Every finding on record at Maxim Healthcare Services

An unannounced Complaint survey #2024012496 was commenced on September 16, 2024, and concluded on September 17, 2024, at Maxim Healthcare Services, Home Health Agency provider. The provider was not in compliance with Title 42 Code Of Federal Regulations (CFR), Part 484 Subpart A-C, Conditions of Participation for Home Health Agencies.

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 review of the Home Health Agency's Policy and Procedure, record review and interview, the Home Health Agency failed to follow the patient's Plan of Care for 2 of 3 sampled patients (Patient #1 and #2). The findings include: 1) Review of the Home Health Agency's Policy and Procedure titled, "Confirmation of Supplemental Ordering Practitioner Orders, revised 4/9/21" documents, “Orders will be obtained from a licensed ordering practitioner for care and services to be provided to home health patients” and “Revisions to the plan of care due to a change in patient health status will be communicated to the patient, representative (if any), caregiver, and all ordering practitioners issuing orders for the Home Health Agency plan of care.” Review of the record reveals Patient #1 was admitted to the Home Health Agency's services in 2016 with a degenerative neurological condition, had a tracheostomy (tube in the throat through which to breath) and was ventilator dependent (required a machine to assist breathing through the tube in the throat), and had a tube in the stomach for food and fluids. Patient #1’s Home Health Certification and Plan of Care and Addendum to Plan of Treatment for the certification period of 05/11/24 to 07/09/24 includes physician's orders for Skilled Nursing services 24 hours per day, seven days per week throughout the 60 day certification; a contingency plan that the patient's family/guardian is able to provide care in the absence of skilled nursing coverage; to notify the physician of respiratory rate greater than 32, systolic blood pressure outside of the range 97 mmHg (millimeters mercury) to 115 mmHg, or of diastolic blood pressure outside of the range 57 mmHg to 76 mmHg; and tube feeding orders to give “Pediatric Compleat 1.0” or “Pediasure with Fiber 1.0” as bolus feedings of 280 ml. (milliliters) each four times per day with water flushes of 90 ml. before and after each feeding (180 ml. total with each feed); that the patient could also have 100 ml. “snack” once per day; to add extra juice/water as able throughout the day; may give chilled milk in the morning if requested by patient; and may give 30 to 120 ml. of free water “as needed” for hydration. A "communication note" from 2/14/20 documents the family requested no nursing coverage, and they would provide care for day shifts on Saturdays and Sundays. Patient #1’s "Skilled Nursing Note" for the evening shift on 07/01/24, from 5:54 PM to 7:01 AM on 07/02/24, reveals no evidence of documentation of a respiratory rate or blood pressure by which to determine whether Patient #1 was within the acceptable parameters determined by the physician. Patient #1’s "Skilled Nursing Note" for the evening shift on 07/02/24, from 6:20 PM to 7:01 AM on 07/03/24, reveals a respiratory rate of 48, does not include a blood pressure, and provides no evidence the physician was contacted to notify of the elevated respiratory rate or for any other reason. Patient #1’s "Skilled Nursing Note" for the day shift on 07/03/24, from 7:03 AM to 7:07 PM, documents a respiratory rate of 33, no blood pressure reading, that three tube feedings were administered as ordered (280 ml. of prescribed formula and 180 ml. of water flushes). Patient #1’s "Skilled Nursing Note" for the night shift of 07/03/24, from 7 PM to 7:05 AM on 07/04/24 documents the intake at 10:23 PM as “Compleat pediatric 1.0 cal." 600 ml. by tube feed, flush intake 90 ml. (rather than 280 ml. formula and 180 ml. water as ordered). Further review of Patient #1’s "Skilled Nursing Notes" reveals documentation on 07/04/24, of a respiratory rate of 45 on day shift, on 07/05/24, a respiratory rate of 41 on day shift and 46 on night shift, on 07/06/24 a respiratory rate of 49 on day shift, on 07/07/24 a respiratory rate of 40 on night shift, on 07/09/24 a respiratory rate of 49 on day shift and 46 on night shift; but no evidence the physician was ever notified of these elevated