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 an unannounced on-site complaint investigation survey conducted on 2/21/2020, 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 upon review of agency policies, personnel files (PF), and interview with clinical director ( EMP #1), agency failed to ensure documentation of orientation for staff for one (1) of three (3) files reviewed ( PF # 1); failed to ensure documentation of annual performance evaluations for one (1) of three (3) files reviewed ( PF # 1).

Findings included:

Request for agency policies on 2/21/2020 between approximately 1:30 PM-3:00 PM with none produced for personnel management.

Review of PF on 2/21/2020, between approximately 12:00 PM-1:00 PM revealed:

PF # 1, Date of Hire (DOH) 12/24/17; no evidence employee was oriented at time of hire in 2017. Annual performance evaluation not present for 2019.

Interview with EMP # 1 on 2/21/2010, at approximately 3:00 PM confirmed above findings.












Plan of Correction:

The Clinical Director or Clinical Supervisor will evaluate each active employee annually to determine their clinical competency and progress towards professional goals. Staff will evaluate their strengths and weaknesses in accordance to their job description and will develop annual performance goals.

Staff evaluations will be aligned by annual due date with a spreadsheet to track when they are due. Operations Specialist, Nursing Director and Designated Administrative Staff will work together to schedule the evaluations with each staff member.

The Nursing Director track via GLS report any evaluations that were not completed from October 1, 2019 through present. The Clinical Director will review and assign this list to the Nursing Supervisors. The Nursing Director will update in HealthTrust GLS once the evaluation is completed to ensure accurate tracking.

Ongoing Monitoring, the Clinical Director or Designee will run a bi-weekly report with Annual and Introductory Evaluations that will expire within 30 days. The Clinical Director will review this list with office personnel at the weekly clinical meeting.

The Clinical Director or Designee will monitor ongoing to ensure compliance with Annual Performance Evaluations/implementation of plan of correction.


Initial Comments:


Based on an unannounced on-site complaint investigation survey conducted on 2/21/2020, 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 an unannounced on-site complaint investigation survey conducted on 2/21/2020, Aveanna Healthcare was found to be in compliance with the requirements of 35 P.S. 448.809 (b).










Plan of Correction: