Every finding on record at Maxim Healthcare Services, Inc.

The following reflects the findings of the California Department of Public Health during a Federal Recertification survey. The unduplicated census was 96. The sample size was 7. Total Number of Home visits were 3. Number of Records Reviewed, no Home Visits were 4.

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 observation, interview and record review, the home health agency (HHA) failed to ensure that the tube feeding was administered according to physician’s order for one of seven sampled patients (Patient 5). This failure had the potential to result in unmet healthcare goals. Findings: During a review of Patient 5’s “Home Health Certification and Plan of Care” (POC), certification period from 1/2/2025 to 3/2/2025, the POC indicated the start of care for Patient 5 was 9/2/2024, with diagnoses which included bronchopulmonary dysplasia originating in the perinatal stage (lung disease that affects newborns, especially those who were born prematurely and required oxygen therapy), congenital tracheomalacia (condition that some babies were born in where the windpipe was softer or weaker than it should be), congenital bronchomalacia (condition some babies were born in where the airways in the lung were softer or weaker than normal), dependence on respirator (ventilator - machine that blow air with extra oxygen into the airways and the lungs) status. During a review of Patient 5’s POC, certification period from 1/2/2025 to 3/2/2025, the form indicated, for enteral feedings [delivering liquid nutrition directly into stomach or intestine] Pediasure (nutritional drink designed for kids that need extra help getting vitamins, minerals and calories they need to grow): Administer 625 milliliter (ml, measurement of volume) of Pediasure per day via Jejunostomy tube (J-tube- flexible tube that was placed directly into a part of the small intestine to administer liquid food directly into it) to run through the feeding pump at a rate of 55ml/hour (hr) from 9:30 a.m. to 9 p.m. at primary caregiver’s (PCG) discretion, as per MD orders. During a review of Patient 5’s Supplemental Physician Order (SPO), dated 12/4/2024, the SPO indicated, “Formula Pediasure Change: Decrease Volume to 625mL, Rate 55mL/hr from 0930-2100." During an observation on 1/8/2025 at 9:22 a.m., in Patient 5’s bedroom, Patient 5 was receiving feeding tube via feeding pump. The feeding bag attached to the pump had the following labels written, “8 Jan 25, 55mL/625mL, 0730-1900.” During an interview on 1/8/2025 at 9:25 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that he started Patient 5’s enteral feeding at 7:30 a.m. LVN 1 also stated that Patient 5 went for a physician visit on 1/7/2025 and the physician indicated Patient 5 had been gaining weight. During a concurrent observation and interview on 1/8/2025, at 9:42 a.m., with Responsible Party 1 (RP 1), RP 1 stated that the family want to start Patient 5’s enteral feeding at 9:30 a.m. RP 1 stated that Patient 5 had gained weight, and the dietician ordered to change the administration time of the enteral feeding to help him lose weight. RP 1 showed a message on his phone from Patient 5’s Registered Dietician (RD) that had a title of “New Feeding Plan,” and indicated, “GJ (Gastrojejunostomy-a feeding tube placed into child's stomach and small intestine) feeds: 930am-9pm: 625ml at 55ml/hr x 11.5 hours.” During an interview on 1/8/2025 at 9:51 a.m., with RP 2, RP 2 confirmed that the enteral feeding start time was changed about a month ago to start at 9:30 a.m. and end at 9 p.m. and the family wanted it that way to help Patient 5 lose weight. During an interview on 1/9/2025 at 8:06 a.m., with Director of Patient Care Services (DPCS), DPCS stated that the POC was a doctor’s order and thus the clinicians must follow everything in the POC. During a review of HHA’s policy and procedure (P&P), dated 10/4/2024, the P&P indicated, “The plan of care will describe specific services to be provided based on the clinical assessment and will include amount, frequency, and duration of services and expected outcomes for the patient/client.” P&P also indicated “care/services will be provided according to the agreed to plan of care…Direct Care Staff shall provide services according to the individualized plan of care.”

