Aurora at Home

“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 record review and interview the agency staff failed to complete an initial assessment within 48 hours of referral in 1 of 5 (#1) patient records reviewed. Findings include: Review of agency policy titled “Acceptance to Care and Admission Criteria” dated, 06/24/2025 revealed “Timeliness of care: Current home health regulations require patients referred to home health following a facility stay admitted to the agency within 48 hors of discharge...” Review of Patient #1’s record revealed a referral date of 02/04/2026 and an initial assessment dated 02/07/2026, three days after referral. During an interview with Director A on 04/28/2026 at 11:55 AM, Director A stated that the expectation is to have the initial assessment completed within 48 hours of receiving the referral.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview the agency staff failed to include all physician orders on the patient plan of care (POC) in 1 of 5 (#1) patient records reviewed. Findings include: Agency did not provide a policy/procedure regarding POC development for review. Review of Patient #1’s record revealed a referral dated 02/04/2026 with orders, “Visiting nurse: check BP (blood pressure); and orthostatic BP prn (as needed).” Review of Patient #1’s POC dated 02/07/2026 revealed no documentation to monitor orthostatic BP PRN. During an interview with Director A on 04/28/2026 at 12:00 PM, Director A stated that the physician orders should be found on the patients POC, “I would expect it (orders) on the POC.” During an interview with Area Vice President D on 04/28/2026 at 12:45 PM, the survey team request a policy/procedure for POC development. Area Vice President D stated that the agency did not have one. During an interview via phone with Registered Nurse (RN) B on 04/28/2026 at 3:15 PM, RN B stated that the physician orders should be on the POC. When asked if she had completed any orthostatic vitals on Patient #1, RN B stated, “no”, the family were instructed on how to perform them and were doing them.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview the agency failed to provide ordered services in the plan of care (POC) for 1 of 5 (#1) patient records reviewed. Findings include: Review of agency policy titled “Acceptance to Care and Admission Criteria” dated, 06/24/2025 revealed “Timeliness of care: …The decision to admit a patient is made after the initial home evaluation visit is made by a nurse or therapist, if additional disciplines are ordered, they are provided within seven days of admission.” Review of Patient #1’s plan of care (POC) dated 02/07/2026 revealed ordered services to include physical therapy and occupational therapy evaluations. Review of Patient #1’s nursing visit on 02/09/2026 revealed “Patient/caregiver’s biggest concern identified today is, I (Patient #1) have a hard time getting up.” and PT and OT are the big things as he would like to get stronger.” Review of Patient #1’s nursing visit on 02/12/2026 revealed assessment of standard vital signs. Nursing note revealed “…States he (Patient #1) still has weakness and PT and OT were ordered this a.m. by this clinician (RN B).” Review of Patient #1’s case communication note dated 02/13/2026 revealed a call was made to schedule PT and OT. No answer. A message was left, and a return call was requested. Information was forwarded to the physician. Review of Patient #1’s case communication note dated 02/16/2026 (9 days after SOC) revealed a second call was made to schedule PT and OT. “…spoke to family, who stated that patient (#1) is headed back to the ER (emergency room), case manager notified.” No other documentation was found in Patient #1’s chart that the PT/OT evaluations were completed within 7 days or that the scheduler called to schedule PT/OT or that there was a delay. Review of Patient #1’s Oasis transfer without discharge document dated 02/16/2026 revealed Patient #1 was transferred to the hospital on 02/16/2026. “Ordered home visits are cancelled pending resumption of care orders.” Review of agency safety events log revealed an employee submission on 02/12/2026. “Patient and wife are concerned about PT/OT starting…they have not heard from anyone about scheduling or assessments as of 2/12.” Documentation of manager review of submission showed that the scheduling department was responsible for calling and scheduling PT and OT services within the “first seven days…Unsure why scheduling didn’t call.” During an interview with Director A on 04/28/2026 at 12:05 PM, Director A stated that the initial assessment is to be completed 48 hours after the referral and secondary services, “within seven days of start of care.” Director A stated that once an order is placed for additional services it falls into the work queue and it is then the responsibility of the scheduling department to contact the patient and set up the services.”