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 onsite home health agency state re-licensure survey conducted October 22, 2018 through October 23, 2018, Aveanna Healthcare, was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.








Plan of Correction:




601.21(f) REQUIREMENT
PERSONNEL POLICIES

Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.

Observations:



Based on reviews of policies/procedures, employee handbook, personnel files (PF) and interviews with staff (EMP) the agency failed to ensure annual performance evaluations were completed for staff for five (5) of ten (10) files reviewed. (PF #1, PF #2, PF #3, PF #7, and PF #9)

Findings include:

Review of Aveanna Healthcare Administrative manual: EVALUATIONS-PERFORMANCE conducted on 10/24/18 at approximately 2:00 PM revealed, "All employees will receive a performance evaluation by their supervisor annually..."

Review of Aveanna Caregiver Handbook: YOUR CAREER AT AVEANNA HEALTHCARE: EVALUATION AND FEEDBACK conducted on 10/24/18 at approximately 2:30 PM revealed, "In addition to the 90-day review, you will also participate in our annual performance review process, which is an opportunity for your supervisor to give you formal feedback on your performance over the prior year..."



Review of PF#1 (Date of hire (DOH): 12/20/2016) on 10/22/2018 between 1:45 PM to 2:45 PM and on 10/23/2018 between 9:00 AM to 10:50 AM revealed no performance evaluation completed in 2017.

Review of PF#2 (DOH: 10/8/2013) on 10/22/2018 between 1:45 PM to 2:45 PM and on 10/23/2018 between 9:00 AM to 10:50 AM revealed no performance evaluation completed in 2017.

Review of PF#3 (DOH: 11/10/2015) on 10/22/2018 between 1:45 PM to 2:45 PM and on 10/23/2018 between 9:00 AM to 10:50 AM revealed no performance evaluation completed in 2016 and 2017.

Review of PF#7 (DOH: 3/16/2012) on 10/22/2018 between 1:45 PM to 2:45 PM and on 10/23/2018 between 9:00 AM to 10:50 AM revealed no performance evaluation completed in 2017.

Review of PF#9 (DOH: 8/25/2017) on 10/22/2018 between 1:45 PM to 2:45 PM and on 10/23/2018 between 9:00 AM to 10:50 AM revealed no performance evaluation completed in 2018.



An interview with the Administrator/DON on 10/23/2018 at approximately 3:30 PM confirmed the above findings.














Plan of Correction:

Nursing Supervisors will be re-educated by Nursing Director on caregiver annual performance evaluation policy including the review date. Due Date 11/15/18
Nursing Director will review report of all expired annual evaluations in Health Trust from 1/1/2018 and assign any overdue annual evaluations to the Nursing Supervisors to be completed. Due Date 12/10/2018
Executive Director/Designee will audit 10 Personnel files to ensure the tracking per the Annual evaluations in Health Trust is correct. Any discrepancies will be corrected. Due Date 11/26/18
Going forward, during the weekly clinical meeting the Nursing Director will assign annual performance evaluations to each Nursing Supervisor that are due within the month. Nursing Director will follow up with each Nursing Supervisor weekly during the clinical meeting to ensure annual performance evaluations are completed prior to/on due date Responsible Party: Nursing Director, Nursing Supervisors
Completion Date: December 10, 2018



Initial Comments:


Based on the findings of an onsite unannounced home health care agency state re-licensure survey conducted October 22, 2018 through October 23, 2018, Aveanna Healthcare., was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.







Plan of Correction:




Initial Comments:



Based on the findings of an onsite unannounced home health care agency state re-licensure survey conducted October 22, 2018 through October 23, 2018, Aveanna Healthcare, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: