Every finding on record at Visiting Nurse Assoc of Wisconsin Inc.

An unannounced, federally authorized onsite Complaint survey was conducted on 04/28/2026 at Aurora at Home in Green Bay, WI. in response to complaint #2966498. Aurora at Home is in compliance with the Medicare Conditions of Participation, 42 CFR 484 for Home Health. Citations are issued at a standard level or below. Complaint #2966498 is substantiated.

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.

An unannounced onsite federally authorized Complaint survey was conducted 06/01/2021 to 06/03/2021 at Aurora at Home, in Green Bay, WI, in response to complaints WI00040595 and WI00040596. Aurora at Home was found to be out of compliance with Medicare Conditions of Participation 42 CFR 484 for Home Health Agencies. Complaints WI00040595 and WI00040596 were substantiated. There are citations at a condition level related to these complaints. An extended survey was conducted as a result of condition level non-compliance. A total of 10 patient records reviewed, 5 employee records reviewed and 1 home visit was conducted. 484.700 Condition of Participation: Skilled Professional Services: NOT MET

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on record review and interview, the agency nursing staff failed to ensure ongoing assessments to meet individualized needs of the patient in accordance with agency policies and/or written plan of care in 3 of 9 patients with wound records reviewed (Patient #1, #3, and #10) in a total of 10 records reviewed. Findings include: Agency nursing staff failed to assess the individualized needs of the patients with wounds or risk of skin integrity issues. See G706. The cumulative effect of these systematic failures resulted in the home health agency's inability to ensure the provision of quality health care which resulted in wound deterioration in Patients #1 and #3 and hospitalization of Patient #1.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health nursing staff failed to assess wound and/or skin integrity based on the individualized needs of the patients in accordance with agency policies and procedures and/or physician ordered plans of care and/or nursing judgment in 3 of 9 patients with wound records reviewed (Patient #1, #3, and #10) in a total of 10 patient records reviewed. Findings include: Review of agency policy and procedure titled "Skin Integrity: Assessment and Treatment" dated 04/20/2021 revealed "III. Definitions/Abbreviations. I. Pressure Ulcer/Injury: A pressure ulcer/injury is localized impairment to the skin and/or underlying tissue usually over a bony prominence, which may be result of pressure or pressure in combination with shear and/or friction. V. Procedure A. Skin Assessment 1. Complete a comprehensive head to toe skin assessment at admission, resumption of care, and recertification. 2. Complete a focused skin assessment at each routine encounter. 3. Skin assessment includes inspecting underneath any therapeutic equipment, supportive devices and/or anti-embolism stockings. 4. Particular attention should be paid to skin over bony prominences, under therapeutic equipment or devices, and areas that remain reddened or discolored despite pressure relief/position change. C. Wound Assessment and Treatment. 1. Wound assessments will be documented with every dressing change and completed by the skilled professional or supervised professional. Wound assessment will include but is not limited to: a) condition of wound base b) characteristics and amount of exudate. c) condition of wound edges d) condition of peri-skin. 2. Measurements of skin abnormalities and wounds will be obtained and documented weekly and with actual or perceived deterioration. a) All wound descriptions to include length, width and depth. 4. Changes in condition of a wound requiring documentation and notification to provider include: a) increase in wound measurements since previous measurement. b) a wound exhibiting new areas of breakdown." Review of agency policy and procedure titled "Assessment and Reassessment" dated 01/15/2021 revealed "Routine Home Health Assessment: must accurately reflect the patient's status, must include 1) The patient's current health, psychosocial, functional, and cognitive status including a body system review. Focused Assessment: assessments using minimum assessment parameters, which are planned by the clinical team member based on the patient's risk, symptoms and conditions. The body systems to "focus" on as well as the frequency of the assessments are communicated via the patients' plan of care. A focused assessment may be based upon the following: physician orders, standards of practices, organizational departmental and service policies, patient diagnosis, care and service that the patient is seeking, changes in the patient condition or diagnosis, as well as identified risk level based on approved criteria and his or her consent to treatment. Record review of Patient #1's "Home Health Certification and Plan of Care" orders for certification dates 02/23/2021 to 04/23/2021 revealed "SN (Skilled Nurse) 2 visits every week for 8 weeks, 1 to 5 visits PRN (as needed). Skin Integrity, Alteration. Change dressing: Wound Care: Pressure ulcer of ischium, right, stage III. Change wound vac dressing two times a week and as needed. Bridge to right hip. Instruct in Sensory Perception, Activity and Mobility Interventions PRN: Instruct patient/family on importance of changing positions-encourage small frequent position changes. If bedfast, elevate heels off of bed, HOB (head of bed) at or below 30 degrees, wheelchair cushion. If chairfast, shift