Valley Home Health

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Outcome and Assessment Information Set (OASIS, a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services, (CMS)) data was transmitted within 30 days of completing the OASIS data sets when 273 Oasis reports were submitted after 30 days during the period of 4/1/26- 6/30/26 and 36 were submitted after 30 days for the period of 8/1/26-8/31/26. These failures created the risk of not reporting and coordinating patient care assessments timely for the patients receiving care and services at the HHA. Findings: During a review on 9/3/26 of the agency’s “OASIS Error Detail Reports,” for the periods dated April 1, 2026, to June 30, 2026, and for the month of August 2026, the following was identified: The agency’s “OASIS Error Detail Report,” indicated, 102 data sets were submitted more than 30 days from the assessment completion date in April 2026. The agency’s “OASIS Error Detail Report,” indicated, 105 data sets were submitted more than 30 days from the assessment completion date in May 2026. The agency’s “OASIS Error Detail Report,” indicated, 66 data sets were submitted more than 30 days from the assessment completion date in June 2026. The agency’s “OASIS Error Detail Report,” indicated, 36 data sets were submitted more than 30 days from the assessment completion date in August 2026. During a concurrent interview and record review on 9/3/26 at 11:47 AM, with the Billing Coordinator (BC) and the Office Manager (OM), the OASIS Error Detail Reports were reviewed. The BC stated she completed OASIS submissions daily, Monday – Friday, and usually within the CMS 30-day time frame. The BC stated OASIS assessments were audited for date, signature, and diagnosis code, then a file was generated and uploaded into iQIES (Internet Quality Improvement and Evaluation System, portal run by CMS to manage patient assessments, provider data, and quality reporting of their programs). The MO stated the agency was aware of the issue with late submissions and was working with clinicians to ensure timely completion of their assessments. During a concurrent interview and record review on 9/3/26 at 12:30 PM, with the Administrator (ADM), the OASIS Error Detail Reports were reviewed. The ADM stated the reports indicated a downward trend in late submissions. The ADM further stated he received a daily charting report of outstanding documentation, which was utilized to review staff assignments and patient visits to ensure staff were not overwhelmed and could manage their workload effectively. The ADM stated incomplete documentation affected patient care and agency reimbursement. During a review of an undated agency policy and procedure (P&P) titled, “DOCUMENTATION FOR CLAIMS SUBMISSION,” the P&P indicated, “…Policy: [Agency Name] will establish systems and procedures to assure compliance with Medicare regulations, establish protocols of other payers, and accepted standards of practice…Purpose: To define the responsibilities of [Agency Name] in billing for services. To identify the procedures and processes that will assure regulatory compliance, accurate claims submission and appropriate practices…””

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure skilled nursing services (a high level of medical care provided by licensed nurses and therapists under a doctor’s supervision) were provided at the frequency specified in the individualized plans of care for two of seventeen sampled patients (Patient 5 and Patient 6) when: 1. The licensed nurse missed Patient 5’s scheduled skilled nursing visit on 4/15/26, resulting in no skilled nursing visit being provided during the week of 4/12/26 through 4/18/26. 2. The licensed nurse missed Patient 6’s scheduled skilled nursing visits on 8/27/26, resulting in no skilled nursing visits being provided during the week of 8/23/26 through 8/29/26. This deficient practice resulted in two missed physician-ordered weekly skilled nursing visits and had the potential to delay assessment, treatment, wound care, disease-management education, and timely identification of changes in condition, placing the affected patients at risk for complications, infection, worsening condition, and the need for emergency care and hospitalization. FINDINGS: 1. Review of Patient 5’s clinical record showed the agency admitted Patient 5 to home health services on 4/10/26 for the certification period from 4/10/26 through 8/8/26. Patient 5 was admitted to home health services with skilled nursing ordered for management of a scalp laceration (head wound). Review of Patient 5’s Home Health Certification and Plan of Care showed the plan of care was initiated for the certification period beginning 4/10/26. The plan of care ordered skilled nursing visits one time per week for nine weeks, with two PRN (as needed) visits for wound, medication, and disease management. Review of a “Missed Visit” form dated 4/15/26 identified the missed service as a skilled nursing visit and showed the physician’s office was notified. The clinician documented, “...Patient stated she would call back later today for visit / patient not available at the time / SN [skilled nurse] never received call back...” Further review of the clinical record showed no documented follow-up attempt to reschedule the missed visit. The agency provided no other skilled nursing visit during the week of 4/12/26 through 4/18/26. Therefore, Patient 5 did not receive the physician-ordered weekly skilled nursing visit. The clinical record contained no physician order modifying the required frequency. During a concurrent interview and record review on 9/3/26 at 11:37 a.m., Patient 5’s electronic medical records were reviewed with LN 5. LN 5 stated that when a visit was missed, the nurse attempted to reschedule the visit and documented the attempt in the patient’s electronic medical record. After reviewing Patient 5’s clinical records, LN 5 confirmed there was no documented attempt to reschedule the missed 4/15/26 visit. LN 5 stated timely visits were important, particularly for patients receiving wound care, because delays could increase the risk for infection. LN 5 further stated staff needed to document rescheduling attempts so other agency personnel were aware of the patient’s status. 2. Review of Patient 6’s “Patient Profile” showed the agency admitted Patient 6 to home health services on 7/14/26 following a transfer from the hospital. Patient 6 was admitted to home health services with skilled nursing ordered for management of multiple complex conditions, including supplemental oxygen use and a VAD (vascular access device used to give medications or fluids through a vein). Review of Patient 6’s Home Health Certification and Plan of Care showed the plan of care was initiated for the certification period beginning 7/14/26. The plan of care ordered skilled nursing visits one time per week for eight weeks, with two PRN visits for disease-management education and wound care. The plan of care also directed the skilled nurse to perform a complete physical assessment at each visit, assess comorbidities (two or more medical or mental health conditions that exist in the same person at the same time), recognize and intervene to minimize complications, and notify the physician of problems that could impede recovery or the patient’s goals. Review of a “Missed Visit” form dated 8/27/26 identified a missed skilled nursing visit. Further review of the clinical record showed no completed skilled nursing visit during the week of 8/23/26 through 8/29/26 and no documented attempt to reschedule the missed visit. Therefore, Patient 6 did not receive the physician-ordered skilled nursing visit during that week. The clinical record contained no physician order modifying the required frequency. During a concurrent interview and record review on 9/3/26 at 3:31 p.m., Patient 6’s electronic medical records were reviewed with LN 1. LN 1 verified the missed visit on 8/27/26. LN 1 confirmed the missed visit was documented but there was no documented attempt to reschedule it. LN 1 stated staff were expected to follow physician orders and the visit schedule identified in the plan of care. During a concurrent interviews and record reviews on 9/3/26 at 12:35 p.m. and 3:50 p.m., the Director of Patient Care Services (DPCS) reviewed the clinical records for Patients 5 and 6 and stated staff were expected to document missed visits and attempts to reschedule them. The DPCS stated the agency’s process required staff to make and document approximately three contact attempts. The DPCS confirmed there was no documentation of attempts to reschedule Patient 5’s missed 4/15/26 visit or Patient 6’s missed 8/27/26 visit. The DPCS also confirmed the agency did not provide another skilled nursing visit during the respective weeks of the missed visits and stated staff should follow physician orders and document attempts to reschedule missed visits.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on interview and record review the facility failed to ensure the rights of two of seventeen sampled patients (Patient 1 and Patient 2) to be informed of the coverage provided from the Medicare (federal health insurance program for individuals aged 65 or older and younger people with specific disabilities or conditions) and/or Medi-Cal ( joint federal and state program that helps cover medical costs for some people with limited income and resources) programs when Patient 1 and Patient 2 were asked to sign blank financial responsibility forms on admission. This failure resulted in Patient 1 and Patient 2 not being informed of the insurance coverage for their home health services (skilled medical and therapeutic treatment provided by licensed professionals in the patients home). Findings: During a review of Patient 2’s admission document titled, “Your Home Care Financial Responsibility (Medicare & Medi-Cal),” dated 2/21/25, the document indicated, “… [Agency Name] Charges for service…” The document listed each service it provided, a space to indicate the agency charge for the service and a space to indicate if it was paid for by Medicare, Medi-Cal or the patient. All the spaces were blank. The form was signed and dated by Patient 2 and an agency representative. During a review of Patient 3’s admission document titled “Your Home Care Financial Responsibility (Medicare & Medi-Cal),” dated 7/15/26, the document indicated, “… [Agency Name] Charges for service…” The document listed each service it provided, a space to indicate the agency charge for the service and a space to indicate if it was paid for by Medicare, Medi-Cal or the patient. All the spaces were blank, and the form was signed and dated by Patient 3 and an agency representative. During a concurrent interview and record review on 9/3/26 at 10:50 AM, with the Director of Patient Care Services (DPCS), the DPCS confirmed Patient 2 and Patient 3 had signed financial responsibility forms that did not contain payment information. The DPCS further stated there were financial responsibility forms in Patient 2 and Patient 3’s electronic health record (EHR), that were filled in during the referral process but not provided to Patient 2 and Patient 3 on admission. A review of the unsigned documents indicated that Patient 2’s services would be 100% covered by Medicare and there would be no cost to Patient 2. Patient 3’s form indicated services would be 100% covered by Medi-Cal with no cost to Patient 3. The DPCS stated the clinicians should have filled in the blanks on the forms provided to Patient 2 and Patient 3 to match the completed forms in the EHR. The DPCS further stated the purpose of the financial responsibility form was to provide patients with information regarding covered and non-covered services. During a review of an undated agency policy and procedure (P&P) titled, “PATIENT ADMISSION PROCESS,” the P&P indicated, “…Admission Process Initial Visit…The clinician will…Advise the patient/caregiver of the charges and billing procedures and, to the extent possible, the anticipated insurance coverage, the patient/caregiver liability and other methods of payment…””

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to conduct an initial assessment visit for one of seventeen sampled patients (Patient 7) within 48 hours of receiving a home health agency (HHA) referral when the agency received the referral on 8/19/26 but did not complete the initial assessment visit until 8/27/26. This deficient practice delayed Patient 7’s assessment and the initiation of ordered nursing and physical therapy services, placing Patient 7 at risk for additional injury and delayed identification and treatment of mobility, medication safety, and wound-care needs. Findings: Review of Patient 7’s physician office visit dated 8/18/26 showed Patient 7 was an elderly patient with diabetes (high blood sugar) and hypertension (high blood pressure) who was seen for follow-up of chronic conditions, recent balance problems, and falls. The physician documented that Patient 7 had sustained two falls during the preceding week: one in the garage after her walker moved and one while ascending a step. During one fall, Patient 7 struck the back of her head and did not obtain a subsequent emergency evaluation. The physician also documented impaired balance, difficulty with walking, inability to perform heel-to-toe walking or stand on one foot, used a walker (supportive device used while walking), and a chronic right-shin ulcer (wound) present since late March 2026. Review of the physician’s referral signed on 8/19/26 showed the physician referred Patient 7 for nursing medication management and physical therapy for a balance program. Review of the agency’s communication note dated 8/19/26 showed the agency received the referral that day (8/19/26), assigned a clinician to open the case on 8/21/26, and scheduled a physical therapy evaluation for 8/25/26. Review of the agency’s communication note dated 8/21/26 documented, “...Per clinician unable to reach patient did drive by no answer at door...” The clinician documented one unsuccessful contact and drive-by attempt but did not document the time of the attempt, additional contact attempts, notification to the physician regarding the unsuccessful attempt, or an arranged assessment within the required timeframe. The note did not document that Patient 7 or her representative requested a delayed start of care. Review of Patient 7’s clinical