There are  10 surveys for this facility. Please select a date to view the survey results.

CR #2 Plan of care updated to reflect a clause that states the actual hours that Aveanna provides services for and verbal order was sent to the providing doctor. Missed shifts were added for any hour that was not worked per the frequency section on the Aveanna Plan of Care back to the beginning of February and sent to doctor.
The documentation issues could not be corrected due to being in the past.
CR #3 Client to be discharged this week no updates made
CR #4 Plan of care updated to reflect a clause that states the actual hours that Aveanna provides services for and verbal order was sent to the providing doctor. Missed shifts were added for any hour that was not worked per the frequency section on the Aveanna Plan of Care back to the beginning of February and sent to doctor.
The documentation issues could not be corrected due to being in the past.
CR #5 Plan of care updated to reflect a clause that states the actual hours that Aveanna provides services for and verbal order was sent to the providing doctor. Missed shifts were added for any hour that was not worked per the frequency section on the Aveanna Plan of Care back to the beginning of February and sent to doctor.
The documentation issues could not be corrected due to being in the past.
PRN medication updated with frequency.
CR #6 Missed shifts were added for any hour that was not worked per the frequency section on the Aveanna Plan of Care back to the beginning of February and sent to doctor.
CR#7 Missed shifts were added for any hour that was not worked per the frequency section on the Aveanna Plan of Care back to the beginning of February and sent to doctor.
CR# 9- Client no longer a patient of Aveanna
The Plan of Care unable to corrected to being in the past


Missed Shifts:

Re-education will be provided to operations staff on the missed shift policy. During that time stressing the importance of the need to document anytime that hours are missed not just a full shift being missed. Nursing Director/Executive Director responsibility within two weeks

Re-education will be provided to the internal clinical staff making sure that the Plan of Care frequency matches the authorization and typically scheduled hours. Also, If the case is shared there will be a clause in the frequency section stating what Aveanna is typically responsible for and what other agency is involved with care. Nursing Director/Executive Director responsibility within two weeks

Re-education to all internal staff on the importance of clear up to date communication about changes to the authorization or scheduled shifts. Also, coordination of care with other agencies whom cases are shared with will be documented at least monthly in the notes section in GLS by the operations team. Nursing Director/Executive Director responsibility within two weeks

Clinical supervisors will review all Plan's of care at next recertification period visit and compare every current authorization and hours scheduled to what is in the frequencies section on the Plan of care and assure they match. This will be completed 4/12/2024.

Operations staff will compare all schedules to current authorizations and the frequency section on the Plan of care and assure that all hours Aveanna is responsible for are accounted for in the missed visit reports. This will be completed by 4/12/2024.

A quality improvement indicator has been created to track this process and will be monitored throughout location QAPI meeting. Nursing Director/Executive Director responsible for on-going until compliance is met.



Documentation by external nurses of all interventions on the Plan of Care

Re-educate all clinical staff on reporting anything that is on the Plan of care regardless of if it occurs on the shift or not on their daily assessment. Also, to stress the importance of the timing/frequency for each intervention on the Plan of Care and the need to notify the office is it has changed. Reviewing the treatment sheet section on the daily assessment documentation and how beneficial it is to document interventions efficiently. Nursing Director/Executive Director responsibility within two weeks

Every active nurses documentation will be reviewed before next recertification period and reviewed at visit or over the phone for compliance with documentation of interventions appropriately. A sheet will be created for a quick reference during visit to assist with compliance going forward. 2-3 notes per nurse will be reviewed weekly for compliance until compliance is met. Clinical internal staff responsible for initial review by 4/12/24 and then ongoing for compliance

A quality improvement indicator has been created to track this process and will be monitored throughout location QAPI meeting. Nursing Director/Executive Director responsible.



Medication timing

Re-educate external clinical staff on the importance of documenting all medications during the worked shift as given or not given and if not given the reason why. Text message/email to be sent to Clinical staff within two weeks.

Meet with internal clinical staff and come up with an effective way to document the timing of medications. Nursing Director responsible for within two weeks.

Roll out the plan and update documentation within 30 days

A quality improvement indicator will be created to track this process and will be monitored throughout location QAPI meeting. Nursing Director/Executive Director responsible.


PRN medications with no frequencies

Re-educate all internal clinical staff on the need for all medications including PRN to have a frequency. Clinical director within two weeks

Internal clinical staff will review all medication profiles and update any medication that do not have a frequency attached to it within the next 60 days.
A quality improvement indicator will be created to track this process and will be monitored throughout location QAPI meeting. Nursing Director/Executive Director responsible.


Plan of Care not returned within 30 days

Plans of care will be sent timely and resent every 7 days for the first 14 days. If not returned within 14 days a call will be placed to doctor's office to inquire if there is an issue and it assure it has been received. After the call Plan of care will be sent weekly to obtain signature followed up with a phone call. Internal clinical team ongoing

Re-educate internal clinical team on the policy for plan of care return timeframe. Also, teach them the above guidelines for obtaining a signature. Clinical director within two weeks.

Send a reminder letter about the requirements for homecare orders being signed via fax after 14 days to any doctor that has not signed a plan of care. Internal clinical ongoing

A quality improvement indicator will be created to track this process and will be monitored throughout location QAPI meeting. Nursing Director/Executive Director responsible.