Maxim -- Joint Commission
Do you comply with applicable laws and regulations?
Absolutely.
How often do you check an employee's license after they have been hired?
According to our Background Policy we check the license prior to employment with the appropriate state governing body. The license is also to be checked upon recertification or renewal. This is to be completed via the internet, or if not available by hand on the license verification from.
How do you notify staff when confidential information will be shared?
All employees sign the Employment Records Authorization to Release Information. This form states Maxim will, when required, release specific employee information.
Has this office encountered any emergencies? How were those handled?
As applicable per each office.
How can staff and facilities reach you after hours? How are they notified of this information?
By directly calling the office during normal business hours and via the on-call line after-hours - Maxim is on call 24 hours a day 7 days a week. • Employees: Through the Facility Staffing Compliance Manual (FSG) and Employee Handbook. • Facilities: Through marketing material on our brochure, fliers, external website, and contract.
How are topics determined?
By identifying potential problems, addressing them through education; PI program.
Where do you get the data from that is reviewed?
Currently, data is collected from various data sources that are tied in with the reporting system the staffing incident reporting system (SIRM), key quality indicator action plan data reporting (KQI). Worker's Compensation reports, patient and staff satisfaction surveys and audits.
How often is data collected?
Data is collected on a daily (ongoing) basis and is reported quarterly.
Describe your process for handling an ethical dilemma.
Depending on the nature of the issue, the office would contact the Compliance, Legal and/or Human Resources. Area management would also be notified.
What types of positions does this office staff?
Describe the positions that your office staffs such as, Registered Nurses, Licensed Practical Nurse, Certified Nursing Assistants, Allied Health, etc.
Describe what your office does in the event of an emergency.
Each office follows the core emergency policy.
Explain your hiring process.
Follow the hiring policy: o Recruiting o Application o Interview process o Backgrounds o License verification (as applicable) o Testing/skills oMaxim orientation o Facility orientation
Do you provide written description of the grievance process to customers? To staff? Please show documentation of this.
For staff it is written in the employee handbook; Communication section. For customers it is addressed in our contract (it states that it is the client's sole discretion to report misconduct to Maxim).
How is staff informed of your policies and procedures?
HCPs are provided with our External Employee Handbook, Code of Conduct, and Facility Staffing / Compliance Manual which informs them of all of our Policies. They are required to sign a Handbook Acknowledgement stating they have received and reviewed our Policies and that they will be held accountable to them.
Please describe what happens if a HCP is asked to float.
If a HCP is asked to float they must contact their recruiter/branch representative and notify them of this request. The recruiter/branch representative must ensure that all requirements are on file to work new assignment to include experience, specific competency testing and related JD.
What do you do if there background shows that a candidate was found guilty of a crime?
If a background comes back with a hit, the information is automatically available for our background investigations team (BIT) to review. BIT may request additional documentation and may also consult with other departments to decide if the candidate/employee/contractor meets Maxim's background policy. Maxim follows the Fair Credit Reporting process (via Certiphi).
What if the HCP does not feel comfortable floating?
If at any time the HCP does not feel comfortable floating and the facility is still demanding the employee to float, it is the staff member's responsibility as safe practice to notify the Maxim office immediately.
Does your state have laws regulating staffing? If yes, do you have a copy of these regulations?
If you are in the following states then your office is state regulated: Nevada, Illinois, Rhode Island, Florida, Kentucky, Massachusetts, North Carolina, Minnesota, Maryland, Washington, Maine, New Jersey, and Washington D.C. Yes (office leadership is responsible for having current version of state regulations).
How are improvements made based on the data received?
Improvements are made based on the data received and reviewed each quarter. Improvement are need based and provided through education, clinical competence evaluations, clinical quality improvement meetings, action plans generated through root cause analysis, in-services, online CEUs and Maxim quarterly newsletters.
Who decides when to activate the emergency plan?
In the event of an emergency, the Branch Manager or designee activates the plan. If an emergency happens when the office is closed, the individual that is on-call will contact the Branch Manager or designee in order to activate the plan.
What process do you have in place for notifying the professional board and law enforcement in the event that a staff member is involved in illegal activity?
In the event that an office is notified that a staff member has been involved in illegal activity, the office immediately contacts the Legal Department for further guidance.
Has your office received any state citations from a state survey in the last 12 months? If so, please show them to me.
Joint Commission offices are audited every two year(s). Office should maintain copies of such surveys.
