Every finding on record at Maxim Healthcare Services, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey conducted on December 19, 2023 to December 20, 2023. Representing the California Department of Public Health: Surveyor 29623, HFEN; and Surveyor 44173, HFEN. The following Conditions of Participation were reviewed: 484.50 Patient Rights; and 484.115 Personnel Qualifications/Requirements. The agency's active census : 48 patients. The sample patients : 3 patients. Home visit : 1 patient.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to protect Patient 1 from mistreatment and physical abuse when Licensed Vocational (LVN) 1, grabbed the patient's hair from the back of his head to lay him down in bed as witnessed by the Primary Care Giver (PCG) in the home video footage for one of three patients reviewed (Patient 1). This failure had potential to place Patient 1 at risk for further harm without the knowledge of the PCG, and caused emotional distress to the PCG. In addition, the agency failed to follow their policy and procedure for reporting the allegation of abuse to the California Department of Public Health (CDPH) timely. This resulted in the delay of immediate abuse investigation. Findings: During a review of Patient 1's record on December 19, 2023, Patient 1 had a Start of Care (SOC) date of 11/24/15, with diagnoses which included cerebral palsy (a condition caused by abnormal brain development or damage to the brain before birth that affects a person's ability to control his or her muscles). The re-certification nursing assessment dated December 8, 2023, indicated Patient 1 had visual impairment and severe cognitive impairment, with tracheostomy (a procedure that created an opening in the windpipe to deliver oxygen to the lungs), and gastrostomy tube also called a G-tube (a tube inserted through the belly that brings nutrition directly to the stomach). Patient 1 was dependent entirely upon another person for his Activities of Daily Living (ADL). The Plan of Care (POC) for the certification period from December 12, 2023, to February 9, 2023, indicated Patient 1 was receiving Skilled Nursing hours for LVN 80 -112 hours per week for 60 days and Registered Nurse (RN) for 2 hours per month for case management for 60 days. The POC indicated "Skilled Nursing General contingency plan for back-up nursing coverage: Patient Family Guardian is fully trained and able to provide care in the absence of nursing coverage..." The calendar of visit from October 1, 2020, to October 6, 2023, indicated Patient 1 was receiving care from LVN 1 from Sunday through Thursday, from 8:55 p.m., to 6 a.m., except on October 26, 2023, from 9 p.m. to 6 a.m. During a concurrent interview and record review on December 19, 2023, at 9:45 a.m., with the Clinical Manager (CM), Patient 1's PCG called the agency on October 27, 2023, to remove LVN 1 from the care of Patient 1. Patient 1's PCG informed the agency's staff of the incident that occurred on October 26, 2023, on noc (night) shift, as witnessed by her in the home video, when LVN 1 was working. On October 31, 2023, at 11 a.m., the CM interviewed LVN 1 regarding the incident when LVN 1 reported for duty on October 25, 2023, 9 p.m., until October 26, 2023, 6 a.m. LVN 1 told the CM she was having a "bad time...it just happened...something came over me, I was irritated." LVN 1 did not elaborate any further. During an interview on December 19, 2023, at 10:48 a.m., with Clinical Supervisor (CS) 1, she stated she saw the video footage, and it was "very disturbing". CS 1 stated Patient 1 woke up and sat himself up. She further stated LVN 1 got up from the chair and went to Patient 1. LVN 1 was seen pulling his hair from the back of his head to lay him down. She stated LVN 1 was seen throwing a cover to Patient 1. CS 1 stated LVN 1 did not contact or inform her about the incident. During an interview on December 19, 2023, at 11:23 a.m., with Clinical Supervisor (CS) 2, she stated on November 7, 2023, she visited Patient 1's home to conduct an assessment and saw the home video footage. She stated with the PCG's permission the video footage was downloaded to the Director Of Business Operation's e-mail. She further stated LVN 1 had a good relationship with Patient 1' family, and the PCG told her they lost a nurse but was shocked and frustrated with the incident. During a concurrent interview and record review, on December 19, 2023, at 11:48 a.m., with the CM and the Director of Business Operation (DBO), the facility's policy and procedure (P&P) titled, "ABUSE, NEGLECT, OR EXPLOITATION," dated July 14, 2023, was reviewed. The P&P indicated, "...Alleged incidences...will be reported first to the Legal Department and then to enforcement agencies according to applicable laws and regulations. These agencies may include ...State Survey and Certification Agency..." The DBO and the CM both stated and acknowledged, the allegation of abuse on Patient 1, that occurred on October 26, 2023, and was received by the agency on October 27, 2023, was not reported to California Department of Health (CDPH). The DBO stated she should have guided the CM in handling the abuse allegation reporting and investigation. On December 19, 2023, at 3:01 p.m., a home visit was conducted for Patient 1. Patient 1 was observed awake, sitting in a recliner chair, with a family member at the bedside. Patient 1 was observed with a tracheostomy, receiving 1 Liter (a unit of measurement) of oxygen, a gastrostomy tube, with a formula infusing through a pump at 60 milliliter (a unit of