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 2/8/22 through 2/10/22. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 32525 HFEN, 43247 The agency reported 18 unduplicated annual admissions. The patient sample size was 7 and 3 home visits were conducted.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure privacy of records was maintained when nursing documentation was submitted via mail without verification of receipt and contained patient identifiable information for a census of 53. This failure had the potential for the records to be lost and expose patient's private and medical documentation information. During an onsite visit on 2/8/22 through 2/10/22, a total of 7 medical records were reviewed for a current census of 53 patients. Seven of seven medical records reviewed contained nursing documentation that was sent through post office mail. The patient's name was indicated by initials of first and last name and the medical record number was included. During a home visit on 2/8/22, starting from 2 p.m., a Licensed Nurse (LN 1) reported she submitted her nursing documentation every week via post office mail. LN 1 stated she used an envelope which contained the agency's physical address. LN 1 stated sometimes she had to send the documentation as images using her phone secure app so she can be paid if the mail was late to arrive or was not received by the agency. During an interview with the Agency's Clinical Manager (CM) and the Business Development Manager (BDM) on 2/9/22, at 12:45 p.m., the CM stated the nursing documentation was sent by the nurses via post mail. The CM stated the agency provided pre-paid envelopes containing their address to the nurse and the nurses were required to send the documentation weekly. The CM verified the nursing documentation included the patient's first and last initial, the medical record number and clinical notes. The CM stated there was no process to verify that all of the documentation mailed by the nurses was received. The BDM indicated nurses were required to have submitted their documentation by Monday every week for payroll purposes and can send images of their documentation via a secure app using their personal phone to get paid in a timely manner. During an interview on 2/9/22 with the Nursing Supervisor (NS) at 10:15 a.m., the NS was observed opening envelopes that contained the Medication Administration Records (MARs) to file into Patient 4's home binder. The NS stated the MARs were mailed to the home address for the shift nurse to document. A review of the agency's "... Privacy and Personal Data Protection Policy" dated 1/21/2015 indicated, "The use of personal cellular phones … for any purpose is strictly prohibited … Staff is responsible for safeguarding documentation containing patient information at all times that records are [in] transit … Documentation being placed in the mail shall be secured … addressed to the office, and contain adequate postage for delivery." The policy did not include a verification process to ensure the mail sent out by nursing staff in the field was received by the office.

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 observation, interview, and record review, the agency failed to notify the physician of missed visits for one of seven sampled patients (Patient 4). This failure had the potential to adversely effect the care needs of Patient 4. A review of Patient 4's "Plan of Care," for Certification Period 12/18/21 to 2/13/22, indicated the agency was "to provide LVN (Licensed Vocational Services) skilled nursing services for 32-40 hours per week x 60 days...RN (Registered Nurse) visit for recertification assessment every 56-60 days and as needed for assessment of change(s) in condition and resumption of care for post hospitalization assessment." During an interview and record review on 2/9/22 at 4:47 p.m. and a subsequent interview on 2/10/22 at 9:20 a.m. with the Clinical Manager (CM), Patient 4's "Nursing Flow Sheets," were reviewed for 12/17/21 to 1/5/22. The CM stated the recruiters notified her of missed shifts and she faxed the information to the physician which provided confirmation the physician was notified. Missed Visit documentation was reviewed for 1/12/22 to 1/15/22, 1/21/22 to 1/22/22, 1/26/22 to 1/29/22, and 2/2/22 to 2/5/22, with no indication the missed visit notification had been faxed to the physician. Patient 4 was hospitalized from 12/21/21 to 12/29/21 and from 1/21/22 to 2/7/22. The CM acknowledged Patient 4 was at home from 1/10/22 to 1/18/22, but did not have a visit due to caregiver availability. She acknowledged that the Missed Visit documentation was not faxed to the physician. During an interview on 2/10/22 at 9:40 a.m. with Director of Business Operations (DBO), he stated that the physician was notified by fax when the visits fall below the plan of care. A review of the agency's policy "Patient /Client Scheduling, revised 7/9/21, indicated "...If at any time the services provided do not match the ordering practitioner order (or range of orders) as required by the plan of care, a Missed Shift/Visit Note and notification to the ordering practitioner is required..."

