Every finding on record at Maxwell Home Health Care, Inc

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 7/18/22-7/21/22 at: Maxwell Home Health Care 43494 Woodward Ave. suite 205 Bloomfield Hills, MI 48302 This was a standard survey. The conditions of participation for emergency preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 7/18/22-7/21/22 at: Maxwell Home Health Care 43494 Woodward Ave. suite 205 Bloomfield Hills, MI 48302 The agency has no branches or extension sites. COVID-19 vaccination compliance was reviewed during this survey. For this survey, no home visits were available. 1 active record and 6 discharged records were reviewed. At the conclusion of the survey the agency was found to be out of compliance with standard level deficiencies for the conditions of participation for home health agencies at: 42 CFR Part 484.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Home Health Agency (HHA) failed to ensure the frequency of visits ordered on the Plan of Care (POC) were followed in 3 of 7 records reviewed with skilled nursing (SN) and physical therapy (PT) services ordered (M.R.# 1, 2 and 4) from a total sample of 7 records reviewed, resulting in the potential for unmet patient needs. Findings include: MR #1: The SOC was dated 4/18/22. The POC identified the diagnoses of abnormal gait. PT services were ordered at a visit frequency of 2w7. During review of the record on 7/18/22, it was discovered that 2 PT visits were missing for week 1. There was no documentation in the record as to why the visit was missed. MR #2: The SOC was dated 7/19/21. The POC identified the diagnoses of debility, heart failure, and malaise. SN services were ordered at a visit frequency of 3w2, 3w6, and 1w1. During review of the record on 7/19/22, it was discovered that a SN visit was missing for week 1 and week 5. There was no documentation in the record as to why the visits were missed. MR #4: The SOC was dated 5/11/22. The POC identified the diagnoses of abnormal gait, weakness, and dyspnea. PT services were ordered at a visit frequency of 2w5, and 1w2. During review of the record on 7/19/22, it was discovered that a PT visit was missing for week 2. There was no documentation in the record as to why the visit was missed. During an interview on 7/21/22 at 12:45 p.m., the director of nursing (DON) and the administrator (Adm#1) acknowledged the above findings.

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, it was determined that the home health agency failed to ensure the physician orders were followed in 4 of 7 records (MR# 1, 2, 3, and 6) from a total of 7 records reviewed, resulting in the delay of services ordered, and the potential for unmet care needs for agency patients. Findings include: MR #1: The start of care (SOC) was dated 4/18/22. The plan of care (POC) dated 6/17/22, identified the diagnoses of abnormal gait. The POC documented physical therapy (PT) services ordered at a visit frequency of 2w7. During review of the record on 7/18/22, it was discovered that PT failed to do the initial comprehensive patient assessment within 48 hours of the SOC. PT did not start the initial comprehensive patient assessment until 5 days after the SOC date. There was no documentation in the record explaining the delayed start. MR #2: The SOC was dated 7/19/21. The POC dated 7/19/21, identified the diagnoses of debility, heart failure and malaise. The POC documented PT services ordered at a visit frequency of 2w4 and occupational therapy (OT) services ordered at a frequency of 1w7. During review of the record on 4/18/22, it was discovered that PT did not do their initial visit until 8/4/21, 16 days after the start SOC date. OT did not do their initial visit until 8/7/21, 19 days after the SOC date. There was no documentation in the record explaining the delayed starts. MR #3: The SOC was dated 12/6/21. The POC dated 12/6/21, identified the diagnoses of type 2 diabetes mellitus, epileptic seizures, hypertension and pain. The POC documented OT services ordered at a visit frequency of 1w1 and 2w3. During review of the record on 7/19/22, it was discovered that OT did not do their initial visit until 12/30/21, 24 days after the SOC date. There was no documentation in the record explaining the delayed start. MR #6: The SOC was dated 7/24/21. The POC dated 9/22/21, identified the diagnoses of cerebral infarct, contracture and weakness. The POC documented OT services ordered at a visit frequency of 1w1. During review of the record on 7/20/22, it was discovered that OT did not do their initial visit until 10/2/21, 10 days after the SOC date. There was no documentation in the record explaining the delayed start. During an interview on 7/21/22 at 12:45 p.m., the director of nursing (DON) and the administrator (Adm#1) acknowledged the above findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the home health agency (HHA) failed to notify the physician of any changes to the patient's ordered plan of care (POC) for 4 of 7 records (MR# 1, 2, 3, and 6), from a total sample of 7 records reviewed, resulting in the potential for unmet care needs for agency patients. Findings include: MR #1: The start of care (SOC) was dated 4/18/22. The plan of care (POC) dated 6/17/22, identified the diagnoses of abnormal gait. The POC documented physical therapy (PT) services ordered at a visit frequency of 2w7. During review of the record on 7/18/22, it was discovered that PT failed to do the initial comprehensive patient assessment within 48 hours of the SOC. PT did not start the initial comprehensive patient assessment until 5 days after the SOC date. There was no documentation in the record indicating the physician was notified of the delayed start. MR #2: The SOC was dated 7/19/21. The POC dated 7/19/21, identified the diagnoses of debility, heart failure and malaise. The POC documented PT services ordered at a visit frequency of 2w4 and occupational therapy (OT) services ordered at a frequency of 1w7. During review of the record on 4/18/22, it was discovered that PT did not do their initial visit until 8/4/21, 16 days after the start SOC date. OT did not do their initial visit until 8/7/21, 19 days after the SOC date. There was no documentation in the record indicating the physician was notified of the delayed start. MR #3: The SOC was dated 12/6/21. The POC dated 12/6/21, identified the diagnoses of type 2 diabetes mellitus, epileptic seizures, hypertension and pain. The POC documented OT services ordered at a visit frequency of 1w1 and 2w3. During review of the record on 7/19/22, it was discovered that OT did not do their initial visit until 12/30/21, 24 days after the SOC date. There was no documentation in the record indicating the physician was notified of the delayed start. MR #6: The SOC was dated 7/24/21. The POC dated 9/22/21, identified the diagnoses of cerebral infarct, contracture and weakness. The POC documented OT services ordered at a visit frequency of 1w1. During review of the record on 7/20/22, it was discovered that OT did not do their initial visit until 10/2/21, 10 days after the SOC date. There was no documentation in the record indicating the physician was notified of the delayed start. During an interview on 7/21/22 at 12:45 p.m., the director of nursing (DON) and the administrator (Adm#1) acknowledged the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is 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 HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document submission of the discharge summaries to the physician in 6 of 6 records (MR #'s 2, 3, 4, 5 and 6) discharge records, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: MR#s 2-6: During review of medical records 2-6 from 7/18/22-7/21/22, it was discovered that there was no documentation in the record that the discharge summaries were sent to the physician for review. During an interview on 7/21/22 at 12:45 p.m., the director of nursing (DON) and the administrator (Adm#1) acknowledged the above findings, and the DON said the agency does not send discharge (DC) summaries to the physician, they are available upon physician request.