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 state licensure complaint survey completed April 22, 2021, Aveanna Healthcare was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.






Plan of Correction:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:


Based on review of agency policy, a review of COVID-19 screening documentation, observations, and an interview with the agency Administrator, the agency failed to ensure adequate infection control practices by ensuring that everyone entering the health care facility is screened and triaged for COVID-19 for one (1) of one (1) observations (Observation #1) and one (1) of one (1) interviews (Interview #1).

Findings Include:

Pennsylvania Department of Health 'Health Alert Network' dated August 7, 2020 'Subject' 'Update: Interim Infection Prevention and Control Recommendations for Patients with known or Patients Under Investigation for 2019 Novel Coronavirus (COVID-19) in a Healthcare Setting' section (I) Recommended Routine Infection Prevention and Control (IPC) Practices During the COVID-19 Pandemic' (B) 'Screen and Triage Everyone Entering a Healthcare Facility for signs and symptoms of COVID-19':....symptom screening remains an important strategy to identify those who could have COVID-19 .......". "Screen everyone (patients, healthcare personnel, visitors) entering the facility for symptoms consistent with COVID-19 .....". "Actively take their temperature and document absence of symptoms consistent with COVID-19".

Agency COVID-19 policy/procedure reviewed on April 20, 2021 at approximately 1:00 p.m. (Note: Policy does not address visitors, only employees). ''Covid-19 Self monitoring for Staff and Patients/COVID-19 Mask Protocol' states "Employee will complete self monitoring tool prior to beginning of every shift". "Caregiver COVID-19 Assessment' form "To be completed at start of each shift."
Agency 'Infection Control Guidelines' 'COVID-19 Considerations' state "When making a home visit, the staff should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask patients the following ....." 'COVID-19: Individual/Patient Screening Tool' "To be completed at start of each shift."

Observation #1: On April 20, 2021 at approximately 11:10 a.m. the state surveyor arrived at the agency. Agency front desk staff greeted the surveyor and surveyor's temperature was taken/documented on the 'COVID-19 Internal Employee Screening Tool'. No symptom screening was conducted (The staff member who conducted the screening did check (2) of the (3) screening questions on the log, even though the questions were not actually asked). The surveyor reviewed the agency COVID-19 screening log. The surveyor was the only entry on 04/20/21.
Interview #1: On 04/20/21 at approximately 11:45 a.m. an interview was conducted with the agency Administrator. The Administrator was asked what the agency COVID-19 screening protocols are for people who enter the agency office. She stated the paper log ('COVID-19 Internal Employee Screening Tool') and an "app" was utilized for screening. A list was requested of all staff members that were currently in the building. A list was provided that included thirteen (13) staff members. Documentation was requested of staff that had utilized the "app" for screening prior to office entry. The list included nine (9) staff members. Employees #5-#8 did not self screen for COVID-19 prior to office entry.
The Administrator was asked what the screening protocols were for direct care workers in the field. Administrator stated the field staff self screen (utilizing the 'Caregiver COVID-19 Assessment' form) and also screen consumers (utilizing the 'COVID-19: Individual/Patient Screening Tool' form) prior to beginning a work shift. Documentation was requested of the agency staff self screening and patient (consumer) screening prior to making home visits, per agency policy. Per email correspondence with the Administrator on 04/21/21, "unfortunately we do not have those documents".

An interview with the agency Administrator on April 21, 2021 at approximately 3:00 p.m. and email correspondence on 04/22/21 at approximately 10:35 a.m. confirmed the above findings.















Plan of Correction:

1. All support staff will be re-educated on the COVID-19 policy regarding the COVID-19 self-screening tool to be completed prior to reporting to work every day. Re-education to be completed at staff meeting on 4/26/21.
2. All external staff will be re-educated on the COVID-19 policy regarding the COVID-19 self-monitoring for staff and patients. An email will be sent to all caregivers along with the proper forms to be completed by 4/30/21. Staff will be instructed to hand in all forms for the previous week every Wednesday.
3. A tracker will be created to ensure that all caregivers are performing the COVID-19 self -monitoring for staff and patients. If forms are not received, call will be made to caregivers to obtain all forms.
4. Clinical Director or designee will complete a 100% audit of the tracker on a weekly basis to ensure all COVID-19 self-monitoring forms have been turned in. Re-education and/or coaching will be given to caregivers that have not turned in the forms.



