Kittitas Valley Home Health & Hospice

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: . Based on document review, record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral. Failure to conduct initial assessments within 48 hours of completing the referral puts patients at risk of physical harm due to not receiving services in a timely manner. Findings Included: 1. Failure to conduct the initial assessment visit within 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 5 of 10 patients. 2. Repeated non-compliance identified in recertification survey conducted on 10/12/23. The agency was previously cited under Tag G0514, Initial Assessment Visit, 42.CFR 484.55(a)(1), for failure to complete the initial assessment within forty-eight hours of referral, or forty-eight hours of the patient’s return home, or on the physician-ordered start of care date. Based on the scope and severity of deficiencies identified under 42 CFR 484.55 Condition of Participation: Comprehensive assessment of patients is NOT MET. Cross Reference: G0514 .”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: . Based on document review, record review and interview, the agency failed to ensure that services are provided in the plan of care are provided for 4 of 10 patients. Failure to follow the plan of care could place the patient at risk of worsening symptoms of existing diagnoses. Findings Included: 1. Failure to ensure that there was reasonable determination for each of the missed visits in the plan of care for 4 of 10 patients. 2. Repeated non-compliance identified in the recertification survey conducted on 10/12/23. The agency was previously cited under Tag G0572, Plan of Care, 42.CFR 484.60.(a)(1), for failure to communicate with the patient’s physician of missed visits resulting in changes to the patient plan of care. Based on the scope and severity of deficiencies identified under 42 CFR 484.60 Condition of Participation: Care planning, coordination of services, and quality of care is NOT MET. Cross Reference: G0572 .”

“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 record reviews and interviews, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0102 and M0104 for 4 of 10 patients (Patient #102, Patient #105, Patient #107, and Patient #110). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Record review of patients’ records for Patient #102, Patient #105, Patient #107, and Patient #110 showed: a. Patient #102 was admitted on 03/27/26 with the primary diagnosis of Right Femur Fracture. Physician orders were received for the M0102 Start of Care (SOC) for 03/27/26. Documentation showed a data of referral (M0104) date of 03/24/26, rather than the specific physician-ordered start of care (M0102) date of 03/27/26. b. Patient #105 was admitted on 04/09/26 with the primary diagnosis of Right Shoulder Osteoarthritis. Physician orders were received for the M0102 SOC for 04/13/26. Documentation showed a date of 04/09/26, rather than the specific physician-ordered start of care (M0102) date of 04/13/26. c. Patient #107 was admitted on 04/09/26 with a primary diagnosis of Left and Right Buttocks Stage 1 pressure ulcers. The referral was completed on 04/08/26 for a Skilled Nursing (SN) assessment. Documentation showed a data of specific physician-ordered start of care (M0102) date of 04/09/26, rather that the accurate data of referral (M0104) date of 04/08/26. d. Patient #110 was admitted on 04/07/25 with a primary diagnosis of Right Lower Leg Wound. The referral was completed on 04/03/25 for a SN initial assessment. Documentation showed a data of specific physician-ordered start of care (M0102) date of 04/03/25, rather than the accurate data of referral (M0104) date of 04/03/25. 2. On 04/22/26 at 9:30 AM, the Surveyor interviewed the agency’s Clinical Director (Staff #111) about lack of accuracy in OASIS Data entry for M0102 and M0104. Staff #11 acknowledged the OASIS data error findings and stated that they were not able to provide documentation as to why the OASIS M0102 and M0104 were inaccurate and stated that they were unable to provide documentation on OASIS accuracy policy. .”

