Maxim Healthcare Services, Inc.

“Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the Condition of Participation for Patient Rights was met as follows: 1. The Home Health Agency (HHA) failed to report a suspected abuse to appropriate agencies and/or local enforcement authority in a timely manner for one of seven sampled patients (Patient 1). (Refer to G430). The cumulative effect of this practice resulted in the home health agency’s failure to protect the rights of admitted patient to be free and protected from suspected abuse, mistreatments, and receive an appropriate and reasonable timely care.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on interview and record review, the home health agency failed to conduct an updated assessment following a change of condition for one of 7 sampled patients (Patient 1). This deficient practice resulted in the inability to ensure the provision of quality of health for patients did not promote the wellbeing, comfort, and dignity of the patients. A review of Patient 1’s “Face Sheet” indicated Patient1, a 27-year-old was admitted on 3/22/2019 with primary diagnoses including Cerebral Palsy (is a group of conditions that affect movement and posture, it is caused by damage that occurs to the developing brain, most often before birth) and quadriplegia (s a symptom of paralysis that affects all a person’s limbs and body from the neck down). A review of Patient1’s plan of care with certification period of 12/26/2023 to 2/23/2024 indicated an order to provide in home skilled nursing services for eight (8) hours per day, five (5) days per week with goals of patient will remain within the home environment without an emergency department visit/re-hospitalization for 60 days and patient’s psychosocial, cognitive and behavioral needs will be addressed to promote positive treatment outcome for 60 days period. A review of Patient 1’s clinical records indicated no immediate update of comprehensive assessment was completed by a Registered Nurse following an incident regarding injuries of unknown cause/origin reported by Licensed Vocational Nurse (LVN1) dated 1/3/2024. A review of Patient1’s supervisor visit dated 1/6/2024 indicated in the general comments section, completed by the Clinical Manager “Received patient sitting on her wheelchair watching TV. Patient smiles responsively occasionally. Patient clean and kempt. No acute signs of pain or distress noted. No signs and symptoms of abuse or neglect noted. Patient has a scratch on her right inner thigh approximately six (6) centimeters (cm) long, with a few lighter scratches around it. Scratches appear to be healing/resolving. Patient is easily able to reach thigh area with her hands/fingernails when sitting on wheelchair. Patient’s caregiver (Patient’s father/Family Member/FM1) stated they were likely from her spasm episodes. No other scratches or injuries observed on her body. PCG was cordial and cooperative. Patient appears to be well taken care of.” During an interview with Clinical Supervisor (CS) on 1/11/2024 at 11:00 a.m., CS stated that he received a call from LVN1 on 1/3/2024 at 2:45 p.m. regarding Patient1’s scratches around the inner thighs which is suspicious because Patient 1 is likely unable to scratch the affected areas due to her limited range of motion and it was covered with clothes most of the time. CS stated that he should have conducted and updated an assessment following received of report from the LVN1 to validate it. CS stated that he reported it to his Clinical Manager (CM) to seek guidance on what will be the next step. CS stated that it is important to conduct an immediate assessment after a change of condition which includes injuries of unknown origin to ensure that proper care can be provided if needed. During an interview with the CM (Clinical Manager) on 1/11/2024 at 11:30 a.m., CM stated that he completed his assessment during his supervisory visit on 1/6/2023. CM stated that a surveyor came for the investigation on 1/5/2023 but they were unable to provide the documentations for Patient 1’s assessment. CM stated that he immediately conducted a supervisory visit and assessment the following day (1/6/2024). CM stated that an immediate assessment should have been done on top of the Licensed Vocational Nurse (LVN 1) assessment to determine if additional care can be provided and can be coordinated to the doctor. The agency was unable to provide a policy and procedure in relation to update an assessment by the registered nurse following a patient’s change of condition and/or injuries of unknown origin.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to report a suspected abuse to appropriate agencies and/or local enforcement authority in a timely manner for one of seven sampled patients (Patient 1). This failure resulted in the HHA not implementing its policy and procedures on abuse identification and reporting that had the potential for the patient to experience psychological/emotional discomfort and harm and will jeopardize patient safety. A review of Patient 1’s Face Sheet indicated Patient 1 was admitted to the agency on 3/22/2019 with the primary diagnoses including cerebral palsy (a group of conditions that affect movement and posture and it is caused by damage that occurs to the developing brain, most often before birth) and quadriplegia (a symptom of paralysis that affects person’s limbs and body from the neck down). A review of Patient 1’s Plan of Care with certification period of 12/26/2023 to 2/23/2024, indicated an order to provide in home skilled nursing services for eight hours per day, five days per week with goals of patient will remain within the home environment without an emergency department visit/re-hospitalization for 60 days and patient’s psychosocial, cognitive and behavioral needs will be addressed to promote positive treatment outcome for 60 days period. During an interview with the Licensed Vocational Nurse (LVN1) on 1/10/2024 at 9:30 a.m., LVN 1 stated she took care of Patient 1 for several years. LVN 1 stated that Patient 1’s father is the only closest relative that takes care of her. LVN 1 stated that she takes care of Patient 1 for several days during weekdays (day shift) and Patient 1’s father takes care of her during nights and on weekends. LVN 1 stated there is no other caregiver that was assigned to Patient 1. LVN 1 stated that on 1/3/2024 at 2:45 p.m., she called the agency and spoke with the Clinical Supervisor (CS) to inform that Patient 1 has suspicious and unexplained superficial scratches of unknown origin on her inner left (six superficial scratches) and right (18 superficial scratches) thigh/upper leg areas. LVN 1 stated that Patient 1 was unlikely to reach her thigh areas due to her limited range of motion to her upper extremities. LVN 1 stated that she has not seen Patient 1 scratching her thighs before. LVN 1 stated that she is unsure if it is a suspected abuse. LVN 1 further stated that Patient 1’s father sometimes expressed frustrations verbally when Patient 1 was being difficult to be taken care of. LVN 1 stated Patient 1 is nonverbal and unable to follow commands. LVN 1 stated that she is unsure if this is an abuse that is why she called the CS for guidance. LVN 1 stated that the suspected abuse must be reported immediately to responsible authorities to investigate. LVN 1 stated that she is unsure if this was abuse and stated she does not want to accuse anyone. LVN 1 stated that she should have reported it immediately even if she was unsure if abuse was occurred. During an interview with CS (Clinical Supervisor) on 1/11/2024 at 11:00 a.m., CS stated that he received a call from LVN 1 on 1/3/2024 at 2:45 p.m. regarding Patient 1’s scratches around the inner thighs which is suspicious because Patient 1 is likely unable to scratch the affected areas due to her limited range of motion and it was covered with clothes most of the time. CS stated that per LVN 1, Patient 1 had no scratches to the affected areas before. CS stated that LVN 1 told him that she is unsure of what to report aside from what she observed. CS stated that she told to LVN 1 that the situation will be reported to the Clinical Manager (CM) and will seek advice on how to move forward. CS stated that on 1/4/2024 at 11:30 a.m., after he reported the incident to the CM, he spoke with LVN 1 which she later stated that she is now wanting to report a possible abuse to Patient 1. CS stated that upon learning, the CM started the process of reporting the suspected abuse to responsible authorities/agencies. CS stated that he followed the chain of command by reporting the incident to CM. CS stated that he should have started the suspected abuse reporting as he is also a mandated reporter. During an interview with the CM (Clinical Manager) on 1/11/2024 at 11:30 a.m., CM stated that when the agency received report of suspected abuse, they will notify Adult Protective Services (APS), Child Protective Services (CPS)/if applicable, California Department of Public Health (CDPH), and local district office which is Los Angeles Department of Health. CM stated that the report should be made immediately. CM stated the suspected abuse was first reported by LVN 1 to CS on 1/3/2024, he stated that it was not reported to him until 1/4/2024. CM stated that upon receiving report from the CS, she reported it to CDPH, APS, and local district office on 1/4/2024. CS stated that he did not call the local enforcement agency/police department on 1/4/2024 and stated he should have called the police department immediately upon learning of suspected abuse to ensure Patient 1’s safety. CM stated that she conducted home visit on 1/6/2024. A review of Patient 1’s clinical notes dated from 1/3/2024 to 1/4/2024, indicated no documentation that the local police authority was immediately informed of the suspected abuse. The Department notified of incident about suspected abuse on 1/4/2024 at 12:32 p.m. A review of the agency’s policy and procedure titled “Abuse, Neglect or Exploitation”, revised 7/14/2023, indicated that employees who identify, notice, suspect or recognize incidences or circumstances of physical abuse including injuries of unknown source must report observations/concerns immediately to the agency and other appropriate authorities in compliance with applicable laws and regulations, alleged incidences or circumstances will be reported to enforcement agencies according to applicable laws and regulations which include state law enforcement. The policy further indicated alleged incidences will be reported first to the Legal Department and then to enforcement agencies according to applicable laws and regulations. These agencies may include but not are not limited to State Law Enforcement and State Survey and Certification agencies. A review of the agency’s undated policy and procedure titled “Mandated Reporters”, indicated that each employee and contractor of the agency, regardless of their job title or responsibilities, is required to report any known, suspected, or perceived allegation of abuse, neglect or exploitation towards a child, an elder, or an individual with developmental disabilities. The policy further indicated that it is not the job of the mandated reporters to determine whether the allegations are valid, is the employee’s responsibility to report.