respiratory rates. Patient #1’s "Skilled Nursing Note" for 07/07/24 from 7:00 AM to 11:00 PM documents at 8:00 AM, 11:00 AM, 4:00 PM, and 6:00 PM Patient #1 received 600 ml. “Compleat pediatric” and 90 ml. water flush for each feeding (rather than 280 ml. formula and 180 ml. water as ordered). Patient #1’s "Skilled Nursing Note" for 07/08/24 night shift documents at 11:02 PM the patient again received 600 ml. of “Compleat pediatric” and 90 ml. of water. Patient #1’s Home Health Certification and Plan of Care and Addendum to Plan of Treatment for the certification period of 07/10/24 to 09/07/24 includes orders for Skilled Nursing services 24 hours per day, seven days per week throughout the 60 day certification; that the patient's family/guardian can provide care in the absence of nursing coverage; to notify the physician of respiratory rate greater than 20, systolic blood pressure outside of the range 97 mmHg (millimeters mercury) to 115 mmHg, or of diastolic blood pressure outside of the range 57 mmHg to 76 mmHg; and tube feeding orders to give “Pediatric Compleat 1.0” or “Pediasure with Fiber 1.0” as bolus feedings of 280 ml. (milliliters) each four times per day with water flushes of 90 ml. before and after each feeding for a total of 180 ml. with each feed; and continued directions that the patient could have 100 ml. “snack” once per day; and extra juice, water, chilled milk in the morning if requested; and may give 30 to 120 ml. of free water “as needed” for hydration. Further review of Patient #1’s "Skilled Nursing Notes" reveals the following respiratory rates over 20 without any evidence of notification to the physician as ordered: on 07/10/24 RR (Respiratory Rate) of 28 during the day shift and 21 on night shift; on 07/11/24 RR 36 during the day and RR 24 at night; on 7/12/24 RR 45 at night; on 07/14/24 RR 26 at night; on 07/15/24 RR 31 during the day and 44 at night; on 07/16/24 RR 46 during the day and RR 44 at night; on 07/17/24 RR 32 during the day and RR 28 at night; on 07/18/24 RR 32 during the day and RR 28 at night; on 07/19/24 RR 44 at night; on 07/21/24 RR 26 at night; on 07/22/24 RR 35 during the day and RR 44 at night; on 07/23/24 RR 32 during the day and 44 at night; on 07/24/24 RR 43 during the day and RR 22 at night; on 07/25/24 RR 35 during the day and RR 22 at night; on 07/26/24 RR 44 at night; on 07/28/24 RR 22 at night; on 07/29/24 RR 46 at night; on 07/30/24 RR 43 during the day and 46 at night; on 07/31/24 RR 32 during the day and 24 at night; on 08/01/24 RR 23 during the day; on 08/02/24 RR 44 at night; on 08/04/24 RR 24 at night; on 08/05/24 RR 43 during the day and 46 at night; on 08/06/24 RR 48 during the day and 46 at night; on 08/07/24 RR 42 during the day and 26 at night; on 08/08/24 RR 39 during the day and 22 at night; on 08/09/24 RR 46 at night; and on 08/11/24 RR 26 at night. Review of the "Skilled Nursing Notes" between 07/01/24 and 08/11/24 as well as a Registered Nurse (RN)’s recertification visit on 08/06/24 reveals no evidence a blood pressure was ever taken to see if it was within physician-specified parameters. Further review of the "Skilled Nursing Notes" reveals Patient #1 also received 600 ml. of formula and 90 ml. water (instead of 280 ml. formula and 180 ml. water as ordered) on the following dates and times: on 07/11/24 at 9:34 PM, on 07/14/24 at 8:11 PM, on 07/17/24 at 10:34 PM, on 07/18/24 at 11:51 PM, on 07/21/24 at 10:24 PM, on 07/24/24 at 9:40 PM, on 07/25/24 at 9:40 PM, on 07/28/24 at 10:51 PM, on 07/31/24 10:47 PM, on 08/04/24 at 11:22 PM, on 08/07/24 at 9:51 PM, on 08/08/24 at 10:06 PM, and on 08/11/24 at 8:57 PM. Each of these tube feeding administrations were documented by Staff A. During interview on 09/17/24 at 2:35 PM, the Clinical Manager stated Staff A was no longer employed by the Home Health Agency and she denied any education to other staff to address any concerns since then because she said they were “very isolated.” Staff A could not be reached during the survey. 