Maxim Healthcare Services Inc.

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to determine that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired before it discharged two of three patients reviewed (Patients #115 and #116). This could affect all patients receiving services from the agency. The patient census was 114. Findings include: 1. Review of Patient #116’s medical record revealed a 04/08/23 start of care date. Diagnoses included anoxic brain damage, chronic respiratory failure with hypoxia, encounter for attention to tracheostomy, encounter for attention to gastrostomy, encephalopathy, protein calorie deficit, asthma, psychoactive substance abuse, muscle wasting, atrophy, contractures of muscles multiple sites, hypertension, retention of urine, conjunctivitis, viral hepatitis C, myocardial infarction, type 2 diabetes, chronic pain, anxiety disorder, dysphagia, alcohol abuse, seizures, dry eye syndrome, and gastroesophageal reflux disease. His medical supplies included chux (incontinence pads), gloves, hospital bed, hydraulic lift incontinence pads, nebulizer, incentive spirometry, moisture barrier, syringes, tape, wheelchair, adult incontinence briefs, bedside toilet, bilateral hand mitts, a wheelchair ramp, and communication board. His functional limitations included contractions, endurance, ambulation, and speech. He was allowed to be up as tolerated, transfer from the bed to the chair, have exercises as prescribed, go in a wheelchair and use a Hoyer lift. He was oriented with a fair prognosis. Patient #116 was ordered 84 hours of skilled nursing weekly. Nursing was to do a head to toe pain assessment each shift, nursing assessment, set up weekly medication, vital signs, provide personal care, administer medication, monitor for signs and symptoms of respiratory distress, seizure education, when to notify the nurse, nebulizer administration, oropharyngeal suctioning, oximeter oxygen saturation every shift, may perform passive range of motion to upper and lower extremities only to resistance and as tolerated by patient, assess and monitor a prescribed diet process, check his skin folds daily and reposition every two hours. His tracheostomy was removed 04/2023 and his gastrostomy tube was removed 06/29/23. The recertification period reviewed was 08/06/23 to 10/04/23. Review of communication notes revealed on 07/28/23 a note was written as a follow up to a nurse meet and greet with the patient and his father. The father thought it went well and wanted her to work for his son. The nurse says that it did not go well. The patient was verbally abusive towards her, and she would not like to work with him. That was the only documentation related to behaviors from admission in April until a 09/22/23 note. On 09/22/23 the facility spoke with the doctor’s office and advised the patient’s dad was down grading the nurse and getting upset because the nurse would not give marijuana brownies and alcohol gummies to his son during her shift. The facility informed the doctor’s office they would be discharging the patient due to behaviors as well as environment. On 9/25/23 the patient’s dad was made aware the nurse would not be returning. He was informed of the nurse’s concerns related to the alcohol and gummies. He said that he asked once and told her he understood when she said she was not comfortable giving them since there was not a physician order. The facility initiated a discharge effective 10/04/23 and the notification was sent 09/29/23 to Patient #116. It was sent overnight mail and stated the purpose of the correspondence was to provide formal notice that Maxim Healthcare Services will be terminating their agreement for Home Care Services and discontinuing the provision of in-home services effective 10/04/23. “As you are aware the reason for this action is the order authorization for care services is set to expire on 10/04/23 and that the orders authorization will not be renewed based on the provider’s determination of medical necessity. In addition to medical necessity there have been concerns surrounding behaviors towards Maxim staff and failure to provide a safe working environment.” Review of the patient’s record did not show a pattern of behaviors or resolution attempts to warrant a facility-initiated discharge. There was no evidence of the facility sending a recertification for consideration or a letter of denial received for continued services. There was no evidence of the facility reaching out to other providers or providing other agency recommendations to provide continued care. Review of the complaint log revealed there were no employee complaints filed in the log related to Patient #116. Review of the facility’s transfer discharge information included in the patient handbook revealed the company may transfer or discharge a patient if the transfer discharge is necessary for the patient or other persons in the patient’s home exhibit or display behaviors that are disruptive, abusive or uncooperative to the extent that the delivery of care to the patient or the ability of the company to operate effectively is seriously impaired. Prior to discharge for these reasons, the company shall advise the patient, representative (if any), the physician issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care provider professional that a discharge for cause is being considered. Make efforts to resolve the problems presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation. Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care. Document the problem, efforts made to resolve the problem, and enter documentation into the clinical record. Review of facility’s policy titled, Discharge, effective 01/14/19 and revised 02/21/21, revealed to the extent required by state law, office staff shall obtain the signature of the patient/legal representative on the discharge notice. The signed notice will be maintained in the patient’s medical record. The policy also included to provide the patient and representative (if any) with contact information for other agencies and providers who may be able to provide care. Interview on 02/05/24 at 1:53 P.M. with Staff A verified the facility did not have a letter denying services to the patient. Staff A verified they did not have documentation of a pattern of behaviors that would make it difficult for the facility to provide services. Staff A verified the patient was provided less than a weeks’ notice of discharge. Staff A verified Patient #116 was authorized for 84 hours of service and the facility was asserting he did not require any services and did not send for a recertification for continued services. 