Maxim Healthcare Services, Inc.

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the coordination of care with all agencies providing services for one patient (#3), out of 6 active clinical records reviewed. This failed practice placed the identification of patient’s needs and factors not being known or implemented, which has the potential to affect the patient’s safety and treatment effectiveness and the coordination of care provided by the agency and other agencies, including a hospice agency. Findings: Record review on 3/26/24 – 4/1/24 revealed Patient #3 was admitted on 5/27/21 with diagnoses that included tuberous sclerosis (a rare genetic disease that causes non-cancerous tumors to grow in the brain and other parts of the body) and seizures (sudden, uncontrolled electrical activity in the brain that cause changes in behavior, movements, and levels of consciousness). The certification period of 3/12/24 – 5/10/24 failed to include documentation of the coordination of care with the hospice, who also completed care with this patient. The hospice orders and hospice plan of care were not included in the record. There were not specific lists of what services or a complete listing of medications or supplies the hospice provided, nor who to call at the hospice for clinical support or leadership. Review of the record revealed the Plan of care for the Certification Period of 3/12/24 - 5/10/24. This plan of care revealed: “[Patient #3] remains on hospice services but is currently stable so hospice kit/protocol is not being utilized. [Hospice kit meds of morphine, lorazepam, and haloperidol were securely stored upstairs away from [his/her] bedroom. [The hospice physician] did a brief visit in January 2024 and deemed [[him/her] stable.” There was no information on the plan of care showing which services the hospice provided or a complete list of medications or supplies were supplied by the hospice. The hospice name, contact information, or phone number were not on the plan of care or present in in a documentation or a communication. Review of Patient #3’s “Care Coordination note,” completed by Licensed Nurse #1 and dated 3/7/24, addressing hospice services revealed: “[Patient #3] remains on hospice services but is currently stable so hospice kit/protocol is not being utilized.[TML1] . [The hospice physician] did a brief visit in January 2024 and deemed [him/her] stable.” Review of the record revealed a Clinical Note entry, dated 4/1/24 and signed by the Interim Clinical Manager. This note revealed: “Late entry for 3/27/24 and 3/28/24. Called [name of hospice agency] and left messages to speak with the case manager for [Patient #3]. Left office and cell call back numbers.” During an interview on 3/28/24 at 10:15 AM, when asked how long the patient had been on hospice and how that referral and admission had occurred, the Primary Caregiver of Patient #3 stated Patient #3 was placed on hospice over two years ago after a hospitalization for respiratory difficulty. The hospice nurse visits every two weeks, and the hospice physician visits every two months. During an interview on 4/1/24 at 2:40 PM, the Administrator and Interim Clinical Manager agreed that there was lack of coordination of services with the hospice who cared for Patient #3. There was no knowledge or inclusion of the hospice’s plan of care or the terminal illness diagnosis. There was not a complete list of medications, supplies, physician orders, and services the hospice supplied to the patient. The home health agency had not coordinated or shared their care or plan of care with the hospice. The Interim Clinical Manager added that she had reached out to the hospice late last week. No reply had been received at this time. Review of the agency’s policy “Care Coordination/Case Conference,” dated 10/7/22, revealed: “Purpose: To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services ... to facilitate effective communication amongst the health care team ... Care coordination must be accomplished at least once every certification period. Evidence of the care coordination must be documented in the medical record or system of record.””