How do you maintain confidentiality in the office?
Lock computers when not in use, even briefly; keep all files in locked file cabinet; do not use full names on dry erase boards; do not leave confidential information on desks; no personal information visible; dispose of confidential information using designated shred bin
Please describe how your firm determines conflicts of interest.
Maxim's Code of Conduct defines conflict of interest. In summary, an actual or potential conflict of interest occurs when an employee or contractor has professional or personal interests that compete with his/her services to or on behalf of Maxim, or the best interests of a patient.
Who follows up with a grievance?
Office Manager or Designee
Discuss the process for reporting and investigating of occupational illnesses or injuries.
Office follows the Worker's Compensation policy. There is also a Worker's Compensation department that can handle assist the branch with additional questions.
Who reviews the contract to make sure all areas are addressed?
Office leadership is responsible for making sure that all areas are addressed in the contract. The Legal Department's Contracts team, and or Area/Regional Financial team and Controller perform a final review.
Describe the process for getting a contract with a facility.
Office leadership works with the Legal Department (Contracts team) (refer to policy and flow chart).
Who monitors these regulations to see if there are any changes?
Office leadership works with the Legal, Compliance, and Government Affairs Departments to monitor and interpret regulations.
How do you deal with issues of property damage?
Office would contact area leadership in order to determine the next steps, including reporting to the Risk Department and Real Estate Department.
What type of backup internal and external communication systems are in place in the event of failure during emergencies?
Offices are to follow the Emergency Preparedness Drills, Inspections and Evaluation policy, along with the Information Security policy.
How do you safeguard records and information in the event the office records were lost due to an emergency (tornado, hurricane, etc.)?
Paper records are protected; nightly backup of branch server is performed at corporate.
Describe the process used for effecting improvement within the organization.
Performance Improvement activities are monitored from an organizational perspective to maintain a high level of quality performance within our organization. At Maxim, Quality/ Performance Improvement initiatives are taken very seriously. Each branch has an electronic process for key quality improvement initiatives, reporting of incidents, and, occurrences.
How are performance measures selected? Do you get any data from your staff or facilities?
Performance measurements are selected based on areas of focus as noted by The Joint Commission DNR Clinical DNR Professional and Completeness of Personnel Files. Yes, surveys that depict patient satisfaction, facilities satisfaction and employee satisfaction surveys are compiled once a year and reported to the Maxim executive board members and the leadership team. These surveys are also programmed online for easy accessibility.
Describe your accountability and role-specific job responsibilities.
Reference your individual job description
How is staff informed of policies and procedures of the facility where they are working?
Some facilities require an Orientation at the facility in order for our employees to familiarize themselves with the policies and procedures of their facility. For the facilities that do not require an actual Orientation our branch offices request "Orientation packets" (if they already don't have one in the office) for Maxim employees to review before going to their scheduled first shift at the facility. The packets should include the expectations, policies and procedures of each individual facility.
What do you do when you receive negative feedback from a facility regarding performance?
The branch manager or representative would be expected to follow up with the facility to rectify whatever the issue is. Follow up with our employee/employees that may have been involved, some re-education may be involved. Grievance Report and/or SIRM (in the event of a DNR) would be written with follow up.
Who is the alternate who can activate the plan?
The employee on-call or the designee listed as alternate in office emergency plan. The Administrator or Branch Manager of each office determines the alternate work site. If phones are not working in an office where a disaster has occurred, then the phones are to be rolled over to an alternate work site.
How is staff oriented to a particular facility?
The facility is to provide an orientation to staff prior to them working a shift. Depending on the contract, we may be required to conduct a facility orientation at the office, with the facility providing a unit-specific orientation prior to our employee working a shift at the facility. If the facility requires Maxim to conduct the facility orientation, they are to provide us with all necessary materials and training information so we are able to orient our employees prior to being scheduled at the facility.
How do you decide who is qualified to work at a certain facility?
The facility makes the final decision.
How do you measure perception of care from customers?
The feedback from the surveys is compiled nationally and regionally to view satisfaction or lack thereof.
How is staff informed of the National Patient Safety Goals?
The staff is informed of the National Safety Patient Goals through the Facility Staffing / Compliance Manual.
Please define the process when confidentiality and security are violated.
