Every finding on record at Maxim Healthcare Services, Inc

At this unannounced Emergency Preparedness survey, Maxim Healthcare Services, Inc was found to be in compliance with 42 CFR 484.102, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers. Dates: 3/26/24 - 4/1/24 State of Alaska Department of Health Health Facilities Licensing and Certification 4601 Business Park Blvd, Building K Anchorage, AK 99503

An unannounced Federal Certification survey was conducted 3/26/24 - 4/1/24 at Maxim Healthcare Services, Inc. Census: 31 Active Patients with 19 Pediatric and 12 Adult Patients 44 skilled unduplicated census for the past 12 months 8 Records reviewed. (6 active and 2 discharged.) 3 home visits observed with 2 Registered Nurse Visits and 1 Licensed Practical Nurse visit. The following deficiencies were noted: State of Alaska Department of Health Health Facilities Licensing and Certification 4601 Business Park Blvd, Building K Anchorage, AK 99503

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the coordination of care with all agencies providing services for one patient (#3), out of 6 active clinical records reviewed. This failed practice placed the identification of patient's needs and factors not being known or implemented, which has the potential to affect the patient’s safety and treatment effectiveness and the coordination of care provided by the agency and other agencies, including a hospice agency. Findings: Record review on 3/26/24 – 4/1/24 revealed Patient #3 was admitted on 5/27/21 with diagnoses that included tuberous sclerosis (a rare genetic disease that causes non-cancerous tumors to grow in the brain and other parts of the body) and seizures (sudden, uncontrolled electrical activity in the brain that cause changes in behavior, movements, and levels of consciousness). The certification period of 3/12/24 – 5/10/24 failed to include documentation of the coordination of care with the hospice, who also completed care with this patient. The hospice orders and hospice plan of care were not included in the record. There were not specific lists of what services or a complete listing of medications or supplies the hospice provided, nor who to call at the hospice for clinical support or leadership. Review of the record revealed the Plan of care for the Certification Period of 3/12/24 - 5/10/24. This plan of care revealed: "[Patient #3] remains on hospice services but is currently stable so hospice kit/protocol is not being utilized. [Hospice kit meds of morphine, lorazepam, and haloperidol were securely stored upstairs away from [his/her] bedroom. [The hospice physician] did a brief visit in January 2024 and deemed [[him/her] stable." There was no information on the plan of care showing which services the hospice provided or a complete list of medications or supplies were supplied by the hospice. The hospice name, contact information, or phone number were not on the plan of care or present in in a documentation or a communication. Review of Patient #3’s "Care Coordination note," completed by Licensed Nurse #1 and dated 3/7/24, addressing hospice services revealed: "[Patient #3] remains on hospice services but is currently stable so hospice kit/protocol is not being utilized.[TML1] . [The hospice physician] did a brief visit in January 2024 and deemed [him/her] stable." Review of the record revealed a Clinical Note entry, dated 4/1/24 and signed by the Interim Clinical Manager. This note revealed: “Late entry for 3/27/24 and 3/28/24. Called [name of hospice agency] and left messages to speak with the case manager for [Patient #3]. Left office and cell call back numbers.” During an interview on 3/28/24 at 10:15 AM, when asked how long the patient had been on hospice and how that referral and admission had occurred, the Primary Caregiver of Patient #3 stated Patient #3 was placed on hospice over two years ago after a hospitalization for respiratory difficulty. The hospice nurse visits every two weeks, and the hospice physician visits every two months. During an interview on 4/1/24 at 2:40 PM, the Administrator and Interim Clinical Manager agreed that there was lack of coordination of services with the hospice who cared for Patient #3. There was no knowledge or inclusion of the hospice's plan of care or the terminal illness diagnosis. There was not a complete list of medications, supplies, physician orders, and services the hospice supplied to the patient. The home health agency had not coordinated or shared their care or plan of care with the hospice. The Interim Clinical Manager added that she had reached out to the hospice late last week. No reply had been received at this time. Review of the agency's policy "Care Coordination/Case Conference,” dated 10/7/22, revealed: "Purpose: To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services ... to facilitate effective communication amongst the health care team ... Care coordination must be accomplished at least once every certification period. Evidence of the care coordination must be documented in the medical record or system of record."

. This visit was for an Emergency Preparedness Survey Facility License # HHA-07 Provider CCN #: 027032 Survey Dates: March 1 - March 10, 2021 Maxim Healthcare Services, Inc. was found to be in compliance with 42 CFR Emergency Preparedness for Medicare Participating Providers and Suppliers. State of Alaska Department of Health & Social Services Division of Health Care Services 4601 Business Park Blvd. Building K Anchorage, Alaska 99503 .

This visit was for a Federal Recertification survey, a state re - licensure survey, a Focused Infection Control survey, an Emergency Preparedness Program survey, and an investigation of two complaints. This was a fully extended survey on March 5, 2021. AK 00003980 - Substantiated AK 00004010 - Unsubstantiated: due to lack of evidence There were no deficiencies identified during the Federal Infection Control Survey (FICS) conducted in conjunction. Survey Dates: March 1 - March 10, 2021 Facility license #: HHA-07 Provider CCN #: 027032 Census #: 197 skilled unduplicated skilled admissions since last standard survey 49 skilled unduplicated admissions in past year Total records reviewed: 9 skilled medical records reviewed (7 active records and 2 discharged). Home visits: 3 with skilled nursing observed The following deficiencies were noted: State of Alaska Department of Health & Social Services Division of Health Care Services 4601 Business Park Blvd. Building K Anchorage, Alaska 99503 .

