Every finding on record at Andventure, LLC

Based on the findings of an onsite unannounced home health agency complaint investigation survey conducted June 1, 2023, through June 16, 2023, Aveanna Healthcare, was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies. As a result of the survey, three (3) condition level deficiencies and eight (8) standard level deficiencies were identified. No Immediate Jeopardy situation was identified.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on review of Agency policies and procedures, medical record review, email correspondence and interviews with agency executive director and clinical managers, the agency failed to ensure the client received all orders from the physician for one (1) out of three (3) records reviewed. (MR# 1). Findings: Reviews of medical records conducted 6/1/23 between approximately 11:00 AM to 11:45 AM revealed the following: MR# 1, Start of care (SOC): 8/23/21; certification period: 2/14/23-4/14/23; Physician's orders: Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; Nutritional Requirements: Diet/hydration: gastrostomy tube-Peptamen Junior three hundred sixty (360) milliliters (ml) to run approximately from 9:30 AM-3:30 PM to be run at sixty (60) milliliters per hour (ml/hr) or as tolerated. Start effective date :10/14/2022; Overnight: Peptamen Junior two hundred ninety (290) ml plus two hundred fifty (250) ml of water to equal five hundred forty (540) ml to run at fifty (50) ml/hr for eleven (11) hours. . a.. Review of skilled nurse flow sheets between 2/14/23 and 3/9/23 revealed: Documentation on only four (4) days of blood glucose levels. 1. Review of Skilled Nursing flow sheet from 2/20/23 on 6/1/23 revealed: Nursing narrative documentation: “11:30 AM: blood sugars stable.” 2. Review of Skilled Nursing flow sheet from 2/22/23 on 6/1/23 revealed: Nursing narrative documentation: “2:00 PM: patient had blood sugar checked and within normal limits.” 3. Review of Skilled Nursing flow sheet from 2/28/23 on 6/1/23 revealed: Nursing narrative documentation: “10:30 AM: blood sugar checked before feeding and was low side of normal, patient encouraged to eat rice crisp, reread ten (10) minutes later and raised to acceptable level.” 4. Review of Skilled Nursing flow sheet from 3/3/23 on 6/1/23 revealed: Nursing narrative documentation: “10:00 AM: AM meds administered and glucose within normal limits.” Interviews held between 1:00 PM- 1:30 PM with agency executive director and clinical manager throughout the onsite investigation on 6/1/23 revealed: “There are no blood glucoses documented for the week of the complaint, but the order was changed to as needed on March 9th.” An email response received from an agency clinical manager on 6/14/23 in regard to blood sugar testing per physician’s orders from 2/13/23 through 3/9/23 after surveyor asked if there were any other blood sugars documented during that time frame besides the blood sugars that surveyor already had documentation revealed: “In regard to the blood sugars, those are the only documented blood sugars in those weeks.” An interview conducted with the agency executive director and clinical managers on 6/15/23 at approximately 2:00 PM confirmed the above findings.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on review of Agency policies and procedures, medical record review, email correspondence and interviews with agency executive director and clinical managers, it was determined that the agency failed to ensure staff provided quality care through the establishment of written plans of care, conformance with physician's orders and adherence to written policies. Cross references: 484.60(a)(1) Plan of Care Tag: 0572- failed to ensure a plan of care was established. 484.60(b) Conformance with Physicians Orders Tag: 0578- failed to ensure conformance with physician's orders. The cumulative effect of these systemic problems resulted in the Home Health Agency’s inability to ensure the provision of care planning, coordination and quality of care.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of Agency policies/procedures, medical record (MR), email correspondence from agency clinical managers and interviews with agency executive director and clinical managers, it was determined that the agency failed to ensure that the plan of care was implemented and followed in one (1) of three (3) records reviewed. (MR # 1). Findings: Review of Aveanna Healthcare Physician Orders policy on 6/15/23 at 3:20 PM revealed: Overview: “Care and services will be provided in accordance with physician's (or other authorized practitioner’s) orders, as required by law and regulation.”; “Process/Procedures: Physician orders will be legible, complete, authenticated, and timely. Orders are required for all care and services…” Plan of Treatment/Plan of Care: A complete, individualized Plan of Care/Treatment will be developed for all patients receiving ongoing clinical services according to applicable law and state regulations. The initial Plan of Care/Treatment is developed in conjunction with the physician/prescriber, patient/family, and the Company's health care professional as part of the admission process. The Plan of Care/Treatment must be reviewed and revised as frequently as the patient’s condition or needs require, but no less than 60 days or per applicable law and regulation. The Plan of Care/Treatment is modified in accordance with the physician’s orders.” Reviews of medical records conducted 6/1/23 between approximately 11:00 AM to 11:45 AM revealed the following: MR# 1, Start of care (SOC): 8/23/21; certification period: 2/14/23-4/14/23; Physician's orders: Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; Nutritional Requirements: Diet/hydration: gastrostomy tube(G-tube)-Peptamen Junior three hundred sixty (360) milliliters (ml) to run approximately from 9:30 AM-3:30 PM to be run at sixty (60) milliliters per hour (ml/hr) or as tolerated. Start effective date :10/14/2022; Overnight: Peptamen Junior two hundred ninety (290) ml plus two hundred fifty (250) ml of water to equal five hundred forty (540) ml to run at fifty (50) ml/hr for eleven (11) hours. Certification period: 4/15/23-6/13/23; Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/23; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023; medications: Omeprazole two (2) milligram(mg) per milliliter via G-tube sixteen (16) milligram (take one half-one hour before food) twice per day at 9:30 AM and 3:30 PM start effective date: 8/23/2021. . a. Review of Physician orders no frequency dated 3/10/23 revealed: “Physician communication: New blood sugar orders post appointment earlier this week.”; Interventions: SN endocrine interventions: SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/2023; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023. The plan of care for certification period 4/15/23-6/13/23 was modified to show the changes in blood glucose monitoring. b. Review of skilled nurse flow sheets between 2/14/23 and 3/9/23 revealed: Documentation on only four (4) days of blood glucose levels. 1. Review of Skilled Nursing flow sheet from 2/20/23 on 6/1/23 revealed: Nursing narrative documentation: “11:30 AM: blood sugars stable.” 2. Review of Skilled Nursing flow sheet from 2/22/23 on 6/1/23 revealed: Nursing narrative documentation: “2:00 PM: patient had blood sugar checked and within normal limits.” 3. Review of Skilled Nursing flow sheet from 2/28/23 on 6/1/23 revealed: Nursing narrative documentation: “10:30 AM: blood sugar checked before feeding and was low side of normal, patient encouraged to eat rice crisp, reread ten (10) minutes later and raised to acceptable level.” 4. Review of Skilled Nursing flow sheet from 3/3/23 on 6/1/23 revealed: Nursing narrative documentation: “10:00 AM: AM meds administered and glucose within normal limits.” c. Skilled nurse stated in his written statement dated 6/2/23: Skilled nurse did reveal that he did make a medication error involving the patient’s Omeprazole by administering the medication three (3) times a shift instead of the ordered two (2) times for several days in a row but did not give specific dates. Interviews held between 1:00 PM-1:30 PM with agency executive director and clinical manager throughout the onsite investigation on 6/1/23 revealed: “There are no blood glucoses documented for the week of the complaint, but the order was changed to as needed on March 9th.” An email response received from an agency clinical manager on 6/14/23 regarding blood sugar testing per physician’s orders from 2/13/23 through 3/9/23 after surveyor asked if there were any other blood sugars documented during that time frame besides the blood sugars that surveyor already had documentation revealed: “In regard to the blood sugars, those are the only documented blood sugars in those weeks.” “Skilled nurse did mention to us that the family had a little notebook that all the blood sugars were kept in when they were taken. We do not have a copy of this book but apparently it was sent along to school with the skilled nurse and the patient.” An email response received from an agency clinical manager on 6/15/23 at 2:00 PM in regard to medication error documentation revealed: “I have also attached the documentation for the medication error. We were never notified by complainant or skilled nurse in real time when this supposedly happened, and only learned of it during this investigation.” An interview conducted with the agency executive director and clinical managers on 6/15/23 at approximately 2:00 PM confirmed the above findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of Agency policies/procedures, medical record (MR), email correspondence from agency clinical managers and interviews with agency executive director and clinical managers, it was determined that the agency failed to ensure that staff followed physician's orders in one (1) of three (3) records reviewed. (MR # 1). Findings: Review of Aveanna Healthcare Physician Orders policy on 6/15/23 at 3:20 PM revealed: Overview: “Care and services will be provided in accordance with physician's (or other authorized practitioner’s) orders, as required by law and regulation.”; “Process/Procedures: Physician orders will be legible, complete, authenticated, and timely. Orders are required for all care and services…” Plan of Treatment/Plan of Care: A complete, individualized Plan of Care/Treatment will be developed for all patients receiving ongoing clinical services according to applicable law and state regulations. The initial Plan of Care/Treatment is developed in conjunction with the physician/prescriber, patient/family, and the Company's health care professional as part of the admission process. The Plan of Care/Treatment must be reviewed and revised as frequently as the patient’s condition or needs require, but no less than 60 days or per applicable law and regulation. The Plan of Care/Treatment is modified in accordance with the physician’s orders.” Reviews of medical records conducted 6/1/23 between approximately 11:00 AM to 11:45 AM revealed the following: MR# 1, Start of care (SOC): 8/23/21; certification period: 2/14/23-4/14/23; Physician's orders: Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; Nutritional Requirements: Diet/hydration: gastrostomy tube(G-tube)-Peptamen Junior three hundred sixty (360) milliliters (ml) to run approximately from 9:30 AM-3:30 PM to be run at sixty (60) milliliters per hour (ml/hr) or as tolerated. Start effective date :10/14/2022; Overnight: Peptamen Junior two hundred ninety (290) ml plus two hundred fifty (250) ml of water to equal five hundred forty (540) ml to run at fifty (50) ml/hr for eleven (11) hours. Certification period: 4/15/23-6/13/23; Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/23; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023; medications: Omeprazole two (2) milligram(mg) per milliliter via G-tube sixteen (16) milligram (take one half-one hour before food) twice per day at 9:30 AM and 3:30 PM start effective date: 8/23/2021. a. Blood sugar check orders for certification period 2/14/23-4/14/23: monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023. b. Review of Physician orders no frequency dated 3/10/23 revealed: “Physician communication: New blood sugar orders post appointment earlier this week.”; Interventions: SN endocrine interventions: SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/2023; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023. The plan of care for certification period 4/15/23-6/13/23 was modified to show the change in blood glucose monitoring. c. Review of skilled nurse flow sheets between 2/14/23 and 3/9/23 revealed: Documentation on only four (4) days of blood glucose levels. 