Every finding on record at Maxim Healthcare Services Inc

During the Home Health Survey conducted on January 19-21 2021, at Maxim Healthcare Services in Port Orange, Florida, Emergency Preparedness was reviewed. Maxim Healthcare is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

An unannounced Recertification and Infection Control Focus survey was completed on January 19-21, 2021 at Maxim Healthcare Services in Port Orange. Maxim Healthcare Services was not in compliance with Code of Federal Regulation (CFE) 42 Part 484.22 Condition of Participation for Home Health Agencies.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on agency record reviews and staff interviews, the agency failed to maintain a coordinated agency-wide Quality Assurance Performance Improvement (QAPI) program to measure, track and analyze quality indicators to improve health outcomes. There was no quality data for 6 of 12 months which can potentially impact patient safety and quality of care. The findings include: Record review of the agency's QAPI program for the past twelve months found that there was committee meeting documentation for six out of twelve monthly QAPI meetings. The agency was unable to produce any documents for monthly QAPI meeting for January, July, August, September, or December 2020. The documents they were able to produce for the remaining months (February, March, April, May, June, and October), however, were template-based and did not provide minutes to show discussion of current projects with any measurable data, goals, or outcomes. An interview was conducted with the Administrator on 1/21/2021 at 2:30pm. During the interview, he was asked if the agency had a QAPI committee and if so, who attended. He stated 'yes', and the QAPI committee consisted of eight people which included himself, the Director of Nursing, the two recruiters, the two clinical managers, and two office staff members. He was then asked if the agency had monthly QAPI meetings in 2020 as outlined in the agency's policy and procedure. He stated they had, but they only had documentation to show six out of twelve of those meeting occurred. He was asked if the QAPI templates that were reviewed were indicative of the QAPI meetings that were held. He stated, 'yes', those were considered the minutes for those six meetings. He was asked if any of the quality indicators had been expanded to include newly identified issues, and he said there were no new indicators. Further review of the available committee meeting minutes were not signed as approved or dated. Review of the agency's policy titled, "QAPI- Quality Assessment Performance and Improvement Program" (effective date 2/8/2019, revised 7/30/2020) states: 3.1 The QAPI program within each office provides a systematic, standardized process that is capable of showing measurable improvements in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. 3.2 The QAPI program within each office will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the office to assess process of care, services provided and operations. 3.3 The company level Quality Committee will approve the overall QAPI program. The office leadership is responsible for executing the QAPI program. QUALITY IMPROVEMENT COMMITTEE: 8.1.1 The office based QAPI committee will consist of at least one Registered Nurse, and representatives of other professional services reflecting the full scope of services provided at the office (as applicable). 8.2 The office based QAPI committee will convene at least monthly to analyze the progress of the measurable indicators to determine the need for new or changed action plans to drive targeted measurable outcomes. 8.2.1 Minutes of the office based QAPI committee meetings will be recorded, signed, and dated by the office operations leader or designee of the office. .

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to conduct and document performance improvement projects to improve quality of services provided. The findings include: Record review of the agency's Quality Improvement Performance Improvement (QIPI) program for the past 12 months found that there were no performance improvement projects (PIP) conducted. Review of the committee meeting minutes for the past 12 months found no documentation that any new issues were discussed or identified. An interview was conducted with the Administrator on 1/21/21 at 4:10pm. During the interview, he was asked if they agency had conducted any performance improvement projects, and he stated there were no PIP's conducted during 2020. Review of agency's policy titled "QAPI- Quality Assessment Performance and Improvement Program" (effective date 2/8/2019, revised 7/30/2020) states: Item #6: Performance Improvement Projects: 6.1 The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the offices services and operations. 6.2 The office will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. 6.3 New or revised quality improvement processes will be implemented based on the assessment and comparison of accumulated data. Quality improvement plans will be used to accomplish these improvement processes where deemed appropriate and/or necessary. These quality improvement plans will include at least the following elements: 6.3.1 All actions required to resolve performance and systems areas of concerns as well as gaps in knowledge and training. 6.3.2 Measurable objectives for each quality improvement activity, including degree of expected change in care practices. 6.3.3 Person(s) responsible for implementing, monitoring, evaluating, and reassessing quality improvement activities. 6.3.4 Dates by which corrective actions are to be implemented and evaluated for effectiveness and ongoing compliance with quality improvement plans. 6.3.5 Planning for quality improvement will include the integration of information from other resources including but not limited to the following: clinical best practices, patient/client/employee safety, incident reporting data, utilization statistics, HR employee injury data, Agency compliance audits, regulatory and accrediting body audits, patient/client and employee satisfaction surveys, risk management data, business operations data, and OASIS reporting (where applicable).