Every finding on record at Maxim Healthcare Services Inc

During the recertification survey conducted on 5/6/2021 at Maxim Healthcare Services, INC, a home health agency, Emergency Preparedness was reviewed. Maxim Healthcare Services, INC is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A partial extended re-certification survey was conducted on May 3, 2021 through May 6, 2021 at Maxim Homecare Services, Inc. The home health agency was not in compliance with Code of Federal Regulations (CFR), 42 Part 484.22, Requirements for Home Health Agencies. The Condition of Participation at 42 CFR 484.60, Care planning, Coordination, Quality of care, G570 was not met.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and review of home health records, the home health agency failed to establish an effective process for the provision of care and services through the Plan of Care and Medical Supervision for 7 of 8 sampled pediatric patients (#1, #2, #3, #4, #5, #6, #7). The home health agency failed to provide skilled nursing visits to meet the needs of its patients, failed to assess patient vital signs as ordered by the physician for Patient #1 and Patient #2 (refer to G0578). The cumulative effect of these systemic problems resulted in the Condition of Participation at 42 CFR 484.60, Care Planning, Coordination, Quality of Care, being found not met. The findings include: Refer to G0578: Based on medical record review and interviews, the home health agency failed to provide skilled nursing visits as ordered by the physician for a total of 71 shifts during a review period of 3/7/21 to 5/4/21 for 7 of 8 sampled patients reviewed (#1, #2, #3, #4, #5, #6, #7); failed to assess vital signs as ordered by the physician for 3 of 8 sampled patients, (#2, #4, #5); failed to assess pulse oximetry as ordered by the physician for 1 of 8 sampled patients, (#2) and failed to obtain weights as ordered for 1 of 8 sampled patients, (#2).

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: B Based on medical record review and interviews, the home health agency failed to provide skilled nursing visits as ordered by the physician for a total of 71 shifts during a review period of 3/7/21 to 5/4/21 for 7 of 8 sampled patients reviewed (#1, #2, #3, #4, #5, #6, #7); failed to assess vital signs as ordered by the physician for 3 of 8 sampled patients, (#2, #4, #5); failed to assess pulse oximetry as ordered by the physician for 1 of 8 sampled patients, (#2) and failed to obtain weights as ordered for 1 of 8 sampled patients, (#2). The findings include: Patient #1 A review of patient #1 Home Health Certification and plan of care for certification period 1/27/21 to 3/27/21 and for certification period 3/28/21 to 5/26/21 was completed. The Home Health Certification and Plan of Care revealed physician orders for skilled nursing care 12 hours per day, 7 days per week. The record revealed the pediatric patient has diagnosis of cerebral palsy, epilepsy and has a gastrostomy tube (G-tube) which is a surgically placed device used to give direct assess to the stomach for feeding and hydration. A review of patient #1 medical record for the period of 3/7/21 to 5/1/21 was completed. The following dates did not have a nursing visit note in the medical record: 3/7/21, 3/14/21, 3/20/21, 3/28/21, 4/3/21, 4/4/21, 4/11/21, 4/17/21, 4/18/21, 4/25/21, 5/1/21 and 5/2/21. A review of the missed visit report for the period 3/7/21 to 5/1/21 revealed the agency did not provide skilled nursing care for the following scheduled visits for the reason, "no qualified caregiver available": 3/7/21 from 5AM to 5 PM, 3/14/21 from 5AM to 5 PM, 3/20/21 from 5 AM to 5 PM, 3/21/21 from 5 AM to 5 PM, 3/28/21 from 5 AM to 5 PM, 4/3/21 from 5 AM to 5 PM, 4/4/21 from 5 AM to 5 PM, 4/11/21 from 5 AM to 5 PM, 4/17/21 from 5 AM to 5 PM, 4/18/21 from 5 AM to 5 PM, 4/25/21 from 5 AM to 5 PM, 5/1/21 5 AM to 5 PM. A telephone interview was conducted with the parent of patient #1 on 5/5/21 at approximately 3:58 PM. The parent revealed