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: . Based on observation, record review and interview, the agency failed to ensure that the patient's right to be advised of the state toll free hotline number, the contact number, the hours of operation, and its purpose was understood and easily accessible to the patient / patient representatives for 4 of 9 skilled clinical records reviewed (#1, #3, #4, and #5). This failed practice denied patients and/or their representatives information needed to exercise their right to file a grievance with the State Agency. Findings include: An admission folder titled "Patient Admission Folder" was presented to the surveyors on 3/2/21. Review of this booklet revealed it contained separate stapled pages titled "Local Office Information Sheet" with a section titled "Important State Agency Phone Numbers" which stated, "State hotline for reporting complaints regarding home care agencies and issues regarding the implementation of advance directives: Home Health [HFL&C] Complaint Hotline: 888-0387-9387 or 907-334-2483 - 8 AM - 5 PM Monday through Friday [after business hours messages can be left on the answering machine."] Additionally, within the undated bound version of this "Patient Admission Folder" were the "Patient Rights" on pages 11 - 12 which stated, "Home care patients / clients have the right to ... be advised of the state toll free hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies." Patient #4 Observations made during a home visit on 3/3/21 at 11:00 AM revealed Patient #4's Representative had not received the State complaint hotline number and the toll - free number was not present in the admission folder for Patient #4, which did not have the state complaint hotline phone number in it. During an interview on 3/3/21 at 11:00 AM, the Patient Representative stated, "I had no knowledge of the State home health complaint hotline number." Patient #5 During an interview on 3/3/21 at 1:30 PM, Patient #5's Representative did not recall being told about the State complaint hotline number. During the onsite home visit, review of the admission folder, provided by the home health agency, revealed the state complaint hotline/ toll free number was not present in the folder. During a phone interview on 3/4/21 at 4:16 PM, when asked about the patient representatives not receiving the state hotline complaint number, the Administrator stated the local office information sheet was given to the patient's representative when the admission occurred and then this paper was placed into the patient's home binders. Patient #1 During phone interviews on 3/8/21 at 1:30 PM, Patient #1 and Patient #4's Representative stated having no knowledge of the State hotline number for either Patient and the number was not present in the admission folder or the home binder. The Patients Representative checked the home binder chart for the state complaint hotline number and was unable to locate it. Patient #3 During a telephone interview on 3/8/21 at 4:29 PM, Patient #3's Representative stated, "I am not aware of the state complaint hotline number." Patient #3's Representative stated the nurses visiting for the 60-day assessments had not educated him / her about the hotline number and she / he had no knowledge of the State home health hotline complaint number. The Clinical Manager was present during this phone interview and agreed to send a copy of the State hotline complaint line number and the current admission folder to the representative at his / her request. A review of the agency policy on 3/10/21 titled "Patient / Client Rights and Responsibilities" revised 4/10/20 stated, "Each patient / client will be an active, informed participant in their plan of care. To ensure this process, the patient / client will be empowered with certain rights / responsibilities ... 5. Patient / Client Rights ... Home care patients / clients have the right to ... be advised of ... the state toll free home health telephone hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies." .

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 record review and interview, the agency failed to ensure the patient's medical and nursing needs were met in the patients' place of residence for 2 of 9 clinical records reviewed for patients who were unable to receive adequate home nursing care by licensed staff (see G 0570 below) and failed to ensure Licensed Nurses reported changes to the physician for 1 of 9 patients' medical records reviewed (see G 590), and failed to coordinate care among the different disciplines / entities providing care to 1 of 1 closed patient records reviewed for cares provided by outside agencies, including a patient (#1) receiving Physical and Occupational Therapy from an outside therapy service (see G 606). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services, and Quality of Care. Based on record review and interview, the agency failed to ensure the patient's medical and nursing needs were met in the patients' place of residence for 2 of 9 skilled records reviewed for patients' medical records (#1 and 5) who were unable to receive adequate home nursing care by the licensed nursing staff. This resulted in the patient being admitted to the hospital to recieve adequate medical and nursing care. Findings Patient #1 Record review on 3/1/21 - 3/10/21 of medical record #1 with a start of care dated 1/6/21 and a diagnosis of DiGeorge's syndrome (a disorder caused by a defect in chromosome 22), failed to evidence skilled nursing and other services were provided as needed to keep the patient in the home. Review revealed physician orders dated 12/30/20 for Pediatric Home Health Care 16 hours/day x 6 days per week ...need for skilled nursing care for 11 months. This was signed by the physician on this date and noted by the clinical manager on 1/6/21. Further record review revealed another order dated 12/30/20 for monthly labs required including a complete blood count with differential and other labs." This was ordered for 10 times and was signed by the physician. Another order dated 12/31/20 was for a physical therapy and occupational therapy evaluation and treatment. This was signed by the physician on 12/31/20. Review of the admission assessment, completed 1/6/21 and signed by Licensed Nurse # 2 on 1/12/21 stated, "[Patient #1] will need ongoing neutropenic precautions with diligent oversight by [Patient Representative] to ensure [his/her] safety and to decrease [his/her] chances of acquiring an infection." An addendum note dated 1/6/21 and completed by the clinical manager stated, "Addended to include conversation with [physician] 1/6/21 about [his/her] thoughts on staff allowed in this home due to patient's immunocompromised status. I asked [him/her] if both I and [licensed nurse #2] going to the admission due to [his/her] compromised status and [physician] stated yes as long as we have not been in another patient's home right before going over there and that we wear PPE [personal protective equipment]. [The physician] stated that for nurses going into the home the importance is making sure they shower before shift if they got off work somewhere before going to work with [patient #1], wear mask and gown when in the room with [patient #1] wash their hands, not come to work sick, etc., I verbalized understanding of this, and we will relay these expectations to nurses assigned to this home." Review of another note, dated 1/6/2021 and written by the clinical manager stated, "Spoke to [physician] who stated [he/she] is going to send the lab order to [physician's office] for them to draw it since [he/she] will be there for an appointment today ..." A review of the plan of care with a start of care date of 1/6/21 and certification period of 1/6/21 - 3/6/21 evidenced physician's orders for skilled