Maximum Home Healthcare LLC

The agency failed to ensure a recertification assessment was performed in the last 5 days of the certification period for 3 of 4 active clinical records reviewed.

The agency failed to ensure the POCs were individualized and included service duration, as needed medication indications, diet, and measurable and patient-centered goals ( see G0574), provide services as ordered by physician ( see G0580), obtain physician signatures for all verbal orders received…

The home health agency failed to ensure the administrator was available 24 hours a day, 7 days a week (see G0948), ensure patients' needs were assessed and provided to the patients (see G0966), and had 2 inactive skilled patients and 6 active skilled patients (see G0982).

The agency failed to ensure the patients received all services listed on the POC as ordered by the physician for 4 of 5 active clinical records reviewed.

The agency failed to ensure infection control practices for hand hygiene were utilized for 2 of 2 home visits with HHAs (HHA 1 and 3) providing care and 1 of 1 RN (Administrator) performing an assessment and medication set-up.

The agency failed to ensure they provided SN services for 2 of 2 active clinical records (Patient #1 and #6) reviewed and 2 of 2 inactive clinical records (Patients #6 and #10).

The agency failed to ensure the patients received and signed consent for treatment upon admission to the agency and received the discharge and transfer policy in the admission packet for 3 of 3 active clinical records reviewed with home visits.

The agency failed to ensure the patients received all services listed on the POC as ordered by the physician for 4 of 5 active clinical records reviewed.

The agency failed to ensure a RN conducted an initial assessment within 48 hours of referral or a patient's return home for 2 of 5 active clinical records reviewed.

The agency failed to update the comprehensive assessment for the resumption of care following a hospitalization lasting more than 24 hours for 1 of 1 active clinical records reviewed with a hospitalization.

The agency failed to ensure a Discharge OASIS comprehensive assessment was completed for 2 of 3 inactive clinical records reviewed.

The agency failed to ensure the POCs were individualized and included the correct SOC date, duration of services, patient-centered goals, and reasons for why the patient takes the as needed medication for 5 of 5 active clinical records reviewed.

The agency failed to ensure they provided all services as ordered by the physician on the POC for 4 of 5 active clinical records reviewed.

The agency failed to ensure all verbal orders received were signed by the physician for 5 of 5 active clinical records reviewed (Patients #1, #3, #4, #6, and #7) and 2 of 3 inactive clinical records reviewed.

The agency failed to ensure the physician was notified of a patient's change in condition for 1 of 1 active records reviewed (Patient #3) and 1 of 1 inactive clinical records (Patient #9) for patients requiring a hospitalization.

The agency failed to ensure the medications listed on the medication profile and the POC evidenced the correct route for all medications for 1 of 3 medication profiles reviewed during a home visit.

The agency failed to ensure HHAs provided care within their scope of practice for 4 of 4 active clinical records reviewed with patients receiving HHA and SN services.

The agency failed to ensure they were available 24 hours a day, 7 days a week to meet the patient's needs for 2 of 2 active clinical records reviewed who were not seen within 48 hours of the referral.

The Administrator failed to ensure the patients were assessed and received services to meet their needs in 3 of 3 active clinical records reviewed who had an unauthorized decrease in HHA service frequency.

The agency failed to ensure a transfer summary was completed and sent to the location the patients were admitted for 1 of 1 active clinical records (Patient #3) reviewed with a hospitalization and 1 of 1 inactive clinical records reviewed with a hospitalization.