patient #1 should be getting skilled nursing care 7 days per week, 12 hours per day and stated it has been over 2 years since patient #1 has received the services as identified in the care plan. She stated she is not able to work anymore because she does not get the full coverage. She has spoken to the Director of Nursing, the scheduler, and others regarding the missed visits and has been told "we are not able to find staff since you are in a rural area". An interview was conducted with the Administrator on 5/2/21 at approximately 11:10 AM, who revealed, the agency does not have a nurse available to cover Sundays and every other Saturday for patient #1. Patient #4 A review of patient #4 Home Health Certification and plan of care for certification period 4/1/21 to 5/30/21 was completed. The Home Health Certification and Plan of Care revealed a physician order for skilled nursing care for 12 hours per day for 7 days per week. The patient had a date of birth of 9/3/16 with diagnosis of seizure, traumatic brain injury with an onset of 6/1/19, and quadriplegia. The patient also had a g-tube. A review of patient #4 medical record for the period of 4/1/21 to 5/1/21 was completed. The following dates did not have a nursing visit note in the medical record: 4/10/21, 4/11/21, 4/17/21, 4/18/21, 4/24/21, 4/25/21, 5/1/21 and 5/2/21. A review of the missed visit report for the period 4/1/21 to 5/4/21 revealed the agency did not provide skilled nursing care for the following scheduled visits for the reason, "caregiver canceled - no back-fill (no staff available): 4/29/21. A review of patient #4 Home Health Certification and Plan of Care for certification period 4/1/21 to 5/30/21 revealed a physician's order for the skilled nurse to take vital signs every shift and report abnormal results to the physician. A review of the nursing flow sheet and clinical documentation revealed the following visits did not have vital signs recorded: 4/2/21, 4/4/21, 4/5/21, 4/6/21, 4/7/21, 4/8/21, 4/9/21, 4/12/21, 4/13/21, 4/15/21, 4/16/21, 4/26/21, 4/27/21, 4/28/21, 5/3/21. An interview was conducted with the Director of Nurses on 5/5/21 at approximately 9:15 AM, who confirmed the vital signs were not documented as ordered by the physician. Patient #5 A review of patient #5 Home Health Certification and plan of care for certification period 2/6/21 to 4/6/21 and certification period from 4/7/21 to 6/5/21 was completed. The Home Health Certification and Plan of Care for each certification period revealed a physician order for skilled nursing care for 92-154 hours per week x 60 days. The patients had a date of birth of 8/29/06 with a history of chromosomal abnormality, sepsis, respiratory failure and has a tracheostomy. A review of the missed visit report for the time period 4/1/21 to 5/4/21 revealed the agency did not provide skilled nursing care for the following scheduled visits: 4/11/21 7 AM-7 PM - no qualified caregiver available, 4/12/21 7 AM-5 PM - Caregiver canceled - no back fill, 4/13/21 7AM-5 PM - No qualified caregiver available, 4/14/21 7AM-5 PM - Caregiver canceled - no back fill, 4/17/21 7:00 AM to 7:00 PM, 4/18/21 7AM-7PM No qualified caregiver available, 4/24/21 7AM-7PM No qualified caregiver available, 4/25/21 7AM-7PM No qualified caregiver available, 5/1/21 7AM-7PM No qualified caregiver available, 5/2/21 7 AM-7PM - No qualified caregiver available. On 5/6/21 at approximately 12:15 PM, an interview was completed with a parent of patient #5 who confirmed the agency has never been able to fully staff the case. A review of patient #5 Home Health Certification and Plan of Care for certification period 2/6/21 to 4/6/21 revealed a physician order for the skilled nurse to take vital signs, rectal temperature, pulse, respiratory rate every shift and as needed for changes in condition. A review of the nursing flow sheet and clinical documentation revealed the following visits had oral temperature taken, instead of the ordered rectal temperature: 3/30/21, 3/31/21, 4/1/21. An interview