Every finding on record at Maxim Healthcare Services Inc

The following reflects the findings of the California Department of Public Health-Licensing and Certification during a Standard Recertification Survey. Representing the Department: 39912 HFEN 44589 HFEN 47849 HFEN The census was 27 The sample was 7 with 3 home visits

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure one of seven sampled patients (Patient 1) medication profile was reconciled. This failure has the potential to lead to serious complication and jeopardize the health and safety of Patient 1. Findings: During an observation during Patient 1’s home visit on 9/21/23 at 9:30 a.m. a medication (Lidocaine 2.5% and Prilocaine 2.5% Cream [medicine with numbing effect]) was observed in a tube located in a medication container along with Patient 1’s other prescription drugs (medicine that cannot be obtained over the counter). The medication further indicated, the medication was filled since 6/2/22. During a review of Patient 1’s, "Plan of Care (POC)," dated 8/20/23, the POC indicated, Patient 1 was admitted on 4/27/23, had a tracheostomy (a tube connected to an opening in the throat) and was dependent on respirator (a machine that helps in breathing). Further review of the POC indicated, there was no Lidocaine cream ordered by the physician. During a concurrent observation and interview on 9/21/23 at 9:40 a.m. with the licensed nurse (LN 1), Patient 1's, ""Medication Profile," was reviewed. LN 1 acknowledged the medication had no doctor’s order and was not listed on Patient 1's medication profile. LN 1 further acknowledged, all medications must have a doctor’s order before administration. During an interview on 9/21/23 at 2:35 p.m. with the Registered Nurse Supervisor (RN Sup 2), RN Sup 2 verbalized medication reconciliation is to be done by RN during visit. RN Sup 2 further acknowledged the medication profile was not reconciled. During a review of the facility’s policy and procedure (P&P) titled, “Administration and Documentation of Medications,” dated 10/2022, the P&P indicated, “All medications require a physician order. All medications will be recorded on the Medication Profile. The Medication Administration will be reconciled with the medication profile in all cases.” During a review of the P&P titled, “Comprehensive Assessment,” dated 1/2023, the P&P indicated, “Complete Medication Reconciliation, at the time of the comprehensive assessment.” During a review of the P&P titled, “Administration and Documentation of Medications,” dated 4/2021, the P&P indicated, “Update the System of Record. Document medication on medication profile. Generate updated MARs when applicable.”

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 interview and record review, the facility failed to ensure physicians are notified when the prescribed hours of visitation is not met for three out of seven sampled patients (Patients 1, 4 and 5) This facility failure had the potential to ineffective care due to insufficient nursing visitation hours. Based on interview and record review, the facility failed to ensure physicians were notified when the prescribed skilled nursing hours were not met for three of seven sampled patients (Patients 1, 4 and 5) This facility failure had the potential to ineffective care due to insufficient skilled nursing visitation hours. Findings: During a review of Patient 1’s health records, the records indicated, Patient 1 had an order for 68-80 skilled nursing hours per week for 60 days. During the week of 9/10/23 to 9/16/23 the total number of skilled nursing hours was 62 and did not meet the prescribed hours. No physician notification was located. During a review of Patient 4’s, "Home Health Certification and Plan of Treatment (CPOT),” dated 5/31/23 to 7/29/23, the CPOT indicated, Patient 4 had an order for 80-109 skilled nursing hours per week for 60 days. During a review of Patient 4’s weekly skilled nursing hours, the hours indicated, Week 5/31/23 to 6/3/23 – 5.44 hours, Week 6/4/23 to 6/10/23 – 22.37 hours, Week 6/11/23 to 6/17/23 – 21.95 hours, Week 6/18/23 to 6/24/23 – 20.66 hours, Week 6/25/23 to 7/1/23 – 19.49 hours, Week 7/2/23 to 7/8/23 – 13.34 hours, Week 7/9/23 to 7/15/23 – 20.88 hours, Week 7/16/23 to 7/22/23 – 20.24 hours, and Week 7/23/23 to 7/29 – 13.05 hours. The hours did not meet the ordered hours. No physician notification was documented. During a review of Patient 5’s, “CPOT,” dated 6/5/23 to 8/3/23, the CPOT indicated, Patient 5 had an order for 40--56 skilled nursing hours per week for 60 days. During a review of Patient 5’s weekly skilled nursing hours, the week of 9/10/23 to 9/16/23 indicated, the total number of skilled nursing hours was 66.75 and did not meet the prescribed hours. No physician notification was located. During an interview on 9/21/23 at 2:35 p.m., with the clinical supervisor (RN Sup 2), the RN Sup 2 verbalized, operations team will send a notification to the physician for a missed shift/visit if the total number of visit hours is not met. During an interview on 9/21/23 at 3:20 p.m., with the Administrator (ADM), the ADM acknowledged, the physician was not notified promptly of the prescribed visit hours not being met. During a review of the facility’s policy and procedure (P&P) titled, “Missed Shift/Visit” dated 4/9/2021, the P&P indicated, “If at anytime the services provided do not match the ordering practitioner order (or range of orders) a Missed Shift/Visit Note and notification of the ordering practitioner is required.”

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure qualified personnel were employed when two of seven sampled employees Registered Nurse Supervisors (RN Sups 1 and 2) did not have a written health assessment completed, a prerequisite for employment for employees with direct patient contact. This failure had the potential for the patients to receive care from unqualified health professionals. During a concurrent interview and record review on 9/19/23 at 2:04 p.m. with the Field Support Manager (FSM), RN Sups 1 and 2's, “Personnel Record,” (undated) was reviewed. The Personnel Records indicated, a health assessment was not completed. FSM stated, only external employees are required to have a written health assessment as a prerequisite for employment and RN Sups 1 and 2 are internal employees. During an interview on 9/20/23 at 11:04 a.m. with RN Sups 1 and 2, RN Sups 1 and 2 stated, “We do hands on, head to toe physical assessments on patients.” RN Sup 1 further stated, “I would not consider my job having direct patient care but I kind of do.” Review of "The National Healthcare Safety Network (NHSN) Manual," page 6-1, section titled, “Key Terms,” indicated, direct patient care is hands on, face to face contact with patients for the purpose of diagnosis, treatment and monitoring.