Every finding on record at Maxim Healthcare Services, Inc.

Based on the findings of an onsite unannounced home health agency Medicare recertification survey conducted 1/4/2022-1/6/2022, 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 onsite unannounced home health agency Medicare recertification survey conducted 1/4/2022-1/6/2022, Maxim Healthcare Services Inc., was found to be not in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 upon review of agency policy, clinical records (CR), and interview with administrator (EMP# 1) and clinical manager (EMP # 2) agency failed to show documentation the plan of care (POC) contained orders for type of service with frequency for two (2) of nine (9) files reviewed. ( CR # 3; CR # 9). Findings included: Review of agency policy on 1/6/2022 at approximately 12:00 PM to 1:00 PM titled “Home health Certification and Plan (s) of care, reference # HH-CL-007” stated “5.3 The plan of Care shall include, but not limited to: 5.3.7 Description of orders of discipline and treatments (specify the amount, frequency and duration).” Review of clinical records (CR) on 1/5/2022 between approximately 9:45 AM-11:15 AM and 1/6/2022 between approximately 9:30 AM-12:00 PM revealed: CR # 3, Start of Care (SOC) 8/28/2010; diagnosis of cerebral palsy {congenital disorder of movement}; difficulty walking. Physician orders: 12/27/2021-2/24/2022: “{Agency} to provide personal care services for 21-35 hours per week during the school year and 25.2-42 hours per week when school is not in session (Sunday to Saturday) throughout the 60-day certification period.” Orders for skilled nursing “Nurse to instruct/educate PCG {patient care giver} related to medications, side effects/contraindications, compliance with medication regiment, 911/MD alerts as needed/requested. Nurse may instruct/educate PCG in all aspects of care as needed.” The POC failed to include frequency or duration of those skilled nursing services. CR # 9, SOC 6/2/2017; diagnosis of Downs syndrome {congenital disorder of chromosome 21} and autistic {developmental disorder difficult social interaction}. Physician orders: 11/8/2021-1/6/2022: “{Agency} to provide C.N.A./HHA services Monday-Friday 3 PM-6:30 PM while going to school and Monday-Friday 8 AM-6 PM with school being closed or vacation time, not to exceed 50 hours per week throughout the 60-day certification period.” Orders for skilled nursing “Clinical Supervisor to instruct/educate patient/PCG related to medications, Nurse to instruct/educate PCG {patient care giver} related to medications, side effects/contraindications, compliance with medication regiment, 911/MD alerts as needed/requested. Clinical supervisor may instruct/educate PCG in all aspects of care as needed and/or requested by patient.” The POC failed to include frequency or duration of those skilled nursing services. Interview with EMP # 1 and EMP # 2 on 2/6/2022 at approximately 1:00 PM confirmed above findings.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based upon agency policy, observation during home visit, and interview with administrator (EMP# 1) and clinical manager (EMP # 2) agency failed to show evidence family was educated regarding safety with oxygen for one (1) of one (1) observation. (OBS # 1). Findings included: Review of agency policy on 1/6/2022 at approximately 12:00 PM to 1:00 PM titled “Scope of Services, reference # HH-CL-001” stated “4.13 Skilled Nursing Services: Services that must be provided by a registered nurse (RN), or a licensed practical (vocational) nurse (LPN/LVN) under the supervision of an RN, to be safe and effective…. The nurse provides and coordinates the care and teaching to ultimately accomplish establish patient care goals”. Observation to home visit on 1/5/2022 at approximately 1:30 PM-2:15 PM was conducted with surveyor and with EMP # 1 present. During tour of home by Licensed Practical Nurse (LPN) review of supplies revealed room with approximately twelve (12) portable oxygen canisters sitting upright on the floor without being safely secured. On top of these twelve (12) canisters was a black carrier which looked like a backpack which when lifted off the canisters to count total number, caused canisters to rock with potential for falling. Agency staff failed to secure oxygen canisters or show documentation family were educated in how to secure oxygen canisters safely. Interview with EMP # 1 on 2/6/2022 at approximately 1:00 PM confirmed above findings.