Initial Comments:Based on the findings of an unannounced, onsite Medicare recertification survey conducted on November 2 through November 4, 2022, Aveanna Healthcare 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, onsite Medicare recertification survey conducted November 2 through November 4, 2022, Aveanna Healthcare was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B &;; C, Conditions of Participation: Home Health Agencies.
Plan of Correction:
484.75(b)(3) ELEMENT
Provide services in the plan of care
Name - Component - 00
Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care;
Observations:
Based on the review of agency policies/procedures and clinical records, and based on interview with the area clinical manager and the operations manager, the agency failed to ensure ventilator (mechanical device which assists with breathing) settings were maintained as per physician orders for two (2) of two (2) clients (patients) who were ventilator dependent. (Clients #3 and #5)
Findings include:
On November 4, 2022 at approximately 2:45 PM, review of the agency policy titled "Care Plan" revealed the following: Overview…An individualized plan of care will be developed…to ensure that care and services are appropriate to the patient’s specific needs/problems.
On November 4, 2022 at approximately 2:47 PM, review of the agency policy titled "Physician Orders" revealed the following: Overview...Care and services will be provided in accordance with physician's (or other authorized practitioner's) orders, as required by law and regulations.
On November 4, 2022 at approximately 2:37 PM, review of the agency policy titled "Mechanical Ventilation” revealed the following: Overview…The goal of mechanical ventilation is to provide respiratory support for patients who need assistance to maintain adequate gas exchange…Policy…5. Physician orders for patient ventilator settings…are within acceptable ranges for safe management in the home environment…
Client #3: On November 3, 2022 at approximately 11:19 AM, review of the clinical record revealed the patient is 43 years old, the start of care date was 01/18/2016, diagnoses include dependence on ventilator and that skilled nursing (SN) is to maintain the following ventilator settings as documented on the interim physician order dated 10/24/2022 and “Plan of Care” for the recertification period of 11/01/2022 through 12/30/2022:
- PEEP (positive end-expiratory pressure-the positive pressure provided when a breath is exhaled) setting at 3 during daytime and sleep hours; and
-Humidity setting at 31 degrees Celsius during sleep hours.
Review of SN ventilator flow sheet documentation revealed the PEEP setting was zero (0) and that a sleep-time humidity setting was not documented by the licensed practical nurse (LPN-Employee #6) during the overnight SN shifts provided on 10/25/2022, 10/26/2022 and 10/27/2022.
Client #4: Between November 3, 2022 at approximately 1:01 PM and November 4, 2022 at approximately 7:00 AM, review of the clinical record revealed the patient is 17 years old, the start of care date was 03/22/2017, diagnoses include dependence on ventilator and that skilled nursing (SN) is to maintain the following ventilator settings as documented on the “Plan of Care” for the recertification period of 09/06/2022 through 11/04/2022:
-Humidity setting range 30-32 degrees Celsius from 10:00 AM to 10:00 PM; and
-Humidity setting range 36-38 degrees Celsius from 10:00 PM to 10:00 AM.
Review of SN ventilator flow sheet documentation revealed that the humidity setting range was maintained as follows:
-09/08/2022 between 5:30 AM and 9:00 AM: 30.9 to 31 degrees Celsius;
-09/09/2022 between 11:00 AM and 12:00 PM: 37 degrees Celsius;
-09/30/2022 at 11:00 AM: 37 degrees Celsius; and
-10/10/2022 at 11:00 AM: 37 degrees Celsius.
There was no documentation on the SN ventilator flow sheet which provided evidence that the LPN (Employee #7) maintained the ventilator humidity settings per the physician orders included on the “Plan of Care” on the above referenced dates/times.
During interview conducted on November 4, 2022 at approximately 3:05 PM, the area clinical director and the operations manager confirmed that the above referenced ventilator settings were not maintained as per physician orders for the above identified patients.
Plan of Correction:Plan of Correction:
What action will be taken to correct the deficiency?
Patient #3 and 5's charts will be reviewed for ventilator settings as compared to physician's orders. In instances where discrepancies are identified the physician will be contacted and new orders obtained, or education provided to staff on performing care as per physician order. Employees #6 and 7 will be re-educated immediately on ventilator settings ordered for patients and conformance to these orders as per the plan of care. This will be completed by 12/15/22
How will other potential deficiencies affected by same practice be identified?
The Clinical Director and/or designee will complete a 100% audit of all patients on ventilators. The review will include comparison of ventilator management and settings in nursing notes to physician's orders. In instances where discrepancies are identified the physician will be contacted and new orders obtained, or education provided to staff on performing care as per physician order. This will be completed by 12/31/22
What measures will be put in place to prevent recurrence?
Education on following provider ordered plan of care/conformance to physician order's will be provided to Clinical Supervisors and all other office clinical staff by Clinical Director and/or designee. This will be completed by 12/15/22. Agency will implement an additional auditing process to monitor compliance.
How will the corrective action be monitored?
Clinical Director and/or designee will conduct a 100% audit of patient's with ventilators per quarter x1, then 50% per quarter x1
When will the corrective action be completed?
December 31, 2022
Initial Comments:
Based on the findings of an unannounced, onsite state re-licensure survey conducted November 2 through November 4, 2022, Aveanna Healthcare was found not to be in compliance with the following requirement of 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601.
Plan of Correction:
601.31(d) REQUIREMENT
CONFORMANCE WITH PHYSICIAN'S ORDERS
Name - Component - 00
601.31(d) Conformance With
Physician's Orders. All prescription
and nonprescription (over-the-counter)
drugs, devices, medications and
treatments, shall be administered by
agency staff in accordance with the
written orders of the physician.
Prescription drugs and devices shall
be prescribed by a licensed physician.