1. Review of Skilled Nursing flow sheet from 2/20/23 on 6/1/23 revealed: Nursing narrative documentation: “11:30 AM: blood sugars stable.” 2. Review of Skilled Nursing flow sheet from 2/22/23 on 6/1/23 revealed: Nursing narrative documentation: “2:00 PM: patient had blood sugar checked and within normal limits.” 3. Review of Skilled Nursing flow sheet from 2/28/23 on 6/1/23 revealed: Nursing narrative documentation: “10:30 AM: blood sugar checked before feeding and was low side of normal, patient encouraged to eat rice crisp, reread ten (10) minutes later and raised to acceptable level.” 4. Review of Skilled Nursing flow sheet from 3/3/23 on 6/1/23 revealed: Nursing narrative documentation: “10:00 AM: AM meds administered and glucose within normal limits.” d. Skilled nurse stated in his written statement dated 6/2/23: Skilled nurse did reveal that he did make a medication error involving the patient’s Omeprazole by administering the medication three (3) times a shift instead of the ordered two (2) times for several days in a row but did not give specific dates. Interviews held between 1:00 PM-1:30 PM with agency executive director and clinical manager throughout the onsite investigation on 6/1/23 revealed: “There are no blood glucoses documented for the week of the complaint, but the order was changed to as needed on March 9th.” An email response received from an agency clinical manager on 6/14/23 regarding blood sugar testing per physician’s orders from 2/13/23 through 3/9/23 after surveyor asked if there were any other blood sugars documented during that time frame besides the blood sugars that surveyor already had documentation revealed: “In regard to the blood sugars, those are the only documented blood sugars in those weeks.” “Skilled nurse did mention to us that the family had a little notebook that all the blood sugars were kept in when they were taken. We do not have a copy of this book but apparently it was sent along to school with the skilled nurse and the patient.” An email response received from an agency clinical manager on 6/15/23 at 2:00 PM in regard to medication error documentation revealed: “I have also attached the documentation for the medication error. We were never notified by complainant or skilled nurse in real time when this supposedly happened, and only learned of it during this investigation.” An interview conducted with the agency executive director and clinical managers on 6/15/23 at approximately 2:00 PM confirmed the above findings.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of Agency policies/procedures, Job position descriptions, medical record (MR), email correspondence from agency clinical managers and interviews with agency executive director and clinical managers, it was determined that the agency failed to ensure that the patient medication schedule/instructions were followed in one (1) of three (3) records reviewed. (MR # 1). Findings: Review of Aveanna Healthcare Physician Orders policy on 6/15/23 at 3:20 PM revealed: Overview: “Care and services will be provided in accordance with physician's (or other authorized practitioner’s) orders, as required by law and regulation.”; “Process/Procedures: Physician orders will be legible, complete, authenticated, and timely. Orders are required for all care and services…” Plan of Treatment/Plan of Care: A complete, individualized Plan of Care/Treatment will be developed for all patients receiving ongoing clinical services according to applicable law and state regulations. The initial Plan of Care/Treatment is developed in conjunction with the physician/prescriber, patient/family, and the Company's health care professional as part of the admission process. The Plan of Care/Treatment must be reviewed and revised as frequently as the patient’s condition or needs require, but no less than 60 days or per applicable law and regulation. The Plan of Care/Treatment is modified in accordance with the physician’s orders.” Review of Aveanna Healthcare Licensed Practical Nurse job description on 6/1/23 between 11:45 AM and 12:40 PM revealed: Position overview: “Responsible for providing and documenting skilled nursing care, under the supervision of a Registered Nurse, in accordance with the developed care plan and physicians orders for each individual patient…”; Essential Job Functions: “Responsible for the delivery and coordination of quality patient care in compliance with physician orders.”; “Document all activities, assessments, nursing actions, responses…in a timely manner…”; “accepts responsibility for personal and professional accountability by complying with Aveanna policies, state and federal regulations, accrediting bodies and the Nurse Practice Act…” Reviews of medical records conducted 6/1/23 between approximately 11:00 AM to 11:45 AM revealed the following: MR# 1, Start of care (SOC): 8/23/21; certification period: 2/14/23-4/14/23; Physician's orders: Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; Nutritional Requirements: Diet/hydration: gastrostomy tube(G-tube)-Peptamen Junior three hundred sixty (360) milliliters (ml) to run approximately from 9:30 AM-3:30 PM to be run at sixty (60) milliliters per hour (ml/hr) or as tolerated. Start effective date :10/14/2022; Overnight: Peptamen Junior two hundred ninety (290) ml plus two hundred fifty (250) ml of water to equal five hundred forty (540) ml to run at fifty (50) ml/hr for eleven (11) hours. Certification period: 4/15/23-6/13/23; Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/23; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023; medications: Omeprazole two (2) milligram(mg) per milliliter via G-tube sixteen (16) milligram (take one half-one hour before food) twice per day at 9:30 AM and 3:30 PM start effective date: 8/23/2021. . a. Review of Physician orders no frequency dated 3/10/23 revealed: “Physician communication: New blood sugar orders post appointment earlier this week.”; Interventions: SN endocrine interventions: SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/2023; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023. The plan of care for certification period 4/15/23-6/13/23 was modified to reflect the changes in blood glucose monitoring. b. Review of skilled nurse flow sheets between 2/14/23 and 3/9/23 revealed: Documentation on only four (4) days of blood glucose levels. 