weight in wheelchair every 15 minutes, limitation of wheelchair to 1-2 hour intervals. Instruct Moisture Intervention PRN: Instruct patient to keep skin clean and dry, reposition every 2 hours, keep pressure off boney areas. Instruct negative pressure wound therapy maintenance. Screen for skin integrity PRN: Braden scale risk for pressure sore is 15-18- Mild Risk. Implement risk based interventions as appropriate. Goals: Patient demonstrates adherence to negative pressure wound therapy management plan. Patient maintains or improves skin integrity. Demonstrates techniques and interventions to improve circulation, decrease edema and prevent skin breakdown." Record review for Patient #1 revealed Patient #1 was admitted to this home health agency on 02/23/2021 with primary diagnosis of "Pressure Ulcer of right buttock, stage 3" and secondary diagnosis "Paraplegia, unspecified." Per review of SN Start of Care Admission Note dated 02/23/2021 revealed "Medically necessary treatment due to the following medical conditions: neurological disorder, paraplegic. Resulting in: high risk for infection, complex medical or surgical wound. Supportive devices: Hospital bed, pressure-reducing support surface, wheelchair. Patient has history significant for: Pressure ulcer of right ischium, right stage 3. Has chronic pain, has neuropathy pain to feet/legs, otherwise can not feel from the waist down. Patient states has had various pressure ulcers over the years and they have healed. Braden scale: 17-Mild Pressure Sore Risk. Activity score-chairfast. Integumentary: Issues-decubitus ulcer. Skin temperature-normal. Skin moisture-normal. Skin turgor-normal. OASIS (Outcome and Assessment Information Set): Integumentary Status-Current Number of Unhealed Pressure ulcers-1, stage 3." Record review of Patient #1's SN visit assessment documentation of wound assessment/measurements/wound status for visit dates 03/08/2021, 03/11/2021, 03/13/2021, 04/16/2021, 04/19/2021, 04/23/2021 revealed no wound measurements assessed to pressure ulcer of ischium. SN visits conducted on 03/28/2021, 04/09/2021 revealed no documentation of wound status. SN visits conducted throughout the episode of care 02/23/2021 through 04/23/2021 revealed no assessment documentation for skin integrity related to bony prominent areas and pressure risk of which Patient #1 was at risk for. Record review of Patient #1's recertification visit dated 04/19/2021 revealed no wound measurements by home health SN. OASIS Integumentary Status score-Current Number of Unhealed Pressure ulcers-1, stage 3. The following safety concerns addressed: Patient is to reposition in bed to keep pressure off of his buttocks/wound area. Braden scale for pressure risk- 16 mild pressure sore risk. Activity score-chairfast. Under Wound assessment: Wound left dorsal and right dorsal foot- deep tissue injury." Review of this SN recertification visit documentation from 04/19/2021 revealed 2 new areas as deep tissue injury and that were not documented under the OASIS integumentary status pressure ulcer/injury staging. Review of Patient #1's plan of care revealed that while identified as "mild risk" for skin integrity issues, had history of paraplegia and pressure ulcers and bed/chair bound with risk for friction. Patient #1's plan of care orders contained interventions related to impaired skin integrity for boney areas but did not contain nursing assessments related to impaired skin integrity related to routinely assessing boney prominent areas. During an interview with Clinical Manager E on 06/02/2021 at 2:45 PM, when asked about missing wound measurements as part of the wound assessment for Patient #1, E replied "There are no measurements the week of 03/07/2021, 04/16/2021 or 04/19/2021." The above SN visit assessments related to wound and skin integrity revealed lack of evidence that Patient #1's right pressure wound was assessed per policy and procedure and lack of evidence that skin areas were assessed that were at risk including bony prominences. Patient #1 was hospitalized on 4/24/2021. The hospital medical record history and physical revealed in part "Reason for admission: Severe sepsis with septic shock. Visit diagnoses of Decubitus ulcer of left hip, stage 4, decubitus ulcer of right buttock, stage 4. History of presenting illness: Today presented to emergency department with a new pressure ulcer on the left hip. Patient home health nurse noticed some redness at the last visit, the wound has significantly progressed since that time. Physical exam: Deep sacral ulcer over sacrum Left decubitus ulcer 7cm (centimeter) by 5cm by 3cm." Review of agency "Safety Event" report for past 12 months revealed report of event "Event 21-113487: Pressure Ulcer/Injury" with event dated 04/24/2021 and date received 04/28/2021. Verified with agency Clinical Director D that this event pertained to Patient #1. Review of Safety Event documentation revealed "Patient is a paraplegic with a wound vac to right buttock pressure ulcer. On 04/24/2021, patient's son discovered a new pressure ulcer to left hip. The area was not assessed at the last SN visit. Not present as of 04/19/2021 per patient not noted at 04/23/2021 by home health RN as this site was not assessed during routine visit. Potential for non-application of nursing clinical judgment to assess all bony prominences/areas at risk for breakdown for at risk patient for early identification of breakdown of skin integrity." Review of agency "ACA (Apparent Cause Analysis)" report revealed in part "Patient had received Home Health SN visit on 04/23/2021 for treatment of right ischium pressure ulcer receiving wound vac