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) staff failed to review all the medications and update the medication profile with currently used medications for two of seven sampled patients (Patient 4 and Patient 5). This deficient practice had the potential to put patients at risk for medication errors and adverse drug reactions. Findings: a. A review of Patient 4’s Face Sheet indicated a start of care date (SOC) of 7/18/2023 with a primary diagnosis of other congenital malformation syndrome (structural or functional anomalies that occur during intrauterine life; also called birth defects, congenital anomalies, or congenital malformations). During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 1/10/2024 at 11:30 a.m., Patient 4 was observed sitting on a highchair, awake, and alert. A medication review was completed during the home visit with LVN 2. Upon medication review, it was noted that Patient 4 had stopped taking the following medications: - - Vitamin D3 (vitamin) 400 unit/m (unit of measure). - - Simethicone (a medication used to relieve symptoms of gas/bloating) 40 milligram (mg, a unit of mass)/0.6 milliliter (ml, a unit of capacity) oral drops. - - Mupirocin (a medication used to treat skin infections) 2 percent (%, a unit of portion) topical ointment. - - Dorzolamide (a medication used to treat eye pressure) eye drops. All four medications were listed in Patient 4’s current medication profile as current (active) medications. During an interview with Family Member 2 (FM 2) on 1/10/2024 at 12:10 p.m., FM 2 stated that Vitamin D3 400 unit/ml was discontinued by the physician in August 2023. FM 2 stated that Simethicone 40 mg/0.6 ml oral drop was discontinued about a year ago and that she no longer kept the medication at home. FM 2 further stated that Patient 4 was no longer using Mupirocin 2% topical ointment. Per FM 2, Patient 4 only used it for two to three weeks following her craniofacial surgery (surgical procedure to correct issues with the head, skull, face, and neck) on the incision site, but since it completely healed, then she did not need it anymore. According to FM 2, Dorzolamide eye drop was discontinued on 1/5/2024. FM 2 acted as the primary caregiver for Patient 4. During an interview with LVN 2 on 1/10/2024 at 12:30 p.m., LVN 2 stated that the field nurse was the one that supposed to check with the patient or the family if there was any change in medications. LVN 2 stated that it was important to have an updated medication profile, so the patient or the family would not administer the discontinued medications. b. A review of Patient 5’s Face Sheet indicated a start of care date (SOC) of 5/2/2014 with diagnoses that included epilepsy (a long-term/chronic disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells) and congenital malformation of face and neck (structural or functional anomalies that occur during intrauterine life; also called birth defects, congenital anomalies, or congenital malformations). During a joint home visit with Licensed Vocational Nurse 3 (LVN 3) on 1/10/2024 at 5:00 p.m., Patient 5 was observed lying down in a crib, awake. A medication review was completed during the home visit with LVN 2. Upon medication review, it was noted that the medication profile for Patient 5 was listed Glycopyrrolate 0.2 mg/ml injection solution, 5 ml/1 mg, as needed three times daily for excess secretions. The medication found at Patient 5’s residence was Glycopyrrolate 0.2 mg/ml oral solution. During an interview with LVN 3 on 1/10/2024 at 6:00 p.m., LVN 3 stated that the Glycopyrrolate was given through the jejunostomy tube/J tube (a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine). LVN 3 stated the Glycopyrrolate was not an injection solution. LVN 3 stated, “It’s important to have the right medication, right dose, right route, right time, and of course right patient to prevent medication error.” During an interview with the Clinical Manager (CM) on 1/11/2024 at 3:40 p.m., the CM stated that medication profile needed to be kept current and updated. According to CM, it was important to maintain an updated medication profile to monitor drug interactions, adverse reactions, and for patient teaching. A review of the HHA’s policy, titled “Medication Profile,” revised 4/9/2021, indicated that patients receiving medications will have a current and accurate medication profile maintained in the medical record and the home folder. The policy indicated the Medication Profile will include a list of all current patient medications, prescribed, over the counter (OTC) or herbal remedies, name of the medication, dose, frequency, date started and/or discontinued, and other comments (as appropriate). The policy further indicated the patient’s medications are reviewed and compared to the Medication Profile during each skilled shift/visit.”

