Valley View Home Health Care LLC

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on document review, and staff interview, the facility failed to develop and implement emergency preparedness policies and procedures which addressed the use of volunteers in an emergency or other emergency staffing strategies, thereby preventing patients from receiving necessary care during a crisis, leading to potential harm or deterioration of their health. This has the potential to affect all patients and staff during an emergency. Findings include: A review of the Emergency Preparedness Plan provided by the facility did not include a policy which addressed the use of volunteers in an emergency or other emergency staffing strategies. During a request submitted to the Administrator for a policy outlining the agency’s emergency procedures that addressed the use of volunteers in emergencies, on 05/21/25 at 1:00 PM, the Administrator was unable to provide the requested policy. During an interview on 05/22/25 at 2:00 PM, the Director of Nursing (DON) revealed that the facility had not established a policy regarding the use of volunteers during emergencies or other emergency staffing strategies, and stated “I just recently took over the emergency preparedness plan, and was not aware that there was a requirement for policies related to volunteers.””

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a document review, a request for policy, and staff interview, the facility failed to complete an after-action report (AAR) following their full-scale exercise, which could lead to repeated mistakes in future emergencies. This deficient practice has the potential to affect all staff and patients during an emergency. Findings include: Review of the agency’s Emergency Preparedness Plan Book provided by the facility, indicated the facility participated in a full-scale emergency exercise on 10/16/24. The book lacked evidence that the facility completed an AAR following that exercise. A request was made to the Administrator on 05/21/25 at 11:05 AM, for a policy related to AARs following full-scale exercises. The Administrator was unable to provide one. During an interview on 05/21/25 at 11:15 AM, the Administrator acknowledged that an AAR had not been completed and stated, “I was not aware that one was required.””

“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 document review and interview, the Home Health Agency (HHA) failed to electronically transmit completed OASIS assessments (a comprehensive patient assessment) to the Centers for Medicare and Medicaid Services (CMS) system within 30 days after completing the assessment. This failure had the potential to affect funding for the agency. Findings include: The CMS OASIS assessment reference manual, effective 01/01/23 and located at https://www.cms.gov/files/document/oasis-e-guidance-manual51622.pdf, directed that the OASIS assessments must be transmitted to CMS within 30 days of completion. Review of the Transmission Summary Report provided by the facility, revealed OASIS assessments were submitted to CMS greater than the 30 days after the completion of the assessment for 114 assessments submitted for 2020 Quarter (Q) 4, 146 assessments submitted for 2021 Q2, 51 assessments submitted for Q3, 27 assessments submitted for 2022 Q3, 25 assessments submitted for Q4, 25 assessments submitted for 2022 Q4, 29 assessments submitted for 2023 Q1, 172 assessments submitted for Q2, 21 assessments submitted for Q3, 21 assessments submitted for Q4, 19 assessments submitted for 2024 for Q1, 33 assessments submitted for Q2, 17 assessments submitted for Q4 and 37 assessments submitted for 2025 Q1. During an interview on 05/21/25 at 2:30 PM, the Director of Nursing (DON) stated the HHA used the CMS manual for the completion and transmission instructions for the completion and submission of the patients’ OASIS assessments. The DON confirmed the HHA had failed to submit OASIS assessments within 30 days of completion. The DON also stated that OASIS assessments were delayed in being submitted due to HHA’s process for completing the OASIS for transmission. The DON stated that the Registered Nurse or Physical Therapist performed the assessment, and it was available to the HHA’s office. The DON stated the assessment information was then sent to a third party affiliated with the software vendor for coding with the patient’s diagnoses. The DON stated after the third-party contactor (which is in India) completed the coding, the assessment was returned to the HHA for quality assurance review and corrections, if needed. The DON also stated that the HHA was unaware the OASIS assessments, which contained patient protected health information, were coded by a third-party and acknowledged OASIS assessments were submitted more than 30 days after the completion of the assessment.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on interview, document review, and policy review, the Home Health Agency (HHA) failed to inform one of three discharged patients (Patient (P) 1), the payor source for the HHA’s services would not pay for services provided. This failure had the potential to affect the adequate care provided to the residents. Findings include: Review of the undated Patient Handbook, under Patient Rights…Standard: Patient Liability of Payment, documented “You have the right to be informed, verbally and in writing, before initiation of care, of the extent to which payments for Agency services may be expected…” and “You have the right to be informed verbally and in writing of any changes in payment information as soon as possible but no later than 30 calendar days for the date the Agency becomes aware of the change.” In the handbook, under the section titled Discharge Policy, documents patients will be discharged for services for the following criteria: death, moves from service area, patient request discharge, services are no longer needed, services cannot be provided safely, patient fails to follow physician orders, the physician orders discharge from service of the patient is no longer homebound. Review of the HHA’s policy titled, Discharge Criteria with a revision date of 05/18/17, revealed “Procedure 2. The patient is informed of the discharge plan in a timely manner and acknowledges understanding of the reason.” Review of the electronic medical record (EMR) for P1 revealed a start of care, date of 01/19/24, with diagnoses including Ehlers’s Danlos Syndrome (a disease characterized with loose/flexible joints and easily bruised skin) and aphasia (the inability to speak). The Skilled Nurse (SN) made visits to P1 on 01/25/24 for the start of care. Physical Therapy (PT) made visits on 01/25/24, 02/21/24, and 02/18/24. Review of the EMR revealed P1 was discharged from HHA services on 02/09/24, with notes indicating the payor source would not agree to pay for the HHA’s services. During an interview on 05/21/25 at 2:30 PM, the Director of Nursing (DON) confirmed P1 was admitted to HHA’s services with the anticipation of the payor source paying for the HHA’s services. The DON also stated that the payor source denied payment for services and the HHA stopped providing services to P1. The DON confirmed the HHA failed to follow their policy for the discharge of patient who was admitted to the HHA for services.”