record showed licensed nurse (LN) 1 conducted the initial assessment visit and initiated care on 8/27/26, eight calendar days after the agency received the referral. The clinical record contained no initial assessment visit between 8/19/26 and 8/26/26 and no physician- or allowed practitioner-ordered start-of-care date later than the 48-hour timeframe. During a concurrent interview and record review on 9/3/26 at 3:55 p.m., the Director of Patient Care Services (DPCS) reviewed Patient 7’s electronic medical records. The DPCS stated the initial assessment visit, or start of care, must be completed within 48 hours of receiving the referral. The DPCS stated that when staff were unable to complete the visit within 48 hours, staff must notify the physician and obtain an order to delay the start of care. The DPCS reviewed Patient 7’s clinical record and confirmed the agency received the referral on 8/19/26, completed the start of care on 8/27/26, and had no physician order authorizing a delayed start of care. The DPCS stated it was important to assess the patient after hospitalization and acknowledged that Patient 7’s start of care was delayed. Review of the agency-provided policy titled “Timely Initial Assessment and Delayed Start of Care,” Policy No. OC-780, undated, indicated, “... 2. The agency will complete the initial assessment visit within 48 hours of referral, within 48 hours after the patient’s return home, or on the physician- or allowed practitioner-ordered start-of-care date. The earliest applicable requirement will be identified during intake and tracked through completion.... Scheduling staff offer timely appointment options, document every contact attempt, and escalate any threat to the deadline immediately....””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure an accurate review of all medication orders was performed to ensure safe medication use for 2 out of 17 sampled patients (Patient 4 and Patient 1) when: 1. Patient 4’s medications were not reviewed for frequency of PRN (as needed) medications; and, 2. Patient 1’s medication profile was not updated with current medication orders. These failures had the potential to result in unsafe medication use and decreased well-being for Patient 4 and Patient 1. Findings: 2. A review of Patient 1’s “PATIENT PROFILE,” indicated, she was admitted to the agency with diagnoses which included essential hypertension (high blood pressure). During a concurrent interview and record review on 9/2/26 at 1:25 PM, in Patient 1’s home, with Family Member (FM) 1, Patient 1’s home medications were reviewed and compared to the agency provided medication profile. FM 1 stated he was responsible for Patient 1’s medications and maintained an up-to-date list. FM 1 confirmed the agency list differed from Patient 1’s current medication regimen. FM 1 stated since 4/21/26, Patient 1 was prescribed lisinopril (blood pressure medication) 20 milligrams (dose strength) twice a day, Aller-tec (medication to relieve allergy symptoms) daily, and a multivitamin with D3 (dietary supplement) daily. During a review of Patient 1’s home health clinical document titled, “MEDICATION PROFILE,” for the period dated 8/1/26-9/29/26, the document indicated, “…Lisinopril 20 MG [milligrams]…daily…” Aller-tec and the multivitamin with D3 were not listed on the document. During an interview on 9/2/26 at 2 PM, with the occupational therapist (OT), the OT stated when she visited Patient 1, she asked about pain, but she did not review Patient 1’s medications. The OT further stated medications were reviewed by the licensed nurses (LN) during their visits. During a telephone interview on 9/3/26 at 9:58 AM, with LN 1, LN 1 stated on each visit she asked FM 1 about new medications or any changes to Patient 1’s medications. LN 1 further stated she did not look at the medications she relied on what FM 1 told her. LN 1 stated she was not aware Patient 1’s lisinopril order had changed or that Patient 1 had started any new medications. During an interview on 9/3/26 at 11:13 AM, with the Director of Patient Care Services (DPCS), the DPCS stated it was her expectation that clinicians reviewed Patient 1’s medications on every visit and reconciled the medication profile to include all new prescription and non-prescription medications. The DPCS stated it was important for licensed staff to be aware of changes so they could monitor for any adverse effects and educate Patient 1 and FM 1 about potential side effects and interactions of the medications. During a review of an undated agency policy and procedure (P&P) titled, “MEDICATION MANAGEMENT,” the P&P indicated, “…[Agency Name] has a medication management system that supports patient safety and improves quality of care treatment and services by reducing practice variation, errors and misuse of