Every finding on record at Maxim Healthcare Services Inc

Based on the findings of an onsite unannounced Medicare recertification survey conducted June 8, 2021 through June 11, 2021 and concluded offsite on June 14, 2021, 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 June 8, 2021 through June 11, 2021, Maxim Healthcare Services Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on a review of clinical records (CR) and an interview with the administrator, the agency did not provide care according to the plan of care/physician orders for two (2) of eight (8) CRs. (CR#1 and 6). Findings include: A review of CRs was conducted on 6/9/21 at approximatley 11 AM and revealed the following. CR#1, Start of care: 9/10/20 (Discharge date of: 11/9/20) A review of certification period 9/10/20 through 11/8/20 revealed physician orders for SN (skilled nurse) for 8-12 hours overnight for 5-7 nights per week for the first week then SN 6-8 hours overnight for 5-7 nights per week ongoing and SN 6-8 hours flexible per week for parent to complete essential household duties. The following weeks of service revealed care not administered according to the plan of care: week of 9/27/20-10/3/20 contained only 4 nights of service with no notification to the physician; week of 10/25/20-10/31/20 contained only 2 days of service with no physician notification; week of 11/1/20-11/7/20 contained 0 (zero) days of service with no physician notification. There was no physician order when care was not provided according to the plan of care. CR#6. Start of care: 4/21/20. A review of certification period 4/16/21 through 6/14/21 revealed physician orders for SN (Skilled nurse) 12-16 hours per day for 5-7 days per week with an additional 16 hours per week flexible to use at Mother's discretion for 60 days. In addition, HHA (Home Health aide) 12-16 hours per day for 5-7 days per week for 60 days. No care was documented by a home health aide during the entire certification period. In addition, there was no documentation of physican notification until 6/14/21 discontinuing HHA services. An interview with the administrator and director of nursing on 6/11/21 at approximatley 1:00 PM confirmed the above findings.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on a review of Agency policy, Clinical record (CR) review and interview with the Administrator, it was determined that the Agency did not follow its policy of completing and informing the primary care physican within five (5) business of the patient's discharge for two (2) of two (2) discharged clinical records examined. (CR #1 & 7). Findings include: A review of Agency policy entitled " Discharge" was conducted on 6/10/21 at approximately 12 PM. and stated, "...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 to the patient after discharge from the office (if any) within 5 business days of the patient's discharge..." A review of Clinical records was conducted on 6/9/21 at approximately 11 AM and revealed the following. CR#1. Start of care date: 9/10/20, Agency discharge date: 11/9/20, however the patient discharge had not been completed and sent to the physican until 11/20/20. (11 days later). CR#7. Start of care date: 7/2/20, Agency discharge date: 12/29/20, however the patient discharge had not been completed and sent to the physican until 1/20/21. (22 days later). A interview with the Administrator was conducted on 6/11/21, at approximately 1:00 PM. who confirmed the above findings.

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 personnel file (PF) review, PA Department of Human Services website Review, and an interview with the agency administrator, it was determined the agency failed to ensure ChildLine Abuse Clearances are redone every five (5) years for one (1) of one (1) personnel employed greater than five (5) years who provides services to individuals under 18 years of age. PF #1 Findings include: Review of PA Department of Human services website was conducted on 6/11/21 at approximately 12:00PM. which stated, "The Child Protective Services Law (CPSL) requires certain individuals to obtain clearances in order to be employed, be a resource parent (foster or adoptive), or be a volunteer with children...Clearances are required for an employee or unpaid volunteer at a minimum of every 60 months from the date of the oldest clearance. Clearances may be required more frequently based on licensure or employer requirements..." Personnel files were reviewed on 6/10/21 at approximately 11:00 AM revealing the following: PF#1 (Date of hire: 5/26/10): Childline Abuse clearance was dated 5/3/10. An additional clearance was not run until 6/14/21 (11 years since last clearance was run) after the findings of this survey were complete. An interview the agency adminsitrator on 6/11/21 at approximately 1:00 PM confirmed the above findings.