Initial Comments:
Based on the findings of an onsite unannounced Pediatric Extended Care Center state re-licensure survey conducted October 1, 2024 and October 2, 2024, Aveanna Healthcare was found not to be in compliance with the requirements of PA Act 54 of 1999, The Prescribed Pediatric Extended Care Centers Act, 35 P.S. , 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 an observational tour, facility policies, and interview with administrative director, it was determined that the facility failed to follow agency policies and procedures which assure the health and safety of children under the care of the facility.
Findings include:
Review of facility policy titled "Medication Administration Guidelines" states, "Policy: Additional consideration when administering medications include: 4. Verification of expiration dates..."
The following are expired supplies/medication/ointments that were found during the observational tour completed on:
10/01/2024
9:45 am Supply Room - - Eucerin (1) - exp. 8/2024 - Neosporin (1) exp. 3/2024 - 3M Tegaderm Transparent Film Dressing (18) exp. 5/22/2024 - Dressing Change Tray CVC (1) exp. 4/5/2024 - Similac Advance (1 can) exp. 9/1/2024 - Nestle Peptamen Junior (42) exp. 9/11/2024 - Coiled Suction Catheter (17) exp. 6/20/2024 - Coiled Suction Catheter (4) exp. 5/28/2024 - Ear/Ulcer Bulb Syringe (1) exp. 7/2020 - Tuberculin Syringes (278) exp. 3/2/2024 - Tuberculin Syringes (61) exp. 11/2/2023 - 3ml Syringes (2) exp. 4/30/2024
During an observational tour in the presence of the Nurse Manager on October 1, 2024, at approximately 11:00 A.M. and in the presence of the Nurse Administrator on October 2, 2024 at approximately 9:00 A.M., the following items were found to be expired:
October 1, 2024 Classroom #3 - Sodium Chloride Inhalation Solution (7) exp. 8/2024
Classroom #4 - Dextrose IV Solution 20% (1) exp. 11/30/2023
October 2, 2024
Classroom #1 - Aquaphor -(1 jar) exp. 6/2022
9:20 am - Emergency Go-Kit - Coiled Suction Catheter -(1) exp. 5/28/2024
In an interview with the Administrator, on October 2, 2024, at approximately 11:30 A.M. confirmed the above findings.
Plan of Correction:E0005 Sanitary Conditions: Section 15. Regulations, Standards (a)(5) 1. The facility will ensure that all staff adhere to the Medication Administration policy, specifically regarding storage, labeling 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. 2. 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. 3. The facility will institute the following process to ensure that all items are stored appropriately, monitored, and remain current. a. Daily, the facility staff will inspect the emergency Go-Kit as part of their opening procedures, managing expired items as appropriate. b. Daily, the facility staff will inspect medications and supplies prior to use, verifying expiration dates. a. Weekly, the facility staff will inspect classroom cabinets for content, managing expired items as appropriate. b. 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 policy and the process of appropriate storage and labeling, monitoring expiration dates and maintaining sanitary conditions, during staff meetings held: 10/18,2024, 10/22/2024, or by 11/4/2024 if not present at the meetings. 5. The Administrative Director will ensure that the deficient practice does not recur by reviewing the associated logs & storage content monthly for completion. Who: Administrative Director Plan of Correction Date: 11/4/2024
REQUIREMENT ADMINISTRATOR Name - Component - 00 SECTION 15. Regulations. Requirements. (b)(2)
The department shall require that the PECC has employed an administrator whose qualifications are that of a physician who has a current, active, unrestricted license in the Commonwealth, a certified registered nurse practitioner licensed to practice in this Commonwealth, a licensed nursing home administrator, personal care home administrator, a child day-care administrator or a registered nurse with five years of documented experience in pediatric medicine. The administrator shall be responsible for the operation of the PECC.
Observations:
Based on review of center policies/procedures, personnel files and clinical records, and based on interview with the Nursing Administrator, the administrator failed to ensure that one (1) of seven (7) center staff had child abuse clearances on file upon hire. (Employee #6)
Findings include:
On October 1, 2024 at approximately 2:30 pm during a review of the personnel files revealed the following: Employee #6, Date of Hire: 8/20/2024. The file did not contain documentation that a child abuse clearance was obtain upon hire.
During interview on October 2, 2024 at 11:30 AM, the Nursing Administrator confirmed the above findings.
Plan of Correction:E009 Qualifications: SECTION 15. Regulations, Requirements. (b)(2). 1. The Nursing Administrator hired an LPN, however failed to ensure that the appropriate child abuse clearance was on file. The newly hired LPN was initially confused by the requirement and has since completed the application and received the appropriate results. The clearance is on file in the location. 2. 100 % review of all background clearance files will be performed. Any missing clearances will be retrieved and acted upon if applicable. 3. The Nursing Administrator will ensure that the deficient practice does not reoccur by utilizing the Aveanna personnel file checklist and audit tool, enlisting the assistance of the Administrative Assistant as a double check who will enter tracking dates into the facility's EMR. Who: Administrative Director Plan of Correction Date: 10/25/2024
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