Every finding on record at Maximum Home Health LLC

Purpose of Visit: To conduct a Re-Certification Survey and a follow-up to survey dated 07/22/22. Census: Licensed & Certified- 1 Licensed Home Health Services – 0 Personal Assistance Services – 60 Total: 61 The Agency was in compliance with no violations cited.

Purpose of Visit: To conduct a Re-Certification Survey and a follow-up to survey dated 07/22/22. Census: Licensed & Certified- 1 Licensed Home Health Services - 0 Personal Assistance Services – 60 Total: 61 ADL- Activities of Daily Living Alt Adm- Alternated Administrator DON- Director of Nursing Md-Medical Doctor O2 sat- Oxygen Saturation OASIS- Outcome and Assessment Information Set (a tool used by CMS to collect certain patient information) POC- Plan of Care RN- Registered Nurse SN- Skilled Nursing

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 clinical record review and interview, the agency failed to ensure that the POC included a description of the patient’s risk for emergency department visits and hospital re-admissions for 1 of 1 active Patient (#1) and 1 of 1 Discharged Patient (#2) whose records were reviewed. 1. RN B failed to include O2 sat parameters of 2. RN B failed to include risk for emergency department visits and hospital re-admissions on Discharged Patient #2’s POC. This deficient practice placed Patients at risk for not receiving the necessary care and services needed to address the risk factors. The Findings Included: 1. Review of Patient #1's clinical record included an OASIS Recertification that was signed and dated by the RN B 03/21/25 read in part, … “Plan of Care: Vital Sign Parameters: … O2 Saturation less than (Dyspnea (short of breath)” … “2 Risk for hospitalization… 7. Currently taking 5 or more medications… 9. Other risk(s) not listed in 1-8.” Review of Patient #1's clinical record included a POC signed and dated by the RN B 07/15/22 for the Certification period of 03/26/25 to 05/24/25 with a primary diagnosis of Chronic Atrial Fibrillation (constant racing heartbeat). The POC included a SN visit frequency of one visit a week for four weeks, two visits a week for one week and one visit a week for four weeks. Continued review of the POC failed to reveal documented evidence of O2 sats During an interview and record review on 06/12/25 at 10:04 a.m. with the Alt Adm/DON, Office Manager in the office and RN B on a conference call, the Surveyor presented the above findings. RN B stated, “I don’t believe it does have that (02 sat parameters and patient’s risk for emergency department visit & hospital readmission). The OASIS has it. RN B then stated that there must be a software issue. The Surveyor asked what the Agency’s process was when doing a recertification. RN B stated, “the Schedular will create the visit, the nurse goes out and does the OASIS assessment.” The Surveyor then asked who reviews the OASIS. RN B stated, “myself within 48 hours. As soon as the OASIS is submitted it gets generated to a POC, everything should get pulled.” The Surveyor then asked who were responsible for reviewing the POC/485 prior to sending it out to the MD. RN B stated, “I do. There has to be a glitch in the software. It was an oversight. We need to know the risks to prevent the risk factors that poses a high risk for being hospitalized.” 2. Review of Discharged Patient #2's clinical record included an OASIS Recertification that was signed and dated by the RN B 12/19/24 read in part, … “Hospital Risk assessment Tools and Emergency Preparedness… Poly Pharmacy (greater than 7 medications), Help with managing medications needed, confusion, more than two secondary diagnosis, ADL assistance needed, Home Safety risks, and Dyspnea, Low literacy level, lives alone” … “2 Risk for hospitalization… 7. Currently taking 5 or more medications… 9. Other risk(s) not listed in 1-8.” Review of Discharged Patient #2's clinical record included a POC signed and dated by the RN B 12/19/24 for the Certification period of 12/24/24 to 05/24/25 with a primary diagnosis of Chronic Atrial Fibrillation (constant racing heartbeat) Hypertensive chronic kidney disease, (Kidney damage caused by high blood pressure). The POC included a SN visit frequency of one visit a week for four weeks, two visits a week for one week and one visit a week for four weeks. Continued review of the POC failed to reveal documented evidence of the patient’s risk for emergency department visit and hospital re-admissions. During an interview and record review on 06/12/25 at 10:025 a.m. with the Alt Adm/DON and Office Manager in the office and RN B on a conference call, the Surveyor presented the above findings. RN B stated, “It is not transferring over, risk of falls. We need to contact Software X.” Review of the agency's policy manual included a policy titled "TX.6 Plan of Care” dated 12/29/22. The policy revealed, in part: “…C. The Individual Plan of Care will specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment… The POC will contain the following elements: 10 All medications and treatments; … 12. A description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors;” …