Maxwell Home Health Care, Inc

The Home Health Agency (HHA) failed to ensure the frequency of visits ordered on the Plan of Care (POC) were followed in 3 of 7 records reviewed with skilled nursing (SN) and physical therapy (PT) services ordered (M.R.# 1, 2 and 4) from a total sample of 7 records reviewed, resulting in the…

The home health agency failed to ensure the physician orders were followed in 4 of 7 records (MR# 1, 2, 3, and 6) from a total of 7 records reviewed, resulting in the delay of services ordered, and the potential for unmet care needs for agency patients.

The home health agency (HHA) failed to notify the physician of any changes to the patient's ordered plan of care (POC) for 4 of 7 records (MR# 1, 2, 3, and 6), from a total sample of 7 records reviewed, resulting in the potential for unmet care needs for agency patients.

The agency failed to document submission of the discharge summaries to the physician in 6 of 6 records (MR #'s 2, 3, 4, 5 and 6) discharge records, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs.

The agency failed to ensure the ongoing interdisciplinary re-assessments of the patient's health status in 1 of 1 records reviewed with a patient hospitalization (MR# 1) (see G706); failed to ensure that Physical Therapy and Home Health Aide services were provided at the frequency ordered in the…

The agency failed to ensure that 1 of 1 Home Health Aide employed by the Agency, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs.

The agency failed to ensure ongoing communication between Skilled Nursing (SN), Physical Therapy (PT), Administration and Home Health Aide (HHa) in 1 of 7 records reviewed (MR# 1), which resulted in a hospitalization for an unknown reason.

The agency failed to ensure that skilled services were administered in accordance with the physician's orders and the plan of care in 3 (MR's #1, 3 and 5) of 7 sampled patients reviewed for skilled services, resulting in the potential for decline in physical functioning, unidentified health…

The agency failed to ensure the Physical Therapist prepared complete and accurate orders in 1 of 7 records (MR#1) reviewed, resulting in not having a complete clinical picture of the patient's care.

The agency failed to ensure the Home Health Aide provided care in accordance with the plan of care for 1 of 2 (MR# 1) patients in which HHa services were provided, resulting in the potential for patients to receive sub-standard services from this HHa.

The agency failed to ensure adequately documented on-site supervisory visit to the patient's home to supervise the services that were provided by the home health aide for 2 of 2 records reviewed (MR# 1, and 3) in which aide services had been provide, from a total sample of 7 records reviewed…

The agency failed to ensure that 1 of 1 Home Health Aide employed by the Agency, received a background check.

The Agency failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, and documented progress toward goals in 3 (MR# 1, 3 and 5) of 3 discharged records, from a total of 7 records reviewed, resulting in the potential for unidentified…

The Administrator #1 failed to ensure a Clinical Manager was available during all operating hours, from November 23, 2018 to January 18, 2019, resulting in a lack of clinical and supervisory oversight of patient care services for the 24 active patients (Refer to G 950 and 958), the Administrator #1…

The Administrator #1 failed to ensure a Clinical Manager was available during all operating hours, from November 23, 2018 to January 18, 2019 to provide oversight of patient care services for the 24 active patients, resulting in a lack of clinical and supervisory oversight of patient care services…

The home health agency failed to provide the name and contact information of the clinical manager to 24 of 24 active patients, resulting in failure to provide accurate information for the agency's complaint process.

The Administrator #1 failed to ensure a Clinical Manager was available during all operating hours, from November 23, 2018 to January 18, 2019, resulting in a lack of clinical and supervisory oversight of patient care services for the 24 active patients.

The Administrator #1 failed to maintain a complete and current personnel file for all agency employees for 2 of 11 personnel files reviewed (Director of Nursing #1, and Office Manager #1).

The agency failed to ensure the Clinical Manager coordinated services that were documented on the referral form and the physician's orders were followed for 2 of 4 records reviewed (M.R. #2 and 3), resulting in unmet care needs.

The Administrator #1 failed to ensure a Clinical Manager was available during all operating hours, from November 23, 2018 to January 18, 2019 to monitor and assess patient needs and to ensure services were provided as ordered, for the 24 active patients, for a potential of unmet care needs.

The home health agency failed to ensure the plans of care were completed timely, and implemented according to the patients' needs for 2 of 4 active records reviewed (M.R. #1 and 4), for a potential of unmet care needs.