measurement) per hour. Patient 1 was non verbal, making hand gestures. During an interview with the PCG on December 19, 2023, during the home visit, the PCG stated LVN 1 had taken care of Patient 1 for two years. The PCG shared the video footage that was recorded on her cell phone dated October 26, 2023, at 3:30 a.m. The video showed Patient 1 woke up and sat up in bed two times and LVN 1 laid him down back to bed. At 4:40 a.m., Patient 1 woke and sat up in his bed. LVN 1 got out of her chair, went to Patient 1's bedside and grabbed Patient 1's hair at the back of his head to lay him down. LVN 1 threw a cover over Patient 1, returned to the chair, elevated her legs on top of the dresser and proceeded to check her cellular phone. During further interview with the PCG on December 19, 2023, The PCG stated LVN 1 did not check if Patient 1 needed diaper change, or needed suctioning or needed a breathing treatment. The PCG stated LVN 1 denied her actions, until confronted by the recorded video footage that occurred on October 26, 2023. The PCG stated LVN 1 admitted her physical mistreatment of Patient 1. A review of the agency's policy and procedure titled, "ABUSE, NEGLECT, OR EXPLOITATION," dated July 14, 2023, indicated, "...The Company will promote an abuse-, neglect-, and exploitation-free environment for all patient/clients receiving care, treatment and or services..."

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey authorized by the Centers for Medicare and Medicaid Services conducted on June 11 and 14, 2021. Representing the California Department of Public Health: 18821, HFEN, and 37536, HFEN. Unduplicated Census: 120 Sample Size : 5 The following Conditions of Participation were surveyed: Care planning, coordination, quality of care; Infection prevention and control; Skilled professional services; Compliance with Federal, State, Local law; and Organization and adminisration of services.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure physician orders were implemented per the plan of care for one of five sampled patients (Patient 1) when: 1. Patient 1 did not receive Polyvinyl alcohol eye drops (medication used to relieve dry, irritated eyes) as ordered by the physician; and 2. Patient 1 did not receive the right dose of the medication Robinul tablet (used to reduce drooling in children who have certain medical conditions) as ordered by the physician. In addition, the ordered doses of Robinul tablet at noon were not administered to Patient 1. These failures resulted in Patient 1 not receiving the eyedrops and Robinul which could worsen Patient 1's medical condition. Findings: 1. On June 11, 2021, Patient 1's record was reviewed. Patient 1's Start of Care Date was January 29, 2021, with diagnoses which included non traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane). The Plan of Care (POC) for the certification period of March 30 to May 28, 2021, and May 29 to July 27, 2021, was reviewed. The POC included the following medications: a. "polyvinyl alcohol 1.4% eye drops - Administer 1 drop into both eyes four times daily." b. "Robinul 1 mg (milligram) tablet - Administer 1 tablet/1mg via G-tube (gastrostomy tube - tube inserted in the stomach for feeding and administration of medication) in the AM (morning) and 1 tablet/1 mg at 1200 (12 noon), then administer 0.5 tablet/0.5mg in the PM (afternoon)." The medication records for April 11 to June 5, 2021, were reviewed and indicated the following: a. There was no documented evidence in Patient 1's medication record that the polyvinyl alcohol eye drops were administered to Patient 1. b. The licensed nurse administered one tablet of Robinul on April 12, 15, 16, 19, 20, 21, 22, 23, 26, 27, 29, 2021, and on May 4, 5 and 7, 2021, at 2 p.m., instead of half a tablet of Robinul. In addition, there was no documented evidence Patient 1 was given Robinul tablets at noon on the following dates: - For the month of April, 2021, April 12, 13, 14, 15, 16, 19, 20, 21, 23, 26, 27, 29, 30, 2021; - For the month of May, 2021, May 4, 5, 7, 12, 13, 14, 15, 25, 26, 28, 2021; and - For the month of June, June 3 and 4, 2021. On June 14, 2021, at 9 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated the licensed nurse should administer the medication as per physician order. On June 14, 2021, at 3:15 p.m., the Case Manager (CM) was interviewed. The CM stated the licensed nurse had to follow the physician order. The CM stated if the medication was not administered "for some reason," the physician should be notified. The CM stated polyvinyl alcohol eye drops was a routine medication and it should have been given. During a concurrent review of Patient 1's medication record, the CM stated there was no order to discontinue the medication in the medication record. The CM stated the polyvinyl eye drops were not given to Patient 1. Upon further review of Patient 1's medication record with the CM, he stated there was no section for the licensed nurse to document in the medication record for the noon dose. He stated there was no documentation the noon dose for Robinul was given. The CM agreed the dose for Robinul was not followed as prescribed by the physician. A review of the facility policy and procedure titled "ADMINISTRATION OF DOCUMENTATION AND MEDICATIONS," revision date April 9, 2021, indicated, "...Administer medication...Administer only medications that are ordered as part of the plan of care and are approved for administration...Document administration...Document administration on the medication administration record..."

