Every finding on record at Maxim Healthcare Svcs Miami

During an unannounced recertification survey conducted on 7/21/2025 to 7/24/2025 at Maxim Healthcare Services, a Home Health Agency, Emergency Preparedness was reviewed. Maxim Healthcare Services is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

An unannounced recertification survey was conducted on 7/21/2025 to 7/24/2025 at Maxim Healthcare Services, a Home Health Agency Provider. The provider was non-compliant with 42 Code of Federal Regulations (CFR) 484 Subpart A-C, Requirements for Home Health Agencies.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency was unable to demonstrate that 1 out of 7 sampled patients (SP), SP#5 received all services outlined in the plan of care. Findings include: The surveyor reviewed SP#5’s Plan of Care on 7/22/2025 at 2:50 PM. The plan of care showed the following order: “VITAL SIGNS: Temperature, pulse, respiratory rate, B/P 3 times a day and as needed for changes in patient condition.” Staff Nurse F failed to take SP#5’s B/P during a home visit that the surveyor observed on 7/22/2025 from 3:00 PM until 3:40 PM. The surveyor conducted an interview with the Director of Nursing on 07/23/25 at 4:30 PM. The Director of Nursing said that taking B/P is optional on some orders; the nurses know to take vital signs especially for change in condition. The surveyor reviewed Staff Nurse F's nursing notes on 7/24/2025 at 2:16 PM. Staff Nurse F’s nursing note dated 7/22/2025 starting at 3:00 PM revealed that Staff Nurse F failed to record B/P for the entire skilled nursing visit. The surveyor reviewed Staff Nurse M's nursing notes on 7/24/25 at 2:17 PM. Staff Nurse M’s nursing note dated 7/21/2025 starting at 12:24 PM revealed that Staff Nurse M failed to record B/P for the entire skilled nursing visit. The surveyor reviewed Staff Nurse F's nursing notes on 7/24/2025 at 2:18 PM. Staff Nurse F’s nursing note dated 7/20/2025 starting at 7:00 PM revealed that Staff Nurse F failed to record B/P for the entire skilled nursing visit.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency was unable to demonstrate that Staff Nurse F and Staff Nurse M were following the Plan of Care/Physician orders while providing care to 1 out of 7 Sampled Patients (SP), SP#5, by not taking the patient’s blood pressure (B/P) during their skilled nursing visits. Findings include: The surveyor reviewed SP#5’s Plan of Care on 7/22/2025 at 2:50 PM. The plan of care showed the following order: “VITAL SIGNS: Temperature, pulse, respiratory rate, B/P 3 times a day and as needed for changes in patient condition.” Staff Nurse F failed to take SP#5’s B/P during a home visit that the surveyor observed on 7/22/2025 from 3:00 PM until 3:40 PM. The surveyor conducted an interview with the Director of Nursing on 07/23/25 at 4:30 PM. The Director of Nursing said that taking B/P is optional on some orders; the nurses know to take vital signs especially for change in condition. The surveyor reviewed Staff Nurse F's nursing notes on 7/24/2025 at 2:16 PM. Staff Nurse F’s nursing note dated 7/22/2025 starting at 3:00 PM revealed that Staff Nurse F failed to record B/P for the entire skilled nursing visit. The surveyor reviewed Staff Nurse M's nursing notes on 7/24/25 at 2:17 PM. Staff Nurse M’s nursing note dated 7/21/2025 starting at 12:24 PM revealed that Staff Nurse M failed to record B/P for the entire skilled nursing visit. The surveyor reviewed Staff Nurse F's nursing notes on 7/24/2025 at 2:18 PM. Staff Nurse F’s nursing note dated 7/20/2025 starting at 7:00 PM revealed that Staff Nurse F failed to record B/P for the entire skilled nursing visit.