1. Review of Skilled Nursing flow sheet from 2/20/23 on 6/1/23 revealed: Nursing narrative documentation: “11:30 AM: blood sugars stable.” 2. Review of Skilled Nursing flow sheet from 2/22/23 on 6/1/23 revealed: Nursing narrative documentation: “2:00 PM: patient had blood sugar checked and within normal limits.” 3. Review of Skilled Nursing flow sheet from 2/28/23 on 6/1/23 revealed: Nursing narrative documentation: “10:30 AM: blood sugar checked before feeding and was low side of normal, patient encouraged to eat rice crisp, reread ten (10) minutes later and raised to acceptable level.” 4. Review of Skilled Nursing flow sheet from 3/3/23 on 6/1/23 revealed: Nursing narrative documentation: “10:00 AM: AM meds administered and glucose within normal limits.” c. Skilled nurse stated in his written statement dated 6/2/23: Skilled nurse did reveal that he did make a medication error involving the patient’s Omeprazole by administering the medication three (3) times a shift instead of the ordered two (2) times for several days in a row but did not give specific dates. Interviews held between 1:00 PM-1:30 PM with agency executive director and clinical manager throughout the onsite investigation on 6/1/23 revealed: “There are no blood glucoses documented for the week of the complaint, but the order was changed to as needed on March 9th.” An email response received from an agency clinical manager on 6/14/23 regarding blood sugar testing per physician’s orders from 2/13/23 through 3/9/23 after surveyor asked if there were any other blood sugars documented during that time frame besides the blood sugars that surveyor already had documentation revealed: “In regard to the blood sugars, those are the only documented blood sugars in those weeks.” “Skilled nurse did mention to us that the family had a little notebook that all the blood sugars were kept in when they were taken. We do not have a copy of this book but apparently it was sent along to school with the skilled nurse and the patient.” An email response received from an agency clinical manager on 6/15/23 at 2:00 PM in regard to medication error documentation revealed: “I have also attached the documentation for the medication error. We were never notified by complainant or skilled nurse in real time when this supposedly happened, and only learned of it during this investigation.” An interview conducted with the agency executive director and clinical managers on 6/15/23 at approximately 2:00 PM confirmed the above findings.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on review of Agency policies and procedures, medical record review, email correspondence and interviews with agency executive director and clinical managers, it was determined that the skilled professionals failed to ensure that their responsibilities were completed in one (1) of three (3) records reviewed (MR # 1) and the agency failed to ensure the skilled nurse provided all orders in the plan of care for one (1) out of three (3) records reviewed. (MR# 1). Cross Reference: 484.75(b) Responsibilities of Skilled Professionals: Tag 0704- the skilled professionals failed to ensure that their responsibilities were completed in one (1) of three (3) records reviewed (MR # 1) 484.75(b)(3) Provide Services in the Plan of Care: Tag 0710- the agency failed to ensure the skilled nurse provided all orders in the plan of care for one (1) out of three (3) records reviewed. (MR# 1). The cumulative effect of these systemic problems resulted in the Home Health Agency's inability to ensure the provision of services by Skilled Professionals and quality of care.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on review of Agency policies/procedures, medical record (MR), email correspondence from agency clinical managers and interviews with agency executive director and clinical managers, it was determined that the skilled professionals failed to ensure that their responsibilities were completed in one (1) of three (3) records reviewed. (MR # 1). Findings: Review of Aveanna Healthcare Physician Orders policy on 6/15/23 at 3:20 PM revealed: Overview: “Care and services will be provided in accordance with physician's (or other authorized practitioner’s) orders, as required by law and regulation.”; “Process/Procedures: Physician orders will be legible, complete, authenticated, and timely. Orders are required for all care and services…” Plan of Treatment/Plan of Care: A complete, individualized Plan of Care/Treatment will be developed for all patients receiving ongoing clinical services according to applicable law and state regulations. The initial Plan of Care/Treatment is developed in conjunction with the physician/prescriber, patient/family, and the Company's health care professional as part of the admission process. The Plan of Care/Treatment must be reviewed and revised as frequently as the patient’s condition or needs require, but no less than 60 days or per applicable law and regulation. The Plan of Care/Treatment is modified in accordance with the physician’s orders.” Review of Aveanna Healthcare Job title: Nursing Supervisor on 6/15/23 at 3:00 PM revealed: “Position Overview: The Nursing Supervisor provides overall management and supervision of client care activities within the home care setting. Work in conjunction with other team