was conducted with the Director of Nurses on 5/5/21 at approximately 9:15 AM, who confirmed the temperatures were not documented as ordered by the physician. Patient #7 A review of patient #7 Home Health Certification and plan of care for certification period 2/18/21 to 4/18/21 was completed. The Home Health Certification and Plan of Care revealed a physician order for skilled nursing care for Skilled nursing care 8 hours per day for 7 days per week. The patient had a date of birth of 2/20/98 and a history of cerebral palsy and has a G-tube. A review of patient #7 medical record for the period of 4/1/21 to 5/1/21 was completed. The following dates did not have a nursing visit note in the medical record: 3/11, 3/12, 3/18., 3/19, 3/25, 3/26, 4/1, 4/2, 4/8, 4/9. A review of the missed visit report for the period of 4/1/21 to 5/4/21 revealed the agency did not provide skilled nursing care for the following scheduled visits: 3/11/21 9:00 AM to 5:00 PM, 3/12/21 9:00 AM to 5:00 PM, 3/18/21 9:00 AM to 5:00 PM, 3/19/21 9:00 AM to 5:00 PM, 3/25/21 9:00 AM to 5:00 PM, 3/26/21 9:00 AM to 5:00 PM, 4/1/21 9:00 AM to 5:00 PM, 4/2/21 9:00 AM to 5:00 PM, 4/8/21 9:00 AM to 5:00 PM, 4/9/21 9:00 AM to 5:00 PM. Patient #2 A review of sampled patient #2's Home Health Certification and plan of care for certification periods 3/01/21 to 4/29/21 and 4/30/21 to 6/28/21 was completed. The Home Health Certification and Plan of Care revealed a physician order for skilled nursing care for 12 hours per day for 7 days per week for each recertification period. The patient had a date of birth of 4/2/2018, had a history of failure to thrive, and unspecified abnormalities of breathing. A review of sample patient # 2's medical record for the period of 3/7/21 to 5/6/21 was completed. The following date did not have a nursing visit note in the medical record 03/26/21. A review of the missed visit report for the period 3/6/21 to 5/4/21 revealed the agency did not provide skilled nursing care for the following scheduled visits for the reason, "caregiver canceled - no back-fill" 3/26/21. A review of patient #2 Home Health Certification and Plan of Care for certification periods 3/1/21 to 4/29/21 and 04/30/21 to 06/28/21 revealed a physician's order for the skilled nurse to take vital signs every shift, obtain oxygen saturations every shift and to weight every seven days . A review of the nursing flow sheets and clinical documentation for the review period of 3/7/21 through 5/6/21 did not have vital signs, oxygen saturations or weight recorded. An interview was conducted with the Director of Nurses on 5/5/21 at approximately 9:15 AM who confirmed the vital signs, oxygen saturations and weight were not documented as ordered by the physician. Patient #3 A review of sampled patient #3's record revealed a Home Health Certification and plan of care for certification period 2/10/21 to 4/10/21 and 4/11/21 to 6/9/21 revealed a physician's order for skilled nursing care for eight hours a day, four days a week for sixty days for each certification period. The pediatric patient had a date of birth of 8/26/20 with a history of downs syndrome and a G-tube. A review of the medical record, for the review period of 03/07/21 through 05/06/21, revealed that patient #3 was only seen one time which was on 03/11/21. Documentation supported missed visits for the 7:00 AM - 3 PM, on the following days: 3/9/21, 3/10/21, 3/16/21, 3/17/21, 3/22/21, 3/23/21, 3/24/21, 3/25/21, 3/29/21, 3/30/21, 3/31/21, 4/1/21, 4/5/21, 4/6/21, 4/7/21, 4/8/21, 4/12/21, 4/13/21, 4/14/21, 4/15/21, 4/19/21, 4/20/21, 4/21/21, 4/22/21, 4/26/21, 4/27/21, 4/28/21 and 4/29/21. Review of the missed visit report revealed there was no qualified caregiver. An interview with the patient's mother was conducted on 5/5/21 at approximately 5:10 PM, she revealed the agency has not been able to staff her daughter's case since 3/11/21. She stated that the agency keeps promising to send staff and that they have hired someone, she has a really hard time due to the patient