During the recertification survey conducted on 08/30/2022 to 09/01/2022 at Maxim Healthcare Services, a Home Health Agency, Emergency Preparedness was reviewed. Maxim Healthcare Services is in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey and Complaint #2022007429 survey were conducted on 08/30/2022 to 09/01/2022 at Maxim Healthcare Services. The home health agency was not in compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to electronically transmit each OASIS (Outcome and Assessment Information Set) data within 30 days of completing the assessment of the beneficiary for 1 out of 10 Sampled Patients (SP) SP#4 Findings include: Clinical record review of SP#4 on 08/30/22 to 08/31/22 revealed the patient was admitted to service on 07/28/22 for skilled nursing service. The documentation titled “Adult Non-OASIS Admission Assessment V4” was documented as the initial comprehensive assessment completed by the registered nurse with date 07/28/22 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed the SP#4 is an adult with a payor source of Medicaid HMO (health maintenance organization). The OASIS (Outcome and Assessment Information Set) requirements states that Medicaid Home Health Program, are required to meet Medicare Conditions of Participation for HHA’s (Home Health Agency). Therefore, the provider must complete, record, encode and transmit the OASIS for all Medicaid patients receiving skilled care under this enrollment. Interview conducted with the Director of Nursing on 09/01/22 at 3:51 pm stated that she believed the patient was a private insurance, therefore did not require an OASIS assessment.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the provider failed to demonstrate the patient received all services outlined in the plan of care for 2 out of 10 Sampled Patients (SP). SP#9 and SP#10 Findings include: Closed clinical record reviews was conducted on 08/30/22 to 08/31/22 of SP#9 and SP#10. SP#9's clinical record contained a Plan of Care for certification period 04/17/22 to 06/15/22 that under section "Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)" reads "Frequency and Duration [name] to provide skilled nursing services for 7-12 hours per day, 3-5 days per week, and 12-14 hours for 1-2 days a week, for the 60 day certification period”. Further review of the clinical record revealed that patient was admitted to the hospital on 06/05/22. The provider conducted a Resumption of Care on 06/07/22, then on 06/16/22 the patient was re-admitted to the hospital. The record revealed the last visit made by a staff from the provider was on 05/29/22. Further review revealed the patient was discharged from the agency on 07/29/22 with “reason for discharge: unable to staff”. Interview conducted with the Director of Nursing (DON) on 08/31/22 at 1:56 PM. The DON confirmed the last shift provided was on 05/29/22, and then patient was hospitalized. The DON added that due to the nurse on that case finding another job, the agency did not have a staff trained for [Total parenteral nutrition] feeding and “we couldn’t find one”. The DON confirmed that SP#9 was discharged from agency on 07/29/22 due to "no staffing" issues, and mother requested to have another agency provide the service. SP#10's clinical record contained a Plan of Care for certification period 05/15/22 to 07/13/22 that under section "Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)" reads "Frequency and Duration [name] to provide skilled nursing services for 12-24 hours per day, 4-7 days per week, for the 60 days.” Further review of the clinical record for date range 05/01/22 to 07/07/22 revealed the patient was seen Monday – Friday for 12 hours per day shift. The record contained missed visits for 05/03/22, 05/04/22, 05/05/22, 05/06/22, 05/30/22 and 07/04/22 (no care provided in 24 hrs shift). The record contained a modified order dated 07/07/22 with “reason for discharge: per mother request in writing”. On 8/31/22 at 10:02 am the DON informed that SP#10 was scheduled mostly Monday – Friday for 12 hours shifts and at times weekends when staffing was found to cover. The DON stated that mainly one nurse on the case, then the DON explained that it’s a vent case, and cases like [Total parenteral nutrition] and vents are limited skills of staff knowledge, they have hard time staffing full cover. The DON states that for the past 2 years staffing has been difficult due to limited experience and at times they even had to turn down cases for this reason. The DON states that SP#10’s mother made date change request for discharge, but then finally gave a confirmed date to transfer and it was done as per mother request to another agency due to agency unable to find staff.

Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to incorporate the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items to have a completed comprehensive assessment for 1 out of 10 Sampled Patients (SP). SP#4 Findings include: Clinical record review of SP#4 on 08/30/22 to 08/31/22 revealed the patient was admitted to service on 07/28/22 for skilled nursing service. The documentation titled “Adult Non-OASIS Admission Assessment V4” was documented as the initial comprehensive assessment completed by the registered nurse with date 07/28/22 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed the SP#4 is an adult with a payor source of Medicaid HMO (health maintenance organization). The OASIS (Outcome and Assessment Information Set) requirements states that Medicaid Home Health Program, are required to meet Medicare Conditions of Participation for HHA’s (Home Health Agency). Therefore, the provider must complete, record, encode and transmit the OASIS for all Medicaid patients receiving skilled care under this enrollment. Interview conducted with the Director of Nursing on 09/01/22 at 3:51 pm stated that she believed the patient was a private insurance, therefore did not require an OASIS assessment.