members to ensure appropriate level of staffing and coordination of care in order to meet client goals. This position requires an ability to be flexible and work with all members of the health care team and provide ongoing supervision, clinical education, support, and evaluation to the nursing staff.” “Responsibilities: Assume responsibility in coordinating care to assigned clients, establishing a goal directed care plan…; Perform on site supervisory visits to assess client, family, environment, and clinical care givers and complete follow-up documentation; Provide ongoing supervision, orientation, training, education, and evaluation of clinical field staff; Maintain compliance in accordance with company policies and procedures, laws and regulations, and professional standards within the state of practice.” Review of Aveanna Healthcare Licensed Practical Nurse job description on 6/1/23 between 11:45 AM and 12:40 PM revealed: Position overview: “Responsible for providing and documenting skilled nursing care, under the supervision of a Registered Nurse, in accordance with the developed care plan and physicians orders for each individual patient…”; Essential Job Functions: “Responsible for the delivery and coordination of quality patient care in compliance with physician orders.”; “Document all activities, assessments, nursing actions, responses…in a timely manner…”; “accepts responsibility for personal and professional accountability by complying with Aveanna policies, state and federal regulations, accrediting bodies and the Nurse Practice Act…” Reviews of medical records conducted 6/1/23 between approximately 11:00 AM to 11:45 AM revealed the following: MR# 1, Start of care (SOC): 8/23/21; certification period: 2/14/23-4/14/23; Physician's orders: Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; Nutritional Requirements: Diet/hydration: gastrostomy tube(G-tube)-Peptamen Junior three hundred sixty (360) milliliters (ml) to run approximately from 9:30 AM-3:30 PM to be run at sixty (60) milliliters per hour (ml/hr) or as tolerated. Start effective date :10/14/2022; Overnight: Peptamen Junior two hundred ninety (290) ml plus two hundred fifty (250) ml of water to equal five hundred forty (540) ml to run at fifty (50) ml/hr for eleven (11) hours. Certification period: 4/15/23-6/13/23; Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/23; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023; medications: Omeprazole two (2) milligram(mg) per milliliter via G-tube sixteen (16) milligram (take one half-one hour before food) twice per day at 9:30 AM and 3:30 PM start effective date: 8/23/2021. . a. Review of Physician orders no frequency dated 3/10/23 revealed: “Physician communication: New blood sugar orders post appointment earlier this week.”; Interventions: SN endocrine interventions: SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/2023; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023. The plan of care for certification period 4/15/23-6/13/23 reflected the change to blood glucose monitoring. b. Review of skilled nurse flow sheets between 2/14/23 and 3/9/23 revealed: Documentation on only four (4) days of blood glucose levels. c. No Documentation that the agency verified the order for G-tube feedings and blood glucose checks times or administration with the patient's physician for clarification (G-tube feedings ordered to run continuously from 9:30 AM-3:30 PM then to run overnight for eleven (11) hours; order to monitor blood glucose four (4) times daily between feedings) An interview conducted with the agency executive director and clinical managers on 6/15/23 at approximately 2:00 PM confirmed the above findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on review of Agency policies and procedures, Job position descriptions, medical record review, email correspondence and interviews with agency executive director and clinical managers, the agency failed to ensure the skilled nurse provided all orders in the plan of care for one (1) out of three (3) records reviewed. (MR# 1). Findings: Review of Aveanna Healthcare Physician Orders policy on 6/15/23 at 3:20 PM revealed: Overview: “Care and services will be provided in accordance with physician's (or other authorized practitioner’s) orders, as required by law and regulation.”; “Process/Procedures: Physician orders will be legible, complete, authenticated, and timely. Orders are required for all care and services…” Plan of Treatment/Plan of Care: A complete, individualized Plan of Care/Treatment will be developed for all patients receiving ongoing clinical services according to applicable law and state regulations. The initial Plan of Care/Treatment is developed in conjunction with the physician/prescriber, patient/family, and the Company's health care professional as part of the admission process. The Plan of Care/Treatment must be reviewed and revised as frequently as the patient’s condition or needs require, but no less than 60 days or per applicable law and regulation. The Plan of Care/Treatment is modified in accordance with the physician’s orders.” Review of Aveanna Healthcare Job title: Nursing Supervisor on 6/15/23 at 3:00 PM revealed: “Position Overview: The Nursing Supervisor provides overall management and supervision of client care activities within the home care setting. Work in conjunction with other team members to ensure appropriate level of staffing and coordination of care in order to meet client goals. This position requires an ability to be flexible and work with all members of the health care team and provide ongoing supervision, clinical education, support, and evaluation to the nursing staff.” “Responsibilities: Assume responsibility in coordinating care to assigned clients, establishing a goal directed care plan…; Perform on site supervisory visits to assess client, family, environment, and clinical care givers and complete follow-up documentation; Provide ongoing supervision, orientation, training, education, and evaluation of clinical field staff; Maintain compliance in accordance with company policies and