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 [Named Web Based Clinical Skills], policy review, medical record review, and interview, the facility failed to accurately and appropriately assess pressure ulcers for 1 of 2 (Patient #7) sampled patients with pressure ulcers. 1. Review of the “WOUND CARE,” dated 1/17/2025, revealed “...To provide guidance for the management of wounds in the home setting…Wound measurements shall be obtained and documented by the qualified clinician at least one a week...Wound care pr4ocedures will be in accordance with the Named Nursing Protocols…Weekly wound measurement will be completed by the qualified clinician. Documentation of wound measurement(s) will be noted and include a description of…Wound size…length, width and depth…Wound bed tissue…type/color, necrotic, slough, eschar, granulating and epithelia…Evidence of wound healing or deterioration…Drainage characteristics…type, amount, color, and odor…Any symptoms of infection…any redness, swelling, pain, discharge or increased temperature…Any development of undermining or sinus tract that may require packing…” 2. Review of the “Named Web Based Clinical Skills,” Staging of Pressure Injuries dated 2026 revealed, “…Stage 3 pressure injury…Full thickness skin loss…in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) may be present. Slough and /or eschar may be visible. The depth of tissue damage varies but anatomic location… areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur, Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury...Stage 4 pressure injury…Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the injury. Slough and/or tunneling may occur. Depth varies by anatomic location. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury…Unstageable pressure injury…Obscured full-thickness skin and tissue loss…Full-thickness skin and tissue loss in which the extent of tissue damage within the pressure injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (…dry, adherent, intact without erythema or fluctuance) on ischemic limb or the heels(s) should not be softened or removed...” 3. Review of the “Name Web Based Clinical Skills,” dated 2026, revealed, “...Do not attempt to stage pressure injuries that are covered with slough or necrotic tissue. Ensure that the eschar is debrided and the slough is removed so that the base of the wound is visible and the dept can be determined. Until such debridement, document the pressure injury as unstageable…Measure the wound dimensions in centimeters using a wound measurement guide…measure the three dimensions of length, width, and depth…Measure the depth of the pressure injury using a sterile cotton-tipped application…Gently place the applicator into the pressure injury until it touches the bottom...” 4. Record review for Patient #7 revealed a Start of Care (SOC) of 6/6/2026 with diagnoses of Pressure Ulcer of Sacral Region Stage 3, Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Left Buttock Stage 4, and Cerebral Palsy. Review of the “Plan of Care (POC) ,”dated 4/7/2026, Certification Period from 6/6/2026 to 8/4/2026, revealed “…SKILLED NURSING…Frequency and Duration …to provide skilled nursing services for 40 hours per week, for 60 days…Wound Care Document wound measurements weekly and as needed…Follow Name Hospital #1 Wound Care orders to clean and dress wounds…Cleanse with normal saline and gauze, apply zinc oxide [contributes to wound healing through several mechanisms. It forms a physical barrier on the skin, shielding the wound from moisture, irritants, and contaminants, which helps maintain a favorable healing environment] to periwounds, lightly pack each wound bed with durafiber [Durafiber] [is a highly absorbent, designed for managing medium to heavily exuding infected wounds while providing sustained antimicrobial protection], cover with bordered foams. Change daily and PRN soiling…” Review of the “Skilled Nursing Note,” dated 6/2/2026, revealed Pressure…Back, left lateral…Width 1.5cm [centimeters]…Length 1.1 cm…Depth…0.1 cm…Back, right lateral… Width cm [centimeters]…Length 1cm…Depth…0.1 cm…Sacral-Coccyx, lower medial… Width 3.5cm [centimeters]…Length 3.5cm…Depth…0.1 cm…” Review of the Skilled Nursing Note for the week of 6/7/2026 to 6/13/2026, revealed measurement for right heel the Width 2cm [centimeters]…Length 2.5 cm…Depth…0.1 cm there are not measurement documented for the Left side lateral left medial, back left lateral, sacral-coccyx lower medial and the back right lateral. Review of the Skilled Nursing Note for the weeks of 6/14/2026 to 6/20/2026, 6/28/2026 to 7/4/2026, and 7/5/2026 to 7/11/2026 there are no documentation of the wound measurements or assessments. There were no Skilled Nursing Note documentation of the wounds assessment and treatments on 6/12/2026, 6/16/2026, 6/24/29026, 6/29/2026, 7/2/2026 and 7/3/2026. The facility failed to accurately assess and provide measurements of the wounds at least weekly according to the facilities policy. 5. During an interview on 7/15/2026 at 1:39 PM, the Director of Clinical Operations stated the staff members should accurately assess, measure and stage the wounds at least weekly.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on [Named Clinical Skills], policy review, medical record review, observation and interview, the facility failed to perform hand hygiene and don appropriate personal protective equipment (PPE’s) during assessment and dressing change for 1 of 4 (Patient #4) sampled patients with surgical incisions and Gastrotomy Tube (GT). 