nursing care for 89.6 - 112 hours per week for the certification period and these orders included skilled observation and assessment of vital signs, physical and mental emotional status, medication administration, skilled nursing general addendum precautions to follow due to severe immunocompromised status, enteral feedings and care of G tube site and tubing, skin care, and COVID-19 monitoring. Goals/Rehabilitation Potential/Discharge plans on this document included the patient/caregiver demonstrates proper techniques to prevent the development of skin breakdown, minimize risk of COVID-19 exposure over the next 60 days, patient remains seizure free throughout the 60 days, Patient stated goal: [patient representative]: states goal is to keep patient safe and free of infections, hospitalizations in the next 60 days, and patient will remain free of harm and will be safe during all transfers throughout the certification period. A review of a "Medicaid Physician Documentation Face - to - Face Encounter" signed by the physician on 1/7/21 for an encounter on 1/4/21 stated the reason for the visit was to establish care post hospital discharge. The patient had a need for ongoing medication administration, tube feeding and g-tube care (tube feed via the stomach). The patient had need for nursing and required treatment of all body systems due to instability of condition, requires constant monitoring, requires frequent treatments, and/or adjustments due to the complexity of the prescribed services, requires hands on assistance with activities of daily living and medications, and requires acquisition of skills, to promote progression or to prevent regression. The community physician to follow for home health need and ongoing nursing services. This document was reviewed by the clinical manager on 1/8/2021. A review of a document with no title or date showed the skilled nurse worked 18.58 hours the first week from 1/6/21 - 1/9/21, 36.08 hours the second week from 1/10 - 1/17/21, 72.42 hours the third week from 1/17/21 to 1/23/21, and 0 hours the fourth week 1/24/21 - 1/26/21. The plan of care hours was not met as ordered for those weeks. No week's total hours met the ordered 89.6 - 112 hours per week found on the plan of care. A review of a document titled "Missed shifts for Private Duty Nursing" stated, "Client canceled hours." This document showed that two four shifts on 1/15/21 and 1/16/21 were cancelled by the client's representative. This was faxed to the physician on 1/14/2021. A review of a document titled "Missed shifts for Private Duty Nursing" stated, "Client cancelled hours: 28." This document showed that the caregiver cancelled 4 hours per day from 1/17/21 - 1/23/21." A note stated, "Client cancelled shift. [Representative] prefers shift time 8 am - 8 pm to align with other patient in home and does not desire night nursing." This was faxed to the physician on 1/21/21. A review of a document titled "Missed shifts for Private Duty Nursing" stated, "Client cancelled hours: 28." This document showed that the caregiver cancelled 4 hours per day from 1/24/21 - 1/30/21." This was faxed to the physician on 1/28/21. A review of an email between Staff #4 and the Clinical Manager dated 1/22/2021 stated, "[Patient #1 representative] asked for Licensed Nurse #1 to be pulled from [Patient #1's] case immediately." During a phone interview on 3/3/21 at 9:05 AM, the patient representative of patient #1 stated that there was not enough staffing available for this patient and that the lack of PPE use was a concern also. To help with the staffing situation, the agency offered to use the personal service agency caregivers. There were concerns due to confidentiality and the lack of PPE use by some nurses and some personal service caregivers. Physical therapy and occupational therapy were set up through telehealth but not through the home health agency and no discussion of assistance with setting up physical therapy or occupational therapy occurred. The last visit with this agency occurred around 1/25/21 when patient #1 was admitted to the hospital due to the lack of home health services available through this agency. There were lack of visits including a no - call, no -show. On 1/24/21, there was no nurse available. There was concern that the agency could not complete the lab draws due to lack of training. The agency did not supply adequate personal protective equipment including gloves, masks and gowns. A review of a document titled "Missed shifts for Private Duty Nursing" stated, "Client cancelled hours: 28." This document showed that the caregiver cancelled 4 hours per day from 1/31/21 - 2/6/21." A transfer summary dated 1/29/21 signed by Licensed Nurse #2 evidenced Patient #1 was transferred to the hospital on 1/25/21 at 8 AM. The documentation stated the reason for the transfer was the inability of [patient #1's representative] to safely care for patient without Maxim full time staffing. During an interview on 3/4/2020 at 3:08 PM, the Clinical Manager explained that the hours were not met due to the family not wanting to split the hours into two shifts. The patient did not get the ordered physical/occupational therapy through the home health agency due to the agency not offering that service. The agency nurses did not complete the labs that were ordered with the referral order because the family was able to take the patient for labs at the same time as a scheduled physician appointment. During an interview on 3/8/2021 at 1:30 PM, the patient representative for patient #1 stated the patient advocate for patient #1 had requested no LPNs (licensed practical nurse) staff this case. During an interview on 3/8/2021 at 2:00 PM, the patient advocate for patient #1 stated, "The LPN was declined in the case conference. The administrator was aware of this and agreed that RNs (registered nurse) should be used for staffing in the home." A review of a hospital record on 3/10/21 evidenced the patient needs were not met due to the lack of personal protective equipment and lack of home nursing availability as follows: A review of an outpatient clinic note dated 1/25/2021 time 3:30 PM evidenced patient #1 had a planned admission to the hospital on this date. The document stated, "The reasons for admission being inadequate skill and appropriate use of PPE from Maxim nursing in regard to [patient #1]. A care conference with multiple people in the care of [patient #1 including [patient representatives], Medicaid staff, OCS [office of children's services] staff ...PCP [primary care physician] team were present on this call on 1/22. Concerns for appropriate care were discussed at this meeting ... "A review of a discharge coordination/social services note completed by nurse at hospital dated 1/28/21 time 11:39 Alaska time stated, "Writer spoke with [Staff #4] who reports after notification of PPE issue met with and educated the nurse. Maxim expects all staff wear PPE all shifts, every shift and is non - negotiable [He / she] reports the [patient representative] call ... Friday at 4:58 PM and asked for the nurse not be sent back to the home. This creates a deficit in nursing coverage in the home. Maxim has another nurse, just cleared by immunology that can go in 4 days/week. Since [patient representative] does not want the previous nurse they will not have all 3 days covered until another nurse is found. Also [Staff #4] reports when services were initiated, it was known and agreed that there would be missed shifts, because the admission agreement was for 3 days per week until another nurse was to start the week of the 19th." o A review of a provider progress note dated 2/2/21 and completed by the registered dietician stated, History [patient #1] ... admitted for social reasons as home health nursing unable to provide adequate PPE." o A review