Every finding on record at Maxim Healthcare Services, Inc.

An onsite recertification survey was conducted 06/21/21 to 06/22/21. No deficiencies were identified to the Emergency Preparedness Program. ABH

An onsite recertification survey was conducted 06/21/21 to 06/22/21. A deficiency to the Medicare Conditions of Participation was identified. ABH

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy and procedure, client record review, and staff interview the plan of care lacked the following elements of: description of the patient’s risk for emergency department visits/hospital readmission, patient specific goals, and information related to advanced directed for 6 of 7 patients (1,3, 4, 5, 6, and 7). Findings include: A policy “Home Health Certification and Plan(s) of Care” revised 04/09/21, was received from the Operations Manager on 06/22/21 at 9:13 a.m. The policy stated” the plan of care shall include, but not limited to... advanced directive… individualized goals …a description of the patient’s risk for emergency department visits and hospital re-admission”. 1.Patient #1 was admitted 07/23/2019. The plan of care for certification period 05/13/21 to 07/11/21 included diagnoses of encounter for adjustment and management of vascular access device, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. The plan of care lacked the following element: a description of the patient’s risk for emergency department visits/hospital readmission. Interview with Employee #2 was conducted on 6/22/21 at 10:58 a.m. revealed, “we have identified some issues and are working with staff to educate them to fix them…and we have had some new office staff”. 2.Patient #3 was admitted on 01/23/2019. The plan of care for certification period 01/23/2019 to 03/23/2019 included diagnoses of encounter for attention to tracheostomy, and gastro esophageal reflux disease. The plan of care lacked the following element: a description of the patient’s risk for emergency department visits/hospital readmission. Interview with Employee #2 was conducted on 6/22/21 at 10:58 a.m. revealed, “we have identified some issues and are working with staff to educate them to fix them…and we have had some new office staff”. 3. Patient #4 was admitted on 06/03/2020. The plan of care for certification period 06/04/2020 to 08/2/2020 included diagnosis of type 2 diabetes mellitus with foot ulcer. The plan of care lacked the following element: a description of the patient’s risk for emergency department visits/hospital readmission. Interview with Employee #2 was conducted on 6/22/21 at 10:58 a.m. revealed, “we have identified some issues and are working with staff to educate them to fix them…and we have had some new office staff”. 4. Patient #5 was admitted on 03/04/2020. The plan of care for certification period 03/04/2020 to 05/02/2020 included diagnoses of sepsis(blood infection), encounter for adjustment and management of vascular device, and type 2 diabetes mellitus. The plan of care lacked the following elements: a description of the patient’s risk for emergency department visits/hospital readmission, patient specific goal, and information related to an advanced directive. Interview with Employee #2 was conducted on 6/22/21 at 10:58 a.m. revealed, “we have identified some issues and are working with staff to educate them to fix them…and we have had some new office staff”. 5. Patient #6 was admitted on 06/09/2020. The plan of care for certification period 06/09/2020 to 08/07/2020 included diagnoses of pressure ulcer of left buttock, paraplegia (paralysis of legs/lower body), and essential hypertension. The plan of care lacked the following element: a description of the patient’s risk for emergency department visits/hospital readmission. Interview with Employee #2 was conducted on 6/22/21 at 10:58 a.m. revealed, “we have identified some issues and are working with staff to educate them to fix them…and we have had some new office staff”. 6. Patient #7 was admitted on 01/14/2021. The plan of care for certification period 03/15/2021 to 05/13/202 included diagnoses of multiple sclerosis, other specified disease of upper respiratory tract and encounter for attention to tracheostomy. The plan of care lacked the following element: a patient specific goal. Interview with Employee #2 was conducted on 6/22/21 at 10:58 a.m. revealed, “we have identified some issues and are working with staff to educate them to fix them…and we have had some new office staff”.