1. Review of the undated “Named Clinical Skills,” revealed “…If a gastrotomy tube…Clean hands and put on appropriate PPE [personal protective equipment] based on the risk of exposure to body fluids or infection precautions…Moisten gauze pads and cotton-tipped applications with soap and warm water…wipe the area closest to the tube…Gently clan and dry beneath the bumper…Rotate the GT [Gastrotomy Tube] 360 degrees to prevent buried bumper syndrome…Dry the skin and stoma thoroughly with a dry gauze pad…Apply a split gauze dressing around the tube…Assess skin integrity and the quality of drainage form the stoma…Be sure that the GT has the eternal securement device (bolster, bumper, disc, or phalanger) properly separated at least 0.5 cm [centimeters] (0.2 inch) form the skin…” 2. Review of the undated “Named Clinical Skills,” revealed “…Carry alcohol-based hand rubbing solution, small containers of liquid soap, and disposable paper towels to every home visit, Never use the patient personal bar or liquid soap or cloth towel because these may be contaminated…if use soap and water…Avoid splashing water on clothing…Regulate the flow of water so that the temperatures is warm…wet hands and wrist thoroughly under running water. Keep the hands ad forearms lower than the elbows during washing…Apply an adequate amount of soap in the palm of hand and rub the hands together to work up a lather…Use a rotating friction motion, applying friction to all surfaces of the hands and wrist, including the palms of the hands, between fingers, and around and under the nails. Interlace the finger and rub up and down. Continue washing for at least 15 seconds…Rinse the hands and wrists thoroughly, keeping the hands down and elbows up…Dry the hands thoroughly with a paper towel…Discard the paper towel in a trash can…Turn off the faucet with a clean, dry paper towel. Avoid touching the handles with the hands…” 3. Record review for Patient #4 revealed a Start of Care (SOC) of 10/8/2026 with diagnoses of Attention to Gastrostomy, Malformation of Spinal Cord, Disorder of the Brain, Congenital Hypoplasia, Dysplasia of Lung, Dislocation of Left and Right Hip, and Reduced Mobility. Review of the “Plan of Care (POC),” dated 6/5/2026 to 8/3/2026, revealed “… SN [Skilled Nurse] effective 6/5/2026… 40 hours per week, for 60 days…T-tube site care Cleanse G Tube site with warm soapy water using clean techniques twice a day…May apply split gauze per client tolerance…Rotate tube daily…G tube placement check…the tube for placement before feeds and medications…” Observation at Patient #4’s home during a home visit on 7/14/2026 at 10:30 AM, revealed Licensed Practical Nurse (LPN) #1 approached Patient #4 who was lying on the couch and disconnection the tube feeding from the GT with her bare hands and failed to perform hand hygiene and flushed the GT with 5 millimeter of water. LPN #1 lifted Patient #4 off the couch and carried the patient to the bedroom and placed him on the changing table to assess the wound and perform GT dressing change. Patient #4 had a surgical incision to the right hip, left hip, left knee, left heel and mid back with 2 Steri-Strips intact [adhesive strips used to close small, shallow wounds by holding the skin edges together, promoting healing and reducing infection risk]. Observation at Patient #4’s home during a home visit on 7/14/2026 at 10:50 AM, revealed LPN #1 entered the bathroom to wash her hands and dried her hands with the personal towel handing in front of the sink and filled a volumetric cylinder with water and a small amount of soap and reentered the bedroom. LPN #1 gathered her supplies, removed the old dressing with her bare hands that contained a moderate amount of creamy drainage. LPN #1 failed to perform hand hygiene and open the 2 x 2 gauze and soaked it in the water solution and cleansed around the GT site. LPN #1 open a cotton tip applicator and dipped it into the water solution and cleansed around the GT. LPN #1 open another 2 x 2 gauze and dried the area with her bare hands and rotated the GT. LPN #1 secured the GT with tape. The facility staff member failed to perform hand hygiene and don the appropriate PPE’s during wound assessment, and dressing change to the GT. 4. During an interview on 7/8/2026 at 2:07 PM, the Director of Clinical Operation stated that the nursing staff members should perform hand hygiene, and don the appropriate PPE when provide care and dressing changes.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to ensure a discharge summary was sent to the physician or other healthcare professional responsible for care after discharge within 5 days of discharge for 1 of 3 (Patient #8) records reviewed. Based on policy review, medical record review and interview, the agency failed to ensure a discharge summary was sent to the physician or other healthcare professional responsible for care after discharge within 5 days of discharge for 1 of 3 (Patient #8) records reviewed. The findings included: 1. Review of the agency’s “Discharge” policy with a revision date of 7/10/2026 revealed, “...a completed discharge summary will be completed and sent to the primary care practitioner…within 5 business days of the patient’s discharge...” 2. Medical record review for Patient #8 revealed a Start of Care date of 12/23/2025 with diagnoses which included Unspecified Intracranial Injury. The agency discharge date was 6/2/2025. Review of the “…[Named Facility] Cover Sheet” dated 6/10/2026 revealed Patient #8’s documentation of the discharge summary was sent to the physician. 3. During an interview in the conference room on 7/15/2026 at 2:01 PM, the Director of Clinical Operations stated the discharge summary for Patient #8 was not sent to the physician within 5 days after discharge. The findings included: 1. Review of the agency’s “Discharge” policy with a revision date of 7/10/2026 revealed, “...a completed discharge summary will be completed and sent to the primary care practitioner…within 5 business days of the patient’s discharge...” 2. Medical record review for Patient #8 revealed a Start of Care date of 12/23/2025 with diagnoses which included Unspecified Intracranial Injury. The agency discharge date was 6/2/2025. Review of the “…[Named Facility] Cover Sheet” dated 6/10/2026 revealed Patient #8’s documentation of the discharge summary was sent to the physician. 3. During an interview in the conference room on 7/15/2026 at 2:01 PM, the Director of Clinical Operations stated the discharge summary for Patient #8 was not sent to the physician within 5 days after discharge.”