procedures, laws and regulations, and professional standards within the state of practice.” Review of Aveanna Healthcare Licensed Practical Nurse job description on 6/1/23 between 11:45 AM and 12:40 PM revealed: Position overview: “Responsible for providing and documenting skilled nursing care, under the supervision of a Registered Nurse, in accordance with the developed care plan and physicians orders for each individual patient…”; Essential Job Functions: “Responsible for the delivery and coordination of quality patient care in compliance with physician orders.”; “Document all activities, assessments, nursing actions, responses…in a timely manner…”; “accepts responsibility for personal and professional accountability by complying with Aveanna policies, state and federal regulations, accrediting bodies and the Nurse Practice Act…” Reviews of medical records conducted 6/1/23 between approximately 11:00 AM to 11:45 AM revealed the following: MR# 1, Start of care (SOC): 8/23/21; certification period: 2/14/23-4/14/23; Physician's orders: Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; Nutritional Requirements: Diet/hydration: gastrostomy tube(G-tube)-Peptamen Junior three hundred sixty (360) milliliters (ml) to run approximately from 9:30 AM-3:30 PM to be run at sixty (60) milliliters per hour (ml/hr) or as tolerated. Start effective date :10/14/2022; Overnight: Peptamen Junior two hundred ninety (290) ml plus two hundred fifty (250) ml of water to equal five hundred forty (540) ml to run at fifty (50) ml/hr for eleven (11) hours. Certification period: 4/15/23-6/13/23; Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/23; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023; medications: Omeprazole two (2) milligram(mg) per milliliter via G-tube sixteen (16) milligram (take one half-one hour before food) twice per day at 9:30 AM and 3:30 PM start effective date: 8/23/2021. . a. Review of Physician orders no frequency dated 3/10/23 revealed: “Physician communication: New blood sugar orders post appointment earlier this week.”; Interventions: SN endocrine interventions: SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/2023; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023 b. Review of skilled nurse flow sheets between 2/14/23 and 3/9/23 revealed: Documentation on only four (4) days of blood glucose levels. 1. Review of Skilled Nursing flow sheet from 2/20/23 on 6/1/23 revealed: Nursing narrative documentation: “11:30 AM: blood sugars stable.” 2. Review of Skilled Nursing flow sheet from 2/22/23 on 6/1/23 revealed: Nursing narrative documentation: “2:00 PM: patient had blood sugar checked and within normal limits.” 3. Review of Skilled Nursing flow sheet from 2/28/23 on 6/1/23 revealed: Nursing narrative documentation: “10:30 AM: blood sugar checked before feeding and was low side of normal, patient encouraged to eat rice crisp, reread ten (10) minutes later and raised to acceptable level.” 4. Review of Skilled Nursing flow sheet from 3/3/23 on 6/1/23 revealed: Nursing narrative documentation: “10:00 AM: AM meds administered and glucose within normal limits.” Interviews between 1:00 PM-1:30 PM with agency executive director and clinical manager throughout the onsite investigation on 6/1/23 revealed: “There are no blood glucoses documented for the week of the complaint, but the order was changed to as needed on March 9th.” An email response received from an agency clinical manager on 6/14/23 regarding blood sugar testing per physician’s orders from 2/13/23 through 3/9/23 after surveyor asked if there were any other blood sugars documented during that time frame besides the blood sugars that surveyor already had documentation revealed: “In regard to the blood sugars, those are the only documented blood sugars in those weeks.” “Skilled nurse did mention to us that the family had a little notebook that all the blood sugars were kept in when they were taken. We do not have a copy of this book but apparently it was sent along to school with the skilled nurse and the patient.” An interview conducted with the agency executive director and clinical managers on 6/15/23 at approximately 2:00 PM confirmed the above findings.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on review of Agency policies and procedures, medical record review, email correspondence and interviews with agency executive director and clinical managers, it was determined that the agency clinical manager failed to provide oversight to ensure the skilled professionals followed conformance to physician orders, the plan of care, the patient medication schedule/instructions and failed to ensure the skilled professionals completed their responsibilities for one (1) out of three (3) records reviewed. (MR # 1) Cross Reference: 484.105(c) Clinical Manager: Tag 0958- the agency clinical manager failed to provide oversight to ensure the skilled professionals followed conformance to physician orders, the plan of care, the patient medication schedule/instructions and failed to ensure the skilled professionals completed their responsibilities for one (1) out of three (3) records reviewed. (MR # 1) The cumulative effect of these systemic problems resulted in the Home Health Agency's inability to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity and provide optimal care.