of a provider progress note dated 2/6/21 completed and signed by the physician stated, "Discharge once adequate and appropriately safe home nursing [ideally] 7 days / week] can be re-established ..." o A review of a provider progress note dated 2/8/21 completed and signed by the physician stated, "Requiring admission due to inadequate home nursing including concerns for inadequate use of appropriate PPE. Working on therapies and skin cares while awaiting establishment of appropriate / adequate home nursing. Problem list: 1. Inadequate Home Nursing." Record #5 Record review on 3/2-8/2021 revealed Patient #5, start of care date 7/29/2019, had diagnoses that included Mitochondrial Disease (a genetic disorder that effects energy production), Cerebral Palsy (congenital disorder due to abnormal brain development), immunodeficiency, restrictive lung disease, urinary retention, dysphagia (difficulty swallowing), and a history of seizures. Review of the physician orders for nursing services, signed 2/4/21, revealed "Treatments: -Skilled Nursing-Frequency and Duration Maximum Healthcare Services to Provide nursing services for 133-166.25 hours per week through the certification period." Review of the current certification period dated 1/19-3/18/2021, revealed the following physician orders. Review of treatment orders included: " Chest Percussion Therapy Vest three Times a Day (vest that vibrates the chest wall to loosen mucus), " Levolbuterol (an inhaled medication used to treat bronchospasm) followed by 3% normal saline mist by nebulizer, " Cough assist machine three times a day (machine that blows in air and pulls it out quickly), " Oropharyngeal (oral throat) and nasal suctioning, " Oxygen with Bipap (Bilevel Positive Airway Pressure-machine that forces air into the lungs) at night and as needed during the day, " Feeding and medications via g-tube (tube surgically implanted into the stomach to deliver feedings) and had a j-tube (jejunostomy tube-surgically implanted into the small bowel), " Mitrofanoff catheter (a tube that connects the bladder to the surface of the skin) strait cathed (drained) 2-5 times daily and connected to a draining bag at night, and " Gammaplex infusion (immune globulin for immunodeficiency) given weekly subcutaneously (through the skin) " Listed goals: "Patient stated Goal: Per [Patient Representative]- 'Try to keep [him/her] home] during the next 60-day certification period." Review of the hours provided during the current certification period revealed: Week #1 1/17-23/2021-130.41 nursing hours Review of a "Missed Shifts for Private Duty Nursing" for Patient #5, scheduled visit date range 1/17-1/23/2021 "Reason for Missed Hours: 12 No Qualified Caregiver Available...Comments: See Report Below...no qualified Caregiver available for this shift family will resume care." Week #2 1/24-30/2021-150.87 nursing hours Review of a provider note, dated 1/26/2021, revealed "...Pediatrician: stated in regard to [less than] 60 hours of uncovered nursing care, it wouldn't be appropriate to expect one individual to take care of [Patient #5] for more than 24 hours especially 60 hours. Up until this point Maxim has provided that care. If Maxim can't provide, then [he/she] would have to be admitted. Unfortunately, there are no extended care facilities that we know of for [his/her] acuity and [his/her] age leaving ...Hospital as the only option." Review of a clinical note, dated 1/28/21, revealed "[Clinical Manager] and [Administrator] called [Patient #5's Physician's] Office and spoke with RN [Name]. We notified them that we do not have a nurse available to work the night shifts on Friday, Saturday, or Sunday nights and asked them if there needed to be a plan in place for institutionalization. [RN] reported that [he/she] spoke to the [Patient Representative] this morning and they gave [Patient #5's Representative] the option. [Patient #5's Representative] reported that [he/she] did not want to have [his/her child] moved to inpatient and that [he/she] will be able to provide care for [his/her child] overnight. [Administrator] also mentioned that we need to have a good orientation process and I'm 'pretty sure' we will not have a night nurse for the next weekend either. [RN] asked about the 3 other staff members ...[RN] acknowledged and understands staffing is a challenge and [Resident #5] is complex." Review of a clinical note, dated 2/28/21, revealed "Called [Patient #5's Representative] to see how [he/she] is doing how [his/her] appointment with [Patient #5's Physician] went this past Monday and let [him/her] know we have a message out to see if [RN Name] can pick up any extra shifts to accommodate this Sunday shifts before [Patient #5's] upcoming MD appointments on 3/1 and 3/8. [Patient #5's Representative] stated the appointment was OK and that [Physician's Name] just feels stuck in the middle of whatever this is and that they all agree that [Patient #5] needs nursing level of care ...I told [him/her] if it takes six weeks to orient there will always be holes. [The Patient Representative] said 'Well, it really doesn't take 6 weeks, [RN name] got things quickly.' [Patient #5's Representative] states the nurses just have to be calm, soft spoken, and be able to follow the needs of [Patient #5]. I told [Representative] we are committed to finding nurses for [his/her] home that are a good fit and [the Patient's Representative] said [he/she] appreciates that." Week #3- 1/31-2/6/2021-135.86 hours Week #4- 2/7-2/13/2021-137.68 hours Week #5 -2/14-2/20/2021-131.4 hours Week #6- 1/21-2/27/2021-118.7 hours Review of a "Missed Shifts for Private Duty Nursing" for Patient #5, scheduled visit date range 2/21-2/27/2021 "Reason for Missed Hours: 12 No Qualified Caregiver Available...Comments: See Report Below...no qualified Caregiver available for this shift family will resume care." Week #7 -2/28-3/6/2021-131.97 hours During an interview on 3/4/2021 at 12:10 pm, Patient Representative #5 stated Patient #5 was currently understaffed for a night nurse 3 nights a week. The Patient Representative stated although the agency offered a Patient Care Assistant, Patient #5's medical needs were too complex. When asked about nurses training to provide care to Patient #5, the Patient Representative stated some nurses can learn how to provide care on a day and some nurses take longer. Patient #'5's Representative stated no one had been out to train with Patient #5 since the first week of February, a month ago. Review of the posted schedule for Patient #5 revealed no nurses had been scheduled for weekend coverage. During an interview on 3/5/2021 at 4:06 pm, Agency Staff #3 stated he/she was a client coordinator and coordinated the schedules between the nurses and the patients, his/her job is to "fill the screen". When asked about the deficit in training for Patient #5 and the concerns about staffing, Agency Staff #3, stated the Administrator is responsible for that case and the Patient Representative covered the deficit hours. During an interview on 3/5/21 at 5:00 pm, when asked about the plan for providing coverage for Patient #5, the Clinical Manager stated it was in the Administrator emails. During an interview on 3/8/21 at 11:11 am, the Clinical Manager presented a typed document titled, "[Patient #5] Orientation Plan", undated. When asked about the date, the Clinical Manager stated the plan had been developed on 2/12/21. The agency policy titled "Acceptance and Admission" revised 4/10/2020 stated, "Purpose: Patients/clients will be accepted for service based on the adequacy and suitability of the personnel, resources to provide required services, and the reasonable expectation that the patient/client's medical, nursing, rehabilitative, and / or social needs can be adequately met in the patient/client's place of residence." .

