QA Investigation Results

Pennsylvania Department of Health
AVEANNA HEALTHCARE
Health Inspection Results
AVEANNA HEALTHCARE
Health Inspection Results For:


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Initial Comments:

Based on the findings of an unannounced on-site Medicare recertification survey conducted on March 13, 2018, Epic Health Services was found not to be in compliance with the requirements of 42CFR, Part 484, Subparts B & C, Conditions of Participation: Home Health Agencies.




Plan of Correction:




484.45(a) STANDARD
Encoding and transmitting OASIS

Name - Component - 00
Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary.

Observations:

Based on a review of validation reports, agency policy, and interview with the administrator and director of clinical services clinical manger, the agency failed to follow their policy regarding transmitting OASIS (Outcome Assessment Information Set) within thirty (30) days of assessment for two (2) of two (2) clinical records receiving skilled services for waiver cases. Clinical records # 15 and 16.

Findings:
Review of policy on March 15, 2018 at 1600 titled " Comprehensive Assessment " states " For all adult, non-maternity, publicly funded (Medicare, Medicaid and/or Medicare/Medicaid HMO), the comprehensive assessment must incorporate the use of current version of the Oasis data set for Medicare and Medicaid patients."
Policy failed to state tha the organization may take up to 30 days after the date of completion of the comprehensive assessment to enter Oasis data into their computer using HAVEN software. "

Review of the agency ' s OASIS Validation Reports on March 13, 2018 at 1500 revealed that the agency did not submit OASIS data for two (2) of two (2) clinical records.

Interview with the clinical director on March 13, 2018 at 1100 revealed "Oasis data is collected; however, no Oasis transmission have been submitted when the patients were waiver cases."

Review of clinical records revealed:
Clinical record # 15 on March 12, 2018 at 1030 with certification period February 22, 2018 to April 22, 2018. No documentation of transmitting OASIS (Outcome Assessment Information Set) within thirty (30) days of assessment for patient receiving skilled services.
Clinical record # 16 on March 12, 2018 at 1000 with certification period January 30, 2018 to March 30, 2018. No documentation of transmitting OASIS (Outcome Assessment Information Set) within thirty (30) days of assessment for patient receiving skilled services.

Interview with the administrator and the director of clinical services on March 13, 2018 at 1600 confirmed the above.










Plan of Correction:

Effective 4/22/18 - Oasis data will be submitted within thirty days of assessment. Transmission will be checked and verified by the Clinical Nursing Director and one Clinical Supervisor two times a month to ensure that 484.45 (a) is being followed. 100
% Internal audits will be completed quarterly and documented in the QAPI minutes.

Effective 4/22/18 - Oasis data and transmission will be collected for all adults, non-maternity, publicly funded using the current version of the Oasis data set for Medicare and Medicaid patients to ensure that 484.45 (a) is being followed. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.



484.80(g)(1) STANDARD
Home health aide assignments and duties

Name - Component - 00
Standard: Home health aide assignments and duties.
Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist).

Observations:

Based on review of clinical records, agency policy and an interview with the administrator and director of clinical services, the agency failed to follow its policy to ensure that the home health aide plan of care was prepared by the registered nurse to individualize the duties to be performed by the home health aide for two (2) of five (5) clinical records with home health aide services ordered on the plan of care. Clinical records # 7 and 15.
Findings include:
Review of policy on March 13, 2018 at 1500 titled " Home Health Aide Assignments and Duties " states " The home health aide are assigned to a specific patient by a registered nurse with written patient care instructions for the home health aide prepared by that registered nurse. "
Review of clinical records revealed:
Clinical record # 7 on March 12, 2018 at 1515 with certification period February 8, 2018 to April 8, 2018. Home health aide plan of care failed to identify the type of bath to be administered

Clinical record # 15 on March 12, 2018 at 1030 with certification period February 22, 2018 to April 22, 2018. Home health aide plan of care failed to identify the type of bath to be administered

Interview with the administrator and director of clinical services on March 13, 2018 at 1600 confirmed that the above home health aide services were not individualized for each patient.










Plan of Correction:

Effective 4/22/18 - Existing home health aide plans of care for patients, prepared by a Registered Nurse, will be revised to indicate a specific type of bath that the home health aide may provide to the patient to ensure that 484.80 (g)(1) is being followed. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.

Effective 4/22/18 - All new home health aide plans of care for patients, prepared by a Registered Nurse, will have a specific type of bath that the home health aide may provide to the patient to ensure that 484.80 (g)(1) is being followed. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.

Effective 4/22/18 all home health aide plans of care will be checked by the Nursing Director or a Clinical Supervisor, for all new home health plans of care and when an existing home health aide plan of care has changes. to ensure that 484.80 (g)(1) is being followed. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.



Initial Comments:

Based on the findings of an unannounced on-site Medicare re-certification survey completed on March 13, 2018, Epic Health Services was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.





Plan of Correction:




Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on March 5 and 6, 2018 and March 12 and 13, 2018, Epic Health Services was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601.




Plan of Correction:




601.3 REQUIREMENT
COMPLIANCE W/ FED, ST, & LOCAL LAWS

Name - Component - 00
601.3 COMPLIANCE WITH FEDERAL,
STATE AND LOCAL LAWS.
The home health agency and its staff
are in compliance with all applicable
Federal, State and Local Laws and
regulations.

Observations:

Based on a review of validation reports, agency policy, and interview with the administrator and director of clinical services clinical manger, the agency failed to follow their policy regarding transmitting OASIS (Outcome Assessment Information Set) within thirty (30) days of assessment for two (2) of two (2) clinical records receiving skilled services for waiver cases. Clinical records # 15 and 16.

