When a Home Health Visit Is Missed or Nobody Comes

The nurse was supposed to come Tuesday. Nobody came, and nobody called. Or the aide came Monday but not Thursday, and now it's happened three weeks in a row.

I'm an occupational therapist. I've been the clinician who had to call a family and say I couldn't make it, and I've seen what a missed week can do to someone who is just getting back on their feet. This guide is for families whose parent is already on home health and a visit didn't happen. If the very first visit never came, start with our guide to the first 48 hours after the hospital instead.

Below, a rule means a federal regulation. Surveyor guidance means the manual that inspectors use when they survey an agency for Medicare, and it mostly says "should." Anything else is my own suggestion, and I'll say so.

How Many Visits Your Parent Should Be Getting

The number of visits isn't up to the agency's calendar. It's written in your parent's plan of care. The rule says the plan of care must include "The frequency and duration of visits to be made" (42 CFR §484.60(a)(2)(iv)).

The agency also has to put the schedule in your hands. It must give the patient and caregiver written instructions that include, in the rule's words, the "Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA" (42 CFR §484.60(e)(1)). The same instructions must include the "Name and contact information of the HHA clinical manager" (42 CFR §484.60(e)(5)).

The patient rights rule backs this up. Your parent has the right to "Receive all services outlined in the plan of care" (42 CFR §484.50(c)(5)). Medicare's booklet for patients says it plainly: "Your home health agency must give you all of the home care listed in your plan of care, including services and medical supplies."

Find that written schedule. In my experience, it often uses shorthand like "2W4," meaning two visits a week for four weeks. If you can't find it or can't read it, ask the agency to go over it with you.

What the Agency Should Do When It Misses a Visit

The regulation itself doesn't use the words "missed visit." Medicare's surveyor guidance does, under tag G572 in Appendix B of the State Operations Manual:

"If the HHA misses a visit or a treatment or service as required by the plan of care, the HHA should make every attempt to reschedule the missed visit. If the visit cannot be rescheduled, the responsible physician or allowed practitioner should be notified, and the HHA should document the potential clinical impact of missed treatments or services. The HHA should advise and educate the patient on the potential impacts of missed visits."

So under that guidance, a missed visit should lead to a new time or a call to the doctor. Either way, someone should talk to your parent about what missing it could mean.

The same guidance covers staffing directly:

"The physician or allowed practitioner should not be approached to reduce the frequency of services based solely on the availability of HHA staff."

If an agency is running short, the fix it's expected to reach for is not a smaller order from the doctor.

There's also a firm rule on cuts. Your parent has the right to written notice "in advance of the HHA reducing or terminating on-going care" (42 CFR §484.50(c)(8)). Medicare's booklet calls this the "Home Health Change of Care Notice" (HHCCN), and one of its examples is when "The home health agency makes a business decision to reduce or stop giving you some or all of your home health services or supplies." That notice is for a change to the plan itself. If the agency changed the schedule, say from three visits a week to one, it owed your parent a written notice first. The notice doesn't stop the cut, but it gives you time to talk to the doctor or find another agency. If the plan hasn't changed and visits just aren't happening, that's a missed visit, not a notice problem: call, keep a log, and complain.

When Your Parent Said No

Not every missing visit is the agency's fault. Sometimes the nurse calls and your parent says "not today."

That's allowed. The patient rights rule gives your parent the right to "Participate in, be informed about, and consent or refuse care in advance of and during treatment" (42 CFR §484.50(c)(4)), and one of the listed items is "The frequency of visits". Medicare's surveyor guidance on transfers and discharges (tag G460) says it directly: "It is the patient’s right to refuse services." The next line says: "It is the agency’s responsibility to educate the patient on the risks and potential adverse outcomes that can result from refusing services."

When it happens more than once, surveyor guidance expects more from the agency:

"If the patient or the patient’s representative refuses care that could impact the patient’s clinical wellbeing (such as dressing changes or essential medication) on more than one occasion, then the HHA must attempt to identify the reason for the refusal. If the HHA is unable to identify and address the reason for the refusal, then the HHA must communicate with the patient’s responsible physician or allowed practitioner to discuss how to proceed with patient care."

One "not today" is different from saying no again and again. If refusals get in the way of caring for your parent safely, the same surveyor guidance says: "The HHA may consider discharge if the patient’s decision to decline services compromises the agency’s ability to safely and effectively deliver care to the extent that the agency can no longer meet the patient’s needs." Refusing services is one of the reasons the rule allows a discharge (42 CFR §484.50(d)(4)).

The reason is usually fixable. They're worn out after a bad night. Therapy hurt last time. A bath with a stranger feels embarrassing. A different time of day, or a straight conversation, often solves it. Tell the agency what you know. They can't fix a reason nobody tells them.

What to Do the Same Day

This section is my suggestion, not a rule.

