Every finding on record at Maxim Healthcare Services Inc

A recertification survey was completed on 4/11/24. One deficiency was cited.

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 interviews and record reviews the agency failed to ensure services and treatments were provided as ordered by a physician for 1 of 3 active patient records receiving Certified Nurse Aide (CNA) services (Patient #3). This deficiency was cited previously during a recertification survey on 7/1/21. Although the agency corrected the deficiency, based on the findings below, the agency had not maintained compliance with this regulatory requirement. Findings include: 1. The clinical record for Patient #3 was reviewed on 4/8/24. The plan of care for the certification period dated 2/7/24 to 4/6/24, revealed a start of care date of 10/20/21; diagnoses included paraplegia, injury to thoracic spine level two to six, cerebral infarction, aphasia stage 2 pressure ulcer of sacral region, encounter for fitting and adjustment of urinary device, neuromuscular dysfunction of bladder, orthostatic hypotension and right upper arm contracture. Plan of care orders included skilled nursing (SN) visits once daily and one visit as needed (PRN) for medication administration and suprapubic catheter change every three weeks; and CNA visits seven to eight times daily. a) The agency failed to ensure the CNA provided all tasks in accordance with the care plan. Review of the CNA care plan, dated 10/20/21 to present, showed Patient #3 received seven visits daily consistently. Continued review of the care plan showed Patient #3 was to receive skin care, assistance with transfers, repositioning, toileting and peri-care during every visit; empty catheter bag during visits #1 through #6; catheter care, passive range of motion (PROM), assistance with dressing, incontinence brief changes, regular diet meal preparation and serving, assistance with feeding and fluid encouragement twice daily; and nail care, shaving, bathing, mouth care, bed making and cleaning bedroom and bathroom once daily. Review of completed CNA timesheets from 2/25/24 to 3/23/24 showed Patient #3 failed to receive services as ordered. Specifically: -Patient #3 did not receive the task of nail care at all; -Patient #3 only received shaving during four visits; -Patient #3 only received PROM once daily; and -Patient #3 did not receive assistance with transfers, repositioning, toileting and peri-care at each visit. During an interview during a home visit on 4/9/24 at approximately 9:00 a.m., CNA #7 stated she assisted the patient with bathing, meal preparation, oral care, hair care, transfers using a sliding board, skin care including cleaning the catheter site, bowel program every other day and "sometimes" emptied the catheter bag. During the same interview, the director of nursing (DON) stated the agency tried to provide additional supervision to family CNAs to ensure services were provided as ordered and the patients were safe. During an interview on 4/9/24 at 3:52 p.m., the administrator and DON acknowledged CNA #7 was not providing all tasks in accordance with the care plan. During an interview on 4/11/24 at 10:01 a.m., the DON stated the agency completed quarterly record reviews of approximately 25% of the records, but acknowledged the people completing the quality reviews were reviewing the quality of the notes and to verify the shifts were completed. She confirmed the quality reviews were not ensuring all tasks were completed in accordance with the care plan. She further stated there was already a corrective action plan in place for CNA #7 for issues related to the timeliness and quality of her documentation.

A recertification survey was completed on 7/1/21. Three deficiencies were cited.

