Every finding on record at Maxim Healthcare Services, Inc

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 01/12/23, Maxim Healthcare Services, Inc is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey An admission conference was conducted on 01/10/23 at 10:27 AM with the Administrator. An exit conference was conducted on 01/12/23 at 2:30 PM with administrative staff. The following deficiencies are based on the partial extended recertification survey completed 01/12/23. Maxim Healthcare Services, Inc 368042, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record review, policy review, and staff interview, the agency failed to ensure each patient receives home health services as written in the physician ordered plan of care for three of seven records reviewed (Patient #2, #3 and #4). This could affect all patients receiving services from the agency. The census was 57. Findings include: Review of agency policy titled “Patient/Client Scheduling” effective 10/07/22 revealed if the services provided do not match the physician’s orders on the plan of care, a missed visit note and notification to the ordering physician is required. 1. Review of the medical record for Patient #3 revealed a physician order dated 12/06/22 for skilled nursing services 16 hours per day Sunday to Saturday, for a total of 112 hours per week. Review of the hours worked by the nurse and missed visit reports revealed for the week of 12/11/22 the nurse worked 29 hours and 33.5 hours were documented as missed with the physician notified. There was no documentation the physician was notified that 49.5 hours of skilled nursing services was not provided as ordered. Review of the hours worked by the nurse and missed visit reports revealed for the week of 12/18/22 the nurse worked 41 hours and 36 hours were documented as missed with the physician notified. There was no documentation the physician was notified that 35 hours of skilled nursing services was not provided as ordered. 2. Review of the medical record for Patient #2 revealed a physician order dated 12/24/22 for skilled nursing services 140 hours per week. Review of the hours worked by the nurse revealed for the week of 12/25/22 the nurse worked 87 hours. There was no documentation the physician was notified that 53 hours of skilled nursing services was not provided as ordered. Review of the hours worked by the nurse revealed for the week of 01/01/23 the nurse worked 76 hours. There was no documentation the physician was notified that 64 hours of skilled nursing services was not provided as ordered. 3. Review of the medical record for Patient #4 revealed a physician order dated 12/24/22 for skilled nursing services 48 hours per week. Review of the hours worked by the nurse and missed visit reports revealed for the week of 12/25/22 the nurse worked 16 hours and eight hours were documented as missed with the physician notified. There was no documentation the physician was notified that 24 hours of skilled nursing services was not provided as ordered. Interview with Staff A on 01/12/23 at 10:03 AM confirmed the physician was not notified of all the missed visits.

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 medical record review, staff interview, and policy review, the agency failed to ensure the individualized plan of care included the frequency and duration of visits to be made for two of seven records reviewed (Patient #1 and #2). This could affect all patients receiving services from the agency. The census was 57. Findings include: Review of the agency policy titled, “Home Health Certification and Plan of Care,“ effective 10/07/22, revealed the Plan of Care shall include a description of orders of discipline and treatments (specify the amount, frequency, and duration). 1. Review of Patient #1's plan of care for the certification period dated 11/23/22-01/21/23 revealed an order for skilled nursing services for 60 hours per week for 60 days. There was no frequency or duration of the visits included in the plan of care. 2. Review of Patient #2's plan of care dated 12/24/22 an order for 140 hours of skilled nursing services per week. There was no frequency or duration of the visits included in the plan of care. Interview with Staff A on 01/12/23 at 12:00 PM confirmed there were no frequency and duration of visits included in the plan of care.