“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 observation, document review, interviews, and policy review, the facility failed to provide a written, individualized, complete, plan of care that identified patient-specific measurable outcomes, and goals for one of three home visit patients (Patient (P) 3) of eight sample patients. This deficient practice has the potential to allow different healthcare providers to provide inconsistent or conflicting care and affects all patients. Findings include: Review of the facility’s undated policy titled, Admission/Scope of Service, provided by the facility, revealed under “Procedure 1: During the admission process (and on an ongoing basis when changes occur), staff will provide the patient verbal and written information including: …” During a home visit on 05/21/25 at 9:40 AM, at P3’s residence with a Physical Therapist Assistant (PTA) 1, it was discovered that P3’s admission packet, provided by the facility, lacked a plan of care which included prognosis, rehabilitation potential, activities permitted, and nutritional requirements. During an interview on 05/21/25 at 10:00 AM, P3 revealed that all the paperwork provided by the facility was kept in the admission folder. P3 stated “I don’t remember ever receiving a plan of care.” During an interview on 05/21/25 at 10:10 AM, PTA1 confirmed P3’s admission folder was missing a plan of care. PTA1 stated “Yes, there should always be a plan of care given to the patient and it’s placed in the folder that’s given to the patient on admission.” During an interview on 05/22/25 at 10:00 AM, Director of Nursing (DON) indicated that all patients should have written information about their care. The DON stated “I will look into it. The plan of care should be given to the patient and placed in their admission folder.””

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on document review, staff interview, and facility policy review, the agency failed to investigate a complaint made by a patient (Patient (P) 8) of eight sampled patients, thereby potentially leading to ongoing issues in patient care, such as neglect, medication errors, or inadequate supervision. This deficient practice has the potential to affect all patients and staff. Findings include: Review of facility’s policy titled, “Complaint Resolution,” revised 2008, revealed under “Patient Complaints 2: The Agency will investigate complaints made by a patient, patient’s family or guardian regarding treatment or care that is (or fails to be) furnished. The agency will document both the existence and the resolution of the complaint.” Review of the facility’s Complaint Book, provided by the facility, revealed that a Complaint Report Form, dated 01/22/24, was filed by P8. A partial description of the complaint reads … “Nurse is always snotty … “ The portion of the form which reads Follow-Up, Resolution, Outcome, and Corrective Action, was not completed. Review of the facility’s Grievance/Complaint Report Log, provided by the facility, revealed that patient complaints were filed between 02/15/23 and 04/07/25. P8’s complaint did not appear on the log. During an interview on 05/23/25 at 2:15 PM, the Director of Nursing (DON) confirmed the Grievance Complaint Form for P8 was not completed properly. The DON stated, “The form should have been filled out properly and logged into the Grievance/ Complaint Report Log. I don’t know why it wasn’t done. All complaints should be investigated, but this one fell through the crack.””

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on a request for documents, and staff interview, the facility failed to develop a policy addressing the pneumococcal vaccine administration for patients, thereby increasing the risk of transmitting preventable diseases. This deficient practice potentially affects all patients and staff. Findings include: Following a request submitted to the Administrator for a policy outlining the administration of the pneumococcal vaccine for patients on 05/21/25 at 11:00 AM, the Administrator was unable to provide the requested policy. During an interview on 05/21/25 at 11:15 AM, the Administrator revealed that the facility had not established a policy regarding the administration of the pneumococcal vaccine for patients. The Administrator stated, “All patients are asked about the vaccine upon admission, and if they chose to receive it, and the facility coordinates with their physician to facilitate its administration.””