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on review of policies/procedures, job descriptions, personnel files, medical records, review of Pennsylvania Department of Health Event Reporting System (ERS), email correspondence from clinical managers, and interviews with the Agency executive director and agency clinical managers, the agency clinical manager failed to provide oversight to ensure the skilled professionals followed conformance to physician orders, the plan of care, the patient medication schedule/instructions and failed to ensure the skilled professionals completed their responsibilities for one (1) out of three (3) records reviewed. (MR # 1) Findings: Review of Aveanna Healthcare Job title: Nursing Supervisor on 6/15/23 at 3:00 PM revealed: “Position Overview: The Nursing Supervisor provides overall management and supervision of client care activities within the home care setting. Work in conjunction with other team members to ensure appropriate level of staffing and coordination of care in order to meet client goals. This position requires an ability to be flexible and work with all members of the health care team and provide ongoing supervision, clinical education, support, and evaluation to the nursing staff.” “Responsibilities: Assume responsibility in coordinating care to assigned clients, establishing a goal directed care plan…; Perform on site supervisory visits to assess client, family, environment, and clinical care givers and complete follow-up documentation; Provide ongoing supervision, orientation, training, education, and evaluation of clinical field staff; Maintain compliance in accordance with company policies and procedures, laws and regulations, and professional standards within the state of practice.” Review of Aveanna Healthcare Licensed Practical Nurse job description on 6/1/23 between 11:45 AM and 12:40 PM revealed: Position overview: “Responsible for providing and documenting skilled nursing care, under the supervision of a Registered Nurse, in accordance with the developed care plan and physicians orders for each individual patient…”; Essential Job Functions: “Responsible for the delivery and coordination of quality patient care in compliance with physician orders.”; “Document all activities, assessments, nursing actions, responses…in a timely manner…”; “accepts responsibility for personal and professional accountability by complying with Aveanna policies, state and federal regulations, accrediting bodies and the Nurse Practice Act…” Reviews of medical records conducted 6/1/23 between approximately 11:00 AM to 11:45 AM revealed the following: MR# 1, Start of care (SOC): 8/23/21; certification period: 2/14/23-4/14/23; Physician's orders: Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; Nutritional Requirements: Diet/hydration: gastrostomy tube(G-tube)-Peptamen Junior three hundred sixty (360) milliliters (ml) to run approximately from 9:30 AM-3:30 PM to be run at sixty (60) milliliters per hour (ml/hr) or as tolerated. Start effective date :10/14/2022; Overnight: Peptamen Junior two hundred ninety (290) ml plus two hundred fifty (250) ml of water to equal five hundred forty (540) ml to run at fifty (50) ml/hr for eleven (11) hours. Certification period: 4/15/23-6/13/23; Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/23; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023; medications: Omeprazole two (2) milligram(mg) per milliliter via G-tube sixteen (16) milligram (take one half-one hour before food) twice per day at 9:30 AM and 3:30 PM start effective date: 8/23/2021. a. Review of Physician orders no frequency dated 3/10/23 revealed: “Physician communication: New blood sugar orders post appointment earlier this week.”; Interventions: SN endocrine interventions: SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/2023; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023. The plan of care for certification period 4/15/23-6/13/23 was modified to show the change in blood glucose monitoring. b. Review of skilled nurse flow sheets between 2/14/23 and 3/9/23 revealed: Documentation on only four (4) days of blood glucose levels. c. No Documentation that the agency verified the order for G-tube feedings and blood glucose checks times or administration with the patient's physician for clarification (G-tube feedings ordered to run continuously from 9:30 AM-3:30 PM then to run overnight for eleven (11) hours; order to monitor blood glucose four (4) times daily between feedings) Certification period: 4/15/23-6/13/23; Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/23; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023; medications: Omeprazole two (2) milligram(mg) per milliliter via G-tube sixteen (16) milligram (take one half-one hour before food) twice per day at 9:30 AM and 3:30 PM start effective date: 8/23/2021. a. Skilled nurse stated in his written statement dated 6/2/23: Skilled nurse did reveal that he did make a medication error involving the patient’s Omeprazole by administering the medication three (3) times a shift instead of the ordered two (2) times for several days in a row but did not give specific dates. Interviews held between 1:00 PM-1:30 PM with agency executive director and clinical manager throughout the onsite investigation on 6/1/23 revealed: “There are no blood glucoses documented for the week of the complaint, but the order was changed to as needed on March 9th.” An email response received from an agency clinical manager on 6/14/23 regarding blood sugar testing per physician’s orders from 2/13/23 through 3/9/23 after surveyor asked if there were any other blood sugars documented during that time frame besides the blood sugars that surveyor already had documentation revealed: “In regard to the blood sugars, those are the only documented blood sugars in those weeks.” “Skilled nurse did mention to us that the family had a little notebook that all the blood sugars were kept in when they were taken. We do not have a copy of this book but apparently it was sent along to school with the skilled nurse and the patient.” An email response received from an agency clinical manager on 6/15/23 at 2:00 PM in regard to medication error documentation revealed: “I have also attached the documentation for the medication error. We were never notified by complainant or skilled nurse in real time when this supposedly happened, and only learned of it during this investigation.” Review of incidents on the ERS system on May 31, 2023, prior to the survey, revealed no reported incidents in regard to complaint. Review of agency policy/procedure completed on 6/15/23 at 3:30 PM revealed: 1. Review of Aveanna Healthcare Patient Event Reporting revealed: Overview: The purpose of this policy is to guide the identification, reporting and intensive assessment of adverse Patient Events and Sentinel Events (collectively “Events”) in