2) Review of the record reveals Patient #2 was born in 2023 and had heart defects, congenital hypothyroidism, and a tube in the stomach for feeding; and started Home Health care on 07/24/24. Patient #2’s Home Health Certification and Plan of Care and Addendum to Plan of Treatment for the certification period of 07/24/24 to 09/21/24 include the order, “Enteral Feedings Alimentum (type of feeding) gentile formula 120ml. PGT [per gastric (stomach) tube] over one and a half hours via pump. Administer 120ml. every 3 hours. Flush with 10-30ml. after each feeding. Attempt oral feeding first with a bottle” and documents under SOC [Start of Care] assessment" ... has a G- (Gastric) tube for feedings every 3 hours but is working with ST [Speech Therapy] to take oral feedings” and “Check gastric residual before bolus feeding and as needed for gastric distress. If gastric residual is greater than 1 hours’ worth of feeding, hold feeding for 1 hour and recheck residual. If gastric residual is greater than 50ml. of feeding, hold feeding and notify physician.” No physician orders to change this feeding regimen were found after this date. Patient #2’s "Skilled Nursing Note" dated 08/01/24 (day shift) documents for 7:00 AM, “When I arrived at the patient's home, I saw the ... (parent) feeding the ... (Patient #2) from a bottle. She told me that she preferred feeding the ... (Patient #2) this way rather than using the G-tube. She instructed me to discard any remaining milk in the bottle and to feed the ... (Patient) #2 every four hours. She also said that if the... (Patient #2) missed a feeding, I should let ... (Patient) #2 go hungry until the next feeding time. I explained to her that I needed to obtain a doctor's order before making any changes” and for 10:30 AM, “I accompanied ... (Patient #2) and ... (Parent) to a doctor's appointment. The ... (Patient #2's parent) explained to the doctor what the ... (another parent) of the ... (Patient #2) wanted. The doctor mentioned that the ... (Patient #2) had lost 5 ounces in weight since ... (Patient #2's) last appointment which was a week ago and said she would not recommend that, but will consult with the GI (Gastroenterologist) doctor and have a conference call with the ... (parent)”; that Patient #2 was given Similac Alimentum 15 ml .by mouth and 100 ml. by gastric tube at 8:00 AM; that Similac Alimentum 115 ml. (not 120 ml. as ordered) was administered by gastric tube at 12:25 PM; that Similac Alimentum 115 ml .was administered by gastric tube at 4:00 PM; and in Summary comments, “All medications and feedings were administered as ordered and no adverse reactions noted.” However, Patient #2 had not received feedings every 3 hours as ordered for a total of 4 feedings and 480 ml. of formula, but instead received only 345 ml. of formula, and there was no evidence of attempts to bottle feed before the second and third feedings were given by gastric tube. Patient #2’s Skilled Nursing Note dated 08/01/24 (night shift) documents tube feed intakes of Similac 115 ml. each at 8:05 PM, 12:00 AM, 4:10 AM, and 4:20 AM. Review of Patient #2’s "Skilled Nursing Notes" reveals the following tube feeding intakes of Similac 115 ml. each with no evidence of complications: on 08/02/24 day shift (7:00 AM to 7:32 PM), Licensed Practical Nurse (LPN), Staff B gave tube feedings (TFs) at 8:00 AM, 12:00 PM, and 4:05 PM; on 08/02/24 night shift (7:00 PM to 7:01 PM), LPN, Staff D gave TFs at 8:00 PM, 12:00 AM, and 4:00 PM; there is no day shift note for 08/03/24; and on 08/03/24 night shift (7:00 PM to 7:12 AM), LPN, Staff D gave TFs at 8:30 PM, 12:28 AM, and 4:25 AM. Patient #2’s "Skilled Nursing Note" for 08/04/24 day shift (7:05 AM to 7:11 PM) by Staff E documents at 8:00 AM, “clients ... (parent) stated that she wants the client to be fed every 4 hours instead of three. clients (... (parent) was educated by the previous nurse on feeding orders. ... (Parent's) directions are being followed,” with no evidence the physician or Registered Nurse was notified Patient #2’s nutrition orders were not being followed or that the ... (parent) was educated on the consequences of only providing 75% of the patient’s nutritional needs and the effects of resulting malnutrition and dehydration on the patient’s already compromised health. This note also documents, “i educated ... (parent) and ... (other parent) about formula that the doctor ordered but the client is currently still on Similac” and Patient #2 was given Similac Alimentum formula 115 ml. first offered by mouth and any remaining formula given as tube feedings, at 8:00 AM, 12:27 PM, and 4:00 PM. Further review of Patient #2’s "Skilled Nursing Notes" reveals the following feedings of Similac that continued to be given no more than