Every finding on record at Maxim Healthcare Services Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 10/07/2024 -10/10/2024 Active Census: 34 At this Emergency Preparedness survey, Maxim Healthcare Services INC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers 42 CFR 484.102. QR completed by Area 3 on 10-17-2024.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 10/07, 10/08, 10/09 and 10/10/2024 12-Month Unduplicated Skilled Admissions: 34 This survey was partially extended on 10/09/2024. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN Registered Nurse LPN Licensed Practice Nurse HHA Home Health Aide CM Clinical Manager MD Medical Doctor POC Plan of Care SOC Start of Care EMR Electronic Medical Record QR completed by Area 3 on 10-17-2024.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure an initial nursing assessment occurred within 48 hours of receiving a referral for 1 of 3 active patient records. (Patient #3). Findings include: 1. Review of a policy titled "Patient/Client Record: Content and Requirements", last revised on 09/12/2024 indicated but was not limited to: "To outline the components and requirements of the patient/client record…Admission paperwork, Client referral… and accompanying communication notes…" 2. The clinical record for Patient #3 included a referral received on 7/23/2024 with an initial nursing assessment and SOC admission completed on 9/25/2024 for the POC certification period of 09/25/2024 to 11/23/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and admission into the agency with the initial nursing assessment. 3. During an interview on 10/10/2024 at 9:40 AM, the CM indicated after speaking with the Regional Operations Manager there was no information documented as to why there was a delay from the time the referral was received by the agency and when the initial nursing assessment was completed. The CM indicated the communication with the family and MD should have been documented while the patient was still in the hospital to assure the initial assessment occurred upon patient's discharge from the hospital and discharge paperwork should have been attached into the EMR as well. 17-14-1(a)(1)(A)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure home health staff followed standard precautions to prevent the transmission of infections and communicable diseases for 1 of 3 home visits conducted (RN 1). Findings include: Review of a policy titled "Hand Hygiene", last revised on 09/07/2016 indicated but was not limited to: "To prevent cross-contamination and/or health care associated infections. Personnel providing care or services in the home setting will regularly wash their hands per the most recently published Centers for Disease Control regulations and guidelines for hand hygiene in the health care settings…when hands are not visibly soiled, they should be decontaminated using an alcohol-based hand rub…Hand decontamination using an alcohol-based hand rub should be performed: Before having direct contact with patient/clients. If applicable, before donning sterile gloves when performing sterile procedures…after contact with body fluids or excretions… when moving from a contaminated body site to a clean body site during patient care… after removing gloves…" During an observation on 10/09/2024 at 9:40 AM, RN 1 donned clean gloves without performing hand hygiene. The RN proceeded to change Patient #2's soiled brief and threw it away in the trash. RN 1 picked up the patient's socks and put them on the patient; he/she then picked up the patient's pants, removed clean gloves and proceeded to put on the patient's pants without performing hand hygiene. RN 1 removed the split 4x4 gauze from Patient #2's tracheostomy, then opened a package of sterile split 4x4 gauze and placed it around the patient's tracheostomy and placed a bib under the patient's chin. RN 1 then opened a package of sterile gloves and put them on without performing hand hygiene. He/she turned on the suction machine at bedside and picked up a suction catheter and proceeded to suction the patient's tracheostomy. RN 1 put the suction catheter down on the bedside table and touched the bedspread. He/she then removed the sterile glove from their left hand and proceeded to touch the patient's oxygen mask and switched the patient's tracheostomy tube to the oxygen mask to supply oxygen to the patient while the patient. RN 1 removed the sterile glove from their right hand without performing hand hygiene and transferred Patient #2 into the wheelchair, adjusted the patient in the wheelchair and applied the safety belt to the patient. RN 1 changed the patient's pillowcase on the bed, removed the disposable pads from the bed and then made up the bed sheets. He/she then turned off the patient's television with a remote control. He/she then donned a clean glove on their right hand, picked up the suction catheter and suctioned the patient's tracheostomy. RN 1 then picked up trash off of the bed and placed it in the trash, adjusted the patient's wheelchair, and then removed the clean glove from their right hand without performing hand hygiene. During an interview on 10/09/2024 at 10:20 AM, RN 1 indicated hand hygiene was not used before donning gloves or after removing gloves during patient care. He/she indicated gloves should have been removed and hand hygiene completed after changing the patient's soiled brief. RN 1 indicated no hand hygiene was used prior to donning sterile gloves or after removing sterile gloves during patient care. During an interview on 10/09/2024 at 3:45 PM, the CM indicated the expectation for staff is to adhere to infection prevention measures. She indicated RN 1 should have performed hand hygiene before donning gloves and after removing gloves. Gloves need to be changed after performing incontinence care followed with hand hygiene; she expects staff should not keep dirty gloves on while touching other items in the patient care area.

