Maxim Healthcare Services Inc.

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program Plan (EP) and interview, the Home Health Agency (HHA) failed to ensure the plan was based on an all-hazards approach that was specific to the location of the agency. This deficient practice placed 78 patients at risk for negative outcomes. Findings include: Review of the “Hazard Vulnerability Analysis,” dated 2023, located in the agency’s “Las Vegas Emergency Management Plan,” dated 09/12/24, identified that “Emerging Infectious Diseases” was a low probability, while “Blizzard, Earthquake, Flooding and Fire” were a high probability. Review of emergency preparedness training contents located in the “Las Vegas Emergency Management Plan” included “Active Shooter” and “Fire Prevention.” “Active shooter” was not on the list of events noted on the “Hazard Vulnerability Analysis” and training contents for the high probability events of “Blizzard, Earthquake and Flooding” were not available. Review of the policy titled, “Emergency Preparedness Program,” revised 04/05/2024, indicated that “The office will develop and maintain an emergency preparedness communication plan based on the Hazard Vulnerability Analysis that complies with Federal, State, and local laws and must be reviewed and updated at least annually.” The 2023 “Hazard Vulnerability Analysis” was not updated. Review of the “Emergency Prep (EP) Survey Prep Checklist” located in the “Las Vegas Emergency Management Plan” revealed that “HVA [Hazard Vulnerability Analysis] should be all hazards approach based on office location.” During an interview on 05/14/25 from 12:15 PM to 1:30 PM, the Administrator and Clinical Manager confirmed that the “Hazard Vulnerability Analysis” probability ratings of events was not applicable to the agency location. The Clinical Manger revealed the “Emerging Infectious Diseases” should not be a one, low probability; “Blizzard, Earthquake and Hurricanes” should not be a three, high probability.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program Plan (EP) and interview, the Home Health Agency (HHA) failed to have a communication plan that included phone numbers of employees, contractors, and physicians to ensure there was no delay in response to emergencies. This deficient practice had the potential to affect all 78 patients receiving services from the HHA. Findings include: Review of the “LAS VEGAS DISASTER PLAN EMERGENCY PHONE TREE 2024” located in the 09/12/24 “Las Vegas Emergency Management Plan” identified the names of employees to include but not limited to the Administrator, Clinical Supervisors, Skilled Team, and Field Support with a brief description of responsibilities. For example, the Clinical Supervisor was to “Contact High Risk clients, Assist with directing activities.” The phone tree did not include the phone numbers or contact information of the employees. Review of the Agency’s “Las Vegas Emergency Management Plan,” dated 09/12/24, provided by the Administrator, indicated the importance of having employees phone numbers as follows: “The Government Emergency Telecommunications Service (GETS) provides offices which are enrolled [Maxim Healthcare Services], priority access and prioritized processing in the local and long-distance segments of the landline networks, greatly increasing the probability of call completion. It allows calls to be completed in an emergency or crisis situation when the network is congested and the probability of completing a normal call is reduced…GETS is intended to be used as an enhancement for Emergency Preparedness.” Review of the “Las Vegas Emergency Management Plan” section dated 09/12/24, titled, “Emergency Communication Plan” item six revealed that “Emergency Supervisors begin calling patients via telephone or alternate form of communication in order of priority (High Risk patients, then Medium Risk patients and finally Low Risk patients).” Item seven, “Emergency Supervisors begin calling caregivers to check on availability and verify contract phone numbers.” Telephone landline or cell phone numbers were not available on the agency’s emergency management plan. Review of the policy titled, “Office Specific Emergency Planning,” revised on 01/17/25, revealed that “The Office Operations Leader or Designee will maintain names and contact information for the following: Caregivers, Patients, Patient’s ordering practitioners, and Entities providing services to patients. Identify alternate means of communicating with the above list. Alternate means of communication may include: In person, Cellular phone, Landline phone...” During an interview on 05/14/25 at 12:15 PM with the Administrator and Clinical Manager regarding the emergency phone tree, confirmed phone numbers of employees were not contained on the phone tree. The Clinical Manager stated, “Phone numbers are included in (name of electronic software); we print it out.””

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program Plan (EP) and interview, the Home Health Agency (HHA) failed to include a method for sharing information and medical documentation for patients under their care with other healthcare providers to maintain continuity of care. This deficient practice had the potential to negatively affect all 78 patients receiving services from the HHA. Findings include: Review of the Agency’s “Emergency Communication Plan” located in the “Las Vegas Emergency Management Plan,” dated 09/12/24, provided by the Administrator, revealed the agency did not document a means for sharing of information and medical documentation of patients with the next care provider. Review of the policy titled, “Emergency Preparedness Program,” revised on 04/05/24, revealed that the “Emergency Communication Plan” will have “A means for sharing information and medical documentation for patients under the HHA’s care, as necessary, with other health care providers to maintain the continuity of care.” Review of the policy titled, “Office Specific Emergency Planning,” revised 01/17/25, included the following information: “Identify primary and secondary method of sharing Continuity of Care Form with other agencies.” During an interview on 05/14/25 from 12:15 PM to 1:30 PM, the Administrator and Clinical Manager confirmed that sharing patient information was not in the emergency preparedness plan. The Clinical Manager revealed they share information electronically and the family would be responsible if patients were transferred to another entity.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on document review and interview, the Home Health Agency (HHA) failed to electronically transmit completed OASIS assessments (a comprehensive patient assessment) to the Centers for Medicare and Medicaid Services (CMS) system within 30 days after completing the assessment. OASIS assessments for three of 17 OASIS assessments submitted Quarter 3 of 2022, three of 14 OASIS assessments submitted Quarter 4 of 2024, and nine of 24 OASIS assessments submitted Quarter 1 of 2025 were submitted to CMS greater than 30 days after completion of the assessment. Findings include: Review of “The CMS OASIS Assessment Reference Manual” directs OASIS assessment must be transmitted to CMS within 30 days of completion. Review of the “OASIS submission data” reported the HHA failed to transmit completed OASIS information and received confirmation the OASIS assessment was accepted by CMS as required for of three of 17 OASIS assessments submitted for the third quarter of 2022, three of 14 OASIS assessments submitted the fourth quarter of 2024, and nine of 24 OASIS assessments submitted the first quarter of 2025. Interview with the Clinical Manager on 05/14/25 at 9:30 AM, stated the HHA used the CMS manual for the completion and transmission instructions for the completion and submission of the patients’ OASIS assessments. The Clinical Manager confirmed the HHA had failed to submit OASIS assessments within 30 days of completion.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on interview and document review, the Home Health Agency (HHA) failed to provide at least one additional service along with skilled nursing services for 78 current patents receiving skilled nursing services. Findings include: Review of the employee listing from the HHA revealed there were only skilled nurses and office staff that do not provide patient care employed by the HHA. An interview with the Administrator and the Clinical Manager on 05/14/25 at 11:30 AM confirmed the HHA did not employ any staff other than skilled nurses.”