Maxim Healthcare Services, Inc.

“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 observation, interview, and record review, the Home Health Agency (HHA) failed to ensure interventions for patient/caregiver teaching on checking placement prior to gastrostomy (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food) feeding, was implemented in accordance with the plan of care for one of seven sampled patients (Patient 5). This deficient practice placed Patient 5 at risk for G-tube complications such as the G tube being misplaced from the stomach and could lead to aspiration pneumonia (lung infection that occurs when food or stomach contents enter the lungs). During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 3/5/2020, with diagnoses including encounter for attention to gastrostomy and disorder of bone density and structure. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period starting from 12/9/2024 to 2/5/2025, the POC included an order for the licensed vocational nurse (LVN) to provide skilled nursing at 144-180 hours per month for the 60-day certification period, and registered nurse (RN) supervisory visit at least once every 60 days and two visits as needed for supervision, case management and resumption of care. The POC included a G-tube enteral (directly to the stomach) feeding order of Peptamen Junior (formula) one could be mixed with Duocal (high calorie) 75 grams with water to equal 15 ounces, and 450 milliliters to give by G-tube, and to educate patient/caregiver on all care including G-tube placement check for proper placement prior to feeding. On 1/15/2025, at 11 a.m., a home visit was conducted at Patient 15’s residence with Registered Nurse (RN 1). Patient 5 was observed with a G-tube (Mic-Key button size 14 french) located at mid stomach area dry and intact. On 1/15/2025, at 11:30 a.m., during an interview with family member (FM 1), she stated she provided the enteral feeding, and that she (FM1) was not instructed by the visiting nurse to check G-tube placement before providing feedings to Patient 5. During an interview, on 1/16/2025, at 11:45 a.ml, with the Director of Patient Care Services (DPCS), the DPCS stated the visiting nurse should have provided patient care teaching on G-tube placement to FM1 to check prior to feeding to ensure that the tube was properly positioned in the stomach to prevent aspiration. During a review of the agency’s policy and procedure (P&P) titled, Home Health Certification and Plan of Care, dated 7/9/2018, the P&P indicated the Home Health Certification and Plan of Care (485) is the ordering practitioner’s order for home care services. The Plan of Care will be individualized to include, but not limited to, all treatments, procedures, medications, and services authorized to be provided by direct care staff(s). The Plan of Care shall include, but not limited to identified patient problems to include diagnoses and surgical procedures”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to update the comprehensive assessment (in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) within 48 hours of the patient’s return to home from a hospital admission, for one of seven sampled patients (Patient 1). This deficient practice had the potential to not to meet Patient 1’s needs. Findings: During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 1 was admitted on 6/18/2024, with a diagnosis that includes short bowel syndrome with colon in continuity (a rare condition that occurs when a patient has less than 200 cm [centimeter, a unit of measure] of small intestine remaining, but still has a colon [also known as the large intestine, is a tube-shaped organ that removes water and nutrients from food waste and passes it to the rectum]), and encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). During a review of Patient 1’s Resumption of Care (ROC) Visit Note, dated 1/6/2025 and conducted by Registered Nurse 1 (RN 1), the ROC indicated Patient 1 was admitted to GACH 1 (General Acute Care Hospital) on 12/13/2024 for abnormal laboratory results and was discharged back to home on 12/26/2024. During an interview with RN 1, on 1/16/2025 at 11:20 a.m., RN 1 stated Patient 1 came back home from a hospital admission on 12/26/2024. RN1 stated she conducted the ROC visit to update Patient 1’s comprehensive assessment on 1/6/2025. RN 1 stated the delay on the ROC visit assessment was due to lack of communication from Patient 1’s family member. During an interview, on 1/16/2025, at 12:45 pm., with the Director of Patient Care Services (DPCS), the DPCS stated an update to the comprehensive assessment should be conducted within 48 hours of patient’s return to the home from a hospital admission of 24 hour or more. DPCS stated and acknowledged the findings. During a review of the agency’s policy and procedure (P&P) titled, Reassessments/Recertifications, revised date 10/4/2024, the P&P indicated a comprehensive reassessment and recertification assessment is conducted by a qualified clinician to identify the patient’s current health status and continued needs for home health services. A follow-up comprehensive assessment is conducted by a qualified clinician within 48 hours of a patient’s discharge from the hospital, or within 48 hours of agency knowledge of the hospital discharge, or on the date as ordered by the physician. This assessment is referred to as a Resumption of Care (ROC).”

“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 interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to develop an individualized plan of care (POC) that included problems, goals and interventions for one of seven sampled patients (Patient 2), who had a diagnosis of epilepsy (a chronic brain disorder that causes seizures, which are brief episodes of abnormal electrical activity in the brain that causes a temporary change in behavior, movement, or consciousness) and was taking anti-seizure medications. This failure had the potential to result in Patient 2 not receiving the identified needs and services, which could lead to a decline in his health status and/or injury. Findings: During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 2 was admitted on 12/14/2000, with a diagnosis that includes moderate intellectual disabilities, encounter for attention to gastrostomy (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and epilepsy, unspecified. During a review of Patient 2’s POC for certification period from 12/10/2024 to 2/7/2025, included an order for the licensed vocational nurse (LVN) to provide skilled nursing at 45-56 hours per week for the 60-day certification period, and registered nurse (RN) supervisory visit at least once every 60 days and two visits as needed for supervision, case management and resumption of care. The POC indicated an order to administer two anti-seizure medications to Patient 2: Oxcarbazepine 300 milligrams(mg)/5 milliliter (ml) oral suspension give 6ml/360mg two times daily via g-tube, and Klonopin 0.5 mg tablet give 1 tablet two times daily via g-tube. The POC indicated there were no nursing precautions for seizures protecting the patient from injury and keeping their airway clear. During an interview, on 1/16/2025 at 12:45 pm., with the Director of Patient Care Services (DPCS), the DPCS stated Patient 2’s POC should have included seizure precautions to keep the patient safe and free from injury in case of a seizure activity. During a review of the agency’s policy and procedure (P&P) titled, Home Health Certification and Plan of Care, dated 7/9/2018, the P&P indicated the Home Health Certification and Plan of Care (485) is the ordering practitioner’s order for home care services. The Plan of Care will be individualized to include, but not limited to, all treatments, procedures, medications, and services authorized to be provided by direct care staff(s). The Plan of Care shall include, but not limited to identified patient problems to include diagnoses and surgical procedures.”

“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 interview, and record review the Home Health Agency (HHA) failed to notify the physician for one of seven sampled patients (Patient 4) of a change of condition. This failure had the potential to result in the delay to provide further treatment and interventions for Patient 4. During a review of Patient 4’s Personal Information, the Personal Information indicated a start of care date of 11/16/2022 with a primary diagnosis of Guillain-Barre syndrome (a condition in which the immune system attacks the nerves). During a review of Patient 4’s Home Health Certification and Plan of Care (POC) for the certification period starting from 1/4/2025 to 3/4/2025, the POC indicated an order for the licensed vocational nurse (LVN) to provide skilled nursing at 48-56 hours per week for the 60-day certification period, and Registered Nurse (RN) supervisory visit at least once every 60 days and 2 visits as needed for supervision, case management and resumption of care. The POC included an order for skilled nurse to observe and monitor client each shift and as needed for any changes in patient condition, and to report all adverse changes to the physician. During a review of Patient 4’s Skilled Nursing Note dated 1/6 and 1/12/2025, the Skilled Nursing Note indicated Patient 4 had a productive cough. The Skilled nursing Notes did not indicate the HHA notify Patient 4’s physician. During an interview on 1/16/2025, at 12 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated there was no documented communication note found that the visiting nurse notified the physician of Patient 4’s existing productive cough episodes. During a review of facility’s policy and procedure titled “Ongoing Evaluation” revised 7/1/2022, indicated “Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. The patient’s physician will be contacted on the same day when any of the following occur: Changes in the patient’s condition. Changes that have occurred regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations).””