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure medications were available for use and documented after administration for 1 of 7 sampled patients (Patient 2). This failure had the potential for Patient 2 to not receive medications as ordered by the physician. During a Home Visit on 2/8/22, starting from 2 p.m., Patient 2 was observed in his room playing with an electronic device. Patient 2 was unable to carry out a meaningful conversation and was observed moving from one place to another. Patient 2 had a tracheostomy (an opening created surgically through the neck into the windpipe (trachea) to allow direct access via a tube to help in breathing) and a surgically created opening via the stomach with a tube placed for administering his feeding and medications. A shift Licensed Nurse (LN 1) and a visiting Registered Nurse (RN ) were present during this visit. A review of Patient 2's most recent Plan of Care (POC) dated 12/2/21 through 2/9/22 contained 8 types of topical creams that were ordered to be used on as needed basis. During an interview and medication availability observation with LN 1 and the RN, they verified 6 types of creams were not available for use. LN 1 stated the family was aware that not all the creams were available and only stocked what Patient 2 was currently using. The RN stated the physician kept the creams on the current medications list so he did not have to be called to order the creams when needed for use. LN 1 stated she had not documented informing the family to restock. LN 1 stated she was not sure if the family was currently applying any creams to Patient 2. A review of Patient 2's 'Medication Administration Record' documentation sheets for the month of February on 2/8/22 shortly after 2 p.m., concurrently with LN 1 and the RN, reflected the morning medications for 2/6/22 were not documented as given including probiotic supplement, Lexapro (antidepressant) and risperidone (a medication used for mental disorders). Additionally, the probiotic was marked unavailable/not given on 2/8/22 in the morning. LN 1 stated she worked on 2/6/22 and she forgot to document she had administered the medications. LN 1 further stated she did not administer probiotic on 2/8/22 in the morning as it was not available. LN 1 stated she had notified the family to buy the probiotic but forgot to document the communication. During a concurrent interview on 2/8/22, shortly after 2:30 p.m., with the RN, she stated she expected LN 1 to have documented the medication administered to Patient 2 during her shift and to document the conversation with the family regarding missing creams and medications. The RN was unable to establish which creams ordered in Patient 2's POC were currently being applied topically on an as needed basis. A review of the agency's 'Administration and Documentation of Medications' policy revised 4/9/2021 indicated, "To provide guidelines for the safe administration of medications by licensed personnel …The nurse will provide instruction to the patient and/or family/caregiver regarding current medications on a continuous basis … Nurses will document medications administered on the Medication Administration Record … Actual time of administration will be noted on the Medication Administration Record … Medications refused … omitted will be indicated … The office clinical leader or clinical designee and attending physician will be notified.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that medical records contained accurate information when three of seven sampled patients (Patient 2, Patient 4, and Patient 6) did not have the current "Nursing Flow Sheets" in the medical record. This failure had the potential to negatively impact the care of these patients by not providing continuity of care. A review of Patient 2's "Plan of Care," certification period 12/12/21 to 2/9/22, indicated "Frequency and Duration LVN (Licensed Vocational Nurse), 78-97 hours per week..." Patient 2 had multiple clinical diagnoses including malformation of the larynx (voice box), tracheostomy (a surgical opening though the neck into the windpipe) and gastrostomy (a surgical opening into the stomach). A review of Patient 4's "Plan of Care," certification period 12/16/21 to 2/13/22, indicated "Frequency and Duration...LVN services, skilled nursing services for 32-40 hours per week..." Patient 4 had multiple clinical diagnoses including intestinal malabsorption (lack of absorption of nutrients through the intestine) that required TPN (total parenteral nutrition-infusion of nutrition through a vein). A closed record review of Patient 6's "Plan of Care," certification period 10/6/21 to 12/4/21, indicated "Frequency and Duration LVN, 32-40 hours per week..." Patient had multiple clinical diagnoses including muscular dystrophy (a disease causing weakness) and chronic respiratory failure (lungs do not exchange oxygen and carbon dioxide properly). A review of Patient 2's medical record reflected the last "Nursing Flow Sheet" in the record was dated 1/22/22. A review of Patient 4's medical record reflected the last "Nursing Flow Sheet" in the record was dated 1/5/22. A closed record review of Patient 6's medical record reflected that "Nursing Flow Sheets" for 11/6/21 to 11/23/21 were not in the medical record. During an interview on 2/8/22 1:10 p.m. with the Clinical Manager (CM), she stated the nurses mail their notes to the office once a week. A yellow copy is retained in a binder at the patient's home. She acknowledged that Resident 2's "Nursing Flow Sheets," the last one dated 1/22/22, were not current in the medical record and were approximately two weeks old. During an interview on 2/8/22 at 2:35 p.m. with Licensed Nurse (LN) 1, she stated she mails her nursing notes to the office once a week. The notes go to the billing office first and then medical records. Medical records puts the notes in the chart. Notes can also be dropped off at the office by the nurse. During an interview on 2/9/22 at 10:15 a.m. with the RN supervisor (NS), she stated the nurse's notes are sent to the office once a week via US mail. The notes are sent to billing and then put in the medical record binder. NS stated the policy is that the notes are to be in the chart in seven days. During an interview on 2/9/22 at 12:45 p.m. with the CM, she acknowledged that Resident 4's last "Nursing Flow Sheet," in the medical record, was dated 1/5/22. The CM stated that if the nursing notes are not in the chart, after 2 1/2 weeks, will obtain the yellow copy from the home and put it in the chart. She stated that because the notes are mailed to the office there is a delay in receipt of the notes. During an interview on 2/10/22 at 3:55 p.m. with the CM, she acknowledged that Resident 6's "Nursing Flow Sheets," from 11/6/21 to 11/23/21 were not in the medical record. Patient 6's family had confirmed the nurse's visits during that time period. The CM stated the nurse had been educated multiple times to submit her notes. The CM stated that she did not have documentation that shows what specific education was done. A review of the agency policy "Patient/ Client Record: Content and Requirements," revised 10/21/18, indicated "...Documentation will be filed in the patient/client record within 14 days of the shift/visit (last shift/visit if a multiple dated form) and/or assessment in paper or electronic format, unless services are provided in a state with more stringent requirements, in which case the state's requirements will be followed...California- Clinical notes shall be signed and incorporated into patient's health record at least every seven working days..."