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to ensure Licensed Nurses [LN] reported changes to the physician for 1 (#11) out of 9 patients' medical records reviewed. This failed practice resulted in the lack of physician oversight for the patient's seizure activity and placed the patient at risk for further medical emergencies. Findings include: A review of Patient #11's clinical record on 3/3/21 and 3/10/21, revealed start of care date of 8/4/17 and a plan of care for the certification period of 1/15/21 - 3/15/21. The Patient's principal diagnosis included septo-optic dysplasia of brain (a condition that causes eye underdevelopment and brain abnormalities). The plan of care included a skilled nurse to assess / monitor/ instruct caregiver in change in neurologic status including increased seizure activity, decreased LOC [level of consciousness], one pupil larger than the other or unexplained emesis [vomiting]. Skilled nursing to assess / monitor / instruct caregiver in seizure precautions, signs and symptoms and emergency interventions. Review of a seizure record found in the record, dated 2/3/21 - 2/6/21, revealed 7 seizures had been recorded by the LN. The record review revealed a seizure, observed on 2/3/21 at 6:20 AM during an assessment, had a duration of less than 10 minutes with movements with arms to midline and head to right with eye deviation of up to right and patient was described as alert. A seizure, documented on 2/3/21 at 3:35 PM, was described "after diaper change, X 7-minute cluster, arms midline legs straight, stiff ...eyes ...down" with lethargy checked. Another note on 2/3/21 indicated Diazepam 1 mg [milligram] was given at 3:45 PM via G tube per orders ...". This was signed by LN #3 on 2/3/21. The nursing flow sheet for this date included documentation which included a neurological section. The nurse had documented that a seizure had occurred and to look at the seizure log. The physician was not notified, and the section titled "Physician Notified" was checked as not applicable (N/A). During an interview on 3/10/21 at 1:02 PM, the Clinical Manager confirmed the record did not show that the doctor was contacted about the seizure activity per the procedure used by the agency. A review of the procedure titled "Nervous Systems - Precautions: Seizure", last updated 9/12, stated "The focus of the care during seizure activity is to protect the patient from injury and to maintain an open airway. 2. In most cases, a seizure will last up to 2 to 5 minutes ... 5. Emergency care may be necessary if a seizure lasts more than 5 minutes ...After care ... 3. Contact physician to report incident and obtain further orders." .

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: . Based on record review and interview, the agency failed to coordinate care among the different disciplines / entities providing care to 1 of 1 closed patient records reviewed for cares provided by outside agencies, including a patient (#1) receiving physical therapy from an outside therapy service. Findings: Record #1 Lack of Coordination of Care with Physical and Occupational Therapy from an outside source A review of the record on 3/1/2021 - 3/10/2021 revealed the patient had been admitted on 1/6/2021 for the start of care (SOC) and services for skilled nursing had occurred after the SOC date. A physician's order had been written on 12/31/2020 for a Physical Therapy / Occupational Therapy evaluation and treat order, which had not been completed by the home health agency. A review of a document titled "Admission CHH ..." dated on 1/6/2021 and signed by Licensed Nurse # 2 on 1/12/2021 revealed the initial assessment did not include any care coordination with outside therapy services. The record did not show any coordination of care activities with the physical therapy or occupational services obtained elsewhere. During a phone call on 3/3/2021 at 9:05 AM, the patient representative for patient #1 stated that the home health agency did not discuss the patient's need for physical and occupational therapy with the patient representative or details about the therapy. The occupational therapy was obtained through the hospital and the physical therapy was completed by an individual physical therapist. These were conducted via telehealth visits. During an interview on 3/4/2021 at 3:23 PM, the Clinical Manager stated that physical therapy and occupational therapy services obtained elsewhere was discussed with the family. .

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 skilled nurses failed to follow the plan of care for 3 of 9 patients' medical records reviewed (see G 0710). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR 484.75 Skilled Professional Services. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment. .

