Every finding on record at Maxim Healthcare Services Inc

Based on the findings of an unannounced onsite Medicare recertification survey completed February 19, 2025, 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 Medicare recertification survey completed February 19, 2025, Maxim Healthcare Services, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for four (4) of seven (7) clinical records (CR#4 - CR#7). Agency policy reviewed on February 18, 2025 at approximately 2:00 p.m. (3) Policy 'Referrals' (MD-CL-003.4) 'Policy' (3.3) " Acceptance of the referral does not imply acceptance of the patient/client for admission. Admission is determined in accordance with the Admission Policy." (6) Referral-Not Accepted' (6.1) "It is the responsibility of the office clinical leader or clinical designee to review with the office operations leader or designee when there is a clinical reason to not accept a referral." (6.1.1) "It is the responsibility of the office clinical leader or clinical designee to notify the referral source of the non-acceptance status." 'Scheduling the In-Home Admission Visit' 'Standard Operating Procedure (SOP) 'Scheduling the In-Home Admission Visit' 'Process Step' '2.0 Identify Date for In-Home Admission Visit', 'When' "After referral is accepted", 'Comments' "The In-Home Admission Visit must be completed: *"Within 48 hours after referral is accepted", *Within 48 hours after patient discharge from the hospital; or *On the date ordered by the physician." (Note: This policy/standard operating procedure is not compliant with regulation). A review of CRs were completed on February 19, 2025 at approximately 3:00 p.m. The patients start of care (SOC) is included below. CR#4 SOC 09/13/24: Referral from (insurance company) for skilled nursing services on 05/2/24. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 09/13/24. CR#5 SOC 01/12/23: Referral from (insurance company) for home health aide services on 12/19/22. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 01/12/23. CR#6 SOC 12/06/24: Referral from (insurance company) for home health aide services on 10/14/24. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 12/06/24. CR#7 SOC 03/04/24: Referral from (insurance company) for skilled nursing services on 12/05/23. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 03/04/24. An interview conducted with an agency Administrator on February 19, 2025 at approximately 3:15 p.m. confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey completed March 2, 2022, 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 Medicare recertification survey completed March 2, 2022, Maxim Healthcare Services, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for four (4) of seven (7) clinical records (CR#1, CR#3, CR#4, CR#7). A review of agency Policy/Procedure was conducted on March 1, 2022 at approximately 2:00 p.m. 'Standard Operating Procedure (SOP) 'Scheduling the In-Home Admission Visit' 'Process Step' 2.0 Identify Date for In-Home Admission Visit' 'Comments' states "The In-Home Admission Visit must be completed: *"Within 48 hours after referral is accepted",*Within 48 hours after patient discharge from the hospital; or *On the date ordered by the physician." (Note: This policy/standard operating procedure is not compliant with regulation). A review of clinical records conducted on March 1, 2022 between approximately 10:00 a.m. and 2:00 p.m. revealed the following: CR#1 SOC 10/22/20: Referral from (hospital) for skilled nursing services on 09/09/20. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 10/21/20. CR#3 SOC 05/16/19: Referral from (hospital) for skilled nursing services on 05/13/19. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 05/16/19. CR#4 SOC 12/07/21: Referral from (hospital) for skilled nursing services on 12/02/21. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 12/06/21. CR#7 SOC 02/06/20: Referral from (health center) for home health aide services on 12/27/19. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 02/05/20. An interview conducted with the agency Administrator on March 2, 2022 at approximately 11:30 a.m. confirmed the above findings.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to ensure a discharge summary was completed and sent to the primary care practitioner, per policy, for one (1) of seven (7) clinical records (CR#6). A review of agency Policy was conducted on March 1, 2022 at approximately 2:00 p.m. Policy 'Discharge' 'Policy' (3.2) states "Prior to discharge, the reason for the discharge and any plans for ongoing care/service needs will be discussed with the patient/client, family/caregiver or legal representative and documented in the client record or system of record." (3.4) states "A discharge summary will be completed for each patient/client discharged from service. the summary will be documented on the Discharge Summary Form." (3.4.1) states "For Home Health Medicare Certified Offices, a completed discharge summary will be completed and sent to the primary care practitioner or other health care professional who will be responsible for providing care and services after discharge from the office (if any) within 5 business days of the patients discharge." A review of clinical records conducted on March 1, 2022 between approximately 10:00 a.m. and 2:00 p.m. revealed the following: CR#6 SOC 05/12/21: Patients last day of service from the agency was 09/03/21. No documentation provided of a 'Discharge Summary Form' being completed nor sent to the primary care practitioner or other health care professional who will be responsible for providing care and services after discharge, per policy. An interview conducted with the agency Administrator on March 2, 2022 at approximately 11:30 a.m. confirmed the above findings.

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 a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to ensure an individualized plan of care, including all of the required elements, per policy, was established for one (1) of seven (7) clinical records (CR#6). A review of agency Policy was conducted on March 1, 2022 at approximately 2:00 p.m. Policy 'Home Health Certification and Plan(s) of Care' 'Purpose' states "To provide direct care staff with the ordering practitioners ordered treatments, procedures, medications, and services to meet the patients home care needs." 'Policy' (3.1) "The Home Health Certification and Plan of Care (485) is the ordering practitioners order for home care services. (3.3) "A written plan of care will be initiated on the start of care date and updated at least within the last five (5) days of the current certification or as patients condition warrants." (3.5) "The care planning process will be documented on the plan of care, individualized discipline specific notes (if applicable), clinical notes, medication profiles, communication notes, case conference notes, and discharge summaries. The care planning process begins with the admission assessment and continues through agency discharge." 'Procedure' (5.2) "The office clinical leader or designee is responsible for creating the 485." (5.4) "The office clinical leader or clinical designee will: (5.4.1) "Review, print and send the 485 for ordering practitioner signature within 5 business days from the initial or comprehensive reassessment visit." (5.4.3.1) "Place one copy in the medical record or system of record." A review of clinical records conducted on March 1, 2022 between approximately 10:00 a.m. and 2:00 p.m. revealed the following: CR#6 SOC 05/12/21: No documentation provided of utilizing a Plan of Care (485), per policy, which contains (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. Documentation provided of a 'Skilled Nursing Written Plan of Care' (Used for 5 visits or less), dated 05/12/21, completed by the Clinical Manager (employee #24). The 'Skilled Nursing Written Plan of Care' was not signed by a physician. "Nursing Procedure' states "Give IM injection once a month for five months." 'Frequency and duration of care' states "Once a month for five months." 'Physician orders' states "Attached." Documentation provided of a physician prescription dated 04/20/21 stating "Please administer (medication) IM once a month (no duration noted)." Documentation provided of a licensed practical nurse administering the (medication) on 05/12/21, 06/11/21, 07/09/21, 08/06/21, and on 09/03/21." An interview conducted with the agency Administrator on March 2, 2022 at approximately 11:30 a.m. confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observations and an interview with the agency Administrator, the agency failed to ensure that everyone entering the health care facility is screened and triaged for COVID-19 for one (1) of one (1) observations (Observation #1). CMS-QSO-20-18-HHA (03/10/2020) 'Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs)' 'Guidance' states "...... Also, HHAs should be monitoring the health status of everyone (patients/residents/visitors/staff/etc.) in the homecare setting for signs or symptoms of COVID-19". "How should HHAs monitor or restrict home visits for health care staff? Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work". A review of agency Policy was conducted on March 1, 2022 at approximately 2:00 p.m. 'COVID-19 CMS Vaccination Mandate' (8) 'Reporting Requirements' (8.3) Daily COVID-19 Symptom Self-Screening: (8.3.1) "Employees are expected to self screen daily prior to reporting to work." (Note: No specific policy/procedure for screening office employees/visitors.) Observation #1: On February 28, 2022 at approximately 9:45 a.m. the state surveyor entered the agency to conduct the survey. The surveyor self screened for COVID-19 and documented on the 'COVID-19 Screening Log' at the entry of the agency. No entries observed on the 'COVID-19 Screening Log' on 02/28/22 nor on 03/01/22 for the following employees who were present at the office. No other documentation provided of these employees self screening prior to reporting to work. 02/28/22: Employees #11-#26. 03/01/22: Employees #11-#18, #23-#25, #27, #28. An interview conducted with the agency Administrator on March 2, 2022 at approximately 11:30 a.m. confirmed the above findings.