The unauthorized or improper disclosure, use or review of protected health information is forbidden by Maxim and by federal HIPAA law. Any employee who violates this will be subject to disciplinary action, up to and including separation of employment (Employee Handbook). • Contact HIPAA Privacy Officer
Do you have information management process in place that support relationships with outside services and vendors (ex: licensing, customers, managerial decisions, operations, PI activities)
These are all present in our applicant tracking system (RecruitCare), where staff and client information is stored. Managerial decisions/information and operations information is stored on Pulse, which is Maxim's intranet.
How do you verify licensure/certification/registrations for staff?
These can be verified through state boards via a Web site or national organizations. Information can be obtained through verbal confirmation, as well as fax or mail.
How can facilities and staff reach you if phone lines are down?
They can contact the corporate office. The information is provided to the staff through the external Employee Handbook. Facilities are informed through the marketing material.
Describe your orientation process.
Upon hire, new employees complete orientation documents. They complete tax forms and I-9; be informed of and sign-off on our policies; provide any necessary medical records; and receive an orientation to Maxim Healthcare. They will receive a copy of the Employee Handbook, Code of Conduct, and Facility Staffing / Compliance Manual. They will also receive training on OSHA and information about the on-call process, hours of service, dress code, timesheet process, paycheck and daily pays, benefits, 401K and how the staffing process works. We will also review any facility- specific orientation requirements.
How do you educate staff on cultural diversity and sensitivity?
We educate staff on cultural diversity and sensitivity through the Facility Staffing / Compliance Manual.
How do you encourage orientation to the relevant unit or setting?
We encourage that orientation be conducted upon arrival to assignment and specific to the unit assigned. It is in our contract language with the facility.
How do you improve performance in your office?
We have a wide ranging Quality/Performance Improvement program that is in place to improve quality of all clinical services in the local office level. The designated clinical leadership reviews the incident reports generated from their field offices on a regular basis and performance improvement initiatives are provided on a need and priority bases in a timely and effective manner. Data is collected on a monthly basis and reported to TJC. Reports include data collected as it pertains to the standards of measurement. DNR Clinical, DNR Professional and Completeness of Personnel Files. This data is communicated to areal leaders and communicated to their respective offices. Identified trends and areas for improvement are reviewed and a plan of action is implemented.
How do you inform staff of the procedure for a sentinel event or incident?
We inform staff of the procedure for a sentinel event or incident in our Employee Handbook (External Employees).
How do you recruit nurses?
We recruit nurses using the following methods: o Referrals o Job Boards (Career Builder, Monster, Craig's List, etc.) o Cold Calls (state registry) o Peer References o Mailers o Job Posts o E-mail campaigns o Flyers o Ads in local newspapers o Social Media
When do you release confidential information?
When required by a facility, we will only release information directly related to the employee's qualifications as a healthcare professional.
Do you have a code of business ethics?
Yes, Maxim's Code of Conduct. Maxim's Code of Conduct lays the framework for the way we work, and how we interact with and care for our patients, customers, referral sources, and one another.
Do you conduct an HVA? How is this completed? How do you determine the score?
Yes, the HVA should be completed annually. Scores are based on historical information of problems and probability of occurrence. Local EOC sites assist during this process.
Do you have job descriptions available for all positions?
Yes. Maxim has a Job Description for every position that's staffed.
Describe your on-call process.
• After business hours, the main office line is forwarded to the cell phone number of the designated office on-call representative. The on-call representative carries with him/her the On-Call material that houses all information (i.e. scheduling reports, active roster, emergency plan/policies and access to system of record). • The on-call representative is responsible for all after-hours business activity.
How do you check a candidate's background?
• All candidates must have proper background checks. Maxim uses a third party vendor called Certiphi to run its backgrounds. Other vendors or state specific registries are also used depending on the state(s) regulations. • OIG /EPLS searches are also conducted on all employees • National Sex Offenders Public Registry search are also conducted • Searches of all state exclusion lists are searched upon hire and monthly thereafter • Maxim reruns criminal backgrounds and sex offender searches on a regular basis
Does your staff participate in in-services, training, or other activities? If so, how is this arranged?
• All external staff participates in Maxim's orientation upon hire. The Facility Staffing / Compliance Manual is reviewed. Topics include, but are not limited to, workplace violence, hand washing techniques, HIPAA, OSHA, age-specific competency, etc. • Employees are given the opportunity to participate in Maxim's educational programs. The programs are offered to all staff members. Topics are chosen by the Staffing Clinical team, based off of our PI program. o CEUs through MedComm; when requested, the branch office will instruct the worker on how to obtain an account
How does your organization define clinical compliance?
