Kelley, Aaron (DOH)
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Gerard, Christopher L (DOH)
Tuesday, July 25, 201 7 3:05 PM
Kirschenman, Sara J (DOH)
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Cascade Behavioral Hospital, HPSY, CLG, NOI.docx; CFR to WAC.docx

Christopher Gerard
Staff Attorney, Office of Legal Services
Washington State Department of Health
P.O. Box 47873
Olympia, WA 98504
Tel: 360-236-4908

1

CASCADE BEHAVIORAL HOSPITAL M2017-712 EMAIL SEARCH PAGE 1

 STATE OF WASHINGTON
DEPARTMENT OF HEALTH
SECRETARY OF HEALTH
In the Matter of

No. M201 7-71 2

CASCADE BEHAVIORAL HOSPITAL LLC.
D/B/A CASCADE BEHAVIORAL HOSPITAL
Credential No. HPSY.FS.604291 97

NOTICE OF INTENT TO MODIFY

Respondent
Pursuant to RCW 43.70.1 1 5, the Executive Director of the Psychiatric Hospital
Program (Program), on designation by the Secretary, having authority to regulate
Psychiatric Hospitals under chapter 71 .1 2 RCW and chapter 246-322 WAC, hereby
provides Notice of Intent to Modify License No. HPSY.FS.604291 97. This Notice will take
effect and become a Final Order, without further notice, twenty-eight (28) days after receipt
absent a timely request for an adjudicative proceeding. This Notice is based on the
following findings of fact and conclusions of law.
1 . ALLEGED FACTS
1 .1

On November 25, 201 3, the State of Washington issued Cascade

Behavioral Hospital LLC d/b/a Cascade Behavioral Hospital (Cascade) a license to
operate as a psychiatric hospital. Respondent’s license is currently active.
1 .2

In addition to being a State licensed psychiatric hospital, Respondent is a

federal certified psychiatric hospital and is subject to meeting Conditions of Participation
in 42 CFR part 482 and 42 CFR part 41 2. The Washington State Department of Health
Psychiatric Hospital Program surveys hospitals on behalf of the Federal Department of
Health and Human Services Centers for Medicare & Medicaid Services (CMS) to
determine compliance with Conditions of Participation.
1 .3

On or around December 21 , 201 6, the Program, on behalf of CMS

completed a Medicare Hospital Complaint Survey of Cascade. The survey resulted in
the issuance of a Statement of Deficiencies (SOD), which is incorporated by reference
and attached to this Notice of Intent to Modify (Notice) as Attachment 1 . As
documented in the SOD, the survey identified conditions at Cascade that did not meet
CMS’ Conditions of Coverage in the areas of: Governing Body, Patient Rights, Quality
NOTICE OF INTENT TO MODIFY
NO. M201 7-71 2

PAGE 1 OF 3

CASCADE BEHAVIORAL HOSPITAL M2017-712 EMAIL SEARCH PAGE 2

 Assessment and Performance Improvement, Pharmaceutical Services, and Physical
Environment. The survey team also identified a situation at Cascade that constituted
“Immediate Jeopardy” as defined in 42 CFR § 489.3. The “Immediate Jeopardy” was
removed eight (8) days after completion of the survey. The conditions identified at
Cascade and documented in the SOD also fell below the minimum standards
established in chapter 70.230 RCW and chapter 246-322 WAC. Cascade agreed to
correct the deficiencies in a Plan of Correction (POC) that was accepted by CMS on or
around XXXXX.
1 .4

On or around March 1 0, 201 7, the Program, on behalf of CMS completed

a Medicare Hospital Complaint Survey Follow-up Visit of Cascade. The survey resulted
in the issuance of a SOD, which is incorporated by reference and attached to this Notice
as Attachment 2. As documented in the SOD, the survey identified conditions at
Cascade that did not meet CMS’ Conditions of Coverage in the areas of: Governing
Body, and Patient Rights. The survey team also identified a situation at Cascade that
constituted “Immediate Jeopardy” as defined in 42 CFR § 489.3. The “Immediate
Jeopardy” was removed by completion of the survey. The conditions identified at
Cascade and documented in the SOD also fell below the minimum standards
established in chapter 70.230 RCW and chapter 246-322 WAC. Cascade agreed to
correct the deficiencies in a Plan of Correction (POC) that was accepted by CMS on or
around XXXXX.
1 .5

On or around May 5, 201 7, the Program, on behalf of CMS completed a

Medicare Hospital Complaint Survey Follow-up Visit of Cascade. The survey resulted in
the issuance of a SOD, which is incorporated by reference and attached to this Notice
as Attachment 3. As documented in the SOD, the survey identified conditions at
Cascade that did not meet CMS’ Conditions of Coverage in the areas of: Governing
Body. The survey team also identified a situation at Cascade that constituted
“Immediate Jeopardy” as defined in 42 CFR § 489.3. The “Immediate Jeopardy” was
removed by completion of the survey. The conditions identified at Cascade and
documented in the SOD also fell below the minimum standards established in chapter
70.230 RCW and chapter 246-322 WAC. Cascade agreed to correct the deficiencies in
a Plan of Correction (POC) that was accepted by CMS on or around XXXXX.
2. ALLEGED VIOLATIONS
NOTICE OF INTENT TO MODIFY
NO. M201 7-71 2