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 facility failed to ensure the skilled nurses followed the plan of care for 3 of 9 patient records reviewed (#s 1, 4, and 5). This failed practice denied patients the services necessary to maintain their highest practicable level of wellbeing and safety. Findings: Patient #1 Review on 3/1/21 - 3/10/21 of the clinical record of Pt. #1 evidenced a start of care (SOC) date of 1/6/21 and a diagnosis of DiGeorge's syndrome (a disorder caused by a defect in chromosome 22). The review revealed skilled nursing services were not provided as ordered on the plan of care. A review of the plan of care with SOC 1/6/21 and the certification period of 1/6/21 - 3/6/21 included physician's orders for skilled nursing care for 89.6 - 112 hours per week for this certification period. These orders included skilled observation and assessment of vital signs, physical and mental emotional status, medication administration, skilled nursing general addendum precautions due to the patient's severe immunocompromised status, enteral feedings (tube feeding through the abdomen into the stomach) and care of G-tube site and tubing (tube feeding), skin care, and COVID-19 monitoring. A review of a document with no title or date showed the skilled nurse worked 18.58 hours the first week from 1/6/21 - 1/9/21, 36.08 hours the second week from 1/10 - 1/17/21, 72.42 hours the third week from 1/17/21 to 1/23/21, and 0 hours the fourth week 1/24 - 1/26. The plan of care hours was not met as ordered for those weeks. Review of each week's total hours revealed none met the ordered 89.6 - 112 hours per week found on the plan of care. A review of a document titled "Missed shifts for Private Duty Nursing" stated, "Client canceled hours." This document showed that two, four shifts, one on 1/15/21 and another one on 1/16/21 were cancelled by the client's representative. This was faxed to the physician on 1/12/21. A review of a document titled "Missed shifts for Private Duty Nursing" stated, "Client cancelled hours: 28." This document showed that the caregiver cancelled 4 hours per day from 1/17/21 - 1/23/21." A note stated, "Client cancelled shift. [Representative] prefers shift time 8 am - 8 pm to align with other patient in home and does not desire night nursing." This was faxed to the physician on 1/21/21. A review of a discharge coordination / social services note dated 1/28/21 11:38 AM and completed by the Registered Nurse at the hospital stated, "Writer spoke with [Staff #4] who reports after notification of PPE issue [he/she] met with and educated the nurse. Maxim expects all staff wear PPE [personal protective equipment] all shifts, every shift and is non - negotiable. [He / she] reports the [patient representative] called ... Friday at 4:58 PM and asked for the nurse not be sent back to the home. This creates a deficit in nursing coverage in the home. Maxim has another nurse, just cleared by immunology that can go in 4 days / week. Since [patient representative] does not want the previous nurse they will not have all 3 days covered until another nurse is found. Also [Staff #4] reports when services were initiated, it was known and agreed that there would be missed shifts, because the admission agreement was for 3 days per week until another nurse was to start the week of the 19th." A transfer summary dated 1/29/21 and signed by Licensed Nurse #2 evidenced Patient #1 was transferred to the hospital on 1/25/21 at 8:00 AM. The reason stated for the transfer on this document was the inability of [patient #1's representative] to safely care for patient without Maxim full time staffing. A review of a document titled "Missed shifts for Private Duty Nursing" stated, "Client cancelled hours: 28." This document showed that the caregiver cancelled 4 hours per day from 1/31/21 - 2/6/21." This was faxed to the physician on 2/2/21. During a phone interview on 3/3/21 at 9:05 AM, the patient representative of patient #1 indicated that there was not enough staffing available for this patient and that the lack of PPE use was a concern also. To help with the staffing situation, the agency offered to use the personal service agency caregivers. The patient representative stated many hours of nursing were missed, and this was a continuous concern which led to the patient's hospitalization around January 25, 2021. During an interview on 3/4/2021 at 3:08 PM, the clinical manager indicated that the hours were not met due to the family not wanting to split the hours into two shifts. A review of a hospital record on 3/10/21 evidenced the patient needs were not met due to the lack of PPE and lack of home nursing availability for the care ordered with the home health agency. This was noted on a provider progress note dated 3/2/21 at 3:36 PM and stated regarding the reason for admission to the hospital: "requiring admission due to inadequate home nursing." Another history and physical report dated 3/3/2021 completed by the physician stated the patient could be discharged once adequate and safe home nursing (ideally 7 days a week) with adequate PPE could be re-established. Patient #4 A review on 3/1/21 - 3/10/21 of Pt #4 clinical record evidenced a SOC on 7/24/2020 and diagnosis of anoxic brain damage (brain damage due to lack of oxygen). Included in the record was a plan of care for the certification period of 1/20/21 - 3/20/21 with skilled nursing hours for 133 hours - 156 hours per week. These hours were not met due to the missing visits noted in the record. A review of missing shifts for private duty nursing evidenced scheduled visit date range of 1/31/21 - 2/6/21 with the reason for missed hours: 51 hours due to client declined due to no qualified caregiver available. Comments made on 2/2/2021, 2/3/2021, 2/4/21, 2/5/21 showed visits were cancelled due to no qualified caregiver available for 11:45 hours; and 2/4/21 4 hours: client cancelled shift. This was faxed to the physician on 2/4/21. A review of hours titled "W/E 2/6/21" showed from 1/31/2021 - 2/6/21 totaled 72.47 hours had been completed by the skilled nurses. A review of missing shifts for private duty nursing evidenced scheduled visit date range for 2/7/21 - 2/13/21 with reason for missed hours: 47 hours due to no qualified caregiver available and client cancelled hours: 4. Comments on 2/9/2021, 2/10/2021, 2/11/21, 2/12/21 were due to no qualified caregiver available for 11:45 hours; and on 2/11/21, 4 hours, client cancelled shift. This was faxed to the physician on 2/11/21. A review of hours titled "W/E 2/13/21" showed from 2/7/2021 - 2/12/21 totaled 60.50 hours had been completed by the skilled nurses. A review of a missing shifts for private duty nursing evidenced a scheduled visit date range