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 services and treatments were provided in accordance with physician's orders for 2 of 2 patients reviewed receiving private duty nursing (PDN) services (Patient #1 and #3). This deficiency was cited previously during a state recertification survey on 8/21/18. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include: AGENCY POLICY According to the agency policy titled "Plan of Care" dated 7/8/19 (in pertinent parts): "3.1 the plan of care will describe specific services to be provided based on the clinical assessment and will include amount, frequency, and durations of services and expected outcomes for the patient/client." 1. The clinical record for Patient #3 was reviewed on 6/30/21. The Plan of Care for the certification period dated 3/12/21 to 5/10/21 revealed a start of care date of 3/12/21; diagnosis included acute respiratory failure, anoxic brain damage, gastronomy tube (GT), and dependence on a respiratory. The Plan of Care orders included skilled nursing (SN) services for 16 hours day for personal care, medication administration, ventilator maintenance, GT feedings, wound care, assessments, and vital signs. a) The agency failed to ensure PDN SN visits followed the frequency in accordance with physician orders. Review of the Plan of Care dated, 3/12/21 to 5/10/21 revealed Patient #3 was to receive sixteen hours of SN services seven days a week for 60 days. Review of the scheduled visit calendars dated 3/12/21 to 5/10/21 revealed Patient #3 received their 16 hours every day in two shifts, a day shift, and an overnight shift. Review of the scheduled visit calendars revealed Patient #3 received shifts shorter than 16 hours, ranging anywhere between three hours to twelve hours for 31 out of 60 shifts. Further review of the visit calendars revealed Patient #3 received no services on 3/13, 3/20, 3/27, 4/3, and 4/18 meaning five out sixty days the patient received no services from the agency. Review of the missed visit documentation dated 3/1/21 to 6/28/21 revealed the missed shifts were documented as "cancelled, no qualified caregiver available." Further review of the record revealed that the agency failed to provide any services on the following dates; 3/13/21, 3/20/21, 3/27/21, 4/3/21, and 4/18/21. Further review revealed that the agency stated the family of Patient #3 would be in charge of his care during those hours when PDN services could not be completed by the agency. Patient #3 was without SN services for 5 out of 60 PDN shifts, and did not receive the full 16 hour shifts for 31 out of 60 shifts. During an interview on 7/1/21 at 10:15 a.m., Employee #1 stated staff schedules were created one to two months in advance and then sent to the nursing staff along with requests for staff to fill in any shifts that didn't have coverage. She stated if there were still shifts that required coverage the agency would contact the families of the patients and let them know they would need to cover the care for those shifts. She further stated that the families signed a home care agreement agreeing to cover patient care in the event the agency couldn't staff a shift. Employee #1 was surprised that there were shifts recorded that were not covered at all by the agency. 2. The clinical record for Patient #2 was reviewed on 6/29/21. The Plan of Care for the certification periods dated 3/30/21 to 5/28/21 and 5/29/21 to 7/27/21 revealed a start of care dated of 4/8/08; diagnosis included muscular dystrophy, intellectual disabilities, hypertension (high blood pressure), gastrostomy tube (GT) and chronic obstructive pulmonary disease (COPD). Plan of care orders included skilled nursing (SN) services for 20-24 hours a day for personal cares, positioning, transfers, medication administration, tracheostomy care, ventilator maintenance, GT feeding, assessments, and vital signs. a) a) The agency failed to ensure PDN SN visits followed the frequency in accordance with physician orders. Review of the Plan of Care for Patient #2 revealed the physician ordered 20-24 hours of private duty nursing every day. Review of the scheduled visit calendars dated 3/1/21 to 6/28/21 revealed Patient #2 received their 20-24 hours every day in two shifts, a day shift, and a night shift. Review of the scheduled visit calendars revealed Patient #2 only received one 12 hour shift on 3/1, 3/11, 4/2, 4/11, 4/23, 5/10, 5/11, 6/10, 6/12, 6/13, 6/25, 6/26, and 6/27/21. Further review of the visit calendars revealed Patient #2 received no services on 4/24 and 6/11/21. Review of the missed visit documentation dated 3/1/21 to 6/28/21 revealed the missed shifts were documented as "cancelled, no qualified caregiver available." During an interview on 6/30/21 at 11:00 a.m., family for Patient #2 stated they were frustrated with the lack of staff to fill shifts for the Patient. The family stated that when the agency did not have staff, the family was expected to be the backup caregivers. Family further stated they questioned the agency's ability to take on new patients when they couldn't staff shifts for the patients they currently have. During an interview on 7/1/21 at 10:15 a.m., Employee #1 stated staff schedules were created one to two months in advance and then sent to the nursing staff along with requests for staff to fill in any shifts that didn't have coverage. She stated if there were still shifts that required coverage the agency would contact the families of the patients and let them know they would need to cover the care for those shifts. She further stated that the families signed a home care agreement agreeing to cover patient care in the event the agency couldn't staff a shift.