requiring tube feedings every 3 hours. Interview with the Administrator on 5/6/21 at 11:45 AM, was conducted and she confirmed the missed visit report was correct and that the last note in the patient's chart was dated 3/11/21. She also stated that the nurse had resigned from the case because of the travel distance and the agency had been unable to staff this case. Patient #6 A review of sampled patient #6's record revealed a Home Health Certification and plan of care for certification period 1/27/21 to 3/27/21 and 3/28/21 to 5/26/21 revealed a physician's order for skilled nursing care for twenty four hours a day, seven days a week for sixty days for each certification period. The patient had a date of birth of 3/12/97 with a history of cerebral palsy, profound intellectual disabilities, contractures and has a G-tube. Review of the missed visit report, revealed missed visits for the 7:00 PM-7:00 AM shift due to no qualified caregiver available on the following days: 4/2/2021, 4/7/2021, 4/19/2021, 4/20/2021, 4/22/2021, 4/23/2021, 4/27/2021, 4/29/2021, 4/30/2021, 5/3/2021 and 5/4/2021. An interview with the grandmother of sampled patient #6 on 5/5/21 at approximately 2:50 PM, revealed the agency has not provided the 24 hour, daily care as ordered for the patient and it has always been a problem. She reports the patient requires a lot of positioning, is nonverbal and is total care. She further stated that she lives in another state and has to stay for weeks to help with the patient's care. An interview was conducted with the Administrator on 5/6/21 at approximately 11:46 AM, during which she confirmed the missed visits listed on the missed visit reports for patients #1, 2, 3, 4, 5, 6, and 7 were accurate, and the visits were missed due to no staffing available. B

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 record review, policy review and interview, the home health agency failed to implement effective action plans to correct identified quality deficiencies related to missed skilled nursing visits for 2 of 2 periods reviewed, (1/1/20 to 12/31/20 and 1/1/21 to 3/31/21). The findings include: A review of the Annual Quality Assurance Performance Improvement, (QAPI) for the period of 1/1/20 to 12/31/20 (period #1) was reviewed. The QAPI plan revealed a performance improvement plan was in place for Missed Opportunities, with an average of 1,392 hours of missed visits per month. A review of the QAPI quarterly report for the period of 1/1/21 to 3/31/21 (period #2) was completed. The quarterly report revealed an average of 2,449.67 hours missed per month. A telephone interview was conducted with the parent of patient #1 on 5/5/21 at approximately 3:58 PM. The parent revealed patient #1 should be getting skilled nursing care 7 days per week, 12 hours per day and stated it has been over 2 years since patient #1 has received the services as planned in the care plan. On 5/6/21 at approximately 12:15 PM, an interview was completed with a parent of patient #5 who confirmed the agency has never been able to fully staff the case. An interview was conducted with the DON on 5/5/21 at approximately 9:12 AM, who confirmed she does not have oversight of the Quality Assurance program. An interview was conducted with the Administrator on 5/6/21 at approximately 11:46 AM, who confirmed the agency has a performance improvement plan for missed visits, and confirmed they continue to have a problem with missed visits. The Administrator confirmed she has overall responsibility for the QAPI program, and confirmed medical record audits are not being done. A review of the agencies policy titled, "Records Review", effective 9/1/14, last revised on 4/9/21 under #3. Policy 3.1. states: a sample of patient records and personnel files will be reviewed on a quarterly basis (or per state requirements), to monitor the timeliness and efficiency, as well as the degree of accuracy and completeness of the information. This review will include an adequate sampling of open and closed records.