from 2/14/21 - 2/20/21 with the reason for missed hours: 51 hours were due to no qualified caregiver available. Comments on 2/16/2021, 2/17/2021, 2/18/2021, and 2/19/2021 11:45 hours each day showed visits were cancelled due to no qualified caregiver available. The client cancelled a 4-hour shift on 2/18/2021. This was faxed to the physician on 2/18/21. A review of hours titled "W/E 2/20/21" showed 2/14/2021 - 2/20/21 totaled 72.55 hours had been completed by the skilled nurses. A review of a missing shifts for private duty nursing evidenced scheduled visit date range from 2/21/21 - 2/27/21 with reason for missed hours: Client cancelled hours: 47. Notes included 2/23/2021, 2/24//2021, 2/25/2021, and 2/26/2021 11:45 hours were cancelled due to no qualified caregiver available. This was faxed to the physician on 2/25/21. A review of hours titled "W/E 2/27/21" showed 2/21/2021 - 2/27/21 totaled 88.37 hours had been completed by the skilled nurses. Patient #5 Record review on 3/2-8/2021 revealed Patient #5, start of care date 7/29/2019, had diagnoses that included Mitochondrial Disease (a genetic disorder that effects energy production), Cerebral Palsy (congenital disorder due to abnormal brain development), immunodeficiency, restrictive lung disease, urinary retention, dysphagia (difficulty swallowing), and a history of seizures. Review of the physician orders for nursing services, signed 2/4/21, revealed "Treatments: -Skilled Nursing-Frequency and Duration Maximum Healthcare Services to Provide nursing services for 133-166.25 hours per week through the certification period." The current certification period was dated 1/19/2021-3/18/2021. Review of the hours provided during the current certification period revealed: Week #1 1/17-23/2021-130.41 nursing hours Review of a "Missed Shifts for Private Duty Nursing" for Patient #5, scheduled visit date range 1/17-1/23/2021 "Reason for Missed Hours: 12 No Qualified Caregiver Available ...Comments: See Report Below ...no qualified Caregiver available for this shift family will resume care." Week #2 1/24-30/2021-150.87 nursing hours Review of a provider note, dated 1/26/2021, revealed "...Pediatrician: stated in regard to [less than] 60 hours of uncovered nursing care, it wouldn't be appropriate to expect one individual to take care of [Patient #5] for more than 24 hours especially 60 hours. Up until this point Maxim has provided that care. If Maxim can't provide, then [he/she] would have to be admitted. Unfortunately, there are no extended care facilities that we know of for [his/her] acuity and [his/her] age leaving ...Hospital as the only option." Review of a clinical note, dated 1/28/21, revealed "[Clinical Manager] and [Administrator] called [Patient #5's Physician's] Office and spoke with RN [Name]. We notified them that we do not have a nurse available to work the night shifts on Friday, Saturday, or Sunday nights and asked them if there needed to be a plan in place for institutionalization. [RN] reported that [he/she] spoke to the [Patient Representative] this morning and they gave [Patient #5's Representative] the option. [Patient #5's Representative] reported that [he/she] did not want to have [his/her child] moved to inpatient and that [he/she] will be able to provide care for [his/her child] overnight. [Administrator] also mentioned that we need to have a good orientation process and I'm 'pretty sure' we will not have a night nurse for the next weekend either. [RN] asked about the 3 other staff members ...[RN] acknowledged and understands staffing is a challenge and [Resident #5] is complex." Review of a clinical note, dated 2/28/21, revealed "Called [Patient #5's Representative] to see how [he/she] is doing how [his/her] appointment with [Patient #5's Physician] went this past Monday and let [him/her] know we have a message out to see if [RN Name] can pick up any extra shifts to accommodate this Sunday shifts before [Patient #5's] upcoming MD appointments on 3/1 and 3/8. [Patient #5's Representative] stated the appointment was OK and that [Physician's Name] just feels stuck in the middle of whatever this is and that they all agree that [Patient #5] needs nursing level of care ...I told [him/her] if it takes six weeks to orient there will always be holes. [The Patient Representative] said 'Well, it really doesn't take 6 weeks, [RN name] got things quickly.' [Patient #5's Representative] states the nurses just have to be calm, soft spoken, and be able to follow the needs of [Patient #5]. I told [Representative] we are committed to finding nurses for [his/her] home that are a good fit and [the Patient's Representative] said [he/she] appreciates that." Week #3- 1/31-2/6/2021-135.86 hours Week #4- 2/7-2/13/2021-137.68 hours Week #5 -2/14-2/20/2021-131.4 hours Week #6- 1/21-2/27/2021-118.7 hours Review of a "Missed Shifts for Private Duty Nursing" for Patient #5, scheduled visit date range 2/21-2/27/2021 "Reason for Missed Hours: 12 No Qualified Caregiver Available ...Comments: See Report Below ...no qualified Caregiver available for this shift family will resume care." Week #7 -2/28-3/6/2021-131.97 hours During an interview on 3/4/2021 at 12:10 pm, Patient Representative #5 stated Patient #5 was currently understaffed for a night nurse 3 nights a week. The Patient Representative stated although the agency offered a Patient Care Assistant, Patient #5's medical needs were too complex. On 3/5/2021 at 2:15 PM, the clinical manager did not agree with the lack of hours found in the clinical record for the current certification period. When questioned about the missed visits, the clinical manager stated to the surveyor, "We gave you the list about that." The agency policy titled "Scope of Services" revised 4/22/19 stated, "Skilled nursing services: Services that must be provided by a registered nurse [RN] or al licensed practical [vocational] nurse / [LPN/LVN] under the supervision of a RN, to be safe and effective. The skilled nurse evaluates the physical, psychological, social, and rehabilitative needs of the patient. In conjunction with appropriate disciplines and community agencies, a treatment plan is formulated, implemented and evaluated. The nurse provides and coordinates the care and teaching to ultimately accomplish established patient care goals." The agency policy titled "Home Health Certification and Plan [s] of Care" revised 4/10/2020 stated, "Purpose: To provide direct care staff with the physician ordered treatments, procedures, medications, and services required to meet the patient's home care needs." The Home Health Certification and Plan of Care [485] is the physician's order for home care services ... all clinicians involved in the patient's care will contribute to the plan of care." .

