Initial Comments:
Based on the findings of an onsite state re-licensure survey completed 10/24/24, Aveanna Healthcare was found not to be in compliance with the following requirements of PA Act 54 of 1999, Prescribed Pediatric Extended Care Centers Act, 35 PS, Section 449.61.
Plan of Correction:
REQUIREMENT
SANITARY CONDITIONS
Name - Component - 00
SECTION 15. Regulations. Standards. (a)(5)
All sanitary conditions within the pediatric extended care center and its surroundings, including watersupply, sewage disposal, food handling and general hygiene, and maintenance thereof, which will ensure the health and comfort of children served.
Observations:
Based on observations (OBS), reviews of policies, and interviews with staff (EMP) the facility failed to maintain conditions within the Pediatric Extended Care Center which promoted the health and safety of children for four (4) of four (4) facility observations. (OBS 1-4)
Findings include:
During a facility tour conducted on 10/24/24 between approximately 8:30 am to 11:00 am the following areas were observed:
OBS1: Kitchen area tour revealed that staff had not completed sanitizing logs for the facility dishwasher since July of 2024. EMP1 and EMP2 explained that weekly dishwasher sanitation logs had been discontinued.
A review of Facility policy Center Operations on 10/24/24 revealed: " 9 ....Dishes are placed in the dishwasher and run on the sanitary cycle ... " The facility staff failed to maintain documentation of dishwasher sanitation cycles during OBS1.
OBS2: Child Care Room 3 restroom contained a child ' s training toilet insert [waste container] soiled with a dried yellow substance. EMP2 was unaware of how long the training toilet insert had been left soiled after use.
OBS3: Child Care Room 2 tour revealed multiple unlabeled patient toothbrushes left at a bathroom sink and foul-smelling, visibly-soiled linen left uncontained and unbagged in a soiled linen storage cupboard. EMP2 verified that the soiled linen was to be placed in plastic bags and taken to the laundry area, while used linens (not visibly soiled) were to be maintained within a storage bin within the cupboard.
A review of facility policy Disinfecting and Cleaning on 10/24/24 revealed: " ...Laundry Room and Linen Handle, transport, and process soiled linen in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and avoids contamination of the environment ... " The facility staff failed to store and process visibly soiled linen in a manner that avoided contamination of the environment as per facility policy during OBS3.
OBS4: Child Care Room 1 tour revealed an unlabeled bottle of formula in a patient refrigerator. The surveyor was unable to identify the child that the bottle was made for or the date and time that the bottle was made. During an examination of the patient supply bins it was determined that used extension tubing for Mic key buttons [percutaneous gastric feeding tube] were not labeled with an initial use date or patient name. EMP2 stated that extension tubing was to be kept for " one week then discarded. " EMP2 was not able to determine when the extension tubing had been initially used.
A review of Facility policy Formula Preparation on 10/24/24 revealed: " Process/Procedure ...8. Formula must be placed in clean, sanitized bottles and labeled with the type, caloric intake, date prepared and child ' s name ...19. A bottle that has been fed over a period that exceeds one hour ...will not be served to an infant and will be discarded. " The facility staff failed to label patient bottles with name, date, and time as per facility policy during OBS4. Facility staff failed to label extension tubing with date and patient name.
The following expired supplies and medications were observed during the facility tour:
During OBS2 10 McKesson 3cc syringes MFR 16-53C expiration date 10/01/24 were discovered in Child Care Room 3.
During OBS3 Triamcinolone 0.5% topical cream expiration date 7/2024 was discovered in Child Care Room 2.
A review of facility policy Medication Administration Guidelines on 10/24/24 revealed: " Additional considerations when administering medications include: 4. Verification of expirations dates ... " Facility staff failed to dispose of expired patient medication as per policy.
The findings were reviewed with EMP1 (supervisor CM), EMP2 (administrator), EMP3 (AVP), and EMP4 (RN) during an exit interview on 10/24/24 at approximately 3:30 PM.