• Being clinically compliant means that Maxim employees follow all of Maxim's Policies and Procedures, which are based on federal and state law, and any specific facility requirements to provide quality health care. • Our employees are screened for the applicable experience, license, and certifications. They must pass our clinical competency exams and prove their abilities based on a self-checklist.
How do you assess ongoing clinical competency?
• Biennial (every two years) evaluations (depending on state/contract requirements and Maxim requirements) • Annual Skills Competency, FSG / Compliance manual • Monitoring expiration of employee documents through requirements Personnel File audits - monitoring compliance with audits conducted by organizations Compliance Team • Monthly Performance Measures are conducted monthly as JC requirement. A sampling is distributed each month and 10 files are pulled according to the sampling and audited by the branch.
How do you address complaints? Do you get any data from your staff or facilities?
• Branch representative will document the complaint • Office representative will contact each party • An outcome/recommendation will take place • Office manager will follow up with each party within 14 days Yes. Experience surveys are sent to all active facilities and staff once annually. These surveys can be completed online.
Who has access to confidential material?*
• Computer-based material - Role-based security applicable to their job description. For example, a recruiter can only see functions related to their position. • Paper-based - files are kept locked. *There is no access unless granted by a manager.
What information is kept in the on-call log?
• Date • Time • Facility • Contact • Description of conversation • Resolution
What types of customers do you serve?
• Hospitals • Clinics • Schools • Long Term Care Centers (Nursing Homes) • Hospice facilities • Psychiatric state facilities • Correctional Facilities • Subcontractors - Hire personnel to work through other institutions
How is staff educated (internal and external) regarding the emergency plan?
• Internal staff is educated through their annual review of the FSG. • External staff is educated through the branch management in the event of an emergency. They are also educated during the orientation process through the facility staffing orientation manual.
Do you review relationships with other providers and payers annually or when there are significant changes to ensure that the relationships do not constitute a conflict of interest?
• Maxim is a private company and doesn't have any ownership of facilities in which it conducts business. • Employees must adhere to the Company's Conflict of Interest policy.
What type of health screenings does your staff have before they can start?
• Maxim policy requires TST for all caregivers that have direct patient care (TST Policy) adhere to state and client specific health requirements. • All health records stored in the PF 2 of electronic personnel file (EPF) maintaining confidentiality.
Describe your Performance Measurement and Improvement program.
• Maxim's Performance Improvement program is designed to improve processes; systems and clinical performance that are consistent with the highest standards of current practice. • Clinical Performance Measurement is captured through the inbuilt data collection systems that are generated from the field offices as incident reports (SIRM), these IR's are evaluated and assessed for clinical quality improvement necessities by the corporate quality assurance clinical team members. • The IR data is managed and evaluated for quality improvement initiates and trends. Once a trend is identified, the Staffing clinical leadership develop a plan for improving these clinical trends. This process is a called a tracer. The tracer is developed to promote prevention, early detection and intervention. Tracers can be completed more frequently as identified by trends or by the National Director of Clinical Operations - Staffing.
How do you monitor records for accuracy?
• Monthly Performance Measures conducted by field support • Expirations report performed 30 to 45 days out • Audits conducted by Compliance team
How do you assess competency of a staff member?
• Only Clinicians can determine clinical competency. We assess competency through a nurse's: o Application o License certification verification o References o Skills checklist o Competency testing o Job description specific to the individual position
Please show me material that states hours and after hours accessibility.
• Our marketing material includes each office's individual contact information and hours/after-hours accessibility (Brochures, fliers, etc.). O Business hours / afterhours o Contact name O Address O Phone and fax number
Describe your business continuity/ disaster recovery plan in the event of an emergency.
• Preparing to shut down: o Notify the Solution Center o IS will initiate database backups o Make sure all equipment is placed up off the floor o Shut down and unplug desktop computers o Shut down and turn off all other office equipment o Forward the phones to the appropriate cell number • Getting back in business: o If everything is ok, plug everything back in and turn equipment on. o If you cannot get back into the office, continue working from the alternate location, where all systems should be accessible as long as there is high speed internet available.
How do you evaluate staff performance? How often is this done?
