Every finding on record at Maxim Healthcare Services, Inc.

Emergency Preparedness HHA 42 CFR 484.102 Home Health The facility must meet all applicable Federal, State, and local emergency preparedness requirements as outlined in the Medicare and Medicaid Programs: Emergency Preparedness Requirements of Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860) September 16, 2016. There were no deficiencies found at the time of the Medicare Recertification survey conducted from August 6, 2024, through August 8, 2024.

The following deficiency was cited during the unannounced onsite Medicare Recertification survey conducted from August 6, 2024, through August 8, 2024. Three (3) home visits were conducted during this survey. Appendix Z, Emergency Preparedness was surveyed at the time of the Medicare Recertification, no deficiencies were cited.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on record review and staff interview it was determined the home health agency governing authority failed to appoint, according to A.R.S. § 36-151(5)(b), an advisory group that consists of four or more members that include: a. A physician. This deficient practice has the potential that the advisory group lacks the advisement of a physician to help with assisting in establishing and evaluating policies and procedures for the home health agency posing the risk of poor patient outcomes. Findings include: A review of Maxim policy titled, " QAPI-Quality Assessment Performance Improvement Program", Reference #MD-QI-001, revised date 10/06/2023, revealed, "State/Program Requirement Arizona The office-based QAPI committee, will convene at least annual meetings of a Professional Advisory Subcommittee, which consist of at least one (1) physician...Committee members will be composed of individuals who are aw[sic] are of the needs of the community related to the population served...." A review of Maxim policy titled, "Professional Advisory Subcommittee", revealed, "... A list of current members of the Professional Advisory Subcommittee must be kept and updated by the administrative lead of the office to include the name, occupation, title, and employer of each Professional Advisory Subcommittee member...." A review of a document titled, "Tucson Home Health Professional Advisory Board Meeting (PAB)", dated June 9, 2023, revealed a list of eight(8) members that did not include a physician. A request for the appointments of the PAB members by the Governing Body (GB) was asked for and not received. In an interview conducted on August 6, 2024, with Employee #1, he/she confirmed no physician was on the PAB. He/she stated it was a misunderstanding of the Home Health Agency (HHA), that a Nurse Practitioner (NP) could be used instead of a physician. In a subsequent interview conducted on August 8, 2024, with Employee #1, he/she confirmed the policy stated a physician was to serve on the PAB.