approximately every 4 hours rather than every 3 hours as ordered: on 08/04/24 night shift (7:00 PM to 5:59 AM) 90 ml. at 8:00 PM, 115 ml. at 12:07 AM, and 115 ml. at 4:00 AM; no notes for 08/05/24 when parents did care; on 08/06/24, 115 ml. each at 8:00 AM, 12:00 PM, and 4:00 PM; no night shift note for 08/06/24; on 08/07/24 beginning at 7:02 AM, 115 ml. each at 8:00 AM, 12:00 PM, 4:00 PM, and 8:05 PM; on 08/08/24, no evidence of midnight feeding, and 115 ml .each at 4:00 AM, 8:05 AM, by 1:30 PM, 4:07 PM, and 8:05 PM; on 08/09/24 115 ml. each at 12:00 AM, 4:00 AM, and 8:20 AM, 85 ml. at 12:30 PM and 50 ml. at 4:05 PM before an overnight hospitalization; on 08/10/24 after care resumed at 3:06 PM, 115 ml. each at 4:00 PM, 8:00 PM; on 08/11/24 115 ml. each at 12:06 AM, 4:00 AM, 8:58 AM, (pt in care of family from 9:00 AM to 1:20 PM), 50 ml. at 6:00 PM, 115 ml. each at 8:00 PM and 11:59 PM; on 08/12/24, 115 ml. at 4:00 AM; (patient in care of parents until 08/13/24 at 9:55 AM); on 08/13/24 115 ml. at 12:03 PM before Patient #2 was taken to a doctor’s appointment, then hospitalized until 08/20/24. Patient #2’s "Skilled Nursing Note" for 08/20/24 from 7:15 PM to 7:37 AM reveals the patient was started on tube feedings of Similac Alimentum at a rate of 37 ml/.hr. (ml per hour) and received 407 ml overnight. Patient #2’s "Skilled Nursing Note" for 08/21/24 night shift documented the tube feeding rate as 37 ml/.hr. with a total of 407 ml. overnight, and that Patient #2 weighed 13 lbs. (pounds), 14 oz (ounces). Patient #2’s "Skilled Nursing Note" for 08/22/24 day shift documents feeding at 37 ml./hr. with intermittent breaks for venting (releasing air through the gastric tube) and 2 hour-long holds for residual stomach contents of 20 and 30 ml. and a total feeding intake of 280 ml. that shift. Patient #2’s "Skilled Nursing Note" for the night of 08/22/24, 7:02 PM to 7:13 AM, documented a feeding rate of 37 ml./hr. and intake total of 420 ml. Patient #2’s "Skilled Nursing Note" for 08/23/24 day shift, 6:59 AM to 7:10 PM, documented the total feeding intake was 140 ml.; that Patient #2 left for a doctor's appointment at 10:15 AM and returned at 11:30 AM and the feeding was restarted at 11:50 AM; and the patient weighed 13 lbs., 7 oz., a loss of 7 oz. since 8/21/24. Patient #2’s subsequent "Skilled Nursing Notes" reveal feeding rates of 37 ml./hr. instead of bolus feedings every 3 hours as ordered with varying feeding intake totals over approximately 12-hour shifts as follows: 420 ml. on night shift 08/23/24; 420 ml. on night shift 08/24/24; no amount documented but a feeding rate of 37 ml./hr. on the day shift 8/25/24; 560 ml. on night shift 8/25/24; and 407 ml. on night shift 08/27/24. A "Skilled Nursing Note" for 08/28/24 from 7:00 AM to 3:03 PM documents Patient #2’s tube feeding was held for about two hours while at a doctor's appointment and “new feed orders” without evidence of the new "orders" in the record, and a total tube feed intake of 275.2 ml. without documentation of a rate. Patient #2’s subsequent "Skilled Nursing Notes" reveal feeding rates of 44 ml./hr. with feeding intake totals per shift as follows: 440 ml. for night shift on 08/28/24; 880 ml. for day shift on 08/29/24; 440 ml .for night shift on 08/29/24; 880 ml. for day shift on 08/30/24; 352 ml. for night shift on 08/30/24; 308 ml. for day shift 08/31/24; and 880 ml. more by 9:00 PM on 09/01/24. During interview on 09/17/24 at 4:05 PM, the Clinical Manager stated the only order she has for Patient #2’s tube feeding is 120 ml. every three hours to be given over 1 ½ hours each from 07/27/24; that the nurses in the home may have been told a different order by the family if they did not attend an appointment, which could be relayed by word of mouth from nurse to nurse; but that the nurse should have called the doctor and obtained a verbal order and submitted it to the office to get the doctor’s signature. During further interview on 9/17/24 at 4:11 PM, the Clinical Manager stated she talked to the Clinical Supervisor who just sent a new order to the physician that day for Patient #2’s tube feed rate at 37 ml/.hr.; that they had not known of changes before this day; denied an order to change the tube feed rate to every 4 hours before that; and stated it is complicated when staff are in the home and the ... (parent) is telling them to do something different.