“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 document review, record review, and interview, the agency failed to ensure that there was reasonable determination for each of the missed visits in the plan of care and that the physician was notified of the missed visits for 4 of 10 patients (Patient #101, Patient #103, Patient #104, and Patient #109). Furthermore, the agency failed to update their policy to ensure that missed visits are based on a reasonable determination of the patient’s needs. Failure to follow the plan of care could place the patient at risk of worsening symptoms of existing diagnoses. Findings included: 1. Document review of agency’s policy titled, “Missed Visits,” (Document ID: 17276, Dated: 04/21/26) showed that all missed visits will be documented and the patient’s physician is notified of the reason and date of the missed visit. In addition, there was no evidence in the policy requiring a clinical assessment of the impact of a missed visit. 2. Record review of the patients’ records for Patient #101, Patient #103, Patient #104, and Patient #109 showed: a. Patient #101 was admitted on 01/06/26. The patient’s physician ordered Home Health Aide (HHA) services with a frequency of 1 visit weekly, then 2 visits weekly for 8 weeks starting 01/08/26. During the Medicare weeks of 01/11/26 and 02/08/26, the record showed HHA missed visits due to a staff illness. In addition, there was no documentation to indicate that the patient or their legal representative and the physician were notified of the missed HHA visits. b. Patient #103 was admitted on 03/19/26. The patient’s physician ordered HHA services with a frequency of 1 visit weekly, then 2 visits weekly for 2 weeks, then 2 visits every 2 weeks for 2 weeks, and then 2 visits weekly for 3 weeks starting 03/22/26. During the Medicare weeks of 03/29/26, 04/05/26, and 04/12/26, the record showed HHA missed visits due to staff vacation, no call back, and no documentation as to why the third HHA visits were missed. In addition, there was no documentation to indicate that the patient or their legal representative and the physician were notified of the missed HHA visits. c. Patient #104 was admitted on 02/03/26. The patient’s physician ordered Physical Therapy (PT) services with a frequency of 2 visits weekly for 9 weeks starting 02/09/26. During the Medicare weeks of 02/22/26 and 03/22/26, the record showed PT missed visits due to PT unable to see patient due to case load, and no documentation as to why the second PT visits were missed. The patient’s physician ordered HHA services with a frequency of 1 visit weekly, and then 2 visits weekly for 8 weeks starting 02/03/26. During the Medicare weeks of 03/01/26, 03/08/26, 03/15/26, and 03/22/26 there was no documentation as to why the HHA visits were missed. The patient’s physician ordered Occupational Therapy services with a frequency of 1 visit weekly, then 2 visits weekly for 7 weeks starting 02/08/26. During the Medicare week of 03/15/26 there was no documentation as to why the OT visits were missed. In addition, there was no documentation to indicate that the patient or their legal representative and the physician were notified of the missed PT, HHA, and OT visits. d. Patient #109 was admitted on 01/14/25. The patient’s physician ordered Skilled Nursing (SN) services with a frequency of 1 visit weekly, then 2 visits weekly, and then 1 visit weekly for 5 weeks starting 01/19/25. During the Medicare week of 01/19/25, the record showed SN missed visit due to SN was unaware of the visit. The patient’s physician ordered HHA services with a frequency of 1 visit weekly for 8 weeks starting 01/19/25. During the Medicare week of 02/09/25, the record showed HHA missed visit due to HHA out on leave. The patient’s physician ordered OT services with a frequency of 1 visit weekly, then 2 visits weekly for 8 weeks starting 01/14/25. During the Medicare weeks of 02/16/25 and 02/23/25, the record showed OT missed visits due to no staffing. In addition, there was no documentation to indicate that the patient or their legal representative and the physician were notified of the missed SN, HHA, and OT visits. 3. On 04/22/26 at 9:30 AM, the Surveyor interviewed the agency’s Clinical Director (Staff #111) regarding the missed visits. Staff #111 acknowledged the findings and stated that they were unable to provide documentation to show reasonable determination for each of the missed visits. Also, Staff #111 stated that it is the agency’s policy is to notify the physician of the missed visits and that reasons for missed visits should be patient focused. This is a REPEAT CITATION, previously cited in the last CMS survey completed on 10/12/23.”

“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 document review, record reviews, and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral for 5 of 10 patients (Patient #102, Patient #103, Patient #105, Patient #109, and Patient #110). Furthermore, the agency failed to develop and implement policies and procedures to ensure compliance with the 48-hour initial assessment requirements as mandated by CFR 454.55(a). Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency’s policies showed no policy or procedure indicating the timeframe for the initial assessment visit and instructions for intake staff regarding the 48-hour requirements or the exceptions such a specific physician-ordered date. 2. Record review of patient’s records for Patient #102, Patient #103, Patient #105, Patient #109, and Patient #110 showed: a. Patient #102’s Start of Care (SOC) date was 03/27/26. The patient was admitted for primary diagnosis of Right Femur Fracture. The agency completed the referral on 03/17/26 for the Physical Therapy (PT) initial assessment, but the SOC for the PT services did not occur until 03/27/26. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the patient or their legal representative and the physician were notified of the delayed of the PT admission. b. Patient #103’s SOC date was 03/19/26. The patient was admitted for primary diagnosis of Venous Insufficiency. The agency completed the referral on 03/11/26 for the Skilled Nursing (SN) initial assessment, but the SOC for the SN services did not occur until 03/19/26. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the patient or their legal representative were notified of the delayed of the SN admission. c. Patient #105’s SOC date was 03/19/26. The patient was admitted for primary diagnosis of Right Shoulder Osteoarthritis. The agency completed the referral on 03/18/26 for the PT initial assessment, but the SOC for the PT services did not occur until 04/09/26. There was no documentation of why the services did not occur within 48 hours of the referral, and no documentation that the patient or their legal representative and the physician were notified of the delayed of the PT admission. d. Patient #109’s SOC date was 01/14/25. The patient was admitted for primary diagnosis of Cerebrovascular Accident. The agency completed the referral on 01/09/25 for the PT initial assessment, but the SOC for the PT services did not occur until 01/14/25. The record showed that on 01/09/25 the agency delayed the SOC due to staffing and weekend issues. In addition, there was no documentation that the patient or their legal representative and the physician were notified of the delayed of the SN admission. e. Patient #110’s SOC date was 04/07/25. The patient was admitted for primary diagnosis of Right Lower Leg Wound. The agency completed the referral on 04/03/25 for the SN initial assessment, but the SOC for the SN services did not occur until 04/07/25. The record showed that on 04/03/25 the agency delayed the SOC due to staffing and weekend issues. In addition, there was no documentation that the patient or their legal representative and the physician were notified of the delayed of the SN admission. 3. On 04/22/26 at 9:30 AM, the Surveyor interviewed the agency’s Clinical Director (Staff #111) regarding the lack of documentation that explains why the services did not occur within 48 hours of the referral and the notification of the patient and their physician of the delayed SOC. Staff #111 acknowledged the findings and stated that they could not provide documentation as to why the services were delayed. This is a REPEAT CITATION, previously cited in the last CMS survey completed on 10/12/23. .”