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 agency failed to ensure wound care treatments were administered by agency staff only as ordered by a physician for 2 of 4 patients reviewed who had wound care ordered (Patients #3 and #8). Findings include: AGENCY POLICY According to the agency policy titled, "Wound care," dated 4/9/21 (in pertinent parts): "2.1 Wound care shall be done in accordance with the ordering practitioner order." 1. The clinical record for Patient #3 was reviewed on 6/30/21. The Plan of Care for the certification period dated 3/12/21 to 5/10/21 revealed a start of care date of 3/12/21; diagnosis included acute respiratory failure, anoxic brain damage, gastronomy tube (GT), and dependence on a respiratory. The Plan of Care orders included skilled nursing (SN) services for 16 hours a day for personal care, medication administration, ventilator maintenance, GT feedings, wound care, assessments, and vital signs. a) The agency failed to ensure wound care was provided only as ordered by the physician. Review of Patient #3 Plan of care dated 3/12/21 to 5/10/21 revealed the following wound care orders: 1. Wash Hands 2. Cleanse wounds with normal saline (NS) or wound cleanser 3. Apply collagen to wound beds 4. Cover with gauze 5. Secure with tape These orders were to be followed for all wounds that Patient #3 which included a wound on the sacrum, scrotum, and left and right gluteal folds daily. Record review of the nursing notes dated 3/18/21 by RN #7 stated she cleaned the wounds and applied "MediHoney". On 3/22, 3/23, and 3/25 RN #7 repeated using medihoney on the wounds of Patient #3. Review of the order update for Patient #3 revealed a verbal order on 3/30/21 that changed the wound care orders to "apply medihoney to wound bed". This reveals that RN #7 used medihoney instead of collage, before receiving physician orders for its use on Patient #3's wound. During interview on 7/1/21 at 9:39 a.m., RN #7 stated she would receive the wound care orders either from Patient #3's physician or from the wound care clinic. When asked about changing the wound care from collagen to medihoney she stated it was by request of Patient #3's family. During interview on 7/1/21 at 10:16 a.m., the Administrator (Employee #1) stated that the nurses are supposed to follow all physician orders including wound care orders. 2. The clinical record for Patient #8 was reviewed on 7/1/21. The Plan of Care for the certification period dated 3/15/21 to 5/11/21 revealed a start of care date of 1/8/21 and a discharge date of 5/13/21; diagnosis included acute abdomen surgical wound. The Plan of Care orders included SN services for three times per week for the certification period or until the wound was healed for patient education, vital signs, and wound care treatments. a) The agency failed to ensure wound care was provided only as ordered by the physician. Review of Patient #8's Plan of Care dated 3/15/21 to 5/11/21 revealed the following wound care orders: Wound care to upper abdomen 3x per week 1. Wash hands 2. Cleanse with NS 3. Hydrofera blue ready foam to wound bed 4. Cover with abdominal (ABD) pad. 5. Secure with tape Wound care to lower abdomen 3X per week 1. Wash hands 2. Cleanse with NS 3. Hydrofera blue classic moistened with NS 4. Cover with ABD pad 5. Secure with tape Record review of the wound care flow sheet dated 3/5/21 to 5/10/21 revealed that RN #6 and RN #8 performed the following wound care: 1. Wash hands 2. Cleanse wounds with NS 3. Maxsorb to upper wound bed 4. Hydrofera blue to wound beds 5. Cover with ABD pads 6. Secure with Tape. Record review of Patient #8's record did not reveal any additional physician orders, or a wound care clinic orders, adding the use of maxsorb. During interview on 7/1/21 at 11:46 a.m., RN #6 stated after reviewing the records she was unable to locate any orders regarding the maxsorb. She then acknowledged it was problem that both herself and RN #8 did not follow the physician's wound care orders as written.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a registered nurse (RN) or other appropriate skilled professional familiar with the patient, the patient's plan of care and the written patient care instructions made an onsite visit to the patient's home no less frequently than every 14 days to conduct home care aide (HCA) supervision for 1 of 2 patients receiving skilled care and HCA services (Patient #1). Findings include: AGENCY POLICY According to agency policy titled, "Supervision of Patient Care," dated 10/9/20 (in pertinent parts): "3.3 For dual cases in which HHA (home health aide) care is in addition to skilled nursing (RN/LPN/LVN) or Therapy (PT/OT/SLP), the RN or PT/OT/SLP (when applicable) will conduct an on-site visit at least every 14 days to ensure care is provided according to the plan of care and continues to meet the needs of the patient." 1. The clinical record for Patient #2 was reviewed on 6/29/21. The Plan of Care for the certification periods dated 3/30/21 to 5/28/21 and 5/29/21 to 7/27/21 revealed a start of care dated of 4/8/08; diagnosis included muscular dystrophy, intellectual disabilities, hypertension (high blood pressure), gastrostomy tube (GT) and chronic obstructive pulmonary disease (COPD). Plan of care orders included skilled nursing (SN) services for 20-24 hours a day for personal cares, positioning, transfers, medication administration, tracheostomy care, ventilator maintenance, GT feeding, assessments, and vital signs. a) The RN failed to conduct onsite visits to supervise the HCA no less frequently than every 14 days as required. Review of the Plans of Care dated 3/30/21 to 5/28/21 and 5/29/21 to 7/27/21, signed by RN #6, showed SN services and HCA services were ordered by Patient #2's physician. Review of the clinical record for the time period dated 3/30/21 to 5/28/21, revealed Patient #2 received HCA services five times a day as ordered. Further review of the clinical record revealed Patient #2 had supervisory visits on 4/5/21 and 4/12/21. Further record revealed the next supervisory visit performed was on 5/3/21 (20 days after the previous supervisory visit). During an interview on 7/1/21 at 10:15 a.m., Employee #2 stated supervisory visits for Patient #2 should have been done every 14 days. During an interview on 1/9/20 at 11:35 a.m., the agency Administrator stated the supervisory visits should have been done every 14 days for Patient #3.