This visit was for a Federal/State Recertification in conjunction with an Emergency Preparedness survey of a home health agency. Survey Dates: November 30th, December 1st, December 2nd, and December 3rd of 2021. Facility ID: 007982 At this survey, Maxim Healthcare Services INC was found to be in compliance with 42 CFR 484.102 Emergency Preparedness Requirements. QR Completed 12/17/2021 A4

This survey was for federal/state recertification of a home health agency. Survey Dates: November 30th, December 1st, December 2nd, and December 3rd of 2021. Facility ID: 007982 Partially Extended: 12/02/2021 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. QR Completed 12/17/2021 A4

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients had updated contact information for the administrator for 2 of 2 home visit observations. (Patient 1 & 2) Findings include: 1. During a review on 12/02/2021 patient 1's admission packet evidenced the name and contact information for a former former administrator. 2. During a review on 12/02/2021 patient 2's admission packet evidenced the name and contact information for a former former administrator. 3. During an interview on 12/03/2021 the administrator stated the agency needed to update the contact information in the patients' homes.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to complete a comprehensive assessment at the time of discharge for 1 of 2 closed records reviewed. (Patient 4) Findings include: 1. A policy title “Discharge”, with a revision date of 04/09/2021, indicated but was not limited to, “ ... a comprehensive assessment will be completed at discharge for all patients ... ” 2. The complete clinical record for Patient 4, start of care date 02/21/2019, was reviewed on 12/01/2021 and evidenced the following: An untitled document containing communication notes was provided by the administrator on 12/03/2021 at 2:55 p.m. The document included an entry on 04/01/2021 which stated “Due to having no staff ... we are moving forward with discharge. Visited patient’s home for discharge assessment on 03/29/21.” A document titled “Treatment/Order Update/Change in Condition”, signed by Employee G on 04/09/2021, was provided by the administrator on 12/02/2021 at 11:52 a.m. The document indicated, but was not limited to, “Discharge client ... effective 04/10/2021 ... Unable to staff area ... ” An untitled document, provided by the administrator on 12/02/2021 at 11:52 a.m., indicated but was not limited to, “Via overnight mail ... Notice of discharge effective as of 04/16/2021 ... as we discussed with you on 04/06/2021 ... we are not seeking authorization for continued care.” 3. During an interview with the administrator on 12/02/2021 at 4:30 p.m., when asked why the discharge assessment was done on 03/29/2021, 18 days prior to the actual discharge date, the administrator stated, “I think that the whole discharge was just poorly documented from start to finish.” IC 484.55(d)(3)

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to update the aide plan of care to reflect care provided on a daily basis for 1 of 2 home health aide records reviewed. (Patient 1) Findings include: A 04/09/2021 policy titled "Home Health Aide Plan of Care" was provided by the administrator on 12/03/2021 at 12:00 p.m. The document indicated, but was not limited to, "The HHA (home health agency) POC (plan of care) will be reviewed and revised at least every 60 days by the professional … the professional may make changes to the HHA POC based upon changes in patient's condition and/or patient/caregiver request." The complete clinical record for patient 1 was reviewed on 12/01/2021 and evidenced the following: A document titled "Plan of Care" for the certification period from 11/18/2021 to 01/16/2021 with a primary diagnosis of muscular dystrophy (a disease that causes progressive weakness and loss of muscle mass), and a secondary diagnosis of mixed (a combination of stress and urge) incontinence (loss of urine). An aide plan of care with an effective date of 07/21/2021-present with orders to assist with a bed bath, hair care/shampoo, assist with dressing, mouth care, skin care, nail care, transfer assist, assist in/out of bed, reposition, cut food into small pieces, serve meal, assist with