sea Mar
10001 17th Place South Seattle, WA 98168-1615
Re: Complaint Investigation
Case Number: #2021-10985
License Number: RTF.FS.00001053
Date(s) of Investigation: 11/15/21 – 03/27/23
Greetings,
The State of Washington Department of Health recently completed an investigation at Sea Mar
on June 12, 2023.
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: BTS03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874


facility_name: Sundown M Ranch

report_date: September 12, 2023

summary: State Inspection

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
No Deficiencies Found
September 12, 2023
Scott Munson
Sundown M Ranch
PO Box 217
Selah, WA 98942-0217
Subject: Inspection Number: X2023-478
License Number: RTF.FS.00001064
Inspection Type: ONGOING - ROUTINE
Dear Scott Munson
This document contains information regarding the recent inspection of Sundown M
Ranch, 2280 State Route 821, Yakima, WA. 98901-8302 by the Washington State
Department of Health. Your state licensing inspection was completed on 08/17/2023.
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 CDP MHP MAC
Behavioral Health Reviewer
Office of Health Systems Oversight
Health Systems Quality Assurance Division
Washington State Department of Health


report_date: November 18, 2021

summary: State Inspection

raw_content:
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PO Box 47874 • Olympia, Washington 98504-7874
No Deficiencies Found
November 18, 2021
Scott Munson
Sundown M Ranch
PO Box 217
Selah, WA 98942-0217
Subject: Inspection Number: X2021-605
License Number: RTF.FS.00001064
Inspection Type: ONGOING - ROUTINE
Dear Scott Munson
This document contains information regarding the recent inspection of Sundown M Ranch, 2280
State Route 821, Yakima, WA. 98901-8302 by the Washington State Department of Health. Your
state licensing inspection was completed on 11/17/2021.
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/ Facility Inspector
Office of Health Systems Oversight
Health Systems Quality Assurance Division
Washington State Department of Health


summary: State Investigation

raw_content:
STATE OK WASHINGTON
DEPARTMENT OF HEALTH
April 8,2021
Sundown M Ranch
2280 State Route 821
Yakima,WA 98901-8302
Re: Complaint Investigation
Case Number: #2020-10670
License Number: RTF.FS.00001064
Date(s) of Investigation: 03/22/2021
Dear: Mr. Loes,
The State of Washington Department of Health recently completed an investigation Sundown M
Ranch on April 8, 2021.
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: BTS03
Department of Health
HSQA/Office of Health Systems Oversight
PO Box 47874
Olympia, Washington 98504-7874