Harbors Home Health / Hospice

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: . Based on document review, record review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral (repeated non-compliance from previous survey). Failure to conduct initial assessments within 48 hours of completing the referral puts patients at risk of physical harm due to to not receiving services in a timely manner. Findings Included: 1. Failure to conduct the initial assessment visit within 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 8 of 19 patients. 2. Repeated non-compliance identified in recertification survey conducted on 04/13/22. The agency was previously cited under Tag G0514, Initial Assessment Visit, 42.CFR 484.55(a)(1), for failure to do the initial assessment within forty-eight hours of referral, or forty-eight hours of the patient’s return home, or on the physician-ordered start of care date. Based on the scope and severity of deficiencies identified under 42 CFR 484.55 Condition of Participation: Comprehensive assessment of patients is NOT MET. Cross Reference: G0514 .”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: . Based on document review, record review and interview, 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). Failure to follow the plan of care could place the patient at risk of worsening symptoms of existing diagnoses. Findings Included: 1. Failure to ensure that there was reasonable determination for each of the missed visits in the plan of care for 5 of 19 patients. 2. Repeated non-compliance identified in recertification survey conducted on 04/13/22. The agency was previously cited under Tag G0572, Plan of Care, 42.CFR 484.60.(a)(1), for failure to communicate with the patient’s physician of missed visits resulting in changes to the patient plan of care. Based on the scope and severity of deficiencies identified under 42 CFR 484.60 Condition of Participation: Care planning, coordination of services, and quality of care is NOT MET. Cross Reference: G0572 .”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: . Based on document review, record review and interview, 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). Failure to follow the plan of care could place the patient at risk of worsening symptoms of existing diagnoses. . Findings included: 1. Document review of agency’s policy titled, “Missed Visits,” (Policy NO-HH-PCTS-2-059, Dated: March 2025) showed that all missed visits will be documented with the reasons for the missed visits, physician notification, description of any unmet needs and how the patient’s needs were met, and any other follow-up needed. 2. Record review of patient records for Patients #101, # 105, #113, #115, and #116 showed: a. Patient #101 was admitted on 01/08/25 with a primary diagnosis of Osteomyelitis of Vertebra-Thoracic Region. On 01/12/25, the physician ordered Skilled Nursing (SN) services for the patient 2 times per week for 1 week, then 1 time per week for 5 weeks. During the weeks of 01/19/25 and 02/02/24, the patient received no SN visits for each week. The record had no documentation to indicate the missed SN visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed SN visits. On 01/08/25, the physician ordered Home Health Aide (HHA) services for the patient 1 time a week for 6 weeks. During the weeks of 02/02/25 and 03/02/24, the patient received no HHA visits for each week. The record had no documentation to indicate the missed HHA visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed HHA visits. b. Patient #105 was admitted on 03/13/25 with a primary diagnosis of Hemiplegia. On 03/17/25, the physician ordered HHA services for the patient 1 time a week for 3 weeks. During the week of 03/30/25, the patient received no HHA visits for this week. The record had no documentation to indicate the missed HHA visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed HHA visits. c. Patient #113 was admitted on 11/20/23 with a primary diagnosis of Pneumonia. On 11/26/23, the physician ordered SN services for the patient 2 times per week for 2 weeks, then 1 time per week for 4 weeks. During the week of 12/03/23, the patient received 1 of 2 SN visits, and during the week of 12/24/23, the patient received no SN visits. The record had no documentation to indicate the missed SN visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed SN visits. d. Patient #115 was admitted on 08/20/24 with a primary diagnosis of Joint Replacement Surgery. On 08/25/24, the physician ordered Physical Therapy (PT) services for the patient 1 time a week for 4 weeks. During the week of 09/08/24, the patient received no PT visit for this week. The record had no documentation to indicate the missed PT visit were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed PT visit. e. Patient #116 was admitted on 06/24/24 with a primary diagnosis of Sepsis. On 08/26/24, the physician ordered SN services for the patient 2 times per week for 8 weeks. During the weeks of 09/01/24 and 09/08/24, the patient received 1 of 2 SN visits during these weeks. The record had no documentation to indicate the missed SN visits were reasonable and necessary, nor was there documentation to indicate that there was coordination with the physician of the missed SN visits. 3. On 04/10/25 at 10:30 AM, Surveyor #1 interviewed the agency’s Chief Operations Officer (Staff#111) regarding of the lack of documentation of the missed visits. Staff #111 acknowledged the findings and stated they were unable to provide any documentation of the missed visits. This is a REPEAT CITATION, previously cited in the last CMS survey completed on 04/13/22. .”