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: . Based on interview and record review the facility failed to ensure the two of services were administered under the organizational structure as required per home health agency requirements. This failed practice had the potential to deny clients necessary services. Findings: During an interview on 3/1/21 at 10:00 am, the Business Development Manager stated the home health agency offered private duty nursing, skilled nursing, companion, PCA (personal care attendant care) and dayhab (assist clients with social and safety skills in community). The Business Development Manager stated the home health did not offer therapy services, home health aides (HHA), social services, or dietary. When asked the difference between a PCA and HHA, as both provide patient care, the Business Development Manager noted PCA care was determined by the consumer and a HHA care plan was determined and signed by a physician. During an interview on 3/1/2021 at 2:00 pm, Agency Staff #1 stated the Home Health Agency did not offer OT (occupational therapy) or PT (physical therapy). When asked about the HHA service, Agency Staff #1 stated they had shut that division down 1 ½ years ago. Review of the list of patients that had received services from the agency revealed no home health aide or therapy services had been provided over the past year. During an interview on 3/3/21 on 9:30 am, when the Field Support Manager checked yes on form that indicated the agency had a HHA program, when asked how the agency could provide home health aide services without home health aide staff, the Field Support Manager stated the agency used to have 2 part - time HHAs but they no longer worked at the agency. During a second interview on 3/3/21 at 5:00 pm, the Business Development Manager stated the agency used to have home health aides, but the staff was terminated so was currently an open position. Review of current job openings https://www.maximhealthcare.com/careers on 3/3/21 revealed no open positions for home health aides at the facility career website. During an interview on 3/5/21 at 3:15 pm the Business Development Manager and the Clinical Manager when asked, about the referral for a patient that requested therapy and home health aide services, both staff restated the agency did not provide those services and would only have provided the nursing services. Review of the "QAPI [Quality Assurance and Meeting Minutes] Meeting Agenda & Notes" dated 5/20/19; 7/22/20; 8/19/20; 10/21/20; 11/18/20; 12/16/20; 1/20/21; and 2/17/21 revealed no information or mention of a home health aide (HHA) program. Review of the policy "Scope of Services Reference #: MD-CL-001.3 Line of Business: Private Duty Home Care; Medicaid waiver Directed Care; Other Directed Care revised date: 8/17/15 revealed 3. Policy ...3.1.1. Qualifying services include Skilled Nursing, and if permitted under the state license, may also include Physical Therapy, Speech Therapy, Occupational Therapy, and personal care services (Private Duty Aide). Review of all the job descriptions provided by the facility revealed there were no job descriptions for Home Health Aides. Review of the Annual Evaluation Report, completed 7/20/20, submitted to the Governing Body revealed "A. Staffing ...Hires 2019 Hires/Active/ On Hold Caregivers 60/30 9 =65% retained LPNS 23/17/2=82% retained RNs 34/19/2=61% retained Closure of the Therapy Department." There are no HHAs listed in the evaluation. The agency policy titled "Governing Body" with a revised date of 12/3/17 stated, "All references to Conditions of Participation [COP], and / or ACHC Home Health standards apply to patients serviced under the Certified Home Health [HH] line of business ... Purpose 2.1 To outline the roles and responsibilities of the Governing Body 3. Policy: The business is directed by the Governing Body, which assumes full legal authority and responsibility for the office's overall management and operation, the provision of all home health services, fiscal operations, review of office's budget ..." The agency policy titled "Scope of Services," for Certified Home Health Line of Business revised date of 4/22/19 stated, "Policy ... The office must provide skilled nursing services and at least one of the following other therapeutic services: Physical Therapy, Speech Therapy, Occupational Therapy, Medical Social Services, and Home Health Aide. The office must provide at least one of the qualifying services directly and the other service may be provided either directly or under arrangement ..." .

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: . Based on interview and record review the agency failed to provide requested home health aide (HHA) services for 1 patient (#2) of 9 clinical records reviewed. This failed practice denied the patient a service requested by his/her physician and denied necessary care and/ or services. Findings: During an interview on 3/1/21 at 10:00 am, the Business Development Manager stated the home health agency offered private duty nursing, skilled nursing, companion and PCA (personal care attendant care) and dayhab (assist clients with social and safety skills in community). The Business Development Manager stated the home health agency did not offer therapy services, home health aides (HHA), social services, or dietary. When asked the difference between a PCA and a HHA, as both provide patient care, the Business Development Manager noted PCA care was determined by the consumer and a HHA care plan was determined and signed by a physician. During an interview on 3/1/2021 at 2:00 pm, Agency Staff #1 stated the Home Health Agency did not offer OT (occupational therapy) or PT (physical therapy). When asked about the HHA service, Agency Staff #1 stated they had shut that division down 1 ½ years ago. During an interview on 3/3/21 on 9:30 am, when asked about the agency providing HHA services without HHA staff, the Field Support Manager stated the 2 part - time home health aides no longer worked at the agency. Review of a closed medical record on 3/1-3/8 2021 revealed Patient #2 had received services from the facility from 10/28/2019 until discharge 2/2021. Review of the medical records revealed a document "Medicaid Physician Documentation of Patient Face-to Face Encounter ... Visit Reason: the reason for the visit is f/u [follow up] care after NICU [neonatal intensive care unit] stay. Clinical Findings Supporting Need for Home Health ...extreme prematurity, feeding difficulties, chronic lung disease. Issues will be long standing. Certification I certify the encounter with the patient was in whole or in part for the treatment of the individual's illness or injury that are appropriate for the patient's diagnosis prognosis, functional limitations and medical conditions:" The boxes below for "Nursing", "Physical Therapy", and "Home Health Aide/ Personal Care Aide" was marked. "Clinical Findings Section: (Check all that apply)" the boxes for "Instability of Condition", "Requires hands on assistance with ADLs [activities of daily living] and/or medications", and "Required acquisition of skills, to promote progression or to prevent regression" was marked. The document was signed by a physician. An entry at the bottom of the document revealed "Noted above treatment ordered for SN [skilled nursing], PT [physical therapy], and HHA [home health aide], note that Maxim will only be providing SN at this time." The entry was signed by a nurse and dated 10/29/19. During an interview on 3/5/21 at 3:15 pm the Business Development Manager and the Clinical Manager stated the nurse that had written the entry no longer worked here. When asked about the offered services from the agency, both staff responded the home health agency did not provide those services and would only have provided the nursing services. .