Findings:
Review of policy on March 15, 2018 at 1600 titled " Comprehensive Assessment " states " For all adult, non-maternity, publicly funded (Medicare, Medicaid and/or Medicare/Medicaid HMO), the comprehensives assessment must incorporate the use of current version of the Oasis data set for Medicare and Medicaid patients."
Policy failed to state tha the organization may take up to 30 days after the date of completion of the comprehensive assessment to enter Oasis data into their computer using HAVEN software. "

Review of the agency ' s OASIS Validation Reports on March 13, 2018 at 1500 revealed that the agency did not submit OASIS data for two (2) of two (2) clinical records.

Interview with the clinical director on March 13, 2018 at 1100 revealed "Oasis data is collected; however, no Oasis transmission have been submitted when the patients were waiver cases."

Review of clinical records revealed:
Clinical record # 15 on March 12, 2018 at 1030 with certification period February 22, 2018 to April 22, 2018. No documentation of transmitting OASIS (Outcome Assessment Information Set) within thirty (30) days of assessment for patient receiving skilled services.
Clinical record # 16 on March 12, 2018 at 1000 with certification period January 30, 2018 to March 30, 2018. No documentation of transmitting OASIS (Outcome Assessment Information Set) within thirty (30) days of assessment for patient receiving skilled services.

Interview with the administrator and the director of clinical services on March 13, 2018 at 1600 confirmed the above.









Plan of Correction:

Effective 4/22/18 - Oasis data will be submitted within thirty days of assessment. Transmission will be checked and verified by the Clinical Nursing Director and one Clinical Supervisor two times a month to ensure that 601.3 is being followed. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.

Effective 4/22/18 - Oasis data and transmission will be collected for all adults, non-maternity, publicly funded using the current version of the Oasis data set for Medicare and Medicaid patients to ensure that 601.3 is being followed. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.



601.35(b) REQUIREMENT
ASSNMNT & DUTIES OF HOME HEALTH AIDE

Name - Component - 00
601.35(b) Assignment and Duties of
the Home Health Aide. The home health
aide is assigned to a particular
patient by a registered nurse. Written
instructions for patient care are
prepared by a registered nurse or
therapist as appropriate. Duties
include:
(i) the performance of simple
procedures as an extension of therapy
services,
(ii) personal care,
(iii) ambulation and exercise,
(iv) household services essential to
health care at home,
(v) assistance with medications
that are ordinarily self-administered,
(vi) reporting changes in the
patient's conditions and needs, and
(vii) completing appropriate
records.

Observations:

Based on review of clinical records, agency policy and an interview with the administrator and director of clinical services, the agency failed to follow its policy to ensure that the home health aide plan of care was prepared by the registered nurse to individualize the duties to be performed by the home health aide for two (2) of five (5) clinical records with home health aide services ordered on the plan of care. Clinical records # 7 and 15.
Findings include:
Review of policy on March 13, 2018 at 1500 titled " Home Health Aide Assignments and Duties " states " The home health aide are assigned to a specific patient by a registered nurse with written patient care instructions for the home health aide prepared by that registered nurse. "
Review of clinical records revealed:
Clinical record # 7 on March 12, 2018 at 1515 with certification period February 8, 2018 to April 8, 2018. Home health aide plan of care failed to identify the type of bath to be administered

Clinical record # 15 on March 12, 2018 at 1030 with certification period February 22, 2018 to April 22, 2018. Home health aide plan of care failed to identify the type of bath to be administered

Interview with the administrator and director of clinical services on March 13, 2018 at 1600 confirmed that the above home health aide services were not individualized for each patient.












Plan of Correction:

Effective 4/22/18 - Existing home health aide plans of care for patients, prepared by a Registered Nurse, will be revised to indicate a specific type of bath that the home health aide may provide to the patient to ensure that 601.35 (b) is being followed. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.

Effective 4/22/18 - All new home health aide plans of care for patients, prepared by a Registered Nurse, will have a specific type of bath that the home health aide may provide to the patient to ensure that 601.35 (b) is being followed. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.

Effective 4/22/18 all home health aide plans of care will be checked by the Nursing Director or a Clinical Supervisor, for all new home health aide plans of care and when an existing home health plan of care has changes, to ensure that 601.35 (b) is being followed. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.



Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on March 5 and 6, 2018 and March 12 and 13, 2018, Epic Health Services was found to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart A. Chapter 51.





Plan of Correction:




Initial Comments:

Based on the findings of an unannounced on-site state licensure survey conducted on March 5 and 6, 2018 and March 12 and 13, 2018, Epic Health Services was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.



Observations:

Based on the review of identification tags for the agency staff, the agency failed to have the title of the employee in block type and the title to occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

Findings:
When identification tags were reviewed on March 6, 2018 at 1500, it was determined that the identification tags did not contain the title of the employee in block type and the title occupying a one-half inch tall strip as close as practicable to the bottom edge of the badge.

Interview with the administrator and director of nursing on March 13, 2018 at 1500 confirmed the above findings.







Plan of Correction:

Effective 4/22/18 - All new and current employees will have an updated ID badge to meet the requirement of 35 P.S. 448.809b. The photo identification tag shall include: a recent photo, employee's name, the employee's title and name of health care agency. The title of the employee shall be in block type and occupy a one-half inch tall strip at bottom of the badge. Titles of employees will be written fully and not abbreviated i.e.; Registered Nurse, Licensed Practical Nurse. 100% Internal audits will be completed quarterly and documented in the QAPI minutes.