Aurora Community Health

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure Home Health Agency federal and state regulations were followed in 1 of 1 Home Health Agency reviewed. Findings include: The agency failed to ensure certification requirements were met to furnish skilled nursing services and at least one other therapeutic service. See tag G0982.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing services and at least one other therapeutic service were furnished for a total of 5 of 5 patients (Patients #1-#5). Findings include: Review of agency policy titled “Admissions” dated 01/2014 revealed in part, “Procedure: [Agency] does not provide or contract for occupational therapy, physical therapy, speech therapy and/or rehabilitation therapies. [Agency] will coordinate and refer the consumer to an agency which can provide said services.” Review of agency policy titled “Services” dated 05/2011 revealed in part, “Procedure: The following services are available to consumers of [Agency]: 1. Skilled nursing care services include medication management/set up provided by or under the direction of a Registered Nurse...2. Home Health Aide Services are provided or arranged in accordance with the physician ordered plan of care and supervised by a Registered Nurse.” Review of agency policy titled “Skilled Nursing Services” dated 01/2012 revelated in part, “Duties of the Registered Nurse: 8. Assign a home health aide/Personal care worker (PCW) services with written instruction for care and duties to be performed...9. Monitor medications to identify possible ineffective drug therapy or adverse reaction, drug allergies, significant side effects, duplicate drug therapy and contraindicated medication.” Review of Patient #1’s medical record revealed start of care of 09/29/2017 with a primary diagnosis of “severe intellectual disabilities” and resides independently in home. Review of Patient #1’s plan of care revealed, “Orders for Discipline and Treatments: Home Health Nurse (HHN) 1 visit every other week for 9 weeks plus 4 as needed (PRN) visits for medication/treatment changes. HHN visits for ongoing health assessment, management of medication issues and medication set up...Services needed: Ongoing.” Review of visits notes from 02/2026 to 06/2026 revealed biweekly visits for medication box set up and medication management. Documentation consistently revealed the patient was stable with no changes noted. Documentation failed to identify additional therapeutic services being provided by agency. Review of Patient #2’s medical record revealed start of care of 05/13/2016 with a primary diagnosis of “Fibromyalgia” and resides independently in home. Review of Patient #2’s plan of care revealed, “Orders for Discipline and Treatments: HHN 1 visit every other week for 9 weeks plus 4 PRN visits for medication/treatment changes. HHN visits for ongoing health assessment, management of medication issues and medication set up...Services needed: Ongoing.” Review of visits notes from 02/2026 to 06/2026 revealed biweekly visits for medication box set up and medication management. Documentation revealed patient had an ongoing wound that was being managed by another agency. Documentation consistently revealed the patient was stable with no changes noted. Documentation failed to identify additional therapeutic services being provided by agency. Review of Patient #3’s medical record revealed start of care of 05/03/2024 with a primary diagnosis of “other symptoms and signs with cognitive functions and awareness” and resides independently in home. Review of Patient #3’s plan of care revealed, “Orders for Discipline and Treatments: HHN 1 visit every other week for 9 weeks plus 4 PRN visits for medication/treatment changes. HHN visits for ongoing health assessment, management of medication issues and medication set up...Services needed: Ongoing.” Review of visits notes from 02/2026 to 06/2026 revealed biweekly visits for medication box set up and medication management. Documentation consistently revealed the patient was stable with no changes noted. Documentation failed to identify additional therapeutic services being provided by agency. Review of Patient #4’s medical record revealed start of care of 04/23/2025 with a primary diagnosis of “obesity” and resides independently in home. Review of Patient #4’s plan of care revealed, “Orders for Discipline and Treatments: Home Health Nurse (HHN) 1 visit every other week for 9 weeks. plus 4 as needed (PRN) visits for medication/treatment changes. HHN visits for ongoing health assessment, management of medication issues and medication set up...Services needed: Ongoing. “ Review of Patient #4’s visits notes from 02/2026 to 06/2026 revealed the patient received biweekly visits for medication box set up and medication management. Review of visit note documentation on 05/06/2026 revealed Patient #4 experienced a fall requiring Physical therapy (PT) and Occupational Therapy (OT). Documentation further revealed Patient #4 was referred to another agency for PT and OT services. Documentation failed to identify additional therapeutic services being provided by agency. Review of Patient #5’s medical record revealed start of care of 07/24/2025 with a primary diagnosis of “hypothyroidism” and resides independently in home. Review of Patient #5’s plan of care revealed, “Orders for Discipline and Treatments: Every other week medication management to include 4 PRN visits for med changes and planner adjustments...Services needed: Ongoing. “Review of visits notes from 02/2026 to 06/2026 revealed biweekly visits for medication box set up and medication management. Documentation consistently revealed the patient was stable with no changes noted. Documentation failed to identify additional therapeutic services being provided by agency. Review of agency personnel files revealed the agency employed two employees/registered nurses consisting of Administrator A and Substitute Administrator B. Review did not identity employed or contracted home health aides, physical therapists, occupational therapists, speech pathologists, medical social workers or additional nursing staff. Review of agency referral log from June 2025 through June 2026 revealed 2 referrals. On December 15, 2025, revealed a referral for skilled nursing services every other day was declined due to the agency being unable to provide the required frequency of visits. On June 22, 2026, revealed a referral for physical therapy services declined due to the agency being unable to provide the requested service. During an interview on 06/22/2026 at 11:30 AM Administrator A stated, “All our patients are on service for medication management...We haven’t done anything besides medication set up for a while... about 2 years ago we had a patient that needed a catheter.” Administrator A stated, “We get all our referrals from my choice, and all our patients have an intellectual disability.” Administrator A stated, “the nurse will go into the patients home every 2 weeks and set up their medication planner and do an overall assessment.” Administrator A stated, “Most of our patients have been on service for many years and for the most part stable.” Administrator A stated, “We could try and contract home health aide if we needed one, but we have never offered any other therapies.” Administrator A stated there is no discussion with patients or their families regarding discharge because there is no intention to discharge the patients since their diagnosis is chronic and long term. Administrator A stated,” We would only be discharge if it was requested by the family or the patient transfers to a residential facility.” Administrator A stated that between the visits with the HHN, an aide from another agency will do reminders with the patient to take medications. During a phone interview on 06/24/2026 at 2:24 PM Patient #2 stated the agency nurse visits every two weeks and fills in the patient’s medication planner. Patient #2 stated no therapy services were provided by the agency. Patient #2 stated personal care services were provided by a separate agency on Monday and Thursdays.”