Plan of Correction:E0005 Sanitary Conditions: Section 15. Regulations, Standards (a)(5)
1. The facility will ensure that the staff maintains conditions within the Pediatric Extended Care Center which promotes the health and safety of the children by following the policies and procedures in place for Center Operations, Disinfecting and Cleaning.
a. Weekly, the facility staff will run the dishwasher on the sterilization setting & document completion, utilizing a log developed for this purpose.
b. Unlabeled toothbrushes were disposed of during site visit.
c. Child-size toilets are available for use. The child sized toilet will be cleaned and disinfected after each use. The soiled potty chair & liner were disposed of after the site visit.
d. Visibly soiled linen will be handled in a manner that avoids contamination of the environment. It will be bagged and placed in the dirty area of the individual child's diaper bag, to be sent home to the child's family. The changing table will be disinfected utilizing bleach solution after use.
e. Reusable individual medical supplies will be cleaned after each use. Extension tubing will be washed with warm soapy water, rinsed and placed on a clean surface to air dry. Items can be placed in the individual child's supply bin when dry.
i. Individual medical supplies will be labeled with the date opened and date of expiration. All supplies will be deemed expired per manufacturer or policy recommendations and discarded or returned to the client's family, if applicable.
2. Staff will adhere to the Formula Preparation policy, specifically regarding storage & labeling.
a. Formula will be placed in clean, sanitized bottles and labeled with the type, caloric intake, date prepared and child's name.
b. At the end of the day, all unused prepared formula is discarded or can be sent home at the parent's request.
3. Staff will adhere to the Medication Administration policy, specifically regarding storage and verification of expiration dates. All supplies and medications will be labeled with the date opened and date of expiration. All supplies and medications will be deemed expired per manufacturer or policy recommendations and discarded or returned to the client's family, if applicable.
a. 100% review of all stored medications and supplies will be performed. All items found to be expired will be disposed of appropriately and replaced with current items.
b. The facility will institute the following process to ensure that all items are stored appropriately, monitored, and remain current.
i. Daily, the facility staff will inspect medications and supplies prior to use, verifying expiration dates.
ii. Weekly, the facility staff will inspect classroom cabinets for content, managing expired items as appropriate.
iii. Monthly, the facility staff will inspect the storage room for content, discarding expired items as appropriate.
4. All staff will be re-educated on the company policies and the processes for maintaining sanitary conditions, during staff meetings held: 11/20/2024, 11/25/2024, or by 12/2/4/2024 if not present at the meetings.
5. The Administrative Director will ensure that the deficient practice does not re-occur by assigning Clinical Management to perform routine room rounds and observations during hours care is provided; in addition the Administrative Director will review the associated logs & storage content monthly for completion.
Who: Administrative Director
Plan of Correction Date: 12/13/2024
REQUIREMENT
MEDICAL RECORD MAINTENANCE
Name - Component - 00
SECTION 15. Regulations. Standards. (a)(7)
Maintenance of appropriate medical records, data and information relative to the children and programs. Such records shall be maintained in the facility for inspection by the department.
Observations:
Based on clinical record reviews (CR), reviews of policies, and interviews with staff (EMP) the facility failed to ensure staff followed Medication Administration Record (MAR) documentation standards for two (2) of five (5) CRs reviewed. (CRs 1 and 3)
Findings include:
A review of facility policy Medication Administration Guidelines on 10/24/24 revealed: " All medications for patient administration will be ordered by a licensed healthcare provider ...All current medications taken by the patient are listed on the Med Profile and the Medication Administration Record (MAR) ... "
A review of CRs on 10/24/24 between approximately 11:30 AM to 1:00 PM revealed:
CR1: Enrollment Date (ED): 3/11/24, an eleven-month-old patient with a history of Trisomy 21 [genetic disorder]. According to the 9/3/24-10/3/24 Plan of Care the patient was ordered the following medications and supplements: Vitamin D3, Acetaminophen, Benadryl, Neosporin, oxygen, and saline.
CR1 ' s September 2024 Medication Administration Record (MAR) contained an order for Albuterol 2.5 MG/3ML Inhalation, 3ML vial solution, inhalation every 4 hours as needed for cough, shortness of breath or wheeze dated 9/24/24. CR1 ' s Medication Administration Record Addendum dated September 2024 documented Albuterol Nebulizer as given on 9-24-24 at 1430 for congestion. The facility failed to maintain accurate medication documentation by including an order for albuterol in the MAR, without obtaining a physician ' s order in the Plan of Care. EMP1 was unable to locate a physician ' s order for Albuterol.
CR3: ED: 8/15/22, aged 2.5 years, primary diagnosis Congenital Malformation Syndrome [genetic disorder]. According to the 8/18/24 - 9/17/24 Plan of Care the patient was ordered the following medications and supplements: Acetaminophen, Benadryl, Neosporin, Oxygen, Saline, Ferrous Sulfate [iron] and Vitamin D3.