611.56(a) LICENSURE
Health Screening

Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.

Observations:


Based upon review of employee files (EF) and an interview with the agency Administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for one (1) out of three (3) EFs reviewed (EF#1).

Findings Include:

The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of employee files was conducted on April 20, 2021 at approximately 11:45 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 12/07/20: No documentation provided of an individual TB risk assessment upon hire.

An interview with the agency Administrator on April 21, 2021 at approximately 3:00 p.m. and email correspondence on 04/22/21 at approximately 10:35 a.m. confirmed the above findings.











Plan of Correction:

1. All support staff will be educated on the individual TB risk assessment that is to be completed upon hire and annually for all caregivers.

2. The three required CDC screening questions will be added to Aveanna's initial and annual TB screening questionnaire.

3. In addition to the initial and annual TB screening questionnaire, all caregivers will be given the three required screening questions as outlined by the CDC to complete by 06/18/2021.


611.57(a) LICENSURE
Consumer Rights

Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:


Based upon review of consumer files, employee visit activity checklists, and an interview with the agency Administrator, agency failed to ensure services were provided as agreed upon for one (1) of one (1) consumer files (CF) reviewed (CF#3).


Findings include:

Review of consumer files and employee visit activity checklists were completed on April 21, 2021 at approximately 4:30 p.m. Consumer start of service (SOS) is listed below.

CF#3, SOS 04/23/18: This consumer is the subject of a complaint against the agency. The complaint alleges "...a direct care worker (EF#1) does not provide home care services per the service agreement ....."

The consumers 'HHA/Aide/DCW/CNA Homemaker Care Plan' was reviewed on 04/21/21. 'Care' 'Housekeeping' 'Level of Support' lists "Make Bed, Tidy rooms where care is delivered, and Clean Surfaces" as "D" (daily).
The employee visit activity checklists completed by EF#1, EF#2, EF#4 reviewed from 03/23/21-04/08/21 revealed the following.

EF#1, Date of hire 12/07/20:
03/23/21: "Change/Make Bed', 'Tidy Rooms' were marked "NO".
03/26/21: "Change/Make Bed' was marked "NO".
03/28/21: 'Clean/Dust/Mop' was marked "NO".
03/31/21: "Change/Make Bed', 'Tidy Rooms', 'Clean/Dust/Mop' were marked "NO".
04/07/21: 'Clean/Dust/Mop' was marked "NO".

EF#4, Date of hire 05/02/18:
03/28/21: 'Clean/Dust/Mop' was marked "NO".
04/04/21: "Change/Make Bed', 'Clean/Dust/Mop' were marked "NO".

All (3) 'Housekeeping' tasks were not completed each direct care worker visit.


An interview with the agency Administrator on April 21, 2021 at approximately 3:00 p.m. and email correspondence on 04/22/21 at approximately 10:35 a.m. confirmed the above findings.





















Plan of Correction:

1. EF#1- employee will be contacted by 4/30/21 to review plan of care for EF#3. The employee will be re-educated on how to read the plan of care and on proper documentation based on the plan of care.
2. EF#4- employee will be contacted by 4/30/21 to review plan of care for EF#3. The employee will be re-educated on how to read the plan of care and on proper documentation based on the plan of care.
3. All external employees will be re-educated on proper documentation based on the plan of care. An email will be sent to all caregivers with re-education by 4/30/21.
4. Clinical director or designee will complete a 100% audit on all caregivers' documentation for 2 weeks. Any caregiver that is not documenting based on the services agreed on the plan of care will be re-educated and/or receive a coaching. At the completion of 2 weeks, 25% of documentation will be audited on a quarterly basis.