Only licensed pharmacists shall
dispense drugs and devices. Licensed
physicians may dispense drugs and
devices to the patients who are in
their care. The licensed nurse or
other individual, who is authorized by
appropriate statutes and the State
Boards in the Bureau of Professional
and Occupational Affairs, shall
immediately record and sign oral
orders and within 7 days obtain the
physician's counter-signature. Agency
staff shall check all medicines a
patient may be taking to identify
possible ineffective drug therapy or
adverse reactions, significant side
effects, drug allergies, and
contraindicated medication, and shall
promptly report any problems to the
physician.
Observations:
Based on the review of agency policies/procedures and clinical records, and based on interview with the area clinical manager and the operations manager, the agency failed to ensure ventilator (mechanical device which assists with breathing) settings were maintained as per physician orders for two (2) of two (2) clients (patients) who were ventilator dependent. (Clients #3 and #5)
Findings include:
On November 4, 2022 at approximately 2:45 PM, review of the agency policy titled "Care Plan" revealed the following: Overview…An individualized plan of care will be developed…to ensure that care and services are appropriate to the patient’s specific needs/problems.
On November 4, 2022 at approximately 2:47 PM, review of the agency policy titled "Physician Orders" revealed the following: Overview...Care and services will be provided in accordance with physician's (or other authorized practitioner's) orders, as required by law and regulations.
On November 4, 2022 at approximately 2:37 PM, review of the agency policy titled "Mechanical Ventilation” revealed the following: Overview…The goal of mechanical ventilation is to provide respiratory support for patients who need assistance to maintain adequate gas exchange…Policy…5. Physician orders for patient ventilator settings…are within acceptable ranges for safe management in the home environment…
Client #3: On November 3, 2022 at approximately 11:19 AM, review of the clinical record revealed the patient is 43 years old, the start of care date was 01/18/2016, diagnoses include dependence on ventilator and that skilled nursing (SN) is to maintain the following ventilator settings as documented on the interim physician order dated 10/24/2022 and “Plan of Care” for the recertification period of 11/01/2022 through 12/30/2022:
- PEEP (positive end-expiratory pressure-the positive pressure provided when a breath is exhaled) setting at 3 during daytime and sleep hours; and
-Humidity setting at 31 degrees Celsius during sleep hours.
Review of SN ventilator flow sheet documentation revealed the PEEP setting was zero (0) and that a sleep-time humidity setting was not documented by the licensed practical nurse (LPN-Employee #6) during the overnight SN shifts provided on 10/25/2022, 10/26/2022 and 10/27/2022.
Client #4: Between November 3, 2022 at approximately 1:01 PM and November 4, 2022 at approximately 7:00 AM, review of the clinical record revealed the patient is 17 years old, the start of care date was 03/22/2017, diagnoses include dependence on ventilator and that skilled nursing (SN) is to maintain the following ventilator settings as documented on the “Plan of Care” for the recertification period of 09/06/2022 through 11/04/2022:
-Humidity setting range 30-32 degrees Celsius from 10:00 AM to 10:00 PM; and
-Humidity setting range 36-38 degrees Celsius from 10:00 PM to 10:00 AM.
Review of SN ventilator flow sheet documentation revealed that the humidity setting range was maintained as follows:
-09/08/2022 between 5:30 AM and 9:00 AM: 30.9 to 31 degrees Celsius;
-09/09/2022 between 11:00 AM and 12:00 PM: 37 degrees Celsius;
-09/30/2022 at 11:00 AM: 37 degrees Celsius; and
-10/10/2022 at 11:00 AM: 37 degrees Celsius.
There was no documentation on the SN ventilator flow sheet which provided evidence that the LPN (Employee #7) maintained the ventilator humidity settings per the physician orders included on the “Plan of Care” on the above referenced dates/times.
During interview conducted on November 4, 2022 at approximately 3:05 PM, the area clinical director and the operations manager confirmed that the above referenced ventilator settings were not maintained as per physician orders for the above identified patients.
Plan of Correction:Plan of Correction:
What action will be taken to correct the deficiency?
Patient #3 and 5's charts will be reviewed for ventilator settings as compared to physician's orders. In instances where discrepancies are identified the physician will be contacted and new orders obtained, or education provided to staff on performing care as per physician order. Employees #6 and 7 will be re-educated immediately on ventilator settings ordered for patients and conformance to these orders as per the plan of care. This will be completed by 12/15/22
How will other potential deficiencies affected by same practice be identified?
The Clinical Director and/or designee will complete a 100% audit of all patients on ventilators. The review will include comparison of ventilator management and settings in nursing notes to physician's orders. In instances where discrepancies are identified the physician will be contacted and new orders obtained, or education provided to staff on performing care as per physician order. This will be completed by 12/31/22
What measures will be put in place to prevent recurrence?
Education on following provider ordered plan of care/conformance to physician order's will be provided to Clinical Supervisors and all other office clinical staff by Clinical Director and/or designee. This will be completed by 12/15/22. Agency will implement an additional auditing process to monitor compliance.
How will the corrective action be monitored?
Clinical Director and/or designee will conduct a 100% audit of patient's with ventilators per quarter x1, then 50% per quarter x1
When will the corrective action be completed?
December 31, 2022
Initial Comments:Based on the findings of an unannounced, onsite state re-licensure survey conducted November 2 through November 4, 2022, Aveanna Healthcare was found to be in compliance with the requirements of 28 PA Code, Health Facilities, Part IV, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:Based on the findings of an unannounced, onsite state re-licensure survey conducted November 2 through November 4, 2022, Aveanna Healthcare was found to be in compliance with the requirements of 35 P.S. &;sect; 448.809 (b).
Plan of Correction:
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