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: . Based on document review, record reviews and interviews, 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). Failure to provide proper written notice prior discharge prevent patients from exercising their rights to dispute early discharge from services. . Findings included: 1. Document review of agency’s policy titled, “Discharge Criteria and Process,” (Policy No-HOS-PCTS-2-071.1, Dated: March 2025) showed the agency will issue a Notice of Medicare Non-Coverage (NOMNC) form at least 48 hours prior to termination of services. 2. Record review of patient records Patients # 115, #116, #119, and #518 showed: a. Patient #115 was admitted on 08/20/24 with a primary diagnosis of Joint Replacement Surgery. On 10/18/24 the patient was discharged from the agency. The patient’s records had no documentation to indicate a NOMNC form was given to the patient prior to termination of services. b. Patient #116 was admitted on 06/24/24 with a primary diagnosis of Sepsis. On 10/17/24 the patient was discharged from the agency. The patient’s records had no documentation to indicate a NOMNC form was given to the patient prior to termination of services. c. Patient #119’s SOC date was 01/16/25. The patient was admitted for primary diagnosis of Chronic Kidney Disease with Heart Failure-Stage 4. On 01/21/25 the patient was discharged from the agency. The patient’s records had no documentation to indicate a NOMNC was given to the patient prior to termination of services.. d. Patient #518’s SOC date was 11/23/20. The patient was admitted for primary diagnosis of Pressure Ulcer of Right Heel-Stage 2. On 12/31/24 the patient was discharged from the agency. i. The patient’s discharge summary dated 12/31/24 showed that the patient’s goals were unattainable, and the patient was being discharged due to non-compliance resulting in danger to self. The post discharge goals included to seek appropriate level of care due to the patient’s medical complexity. ii. A communication note dated 12/20/24 and created on 01/01/25 showed that a Registered Nurse spoke to the patient on the telephone and explained that the patient was being discharged due to extreme self-destructive behaviors observed by agency staff in addition to reports from caregivers and Emergency medical Technicians that visited the home. iii. The patient’s records had no documentation to indicate a NOMNC form was given to the patient prior to termination of services. 3. On 04/10/25 at 10:30 AM, Surveyors #1 and #5 interviewed the agency’s Chief Operations Officer (Staff#111) regarding the lack of documentation of providing the NOMNC form prior to termination of services. Staff #111 acknowledged the findings and stated that they were not able to provide any documentation regarding the NOMNC forms. .”

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: . Based on document review, record review and interviews, 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 discharge for cause of a patient may potentially cause patient abandonment and neglect. . Findings included: 1. Document review of agency’s policy titled, “Discharge Criteria and Process,” (Policy No-HOS-PCTS-2-071.1, Date: March 2025) showed that if the agency terminates services due to the patient’s behavior, the behavior of other persons in the patient’s home, or situation, the clinical record must identify the problems encountered, assess the situation, communicate with organization management, notify the responsible physician responsible, establish a plan to resolve the issues, and document results of the plan implemented. 2. Record review of Patients #119’s medical records showed the following: a. The start of care was on 01/16/25 and the initial comprehensive assessment was completed by a Registered Nurse. The physician ordered Skilled Nursing (SN) services for wound care 2 times a week for 2 weeks and 4 as needed (PRN) visits, and Physical Therapy (PT) services for therapy for 1 time a week for 3 weeks, and then 2 times a week for 1 week. b. Record review showed that the patient lived in a housing unit for paroled sex offenders. c. Record review of the agency’s SN visit note titled, “Prep Notes Communication,” (Dated 01/21/25) showed a routine SN was completed where the patient received wound care per care plan. In addition, the nurse documented that the patient was respectful and cooperative with the nurse, and that the nurse wrote, “…at no point in time did the SN feel unsafe”, during the visit. There was no documentation to show that there was any issues with the patient’s behavior, the behaviors of other people in the patient’s home, or the situation. d. Record review of the agency’s PT visit note titled, “Prep Notes Communication, “(Dated 01/21/25) showed a PT evaluation was completed. Further documentation showed that the patient agreed and understood the home exercise instructions and that the next visit was planned. There was no documentation to show that there was any issues with the patient’s behavior, the behaviors of other people in the patient’s home, or the situation. e. A Physician Communication note dated 01/22/25 showed that the agency discharged the patient from Home Health services due to the unsafe environment for staff due to living location. f. There is no documentation to show that the agency identified the specific problems encountered, established a plan to resolve the issues, and document the results of the implemented plan. 3. On 03/10/25 at 1:00 PM, the Surveyor #1 interviewed the agency’s Chief of Operations Officer (Staff #111) and the agency’s Chief Executive Officer (Staff #113) regarding the discharge situation of Patient #119. Staff #113 stated that the safety concerns were addressed by one clinician who stated that they did not feel safe because it was a halfway house for paroled sex offenders. In addition, Staff #113 stated that documentation could have been better and that there was room for improvements with this situation. .”

“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 document review, record reviews, and interview, 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 places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency’s policy titled, “Initial and Comprehensive Assessment,” (Policy No-HH-PCTS-2-007, Date: October 2024) showed the initial assessment will be conducted within 48 hours of the referral. 2. Record review of patient records Patients #103, #106, #108, #109, #113, #114, #116 and #118 showed: a. Patient #103’s Start of Care (SOC) date was 10/23/23. The patient was admitted for primary diagnosis of Infection of skin and tissue. The referral was dated 10/18/23 for a Skilled Nursing (SN) initial assessment, and the SOC for the SN services did not occur until 10/23/23. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. b. Patient #106’s SOC date was 01/29/20. The patient was admitted for primary diagnosis of Pressure Ulcer of Sacral Region-Stage 4. The referral was dated 01/24/20 for a SN initial assessment, and the SOC for SN services did not occur until 01/29/20. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. c. Patient #108’s SOC date was 11/04/24. The patient was admitted for primary diagnosis of Burn of First Degree of Buttocks. The referral was dated 10/30/24 for a SN initial assessment, and the SOC for SN services did not occur until 11/04/24. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. d. Patient #109’s SOC date was 12/10/24. The patient was admitted for primary diagnosis of Juvenile Osteochondrosis of head of Left Femur. The referral was dated 10/30/24 for a Physical Therapist (PT) initial assessment, and the SOC for PT services did not occur until 12/10/24. There was no documentation as to why PT services were not conducted within the 48 hours of the referral date e. Patient #113’s SOC date was 11/20/23. The patient was admitted for primary diagnosis of Pneumonia. The referral was dated 11/17/23 for a SN initial assessment, and the SOC for SN services did not occur until 11/20/23. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. f. Patient #114’s SOC date was 12/02/24. The patient was admitted for primary diagnosis of Sepsis. The referral was dated 11/27/24 for a SN initial assessment, and the SOC for SN services did not occur until 12/02/24. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. g. Patient #116’s SOC date was 06/24/24. The patient was admitted for primary diagnosis of Cellulitis of the Lower Left Extremities. The referral was dated 06/21/24 for a SN initial assessment, and the SOC for SN services did not occur until 06/24/24. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. h. Patient #118’s SOC date was 11/23/20. The patient was admitted for primary diagnosis of Pressure Ulcer of Right Heel-Stage 2. The referral was dated 11/20/20 for a SN initial assessment, and the SOC for SN services did not occur until 11/23/20. There was no documentation as to why SN services were not conducted within the 48 hours of the referral date. 3. On 04/10/24 at 10:30 AM, Surveyor #1 interviewed the agency’s Chief Operations Officer (Staff#111) regarding the lack of documentation of the delayed SOC services. Staff #111 acknowledged the findings and stated that the agency conducts the SOCs within the 48 hours of the referral but stated that they were not able to provide documentation of the delayed SOC services. This is a REPEAT CITATION, previously cited in the last CMS survey completed on 04/13/22. .”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: . Based on document review, record review and interview, 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). Failure to conduct supervisory visits place patients at risk for physical harm due to receiving services from unvetted HHAs. Findings included: 1. Document review of agency’s policy titled, “Bath Aide Supervisory Visits,” (Policy NO-HHA-PA-1-013, Date: May 2024) showed the registered nurse or therapist must conduct supervisory visits at least every 14 days. 2. Record review of the patient charts for 2 of 4 patients receiving HHA services (Patient #101 and #511) showed: a. Patient #101 had a Start of Care (SOC) on 01/08/25. The physician orders showed HHA services 1 time a week for 6 weeks. There was no documentation in the record to show that agency staff completed a supervisory visit between 01/08/25 and 02/15/25. b. Patient #511 had a SOC date on 01/10/25. The physician orders showed HHA services 2 times a week for 9 weeks. There was no documentation in the record to show that agency staff completed a supervisory visit between 03/06/25 to 04/10/25. 3. On 04/10/25 at 11:00 AM, Surveyors #1 and #5 interviewed the agency’s Chief Operations Officer (Staff#111) regarding of the lack of documentation of supervisory visits on the HHAs. Staff #111 acknowledged the findings and stated that they were unable to obtain documentation on supervisory visits on the HHAs.”