feeding, encourage fluids, record date of last bowel movement, assist with toileting, incontinence/peri-care, incontinence brief, and vacuum/sweep. The record indicated patient 1 had 46 home health aide visits during the certification period and the patient declined a bed bath, hair care/shampoo, incontinence/peri-care, and dressing assistance for all 46 of the visits. During an interview with the administrator on 12/02/2021, the administrator stated the patient can refuse any service and that the family took care of the patient's bath. When asked why an incontinent patient with a history of urinary tract infections would not receive peri-care the administrator stated the patient can refuse. When asked why the plan of care had not been updated to reflect this, or after so many declinations would this indicate the plan of care needed to be revised the administrator stated she was not sure and would have to look into it. No other information was provided related to why the plan of care was not updated to reflect the care the patient would receive.

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 observation, record review, and interview, the agency failed to alert the physician to vital signs outside of the expected parameters for 1 of 6 active patients. (Patient 1) Findings include: 1. An undated document titled "Measurements: Vital Signs" was provided by the administrator on 12/02/2021. The document indicated but was not limited to, "Vital signs have parameters. Parameters indicate when the vital signs are normal or abnormal … Alert the supervising clinician if the vital sign is higher or lower than listed below unless specifically given other parameters … Systolic BP (blood pressure) should be higher than 100 … Diastolic BP should be higher than 50." 2. The complete clinical record for patient 1 was reviewed on 12/01/2021 and evidenced the following: A document titled "Plan of Care" for the certification periods 11/21/2020-01/19/2021, 01/2021-03/20/2021, 03/21/2021-05/19/2021, and 11/18/2021-01/16/2022. The care plan failed to evidence physician-approved vital signs outside of the normal parameters. A document titled "Recertification" with a visit date of 11/12/2020 indicated patient 1's blood pressure reading was 92/80 signed by employee G, Registered Nurse. A document titled "Supervisory Visit" with a visit date of 01/07/2021 indicated patient 1's blood pressure reading was 89/62 signed by employee G, RN. During an observation on 12/02/2021 employee G, RN, indicated the patient's blood pressure reading was 59/41 and a heart rate of 53. Employee G stated the patient's blood pressure tended to run on the lower side. Employee H, Home Health Aide, stated patient 1's pressure does not usually run that low. Employee G stated they would recheck the blood pressure. Employee G said the blood pressure is actually 93/61 with a heart rate of 100. Employee G failed to notify the patient's blood pressure readings outside of the agency's normal parameters. 3. During an interview on 12/03/2021 the administrator stated the agency follows the current accepted clinical guidelines for vital sign parameters unless a patient's plan of care indicates a more specific set of parameters. 17-13-1(d)

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients had updated contact information for the clinical manager for 2 of 2 home observations. (Patient 1 & 2) Findings include: 1. During a review on 12/02/2021 patient 1's admission packet evidenced the name and contact information for a former former clinical supervisor. 2. During a review on 12/02/2021 patient 2's admission packet evidenced the name and contact information for a former former clinical supervisor. 3. During an interview on 12/03/2021 the administrator stated the agency needed to update the contact information in the patients' homes.