CR3 ' s September 2024 MAR [medication documentation form] contained an order for Albuterol 2.5MG/3ML Inhalation, 3ML via nebulizer PRN every 4 hours for wheezing, shortness of breath, and cough dated 5/3/23. The facility failed to maintain accurate medication documentation by including an order for albuterol in the MAR, without obtaining a physician ' s order in the Plan of Care. EMP1 was unable to locate a physician ' s order for Albuterol.
The findings were reviewed with EMP1 (Supervisor) and EMP2 (Facility Administrator) during the clinical record review and then during an exit interview on 10/24/24 at approximately 3:30 pm with EMP1 (supervisor CM), EMP2 (administrator), EMP3 (AVP), and EMP4 (RN).
Plan of Correction:E007
E007 Medical Record Maintenance: Section 15. Regulations, Standards (a)(7)
1. The facility will ensure that the staff adhere to the Medication Administration Guidelines policy, specifically regarding Medication Administration Record Documentation.
a. All medications for patient administration will be ordered by a licensed healthcare provider with the ability to prescribe.
b. All current medications are listed on the Med Profile and the Medication Administration Record (MAR)
2. All staff will be re-educated on the company policies and the processes for Medication Administration Guidelines, during staff meetings held: 11/20/2024, 11/25/2024, or by 12/2/4/2024 if not present at the meetings.
3. The Administrative Director will ensure that the deficient practice does not recur by utilizing a focused audit tool on a weekly basis to ensure that medication orders are documented appropriately, signed by a licensed healthcare provider with the ability to prescribe and transcribed to the MAR. Any documentation issues will be reported to the Clinical Manager for corrective action. This audit will occur weekly x 4, biweekly x 2 and then at that point, the typical auditing process can resume following the Aveanna QAPI plan policy.
Who: Administrative Director
Plan of Correction Date: 01/6/2025
REQUIREMENT
POLICIES AND PROCEDURES
Name - Component - 00
SECTION 15. Regulations. Requirements. (b)(12)
The director of the PECC shall assure that the governing body has developed, approved and implemented policies and procedures regarding the operation of the PECC. At a minimum, the PECC shall have policies and procedures on the prevention, reporting and investigation of abuse, delivery of medical and therapeutic services, control and delivery of pharmaceutical service and prevention of incidents and accidents.
Observations:
Based on clinical record reviews, observations, and interviews with staff the facility failed to create policies for the prevention of incidents and delivery of therapeutic services for two (2) of five (5) CRs reviewed. (CRs 1 and 2)
Findings include:
A review of CRs on 10/24/24 between approximately 11:30 AM to 1:00 PM revealed:
CR1: Enrollment Date (ED): 3/11/24, aged 11 months, primary diagnosis Trisomy 21 [genetic disorder]. CR1 ' s Plan of Care Certification Period 9/3/24 to 10/3/24 contained the following nursing orders: "...Thicken all bottles...can start trial spoon feeding...start with thicker purees...enteral feeding tube: Type G-Tube...give all medications via gtube..."
CR2: ED: 1/19/24, aged one year, primary diagnosis Hypoxic Ischemic Encephalopathy [brain swelling related to decreased perfusion and low oxygen levels] secondary diagnosis of seizures.
During a 10/24/24 interview with EMP1 (supervisor) and EMP2 (Facility Administrator) at approximately 12:30 pm it was determined that the facility did not currently have written policies or procedures in place which addressed aspiration precautions or seizure precautions. The facility failed to create specific policies for the prevention of aspiration in patients with enteral feeding tubes (CR1) and delivery of safe care for patients with seizure histories (CR2).
Plan of Correction:E0021 Policies and Procedures: Section 15. Regulations, Standards (b)(12)
1. The Administrative Director of the PECC will ensure that the Aveanna governing body has developed, approved and implemented policies and procedures that address the prevention of incidents and the delivery of therapeutic services.
a. Current available procedural documents will be consolidated, reformatted and approved by the governing body. This policy will be made readily available in the PECC specific section of the online Aveanna Policy Manual.
2. Once finalized, all facility staff will be re-educated by the Administrative Director, on the location and implementation of this policy as it relates to the prevention of incidents and delivery of therapeutic services.
Who: Administrative
Plan of Correction Date: 12/13/2024
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