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to follow their policy and procedure for notification of potential exposure to COVID 19 ( an infectious virus which is easily transmitted from person to person) when two patients (Patient 1 and Patient 2) were exposed to a clinical staff member who was confirmed as COVID 19 positive. These failures had the potential to result in the transmission of infection to vulnerable population of patients (pediatric and adults) in their homes. Findings: 1. On June 14, 2021, record review was conducted of Patient 2's record. Patient 2's diagnosis included autistic disorder ( a serious developmental disorder that impairs the ability to communicate and interact), status epilepticus ( seizure lasting longer than 5 minutes, or having more than 1 seizure within a 5 minute period) and Gastrostomy tube ( G-tube-[a tube inserted through the belly that brings nutrition directly to the stomach]) for feedings. Patient 2's recertification period was March 12, 2021 to May 10, 2021, for skilled nurse visits (SN) for 32-40 hours per week. Additional review of Patient 2's medical record indicated Clinical Supervisor (CS) 1 visited Patient 2 in her home on May 6, 2021, at 2:30 p.m. On June 14, 2021, at 6 p.m. an interview was conducted with the Clinical Manager (CM). The CM stated when CS 1 notified him of her positive COVID 19 status on May 8, 2021, he called Patient 2's home and left a message for Patient 2's family caregiver to call the agency back as soon as possible. The CM was asked if he heard from Patient 2's family and if he made any additional calls to Patient 2's family after his initial call. The CM stated he did not make any additional calls to Patient 2's home nor did he follow-up with the family caregiver after he made the initial call on May 8, 2021, regarding Patient 2's exposure to a positive COVID 19 staff member. He further stated Patient 2's physician was not notified of Patient 2's COVID 19 exposure. In an interview with CS 1, on June 14, 2021, at 5 p.m., she stated she received positive COVID 19 test results on May 8, 2021, and called the Clinical Manager as per the agency chain of command. 2. On June 11, 2021, the agency's infection log was reviewed. The infection log indicated Clinical Supervisor (CS) 1 tested positive for COVID-19 on May 8, 2021. On June 11, 2021, at 3:50 p.m., the Case Manager (CM) was interviewed. The CM stated the agency would inform the family member if there was an exposure with the staff. The CM stated the physician would be notified and the notification would be documented in the patient's record. On June 14, 2021, at 10:03 a.m., CS 1 was interviewed. CS 1 stated she visited Patient 1 on May 6, 2021, and she became symptomatic of COVID-19 two hours after she visited the patient. CS 1 stated she informed the CM on May 8, 2021, that she tested positive for COVID-19. On June 14, 2021, Patient 1's record was reviewed. Patient 1 had a supervisory visit on May 6, 2021, by the CS who tested positive on May 8, 2021. On June 14, 2021, at 5:44 p.m., CS 1 was interviewed. CS 1 stated she stayed in Patient 1's house during her supervisory visit on May 6, 2021, for one hour. The Clinical Note Entry was reviewed. The clinical note indicated "...On 5/8/21 called family to advise on nursing, left voicemail asking for return call to office ASAP (as soon as possible). There was no documentation a follow up call was made to inform the family member of an exposure to a COVID-19 positive staff. There was no documentation the physician was notified of Patient 1's exposure to a COVID-19 positive staff. The Clinical Note Entry was reviewed with the Case Manager (CM) on June 14, 2021, at 3:15 p.m. In a concurrent interview the CM stated he called and left a voice mail to the family member on May 8, 2021. The CM stated he did not follow-up after the initial phone call. A review of the agency policy and procedure titled "COVID-19 RESPONSE SUMMARY," dated August 12, 2020, indicated, "...Quarantine and Returning to Work Guidelines...Any patient, employee, etc. that is believed to have been potentially exposed will be notified immediately. For any potential patient exposure, the patient's physician should also be notified of the occurrence..."