“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 observation, interview, and record review, the Home Health Agency (HHA) failed to formulate a plan of care (POC - information identified based upon the patient identified needs and development of appropriate interventions) to two of 7 sampled patients (Patient 1and Patient 2). This failure had the potential in a lack of coordination of the plan of care with the patient and other clinicians involved in the patient care and treatment. A review of Patient 1’s (P1) “Face Sheet” indicated P1, a 27-year-old was admitted on 3/22/2019 with primary diagnoses including Cerebral Palsy (is a group of conditions that affect movement and posture, it is caused by damage that occurs to the developing brain, most often before birth) and quadriplegia (s a symptom of paralysis that affects all a person’s limbs and body from the neck down). A review of P1’s plan of care with certification period of 12/26/23 to 2/23/24 indicated an order to provide in home skilled nursing services for 8 hours per day, 5 days per week with goals of patient will remain within the home environment without an emergency department visit/re-hospitalization for 60 days and patient’s psychosocial, cognitive and behavioral needs will be addressed to promote positive treatment outcome for 60 days period. A further review indicated no plan of care was updated/formulated for P1’s injury of unknown origin and/or suspected physical abuse. During an interview with CS (Clinical Supervisor) on 1/11/24 at 11:00 a.m., CS stated that a care plan should have been formulated for P1’s injury of unknown origin and suspected physical abuse to have a better coordination between clinicians and to ensure that appropriate needs have been addressed. A review of the agency’s policy and procedure titled “Home Health Certification and Plan(s) of Care”, revised date of 7/14/23, indicated that the care planning process will be documented on the plan of care, which includes individualized discipline-specific notes, clinical notes and case conference notes, the care planning process begins with the admission assessment and continues through agency discharge.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure that drugs, services, and treatments are administered only as ordered by a physician for one of 7 sampled patients (Patient 5). This deficient practice resulted in necessary interventions not planned and applied, potentially affecting patient outcomes. Findings: A review of Patient 5’s indicated a start of care date (SOC) of 5/2/2014 with diagnoses that included epilepsy (a long-term/chronic disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells) and congenital malformation of face and neck (structural or functional anomalies that occur during intrauterine life; also called birth defects, congenital anomalies, or congenital malformations). During a joint home visit with Licensed Vocational Nurse 3 (LVN 3) on 1/10/2024 at 5 p.m., Patient 5 was observed lying down in a crib, awake. Observed Patient 5 receiving feeding through a feeding pump, administered at 42 ml/hour. The content of the feeding bag was a bright orange liquid. During an interview with Family Member 3 (FM 3) on 1/10/2024 at 5:10 p.m., FM 3 stated that Patient 5 had been having a cold and was having congestion and spit-ups as a result. FM 3 stated she had a telehealth session with Physician 1 on 1/9/2024. According to FM 3, Physician 1 instructed her to hold Kate Farms Pediatric Peptide 1.5 and replace it with Pedialyte to ease the spit ups and congestion. FM 3 stated that Physician 1 said she could administer the Pedialyte at a slower rate than she normally did with Kate Farms so that Patient 5 would tolerate it. A review of supplemental physician order for Patient 5, dated 1/5/2024, indicated that the formula ordered by the physician was Kate Farms Pediatric Peptide 1.5 at 52 ml/hour from 8 a.m. to 10 p.m. During an interview with LVN 3 on 1/10/2024 at 5:20 p.m., when LVN 3 was asked for the physician’s order regarding the Pedialyte, LVN 3 stated that since Pedialyte was available over the counter, a physician’s order was not required. However, LVN 3 also stated that without a