Maxim Healthcare Services Inc.

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to include all required elements in the clinical record. Specifically, the agency failed to ensure the clinical record included an accurate and complete medication administration record (MAR) for 1 of 3 sample patients who received medication administration services (Patient #1). Findings include: The clinical record for Patient #1 was reviewed on 8/6/26. Plan of care orders for the certification period dated 4/10/26 to 6/8/26 revealed a start of care date of 4/10/26; diagnoses included unspecified protein-calorie malnutrition, dysphagia, and hypertension. Plan of care orders included skilled nursing twice a day for enteral tube feedings. a) The agency failed to ensure the clinical record for Patient #1 included an accurate and complete MAR. Review of the clinical record revealed a typed and printed paper MAR. The MAR included spaces designated for handwritten confirmation when each medication was administered by the skilled nurse. The skilled nurse documented by writing the time of administration and initialing in the designated space next to the typed medication information (information included the name of medication as well as the medication dose, route of delivery, and ordered frequency for administration). Review of the MAR from 4/10/26 through 8/6/26 revealed no MAR was kept from 4/10/26 to 5/16/26. Additionally, on 5/22/26 and 5/23/26, the MAR had handwritten notes, “See MAR,” placed in the designated spaces instead of the skilled nurse’s initials and times the medications were administered. During an interview on 8/6/26 at 9:25 a.m., the agency administrator stated the expectation was for the paper MAR to be accurate and kept up to date, and for the paper MAR to be scanned or sent to the agency weekly to be maintained in the clinical record. During an interview on 8/6/26 at 1:58 p.m., Employee #8, a clinical supervisor, stated there was a legend on the MAR for skilled nurses to use if a medication was not administered. The clinical supervisor stated the nurse’s note “See MAR” was not appropriate documentation and did not provide information regarding whether the medication was administered or not. The clinical supervisor further stated the nurse possibly mixed up words and the nurse’s note to “See MAR” may have meant to look for more information in the nurse visit notes. Review of the nurse visit notes from 5/22/26 and 5/23/26 did not reveal information regarding when medications were administered or which specific medications had been administered to Patient #1.”

“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 interviews and record reviews the agency failed to ensure services and treatments were provided as ordered by a physician for 1 of 3 active patient records receiving Certified Nurse Aide (CNA) services (Patient #3). This deficiency was cited previously during a recertification survey on 7/1/21. Although the agency corrected the deficiency, based on the findings below, the agency had not maintained compliance with this regulatory requirement. Findings include: 1. The clinical record for Patient #3 was reviewed on 4/8/24. The plan of care for the certification period dated 2/7/24 to 4/6/24, revealed a start of care date of 10/20/21; diagnoses included paraplegia, injury to thoracic spine level two to six, cerebral infarction, aphasia stage 2 pressure ulcer of sacral region, encounter for fitting and adjustment of urinary device, neuromuscular dysfunction of bladder, orthostatic hypotension and right upper arm contracture. Plan of care orders included skilled nursing (SN) visits once daily and one visit as needed (PRN) for medication administration and suprapubic catheter change every three weeks; and CNA visits seven to eight times daily. a) The agency failed to ensure the CNA provided all tasks in accordance with the care plan. Review of the CNA care plan, dated 10/20/21 to present, showed Patient #3 received seven visits daily consistently. Continued review of the care plan showed Patient #3 was to receive skin care, assistance with transfers, repositioning, toileting and peri-care during every visit; empty catheter bag during visits #1 through #6; catheter care, passive range of motion (PROM), assistance with dressing, incontinence brief changes, regular diet meal preparation and serving, assistance with feeding and fluid encouragement twice daily; and nail care, shaving, bathing, mouth care, bed making and cleaning bedroom and bathroom once daily. Review of completed CNA timesheets from 2/25/24 to 3/23/24 showed Patient #3 failed to receive services as ordered. Specifically: -Patient #3 did not receive the task of nail care at all; -Patient #3 only received shaving during four visits; -Patient #3 only received PROM once daily; and -Patient #3 did not receive assistance with transfers, repositioning, toileting and peri-care at each visit. During an interview during a home visit on 4/9/24 at approximately 9:00 a.m., CNA #7 stated she assisted the patient with bathing, meal preparation, oral care, hair care, transfers using a sliding board, skin care including cleaning the catheter site, bowel program every other day and “sometimes” emptied the catheter bag. During the same interview, the director of nursing (DON) stated the agency tried to provide additional supervision to family CNAs to ensure services were provided as ordered and the patients were safe. During an interview on 4/9/24 at 3:52 p.m., the administrator and DON acknowledged CNA #7 was not providing all tasks in accordance with the care plan. During an interview on 4/11/24 at 10:01 a.m., the DON stated the agency completed quarterly record reviews of approximately 25% of the records, but acknowledged the people completing the quality reviews were reviewing the quality of the notes and to verify the shifts were completed. She confirmed the quality reviews were not ensuring all tasks were completed in accordance with the care plan. She further stated there was already a corrective action plan in place for CNA #7 for issues related to the timeliness and quality of her documentation.”