medications…Comprehensive patient assessment performed at start of care and other defined points in time include a review of all medications patient is taking (prescribed, samples, over the counter, herbal remedies, PRN [as needed] medications) and records this in the patient record…MEDICATION ORDERS…over the counter medications that patient take on an as needed basis must be reviewed for potential side effects or adverse effects related to prescription medications they are taking…MONITORING EFFECTS OF MEDICATIONS…[Agency Name] will develop monitoring parameters and guidelines to assure the medications are appropriate and the patients/caregivers report observations and concerns appropriately to decrease occurrence of adverse events…Patients will be instructed to report perceptions of side effects and/or the effectiveness of the medication…” Findings: 1.A review of Patient 4’s “Patient Information Sheet,” indicated that Patient 4 started care with diagnoses which included Malignant Neoplasm (a medical term for cancerous tumor (a disease where abnormal cells grow without control and invade normal tissue)) of the left breast. A review of Patient 4’s “Patient Medication Report,” on 9/1/26 at 2:20 p.m. indicated, “…LORazepam [a medication prescribed to create a calming effect] 1 MG [unit of measure] Oral Tablet 1 PRN prior to procedures…” A review of Patient 4’s “Patient Medication Report,” on 9/1/26 at 2:20 p.m. indicated, “…Lidocaine External Gel [a medication applied to the skin prescribed to lower feeling in the area where placed to block pain] small amount apply to areas of pain…” During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 9/2/26 at 12:26 p.m., Patient 4’s “Patient Medication Report,” was reviewed. The DPCS stated that her expectation was that the staff reviewed the patient medication reports with the patients on every visit asking if there were any changes and checking the physician orders for changes, additions, and discontinued medications. The DPCS stated that she expected the licensed staff to provide teaching on medication dosage, side effects, and adverse reactions. The DPCS stated that medications ordered PRN should have a time frequency. The DPCS confirmed that the Lidocaine 2% cream and the Lorazepam ordered for Patient 4 did not have a time frequency. The DPCS stated that the risk was overdose of medications. The DPCS stated that the risk should have been explained to Patient 4 during the medication review. The DPCS stated that it should have been caught during the chart audits and corrected. During an interview by phone on 9/2/26 at 2:54 p.m. with Licensed Nurse (LN) 4 regarding Patient 4’s Lidocaine 2% cream and Lorazepam medications, LN 4 stated that Patient 4 used the Lidocaine 2% cream before wound dressing changes by applying the cream after her shower and letting it dry. LN 4 stated that Patient 4 was told to take the Lorazepam thirty minutes before procedures because Patient 4 became anxious before going to the physician for wound care. LN 4 stated that she may have documented the instructions given at the start of care. A record review on 9/2/26 at 3:00 p.m. of Patient 4’s “Home Health Agency Visit Notes,” in the electronic medical record (EMR) indicated that LN 4 did not document instructions provided to Patient 4 for applying Lidocaine 2% cream to skin thirty minutes before wound dressing changes and indicated that LN 4 did not document instructions provided to Patient 4 for taking Lorazepam thirty minutes before procedures at the start of care. An undated facility policy and procedure (P&P) titled, “MEDICATION ORDERS,” indicated, “…PURPOSE…To assess that medication orders are written clearly and transcribed accurately. To minimize errors and misinterpretation of written or verbal medication orders…SPECIAL INSTRUCTIONS…4. All medication orders, including herbal preparations, must contain dosage, route and frequency…6. Orders for PRN Medications must include name, dose, reason for use and any specific time constraints for administration…8. [Facility] staff will verify with the physician any incomplete, illegible or unclear medication orders prior to administering the medication and/or providing patient education about the medication…” A review of an undated facility P&P titled, “MEDICATION MANAGEMENT,” indicated “…POLICY…[Facility] has a medication management system that supports patient safety and improves quality of care treatment and services by reducing patient variation, errors and misuse of medications…PURPOSE…To reduce errors and improve quality of care and promote safety throughout the home care program…MEDICATION ORDERS…1. Written orders must be clearly documented. A complete medication order must include…e. Parameters for using PRN medications including amount and frequency and any other time limitations…””