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 record review and interview, the provider failed to ensure the care follows the written plan of care (POC) established by the physician on 2 out of 10 Sampled Patients (SP). SP#3 and SP#7 Findings include: Clinical record reviews were conducted between 08/30/22 and 08/31/22 of SP#3 and SP#7. The SP#3's clinical record contained a Plan of Care for certification period 08/07/22 to 10/05/22 that under section "Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)" reads "Frequency and Duration [name] to provide skilled nursing services for 7-12 hours per day, 3-5 days per week, and 12 - 24 hours for 1-2 days per week on Saturdays/Sundays during 60 days certification period”. Review of the service date range from 06/26/22 to 08/21/22 revealed the SP#3 receives 12 hrs nursing service Monday thru Thursday, no coverage for Fridays and effective 07/17/22 no coverage for Saturdays and Sundays. On 08/31/22 at 3:07 pm the Director of Nursing (DON) confirmed no staff coverage for SP#3 for Fridays, Saturdays and Sundays, they are missed visits. The SP#7's clinical record contained a Plan of Care for certification period 08/07/22 to 10/05/22 that under section "Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)" reads "Frequency and Duration [name] to provide skilled nursing services for 24 hours per day, 7 days per week, for 60 days certification period”. Review of the service date range from 06/26/22 to 08/27/22 revealed the SP#7 receives 24 hrs nursing service Monday thru Friday, no coverage for Saturdays 7pm – 11pm shift and Sundays 7am – 11pm shift. On 09/01/22 at 11:55 am the Director of Nursing (DON) confirmed no staff coverage for SP#7 for Saturdays 7pm – 11pm shift and Sundays 7am – 11pm shift.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to provide service(s) that are ordered by the physician as indicated in the Plan of Care (POC) for 1 out 10 Sampled Patients (SP). SP#4 Findings include: Clinical record review conducted on 08/30/22 to 08/31/22 contained a Plan of Care that under section "Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)" reads "Frequency and Duration One Time Daily for Twenty-one days”, then “(Vital Signs): Temperature, pulse, respiratory rate, B/P [blood pressure] (optional), and pulse oximetry (optional) each visit and as needed for changes in patient condition.” Further review of the service notes for date range 07/31/22 to 08/20/22 revealed the nurse omitted vital signs notation, marked “N/A” (not applicable) in all the service notes. Interview conducted with the Director of Nursing and Administrator on 09/01/22 at 3:51 PM acknowledged that the nurse failed to follow the POC as established by the physician.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on clinical record reviews and interview, the provider failed to have the clinical manager assure the development, implementation, and updates of the individualized plan of care for 1 out of 10 Sampled Patient (SP). SP#5 Findings include: Clinical record review conducted on 08/30/22 to 08/31/22 of SP#5 contained a Plan of Care for certification period 08/26/22 to 10/24/22 that under section "Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)" reads "Frequency and Duration [name] to provide skilled nursing services for 24 hours per day, 7 days per week, for 60 days”. Review of the service date range from 06/26/22 to 08/29/22 revealed the SP#5 receives 24hrs nursing service Monday to Thursday, then Friday missed shift for 7pm – 7am; Saturday missed shift for 7am – 7 pm; and Sunday missed shift for 7am – 7pm (every other weakened). On 08/31/22 at 2:39 pm the Director of Nursing (DON) was provided with the missing shift dates notation for SP#5 (24hrs care). The DON stated that if it’s chronic missed shifts and specific days, then it must be it was not staffed. Telephone interview conducted on 08/31/22 at 5:34 pm with SP#5’s caregiver. The caregiver stated that SP#5 is to receive 24 hrs a day nursing care, but the agency is unable to provide all the hours due to no staff available. The caregiver states that the agency just tells her that they can’t find person to cover shift. The caregiver confirmed that she has no coverage for Friday’s night shift, and Saturday’s day shift, in addition she gets no coverage on every other Sunday’s day shift. The caregiver states not having issues with weekdays, its being covered. The caregiver states that this affects her because she is unable to work due to not being able to depend on the agency to cover all shifts. The caregiver states that if she gets a job, and the staff calls out then she has to stay home and cover the shift and that would mean she has to call out to her job, so she can’t do that. The caregiver also expressed that a lot of times, the staff nor the agency calls her to notify that they are not coming. Basically, she knows the staff won’t go because the shift starts, and they just don’t show. The caregiver states that last weekend the staff did call her ahead to tell her of not covering shift, but not calling to say they are not going does happen a lot. On 09/01/22 at 9:57 am the DON acknowledged that SP#5 has no coverage for Friday’s night shift, and Saturday’s day shift, in addition she gets no coverage on every other Sunday’s day shift as stated above. The DON added that staff must notify the agency at least 24 hours before shift of not being able to make shift in order to give the office time to seek alternative coverage.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to ensure the clinical record includes all entries appropriately authenticated (signature and a title), dated, and timed for 1 out 10 Sampled Patient (SP). SP#2 Findings include: Review of the clinical record for SP#2 conducted on 08/30/22 to 08/31/22 revealed the patient is active and the current Plan of Care reads for skilled nursing service to be provided for 12 hours per day, for 5 days per week, and 24 hours per day for 2 days a week, for the 60 days certification period. Further review of the clinical record contained service notes from Staff G (title unknown) for date range 06/29/22 to 08/20/22 (all scheduled visits for Sundays 7pm to 7am; Wednesdays for 7pm – 7am; Thursdays for 7pm – 7am; and Saturdays 7am – 7pm) that all omitted the discipline’s title. Review of the staff list provided by the Director of Nursing on 08/30/22 revealed Staff G has a discipline title of Licensed Practical Nurse. Interview conducted with the Director of Nursing and Administrator on 09/01/22 at 2:51 PM, confirmed findings made by the surveyor, failure for the provider to maintain clinical record with all entries properly authenticated.