• Staff's performance is evaluated through biennial (every two years) performance evaluations (Maxim policy) or through first shift evaluations/annual evaluations (state/contract-specific). • Branch offices also stay in constant communication with facilities and seek feedback from the client on the level of service provided. Maxim Policy states every two years, unless required more frequently by client contract or state requirements.
How do you test your emergency plan/disaster drill? How often is this done?
• The offices are to conduct an annual test of their ER plan. They will follow their individual offices' ER plan. • Drills are conducted on an annual basis.
How is information followed up in the on-call log?
• The on-call representative is responsible for taking the initial call, and depending on the situation, would advise appropriate party/parties. • Resolutions are then logged in the on-call note within our system of record as applicable for documentation purposes.
How do you determine if a nurse meets the competency level for a specialty unit, such as OR?
• This can be determined by past experience in this unit. We would prefer a minimum of one year, but the facility may have more stringent requirements. It also depends on special certifications such as an ACLS (ER, ICU) PALS (PEDS), NRP (NICU, L& D), etc. • They must score the recommended minimum passing score on testing for that specific unit. They also fill out a skills checklist showing their level of experience and how frequently they perform duties specific to that unit. This information is provided to the facility in a profile so they are able to determine if they will accept this person.
How do you assess customer satisfaction?
• Through client experience surveys • Customer service phone calls • On site visits • Performance Improvement Program that is released every quarter
How do you assess employee satisfaction?
• Through our Team Member and Caregiver experience surveys • Performance Improvement Program that is released every quarter
How do you ensure worker safety?
• We have a risk management program designed to report, track and document injuries, incidents, errors and other events. • Facility is encouraged to provide an orientation that references its policies and procedures. • Maxim also encourages the facility to provide a policy and procedure manual that can be housed within the branch office. • The worker(s) attend(s) orientation at the facility and is/are given our Facility Staffing Guidelines and Compliance Manual during the boarding process so that they become familiar with Maxim's policies and procedures as well. • Those policies include our worker's compensation process and injury reporting process.
How do you inform staff of patient rights and ethical aspects of care, treatment and services, and the process used to address ethical issues?
• We inform staff of patient's rights and ethical aspects of care, treatment and services, and the process used to address ethical issues in three ways: o Facility Staffing / Compliance Manual o In the Employee Handbook (for caregivers) under the "Employee Ethics" section. o Code of Conduct
How do you inform staff of the Centers for Disease Control Hand Hygiene Guidelines?
• We inform staff of the Centers for Disease Control Hand Hygiene Guidelines in the Facility Staffing / Compliance Manual under the "Hand Washing Techniques." • Employees also receive a hand washing poster during onboarding.
How do you match up a nurse with a facility?
• We match nurses to a facility based on the facility's needs. This can be in terms of credentials such as a specific license or certification, experience, and any other specific training the facility requests. We go off of our contracts and what they require and request. We then also need to consider what the nurse is looking for and their desire to work at a specific facility. If both of these match up, many times we will send over a profile to the facility and they will approve this person to work. Profile can consist of following: o Candidate name, o Licensure verification, o Certifications held, o Work history, o Education, o Competency testing results, o Skills checklists, o Employment verification/references
How do you accurately represent staff qualification, clinical competence, licensure, registration, and/or certification to the customer?
• We provide profiles to our facilities which, depending on the facilities' requests, include license and license verification, BLS/CPR, ACLS, PALS, etc. as applicable, Skills Checklist, Competency Testing results, references, etc. and anything else they may want to see. • The facility is then able to determine if this person is qualified and acceptable to work.
Has your office reported a sentinel event? If so, how was this done?
• Will vary according to the office. If office has not, you simply state that your office has not reported a sentinel event. • If the answer is yes, what course of action was taken? Example: o Incident Reporting system o Clinical Leader Review o Legal/Employee Relations will be contacted
Do you have an emergency plan?
• Yes. Each office will maintain an emergency preparedness plan that is designated to providing continuous care and support appropriate to meeting the clients need in the event of an emergency that would result in interruption of services (i.e. emergencies within the community). Branch staff reviews and participates in an annual drill. Office emergency plans are located in the On-Call Binder and the Performance Improvement (PI) Binder. • Included in the Emergency Binder (On-Call Materials can be electronic): o Emergency Preparedness Drill Policy o HVA Grid (Hazard Vulnerability Analysis) o Internal staff roster/ contact info o External staff roster/ contact info o Facility roster/ contact info o Office Disaster Drill