Harbors Home Health / Hospice
Inspection 2025-04-10
· Recertification · 7 deficiencies · CMS source report (PDF)The agency failed to conduct the initial assessment visit within 48 hours of completing the referral (repeated non-compliance from previous survey).
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The agency failed to ensure that services in the plan of care are provided for 5 of 19 patients (repeated non-compliance from previous survey).
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The agency failed to ensure that there was reasonable determination for each of the missed visits in the plan of care for 5 of 19 patients (Patients #101, #105, #113, #115, and #116).
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The agency failed to provide proper written notice of the Medicare-covered care prior to discharge for 4 of 19 patients (Patients # 115, #116, #119, and #518).
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The agency failed to show that the patient’s behaviors and circumstances to the extent that delivery of care to the patient or the ability of the agency to operate effectively was seriously impaired that warranted the patient’s discharge for cause for patient #119. Failure to determine appropriate…
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The agency failed to conduct the initial assessment visit within the 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 8 of 19 patients (Patients #103, #106, #108, #109, #113, #114, #116 and #118) Failure to meet this requirement…
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The agency failed to conduct supervisory visits no less frequently than every 14 days on home health aides (HHA) for 2 of 4 patients receiving HHA services (Patient #101 and #511).
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Inspection 2022-04-13
· Recertification · 12 deficiencies · CMS source report (PDF)The home health agency failed to maintain and update an Emergency preparedness (EP) plan that must be reviewed, and updated at least every 2 years.
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The home health agency failed to maintain a quality improvement program designed to ensure patient safety and reduce adverse events.
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The agency failed to review and update at least every 2 years an emergency preparedness (EP) plan.
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The agency failed to review and update at least every 2 years an emergency preparedness (EP) policies and procedures (P&P).
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The agency failed to communicate with the patient’s physician of missed visits resulting in changes to the patient’s plan of care in 3 of 17 patients (Patient #105, #107, #112).
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The agency failed to identify and develop improvement projects for health indicators designed to address adverse outcomes, patient safety or improved quality of care.
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The agency failed to use the data derived from OASIS to monitor the effectiveness and safety of services and develop and prioritize opportunities for quality improvement based on the collected data.
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The agency failed to follow state requirements to perform an initial and annual Tuberculosis (TB) screening for 8 of 8 staff (#101, #102, #103, #104, #105, #106, #107, #108).
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The agency Administrator failed to develop policies and procedures on the agency’s implementation of the COVID-19 vaccination or the exemption to the vaccination.
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The agency Administrator failed to operationalize the agency policy and procedure (P&P) for staff performance evaluations for 5 of 8 staff (#102, #105, #106, #107, #108).
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The agency failed to conduct the initial assessment visit within the 48 hours of completing the referral for 12 of 17 patients (Patients #101, #102, #104, #105, #106, #107, #109, #111, #112, #114, #115, #116).
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The agency failed to provide the patient’s discharge summary to the patient’s attending physician within 5 business days of the patient’s discharge for 2 of 5 sample discharge records review (Patients #113, #116).
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