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure all staff providing patient care were following acceptable standards of practice by actively documenting the absence of illness or signs/symptoms of COVID-19 for 1 of 1 agency reviewed. Findings include: 1. A 3/23/2020 CMS Infection Control Covid-19 questionnaire tool indicated, but was not limited to, "Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness? Is the facility actively taking their temperature and documenting the absence of illness (or signs/symptoms of COVID-19 as more information becomes available)?" Ref: QSO 20-20-All 2. A 12/20/2020 CMS Memorandum Ref: QSO-21-08-NLTC indicated but was not limited; "Education, Monitoring, and Screening of Staff. Does the facility have a screening process for all staff to complete prior to or at the beginning of their shift that reviews for exposure to others with known or suspected COVID-19, signs/symptoms of illness and includes whether fever is present (screened upon arrival or self-reported absence of fever)? Is there evidence the provider has educated staff on SARS-CoV?" 3. A document titled, Supplemental Guidelines to Maxim's COVID-19 Playbooks, was provided by the administrator on 12/3/2021 at 12:00 p.m. The document indicated but was not limited to, "Daily Self-Screening We ask that as a valued team member, you take interest in ensuring a safe and healthy work environment. Please voluntarily monitor your health status." 4. An untitled document was provided by employee K on 12/01/2021 at 3:52 a.m. The document indicated but was not limited to, "Based on recent guidance, Maxim will be updating the protocol for Daily Self-Assessment Check-Ins with all caregivers making patient visits in the home. As a reminder, Daily Self Assessment Check-Ins will take place ... Via text message in the morning." 5. During an interview on 12/01/2021 at 11:50 a.m. employee G, RN (Registered Nurse) stated they didn't know if staff documented the absence of COVID-19 symptoms prior to patient care. They stated they did previously at the beginning of the pandemic. 6. During an interview on 12/02/2021 the administrator was asked for employee G's COVID-19 self-screening as employee G was observed, during a home visit, performing a comprehensive assessment and supervisory visit on separate patients. The administrator stated employee G, RN, did not have a text self-screening as they were considered an internal employee and not required to document their self-screen. 17-12-1(m)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the home health followed the plan of care and accurately documented care provided for 1 of 2 home health aide patient records reviewed. (Patient 1) Findings include: A document titled "Home Health Aide" was provided by the administrator on 12/02/2021 at 9:54 p.m. The document indicates, but is not limited to, "Essential Duties and Responsibilities … 5. Must follow patients plan of care and complete all tasks assigned. 6. Adherence to Maxim's policies and procedures, documentation, care procedures, and standards of personal and professional boundaries and conduct." The complete clinical record for patient 1 was reviewed on 12/01/2021 and evidenced the following: A document titled "Plan of Care" for the certification period from 11/18/2021 to 01/16/2021 with a primary diagnosis of muscular dystrophy (a disease that causes progressive weakness and loss of muscle mass), and a secondary diagnosis of mixed (a combination of stress and urge) incontinence (loss of urine). The document indicated patient 1 is non-ambulatory, fully dependent for all ADLs (activities of daily living), has frequent episodes of incontinence, had a urinary tract infection during the recertification visit on 11/03/2021, and needs to be repositioned every 2 hours. Home Health Aide Visit notes for 11/18/2021, 11/19/2021, 11/22/2021, 11/23/2021, 11/29/2021, and 11/30/2021 indicated the aide provided eight hours of care each day. The visit notes indicated the home health aide assisted the patient with ambulation, the patient declined peri care, incontinence care, condom catheter change, and an incontinence brief every visit. During an interview with the administrator on 12/02/2021 when asked why a female patient would have the option of a condom catheter change, why employee H would chart assisted with ambulation for a non-ambulatory patient, and why peri-care or incontinence care was not provided for any visits when the patient is incontinent the administrator stated the patient has a right to refuse services and she is unsure why a condom catheter change would be an option for the patient but believes it may have something to do with the charting system.