Every finding on record at Maxim Healthcare Services Inc

Based on the findings of an unannounced, onsite Medicare recertification survey conducted September 6 through September 8, 2023, with the off-site portion of the survey being conducted on September 11 and September 12, 2023, Maxim Healthcare Services, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted September 6 through September 8, 2023, with the off-site portion of the survey being conducted on September 11 and September 12, 2023, Maxim Healthcare Services, Inc. was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, Pennsylvania Department of Human Services (PA DHS) website documentation, clinical records and personnel files, and based on interview with the Administrator and Operations Manager, the Administrator failed to ensure documentation was maintained in the personnel file which provided evidence a Federal Bureau of Investigation (FBI) criminal history clearance was obtained for one (1) of five (5) employees who provided direct care a client (patient) who was under the age of 18. (Employee #5) Findings include: On September 8, 2023 at approximately 3:56 PM, review of the agency policy titled "Background Checks" revealed the following: Policy: 1. The Company requires defined background checks for...employees...prior to hire, prior to performing services... Pennsylvania...1. The office leader or designee shall assure that a child abuse clearance including fingerprints are obtained for each staff member that provides...services to a minor (an individual 17 years of age or younger... 2. The Company adheres to...state...law...regarding the use of background checks in employment decisions. On September 12, 2023 at approximately 3:00 PM, review of the PA Department of Human Services website revealed the following guidance regarding "Pennsylvania Child Abuse History Certification" clearance requirements was included on the FAQ (Frequently Asked Questions) document: Which clearances are needed? Employees having contact with children must obtain the following three clearances: Report of criminal history from the Pennsylvania State Police (PSP), Child Abuse History Clearance from the Department of Human Services (Child Abuse) and Fingerprint-based federal criminal history submitted through the Pennsylvania State Police or its authorized agent (FBI). Client #4: On September 8, 2023 at approximately 1:00 PM, review of the clinical record revealed the client is 14 months old as evidenced by the date of birth documented on the "Home Health Certification and Plan of Care" for the recertification period of 08/10/2023 through 10/08/2023. "Skilled Nursing Note" documentation revealed a licensed practical nurse (LPN-Employee #5) provided skilled nursing (SN) services in August and September 2023. On September 8, 2023 at approximately 10:42 AM, September 11, 2023 at approximately 1:25 PM and September 12, 2023 at approximately 2:45 PM, review of personnel files revealed the following: Employee #5: The date of hire of the LPN was 10/28/2021. There was no documentation in the personnel file which provided evidence that an FBI criminal history clearance was requested/obtained prior to the assignment to of Employee #5 to provide SN services to Client #4. During interview conducted on September 8, 2023 at approximately 4:05 PM, the Administrator and Operations manager confirmed there was no documentation in the personnel file which provided evidence that an FBI criminal history clearance had been obtained for the above referenced LPN.