PAGE 2 OF 3

CASCADE BEHAVIORAL HOSPITAL M2017-712 EMAIL SEARCH PAGE 3

 2.1

Based on the alleged facts made in Section 1 of this Notice, Respondent is

in violation of RCW 70.230.070(3); RCW 70.230.080(1 ) and (4);
2.2

The above violations provides grounds for modifying Respondent’s license

under RCW 70.1 2.500 and WAC 246-322-025(4).
3. NOTICE TO RESPONDENT
The charges in this document affect the public health, safety and welfare. The
executive director of the Program directs that a notice be issued and served on
Respondent as provided by law, giving Respondent the opportunity to defend against
these allegations. If Respondent fails to defend against these charges, Respondent may
have its psychiatric hospital credential modified under RCW 71 .1 2.500 and WAC 246-322025(4) without further notice or opportunity for a hearing.
DATED: ___________________________________, 201 7
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
PSYCHIATRIC HOSPITAL PROGRAM

________________________________
NANCY TYSON
EXECUTIVE DIRECTOR

NOTICE OF INTENT TO MODIFY
NO. M201 7-71 2

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CASCADE BEHAVIORAL HOSPITAL M2017-712 EMAIL SEARCH PAGE 4

 Cascade Behavioral Hospital
May 5, 2017
Tag
Licensure of Personnel – A023
Governing Body – A043
Medical Staff – A045
Emergency Services – A093

C.F.R.
42 C.F.R. 482.11(c)
42 C.F.R. 482.12
42 C.F.R. 482.12(a)(1)
42 C.F.R. 482.12(f)(2)

Nursing Care Plan – A396

42 C.F.R. 482.23(b)(4)

WAC
WAC 246-322-050(3), (12)(b)
WAC 246-322-040
WAC 246-322-040(8)(c)?
WAC 246-322-040(1), WAC
246-322-035(g), WAC 246322-170(3)(a)
WAC 246-322-200?

March 10, 2017
Tag
Governing Body – A043
Patient Rights – A115

C.F.R.
42 C.F.R. 482.12
42 C.F.R. 482.13

Patient Rights – Care in Safe
Setting - A144
Patient Rights – Restraints or
Seclusion – A164
Patient Safety – A286

42 C.F.R. 482.13(c)(2)

WAC
WAC 246-322-040
WAC 246-322-035(1)(d),
WAC 246-322-050(6)(g),
(7)(b)(iv) 1
No equivalent provision

42 C.F.R. 482.13(e)(2)

No equivalent provision

42 C.F.R. 482.21(a), (c)(2),
(e)(3)

WAC 246-322-040(8)(i)?

Tag
Governing Body – A043
Contracted Services – A084
Patient Rights – A115

C.F.R.
42 C.F.R. 482.12
42 C.F.R. 482.12(e)(1)
42 C.F.R. 482.13

Patient Rights: Notice of
Grievance Decision – A123
Patient Rights: Exercise of
Rights – A129
Patient Rights: Restraint or
Seclusion – A164
Patient Rights: Restraint or
Seclusion – A174
QAPI – A263

42 C.F.R. 482.13(a)(2)(iii)

WAC
WAC 246-322-040
No equivalent provision
WAC 246-322-035(1)(d),
WAC 246-322-050(6)(g),
(7)(b)(iv) 2
No equivalent provision

42 C.F.R. 482.13(b)

No equivalent provision

42 C.F.R. 482.13(c)(2)

No equivalent provision

42 C.F.R. 482.13(e)(2)

No equivalent provision

42 C.F.R. 482.21

WAC 246-332-040(1) and (8)(i)

December 21, 2016

1

These above provisions related to policies and procedures for patient rights and ensuring that staff members are
educated on patient rights pursuant to RCW 71.05 and 71.34
2
These above provisions related to policies and procedures for patient rights and ensuring that staff members are
educated on patient rights pursuant to RCW 71.05 and 71.34

CASCADE BEHAVIORAL HOSPITAL M2017-712 EMAIL SEARCH PAGE 5

 Date Collection and Analysis –
A273
Patient Safety – A286
QAPI: Executive
Responsibilities – A309
Administration of Drugs – A405
Pharmaceutical Services –
A490
Pharmacy Administration –
A491

42 C.F.R. 482.21(a), (b)(1),
(b)(2)(i), (b)(3)
42 C.F.R. 482.21(a), (c)(2),
(e)(3)
42 C.F.R. 482.21(e)(1), (e)(2),
(e)(5)
42 C.F.R. 482.23(c)(1), (c)(1)(i),
(c)(2)
42 C.F.R. 482.25

WAC 246-332-040(1) and (8)(i)

42 C.F.R. 482.25(a)

No equivalent provision, could
argue it is under WAC 246-322210(3). For the specific facts,
could be under WAC 246-322210(3)(g).
No equivalent provisions, but
appears like could be arguably
under WAC 246-322-210(3)(k)
No equivalent, but facts under
the citation arguably fall under
WAC 246-322-210(3)(k)
WAC 246-322-120
WAC 246-322-120(1)

Pharmacy Personnel – A493

42 C.F.R. 482.25(a)(2)

Delivery of Drugs – A500

42 C.F.R. 482.25(b)

Physical Environment – A700
Maintenance of a Physical Plant
– A701
Life Safety from Fire – A710
Facilities Supplies Equipment
Maintenance – A724
Ventilation, Light, Temperature
Controls – A726
Infection Control program –
A749

42 C.F.R. 482.41
42 C.F.R. 482.41(a)
42 C.F.R. 482.41(b)(1)(2)(3)
42 C.F.R. 482.41(c)(2)

WAC 246-322-040(8)(i); WAC
246-322-260
WAC 246-322-040(8)(i) - ?
WAC 246-322-210(3)(c) - ?
WAC 246-322-210

42 C.F.R. 482.41(c)(4)

RCW 71.12.485
No equivalent provision related
to expired products.
WAC 246-322-120(3)-(6)

42 C.F.R. 42(a)(1)

WAC 246-322-100(1)

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