Call the agency that day. Don't wait for the next scheduled visit to find out what happened. Ask:

Was the visit cancelled, or did someone just not show up?
When is the new visit, and who is coming?
Does the doctor know?
What is the clinical manager's name? (It should already be on the written instructions.)

Start a log. A notebook or a note on your phone works. For each missed visit, write the date, which kind of visit it was (nurse, therapy, aide), whether anyone called, who you talked to and what they told you. One missed visit can be a sick nurse or a flat tire. A log shows whether it's a pattern, and it makes the next phone call much shorter.

Ask the agency for its after-hours number. I'm not citing a rule that says every agency has one. Just ask, and keep the number by the phone.

If It Keeps Happening

Once the log shows a pattern, go up the chain. Medicare.gov's page on complaints gives this order for a home health agency: "Call the home health agency and ask to speak to the administrator. If you don’t believe your complaint has been resolved, call your state home health hotline." My own suggestion is to try the clinical manager first, then the administrator. The rule puts the clinical manager in charge of oversight that includes "Making patient and personnel assignments" (42 CFR §484.105(c)(1)), so that's the person who can actually change who comes and when.

You're allowed to complain, and family counts. Your parent has the right to "Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished" (42 CFR §484.50(c)(3)). The agency must investigate complaints made by the patient, "the patient's caregivers and family", including complaints about "Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately" (42 CFR §484.50(e)(1)(i)(A)). It must "Document both the existence of the complaint and the resolution of the complaint" (42 CFR §484.50(e)(1)(ii)).

Worried about making things worse? The rule says your parent has the right to "Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA or an outside entity" (42 CFR §484.50(c)(11)).

Our guide to your rights as a home health patient goes through every right and the full complaint route. For a missed visit, here's where to find the numbers:

The administrator. The agency must give the administrator's name and business phone number "in order to receive complaints" during the initial evaluation visit (42 CFR §484.50(a)(1)(ii)). Check the admission folder.
The state home health hotline. Your parent has a right to be told about it, and its purpose is "to receive complaints or questions about local" agencies (42 CFR §484.50(c)(9)). Medicare's booklet says "Your home health agency should give you this number when you start getting home health services."
1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048). Medicare.gov says you can reach a real person "24 hours a day, 7 days a week (except some federal holidays.)" Medicare's booklet also lists your state's Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for complaints about the quality of home health care, and says "You can call 1-800-MEDICARE to get the phone number for your BFCC-QIO."

Switching Agencies

You don't have to stay. Medicare's booklet says: "You may decide to end your relationship with one agency and choose another at any time." It tells you how: "Contact your doctor or allowed provider to get a referral to a new agency." And it adds: "You should tell both the agency you’re leaving and the new agency you choose that you’re changing home health agencies."

My suggestion: line up the new agency before you end with the old one. Get a yes and a start date first, so your parent isn't left with no visits at all in between. Our guide on how to choose a home health agency covers what to look for the second time around.

If Your Parent Gets Worse While You Wait

This part is general safety, not medical advice.

If it's an emergency, call 911. Don't wait for the rescheduled visit.
If something has changed but isn't an emergency, call the doctor's office, or call the agency and tell them. In my experience, a new symptom is a good reason to ask for the visit sooner, not just rescheduled.
If the missed visit was a wound or medicine visit, say so when you call. Those are the visits I'd never let slide a day without a clear plan.

If You Want the Agency's Side

This article is for families. If you want to see what an agency is expected to write down and who it has to tell when a visit doesn't happen, our article on missed visit documentation walks through it from the clinician's chair.

Frequently Asked Questions

What should the agency do when it misses a home health visit?

Medicare's surveyor guidance says the agency should make every attempt to reschedule. If it can't, it should tell the doctor or allowed practitioner, write down the possible effect on your parent's care, and explain those effects to your parent. That is guidance surveyors use, not the wording of the regulation itself.

Can the agency cut my parent's visits because it is short on staff?

Medicare's surveyor guidance says the doctor should not be asked to reduce visits based solely on the agency's staffing. And if the agency changes the plan to fewer visits, the patient rights rule says your parent must get written notice first. The notice doesn't stop the cut, but it gives you time to talk to the doctor or find another agency.

Is it a missed visit if my parent said no?

No. Your parent has the right to refuse care, including how often visits happen. If your parent refuses care that could affect their health more than once, Medicare's surveyor guidance says the agency must try to find out why, and talk to the doctor if it can't fix the reason. Repeated refusals that keep the agency from caring for your parent safely can lead to a discharge.

Who do I complain to if visits keep getting missed?

Start with the agency. Medicare.gov says to ask for the administrator; I'd try the clinical manager first. The agency must investigate complaints about care that is not furnished or is furnished inconsistently. If that doesn't fix it, call your state's home health hotline. The agency should give you that number when care starts.

Sources

Thinking about switching agencies?

See the Medicare-certified home health agencies that serve your ZIP code, from Medicare's Care Compare data, with phone numbers and star ratings.

Find an agency

When a Home Health Visit Is Missed or Nobody Comes: What Families Can Do