Maxim Healthcare Svcs Miami

The plan of care showed the following order: “VITAL SIGNS: Temperature, pulse, respiratory rate, B/P 3 times a day and as needed for changes in patient condition.” Staff Nurse F failed to take SP#5’s B/P during a home visit that the surveyor observed on 7/22/2025 from 3:00 PM until 3:40 PM.

The plan of care showed the following order: “VITAL SIGNS: Temperature, pulse, respiratory rate, B/P 3 times a day and as needed for changes in patient condition.” Staff Nurse F failed to take SP#5’s B/P during a home visit that the surveyor observed on 7/22/2025 from 3:00 PM until 3:40 PM.

The provider failed to electronically transmit each OASIS (Outcome and Assessment Information Set) data within 30 days of completing the assessment of the beneficiary for 1 out of 10 Sampled Patients (SP) SP#4 Findings include: Clinical record review of SP#4 on 08/30/22 to 08/31/22 revealed the…

The provider failed to ensure the care follows the written plan of care (POC) established by the physician on 2 out of 10 Sampled Patients (SP).

The provider failed to ensure the clinical record includes all entries appropriately authenticated (signature and a title), dated, and timed for 1 out 10 Sampled Patient (SP).

The provider failed to demonstrate the patient received all services outlined in the plan of care for 2 out of 10 Sampled Patients (SP).

The provider failed to incorporate the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items to have a completed comprehensive assessment for 1 out of 10 Sampled Patients (SP).

The provider failed to provide service(s) that are ordered by the physician as indicated in the Plan of Care (POC) for 1 out 10 Sampled Patients (SP).

The provider failed to have the clinical manager assure the development, implementation, and updates of the individualized plan of care for 1 out of 10 Sampled Patient (SP).

The provider failed to ensure the patient participate in, be informed about with respect to any factors that could impact treatment effectiveness and any changes in the care to be furnished on 1 out of 3 Sample Patients (SP).

The provider failed to coordinate care delivery to meet the patient's needs for 1 out of 3 Sampled Patients (SP).

The provider failed to include strategies for addressing emergency events identified by the facility-based and community-based risk assessment.

The provider failed to develop and implement emergency preparedness policies and procedures must address the use of volunteers in an emergency or other emergency staffing strategies.

The home health agency staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases for 1 out of 3 Sampled Patients(SP) with home visit made.

The provider failed to complete a competency evaluation by observing an aide's performance of the tasks (communication skills; reading and recording temperature, pulse and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks; safe transfer techniques and…

The provider failed to ensure that all entries were legible and clear for 1 out of 8 Sample Patients (SP).

The provider failed to ensure that a review of all medications the patient is taking in 1 out of 3 Sampled Patients (SP) with home visit.

The provider failed to maintain documentation of any revision to the plan of care by all the physicians issuing orders for the home health agency plan of care for 1 out 8 Sampled Patients (SP).

The provider failed to demonstrate integration of orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient for 1 out of 8 Sampled Patients (SP).

The provider failed to maintain documentation which demonstrates that an individual may furnish home health services on behalf of an Home Health Agency only after that individual has successfully completed a competency evaluation program for 1 out of 3 personnel file review.

The home health agency staff failed to provide service in accordance with accepted professional standards of practice for 1 out of 3 Sampled Patients(SP) with home visits made.

The provider failed to maintain a complete and accurate clinical record that included all interventions, treatments, and responses to those interventions for 1 out of 8 Sampled Patients (SP).

The provider failed to ensure the clinical record included 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 Home Health Agency (if any) within…

The Home Health Agency failed to ensure that their personnel followed the written Plan of Care (POC) as ordered by the physician for 3 out of 3 Sampled Patients (SP).

The Home Health Agency failed: to ensure that 2 out 3 Sampled Patients (SP)'s records contained a completed non-oasis assessment.

The Home Health Agency failed to ensure that all entries were legible and clear for 1 out of 3 Sample Patients (SP).

The Home Health Agency failed to maintain documentation of any revision to the established plan of care by the physician issuing order for the home health agency plan of care for 1 out of 3 Sampled Patients (SP).

The Home Health Agency (HHA) failed to communicate any revisions related to plans for the patient's discharge to the patient, representative/caregiver and the patient's primary care practitioner for 1 out of 3 Sampled Patients (SP).

The Home Health Agency failed to coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities for 1 out 3 Sampled Patients (SP).

The Home Health Agency failed to provide to 1 out of 3 Sampled Patient (SP) the visit schedule, including frequency of visits to be made by the Home Health Agency personnel and personnel acting on behalf of the Home Health Agency.

The Home Health Agency failed to ensure that a patient's file contained all clinical notes for 1 out of 3 Sampled Patients (SP).

The provider failed to ensure that 2 out of 3 (#1, #2) sample patients (SP) nursing flow sheets were legible and clear.

The provider failed to electronically transmit within 30 days of completing the assessment of the beneficiary for 1 out of 8 Sampled Patients (SP) (SP#1).

The provider failed to consult the physician to approve modifications to the original plan of care for 1 out 3 Sampled Patients (SP) with home visits conducted.

The home health agency staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases for 1 out of 3 Sampled Patients(SP) with home visits made.

The provider failed to complete a competency evaluation by observing an aide's performance of the tasks (communication skills; reading and recording temperature, pulse and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks; safe transfer techniques and…

The provider failed to advise of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging, (ii) Center for Independent Living, (iii) Protection and Advocacy Agency, (iv) Aging and…

The provider failed to ensure that a review of all medications the patient is taking in 1 out of 3 Sampled Patients (SP) with home visits.

The provider failed to consult the physician for the patient's condition or needs that suggest the plan of care should be altered for 1 out 3 Sampled Patients (SP) with home visits conducted.

The provider failed to provide service(s) that are ordered by the physician as indicated in the plan of care for 1 out 3 Sampled Patients (SP) with home visits conducted.

The home health agency staff failed to prepare and record clinical notes for 1 out of 8 Sampled Patients (SP).

The clinical manager failed to assure the development, implementation and updates of the individualized plan of care for 1 out 8 Sampled Patients (SP).

The provider failed to assure the clinical record contained a individualized plan of care for 1 out 8 Sampled Patients (SP) receiving Physical and Occupational Therapies.