physician’s order it would be hard to monitor if there were any side effects or if the medication or treatment was effective. During an interview with the Clinical manager (CM) on 1/11/2024 at 3:30 p.m., the CM confirmed there was no documentation of physician’s order for the Pedialyte for Patient 5. The CM stated that a physician’s order was required for all medications and treatments, including feeding, so that the patient could be monitored properly for adverse effects and drug interactions. A review of the HHA’s policy, titled “Confirmation of Supplemental Ordering Practitioner Orders,” revised 4/9/2021, indicated that orders will be obtained from a licensed ordering practitioner for care and services to be provided to home health patients.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to document a verbal order regarding enteral feeding and have it authenticated and dated by the physician for one of 7 sampled patients (Patient 5). This deficient practice had the potential to result in error in the care provided to the patient. A review of Patient 5’s indicated a start of care date (SOC) of 5/2/2014 with diagnoses that included epilepsy (a long-term/chronic disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells) and congenital malformation of face and neck (structural or functional anomalies that occur during intrauterine life; also called birth defects, congenital anomalies, or congenital malformations). During a joint home visit with Licensed Vocational Nurse 3 (LVN 3) on 1/10/2024 at 5 p.m., Patient 5 was observed lying down in a crib, awake. Observed Patient 5 receiving feeding through a feeding pump, administered at 42 ml/hour. The content of the feeding bag was a bright orange liquid. During an interview with Family Member 3 (FM 3) on 1/10/2024 at 5:10 p.m., FM 3 stated that Patient 5 had been having a cold and was having congestion and spit-ups as a result. FM 3 stated she had a telehealth session with Physician 1 on 1/9/2024. According to FM 3, Physician 1 instructed her to hold Kate Farms Pediatric Peptide 1.5 and replace it with Pedialyte to ease the spit ups and congestion. FM 3 stated that Physician 1 said she could administer the Pedialyte at a slower rate than she normally did with Kate Farms so that Patient 5 would tolerate it. A review of supplemental physician order for Patient 5, dated 1/5/2024, indicated that the formula ordered by the physician was Kate Farms Pediatric Peptide 1.5 at 52 ml/hour from 8 a.m. to 10 p.m. There was no supplemental physician order regarding the Pedialyte. During an interview with LVN 3 on 1/10/2024 at 5:20 p.m., LVN 3 stated she was not sure who received the order. LVN 3 stated the Pedialyte was started the day before. LVN 3 stated she did not work the previous day. During an interview with the Clinical Manager (CM) on 1/11/2024 at 3:30 p.m., the CM confirmed there was no documented evidence in the patient’s clinical record that the verbal order was verified, signed, and dated by the physician. The CM stated the order for Pedialyte was a verbal order received by FM 3 from a doctor via Telehealth. When asked about the process when there was a new order from a physician, the CM stated, “ Whoever received the order should generate a supplemental physician order; it’s a form that we fill out. The nurse or LVN on duty should notify the RN (Registered Nurse) Supervisor, after that the LVN should attempt to call the MD office to verify the order. The white copy of supplemental order must be sent to the office and the yellow carbon copy remains on the patient’s binder.” The CM further stated that a physician’s order was required for all medications and treatments, including feeding, so that the patient could be monitored properly for adverse effects and drug interactions. A review of the HHA’s policy, titled “Confirmation of Supplemental Ordering Practitioner Orders,” revised 4/9/2021, indicated that orders will be taken and documented only by a qualified clinician. The policy indicated that each order will be obtained, read back, and entered into the system of record as a supplemental order. Each order received by a LVN and/or LPN will be reviewed and counter-signed by a qualified clinician.”