2. Review of Patient #115’s medical record revealed a 06/14/23 start of care date. Diagnoses included paraplegia, complete traumatic amputation at knee level left lower leg, chronic pain syndrome, type 2 diabetes, hyperglycemia, neuromuscular dysfunction of the bladder, and neurogenic bowel. Review of the last physician ordered plan of care for the certification period dated 10/12/23 to 12/10/23 revealed the patient had functional limitations due to the amputation, bowel and bladder incontinence, paralysis, and he had endurance issues with ambulation. He was permitted to be up as tolerated, transfer from bed to chair, and used a wheelchair. His mental status was oriented with a fair prognosis. He was a full code. Supplies used in his care included catheter, catheter bag, catheter insertion tray, chux, composite gauze, tape, dressings, cotton tipped applicators, crutches, dressings, gate belt, gauze pads, gauze roll, gloves, hospital bed, hydraulic lift, incontinence products, lubricant ointments, normal saline, tape, wheelchair, wound care cleanser, bedpan and ramp. Orders were for nursing services six hours a week for 60 days and included a dressing to the coccyx and left heel. Review of 06/09/23 Communication notes revealed the nurse had the meet and greet. The note included that it went really well. There were a couple of things she wanted to make the agency aware of: the patient lived off the grid, they have electric, but no running water or heat. They get their water from a well and heat with wood. Their driveway is very long and washed out and has deep ditches on each side. If someone does not have a four by four, they will more than likely not be able to get to the patient’s trailer. The house itself is an old single wide with light coming through cracks in the walls. They have a makeshift ramp they used to get the patient in and out of the house, but it is not very well built. Are there are any resources that the agency can reach out to help with the ramp and stone for their driveway. They reached out to the Veteran’s Administration (VA) and let them know they have arranged to have a nurse in there three times a week. On 06/14/23 and 07/03/23 his driveway was flooded, and the nurse could not make it to the trailer. A Communication note 09/27/23 revealed his nurse came in and said the roach problem has gotten worse. The roaches are not only crawling on the patient but all over his supplies. She advised that the patient had no running water in the home and actually flushed the toilet with jugs of water. The comprehensive assessment completed on 10/10/23 revealed Patient #115 was alert and oriented. His lungs were clear, heart regular, Foley catheter was last changed 10/02/23. He has been flushing and changing the catheter himself since he has been short staffed. There was edema noted to his right lower extremity, and education was given on frequently elevating his leg while in his wheelchair. He reports the wounds on his coccyx and buttocks were healing nicely and almost all healed. He would not let the nurse check his wounds. Unfortunately, Patient #116’s home has a bad infestation of roaches. This nurse refused to enter the home for visits. Patient #115 stated that he plans to have the home professionally sprayed once he receives his money for the month. Patient #115 remains appropriate for six hours of skilled nursing services per week. Nursing services were to include a patient assessment, obtain vital signs, monitor skin integrity, complete dressing changes per physician orders, and urinary catheter management three times weekly. On 11/22/23 the facility sent a letter via FedEx to Patient #115 which stated “the purpose of this correspondence is to address continue reports our staff and patient are being exposed to unsafe and unsanitary conditions at your home and to outline our expectations for continued services. As you are aware we have received reports there is no running water or heat in the home. The cockroaches remain present and active around the house. While we understand we are visitors in your home and some of the issues may be beyond your abilities to repair, we have an obligation to ensure the safety of our patients and staff to ensure that they are free from potential risk and harm. Additionally, the patient rights and responsibilities provision signed at the onset of care indicated our patients and our families have the responsibility to provide and ensure a safe environment to the healthcare provider in which safe and effective care may be rendered. Pursuant to our conversations we will continue our efforts to identify qualified staff to provide services in your home however it’s important that these matters may be resolved swiftly. Please note that in the event this matter is not resolved in the next 30 days we may be left with no other choice but to terminate the agreement for home care services providing care in your home. We hope this action is not necessary and we appreciate your anticipated cooperation.” There was a physician discharge order and summary dated 12/11/23. Review of the discharge summary dated 12/11/23 revealed the patient was being discharged for an unsafe home environment and remains home with his father. He was getting three skilled nurse visits a week for six hours a week. There was no correspondence with the patient as to why he was being discharged from services before the 30-day expiration. There was no evidence of the patient being sent the termination of services letter. Interview on 02/05/24 at 5:25 P.M. with Staff A and B verified the patient was not given the full 30 days to resolve issues. Further, Staff A and B verified the house conditions were the same when they accepted him as a patient as when they discharged him. They knew what they were getting themselves into as far as with the trailer’s condition, there was no heat, no running water, and a driveway that was beat up and difficult to get down. The issues were reported with the initial visit. Staff A and B verified they agreed to accept him as a patient knowing the conditions of the home. Staff B indicated he was trying to help the VA. They were trying to stay in the VA’s good graces. Now they know not to do that. They discharged him citing the same issues that were present on admission as current. Staff A and B acknowledged to discharge the patient when the home had the same issues as to when he was admitted to the facility did not meet criteria for discharge. This deficiency represents non-compliance investigated under Substantial Allegation 103648.”