therapy. Left hip was not assessed in this visit. Patient has alternating pressure point mattress and hospital bed and motorized wheelchair. Also has daily family caregiver assistance. Braden scale completed on 04/19/2021 notes patient to be at Mild Pressure sore risk. Gap in nursing clinical judgment for a comprehensive and frequent assessment of all bony prominences at all visits for wheelchair/bedbound patient with impaired mobility and decreased sensation and patients with known pressure ulcers. Braden scale completed on 04/19/2021 does not indicate high risk although may be room for accuracy in assessment. Failure to apply clinical judgment as best practice, intervention guidelines vague." During an interview with Clinical Director D on 06/03/2021 at 1:45 PM in a follow up related to ACA report and follow through, discussed that after the ACA identified gaps and actions initiated, yet through record review of additional patient records, noted to be continued issues with following policy and procedure and/or plan of care orders related to missing wound assessment measurements for Patient #3 in which the wound worsened, D replied "Highly focused to improve documentation, items missed for wounds, may be issues with other nurses as well, there's just no process to audit, also heading toward education." When asked about the investigation done by the risk management team and that per the report, wound may have developed between 04/20/2021 and 04/24/2021, and if Nurse B admitted to abnormal findings on SN visits of 04/19/2021 and 04/23/2021, D replied "On the recertification on 04/19/2021, a full skin assessment was done, no skin issues found. Family was present to turn (patient) but no skin issues identified. On 04/23/2021 which was a routine visit assessment, per Nurse B admitted did not look at the left side buttock when doing wound care on the right buttock. The patient didn't come in as high risk per the Braden scale, but nursing should have looked at the left." When asked what is the expectation of skin integrity and assessments of the nurses, D replied "A comprehensive assessment is completed on admission, resumption of care, and recertification which includes a head-to-toe full skin check. A focused skin assessment states "under therapeutic devices" so a policy isn't really violated, but clinical judgment tells you one should be checking bony prominences especially due to pressure issues." Record review for Patient #3 revealed Patient #3 was admitted to this home health agency on 05/05/2021 with primary diagnosis of "Fracture of unspecified part of neck of right femur" and other pertinent diagnoses of "Type 2 Diabetes mellitus with diabetic polyneuropathy and pressure ulcer of right heel, unstageable." Patient #3's "Home Health Certification and Plan of Care" orders for certification dates 05/05/2021 to 07/03/2021 revealed "SN 1 visit every week for 1 week, 2 visits every week for 4 weeks, 1 to 3 visits as needed. Skin Integrity Alteration. Evaluation wound progress. Measure wounds weekly usually on first visit of the week." Record review of Patient #3's SN visit documentation revealed SN failed to obtain measurements of the right heel wound the week of 05/09/2021 and 05/23/2021 and revealed the right heel pressure ulcer wound worsened. The SN visit assessment documentation of wound assessment and measurement revealed the following timeline: 05/06/2021: L 2.5cm x W 1.0cm x D 0cm 05/11/2021: Status-unchanged. No wound measurements by home health SN 05/14/2021: Status-improving. No wound measurements by home health SN 05/18/2021: L 2.4cm x W 1.0cm x D 0cm. Status-unchanged 05/22/2021: L 3.5cm x W 2.5cm x D 0.05cm. Status-deteriorating 05/24/2021: Status-deteriorating. No wound measurements by home health SN 05/27/2021: Status-unchanged. No wound measurements by home health SN During an interview with Clinical Manager E on 06/02/2021 at 1:45 PM, when asked about missing wound measurements for the weeks of 05/09/2021 and 05/23/2021 for Patient #3, E replied "No measurements were done on 05/11/2021, 05/14/2021 or 05/24/2021." Record review for Patient #10 revealed Patient #10 was admitted to this home health agency on 05/08/2021 with primary diagnosis of "Metabolic encephalopathy" and other pertinent diagnoses of "Pressure ulcer of sacral region-unstageable, Pressure-induced deep tissue damage of head, Pressure ulcer of other site." Patient #10's "Home Health Certification and Plan of Care" orders for certification dates 05/08/2021 to 07/06/2021 revealed "SN 1 visit every week for 1 week, 5 visits every week for 1 week, 3 visits every week for 7 weeks. 1 to 5 visits as needed. Skin Integrity Alteration. Evaluation wound progress. Measure wounds weekly usually on Monday." Record review of Patient #10's SN visit documentation revealed SN failed to obtain measurements of the pressure ulcer of sacral region, head pressure wound, and left posterior thigh wound the week of 05/09/2021 and 05/23/2021. SN visits were conducted on 05/11/2021, 05/12/2021, 05/13/2021, 05/14/2021, 05/15/2021, 05/16/2021, 05/24/2021, 05/26/2021, and 05/28/2021 with no wound measurements assessed by the SN. During an interview with Clinical Manager E on 06/01/2021 at 2:00 PM, when asked about missing wound measurements for the weeks of 05/09/2021 and 05/23/2021 for Patient #10, E replied "No, I do not see measurements the week of 05/09/2021 or 05/23/2021." During an interview with Nurse B (primary nurse who cared for Patients #1, #3 and #10) on 06/02/2021 at 11:30 AM, when asked about process or policy on wound assessment and measurements, B replied "I measure them weekly and assess each time."