Every finding on record at Maxim Healthcare Services, Inc

Emergency Preparedness Survey At the time of the emergency preparedness survey completed on 09/01/22, 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 entrance conference was conducted on 08/30/22 at 8:26 AM with administrative personnel, and an exit conference was completed on 09/01/22 at 3:45 PM with administrative personnel. The following deficiencies are based on the Partial Extended Recertification survey completed on 09/01/22. Maxim Healthcare Services, Inc 368259, 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 and staff interview, the agency failed to ensure patients received the home health services as written in the plan of care for six of seven medical records reviewed (Patient #1, #2, #3, #4, #6, and #7). The agency census was 48. Findings include: 1. Review of the medical record for Patient #1 revealed plans of care dated 06/16/22 to 08/14/22 and 08/15/22 to 10/13/22 with orders for private duty nursing 56 hours per week. Review of the medical record revealed nursing services were provided in eight hour shifts daily. The medical record lacked documentation of nursing services on 07/09/22, 07/15/22, 07/16/22, 07/17/22, 07/23/22, 07/24/22, 07/30/22, 07/31/22, 08/03/22, 08/06/22, 08/07/22, 08/13/22, 08/14/22, 08/20/22, 08/21/22, and 08/27/22. The medical record lacked documentation of physician notification services were not provided as ordered. The findings were verified in an interview with Staff A on 09/01/22 at 10:23 AM. Staff A stated the missing visits for the dates listed above, with the exception of 07/09/22 were identified yesterday while pulling the visit notes for surveyor review and the physician was notified this morning. Staff A stated the missing visit on 07/09/22 was not identified and had not been communicated to the physician. 2. Review of the medical record for Patient #2 revealed plans of care dated 06/21/22 to 08/19/22 and 08/20/22 to 10/18/22 with orders for private duty nursing services 84 hours per week. Review of the medical record from 06/26/22 through 08/27/22 revealed 50 hours of private duty nursing services were provided the weeks of 06/26/22, 07/03/22, 07/17/22, 08/07/22, 08/14/22, and 08/21/22; 43 hours of private duty nursing services were provided the weeks of 07/10/22 and 07/31/22; and 45 hours of private duty nursing services was provided the week of 07/24/22. The medical record contained a fax dated 09/01/22 to the physician which stated "Following a caregiver, resignation, the patient's guardian declined staff for additional hours, we are currently providing 50 hours weekly with this patient. A request to update orders will be sent shortly." The medical record lacked documentation of physician notification services were not provided as ordered. The findings were verified in an interview with Staff A on 09/01/22 at 10:30 AM. Staff A stated this was identified when pulling visit notes for surveyor review. Staff A stated the services decreased to 50 hours per week on 02/06/22 when a nurse quit and the patient's guardian did not want another nurse. Staff A stated the orders should have been decreased to 50 hours per week but the change was never made. 3. Review of the medical record for Patient #3 revealed a plan of care dated 06/16/22 to 08/14/22 with orders for home health aide services 28 hours per week. Review of the medical record revealed 26 hours of home health aide services was provided the week of 07/10/22. The medical record contained an order dated 07/27/22 to increase the home health aide services to 40 hours per week. Review of the medical record revealed only 32 hours of home health aide services was provided the week of 07/24/22. The medical record contained a plan of care dated 08/15/22 to 10/13/22 with orders for home health aide services 40 hours per week. Review of the medical record revealed only 39 hours of home health aide services was provided the week of 08/14/22. The medical record lacked documentation of physician notification services were not provided as ordered. The findings were verified in an interview with Staff A on 09/01/22 at 11:45 AM. 4. Review of the medical record for Patient #4 revealed a plan of care dated 07/02/22 to 08/30/22 with orders for skilled nursing visits weekly. Review of the medical record revealed no skilled nursing visit was documented the week of 08/07/22. The medical record lacked documentation of physician notification services were not provided as ordered. The findings were verified in an interview with Staff A on 09/01/22 at 10:44 AM. 5. Review of the medical record for Patient #6 revealed plans of care dated 12/19/21 to 02/16/22 and 02/17/22 to 04/17/22 with orders for skilled nursing two hours per day, seven days per week. The medical record lacked documentation of skilled nursing services on 01/16/22, 01/17/22, 01/19/22, 01/21/22, 01/22/22, 01/23/22, 01/24/22, 01/26/22, 01/29/22, 02/04/22, 02/17/22, 02/18/22, and 02/19/22. The medical record lacked documentation of physician notification services were not provided as ordered. The findings were verified in an interview with Staff A on 09/01/22 at 11:00 AM. 6. Review of the medical record for Patient #7 revealed a plan of care dated 07/01/22 to 08/29/22 with orders for private duty nursing services 32 hours per week. The medical record lacked documentation of nursing services the week of 08/07/22. The medical record lacked documentation of physician notification services were not provided as ordered. The findings were verified in an interview with Staff A on 09/01/22 at 11:15 AM.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure patients not receiving skilled care received an on-site supervisory visit at least every 60 days while the aide was providing care for one of one non-skilled medical record reviewed (Patient #3). A total of seven medical records were reviewed. The agency census was 48. Findings include: Review of the medical record for Patient #3 revealed a plan of care dated 06/16/22 to 08/14/22 with orders for home health aide services 28 hours per week. The medical record contained a plan of care dated 08/15/22 to 10/13/22 with orders for home health aide services 40 hours per week. Review of the medical record revealed the supervisory visit forms dated 06/03/22 and 08/01/22 noted the aide was not present on those dates. The findings were verified in an interview with Staff A on 09/01/22 at 11:45 AM.