order to improve patient care, treatment and services and to reduce their probability of recurrence. “; Policy: “All personnel will promptly report Patient Events, Hospice Patient Events and Sentinel Events within 24 hours of becoming aware of such events; For purposes of this policy, all Patient Events and Sentinel Events refer to incidents that are (1) adverse to the patient; (2) potentially the result of a failure or action by an employee, caregiver, or agent of the company; and (3) not related to the natural course of the patient’s illness or medical condition; “Definitions: patient event: A patient event is an unexpected occurrence that involves potential, actual, or alleged injury to a patient that arises from the action or failure to act of employees, contractors, caregivers, family members, patients themselves or third parties and is not related to the natural course of the patient’s illness. Example: a medication error that results no harm to the patient or only in minor patient discomfort is a Patient event…” “General Overview of reporting process: The employee involved in or witnessing an Event should immediately seek whatever level of assistance is needed for the type of event in accordance with the guidelines below. Ensuring patient safety and attending to medical needs is always the first priority; The employee must notify their supervisor immediately or as soon as practical after the Event…” 2. Interviews held between 1:00 PM-1:30 PM with agency executive director and clinical manager throughout the onsite investigation on 6/1/23 revealed: “We didn’t enter an event report yet since our investigation is still ongoing.” An interview conducted with the agency executive director and clinical managers on 6/15/23 at approximately 2:00 PM confirmed the above findings.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on review of policies/procedures, job descriptions, personnel files, medical records, email correspondence from clinical managers, and interviews with the Agency executive director and agency clinical managers, the agency failed to ensure medical records contained adequate and complete documentation. The agency failed to ensure that the plan of care was implemented and followed in one (1) of three (3) records reviewed. (MR # 1); the agency failed to ensure conformance with physician orders in one (1) of three (3) records reviewed. (MR # 1); the agency failed to ensure that the patient medication schedule/instructions were followed in one (1) of three (3) records reviewed. (MR # 1); the skilled professionals failed to ensure that their responsibilities were completed in one (1) of three (3) records reviewed. (MR # 1); the agency failed to ensure the skilled nurse provided all orders in the plan of care for one (1) out of three (3) records reviewed. (MR# 1). Findings: Review of Aveanna Healthcare Job title: Nursing Director on 6/15/23 at 2:45 PM revealed: “Position Overview: The Nursing Director is responsible and accountable for the planning, organizing, directing, and evaluating nursing services of nursing location. Working within the federal, state, and regional regulations covering home health the Nursing Director works innovatively to meet the needs of our exceptional patients…” “Essential Job Functions: Assign patients for day-to-day management to nursing coordinators and/or Nursing Supervisors/Manager; Monitors clinical status of all patients and ensures coordination of patient care; Monitors patient care to ensure quality and appropriateness of services; Perform on site supervisory visits to assess client, family, environment, and clinical care givers and complete follow-up documentation as needed.” Review of Aveanna Healthcare Job title: Nursing Supervisor on 6/15/23 at 3:00 PM revealed: “Position Overview: The Nursing Supervisor provides overall management and supervision of client care activities within the home care setting. Work in conjunction with other team members to ensure appropriate level of staffing and coordination of care in order to meet client goals. This position requires an ability to be flexible and work with all members of the health care team and provide ongoing supervision, clinical education, support, and evaluation to the nursing staff.” “Responsibilities: Assume responsibility in coordinating care to assigned clients, establishing a goal directed care plan…; Perform on site supervisory visits to assess client, family, environment, and clinical care givers and complete follow-up documentation; Provide ongoing supervision, orientation, training, education, and evaluation of clinical field staff; Maintain compliance in accordance with company policies and procedures, laws and regulations, and professional standards within the state of practice.” Review of Aveanna Healthcare Licensed Practical Nurse job description on 6/1/23 between 11:45 AM and 12:40 PM revealed: Position overview: “Responsible for providing and documenting skilled nursing care, under the supervision of a Registered Nurse, in accordance with the developed care plan and physicians orders for each individual patient…”; Essential Job Functions: “Responsible for the delivery and coordination of quality patient care in compliance with physician orders.”; “Document all activities, assessments, nursing actions, responses…in a timely manner…”; “accepts responsibility for personal and professional accountability by complying with Aveanna policies, state and federal regulations, accrediting bodies and the Nurse Practice Act…” Reviews of medical records conducted 6/1/23 between approximately 11:00 AM to 11:45 AM revealed the following: MR# 1, Start of care (SOC): 8/23/21; certification period: 2/14/23-4/14/23; Physician's orders: Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; Nutritional Requirements: Diet/hydration: gastrostomy tube(G-tube)-Peptamen Junior three hundred sixty (360) milliliters (ml) to run approximately from 9:30 AM-3:30 PM to be run at sixty (60) milliliters per hour (ml/hr) or as tolerated. Start effective date :10/14/2022; Overnight: Peptamen Junior two hundred ninety (290) ml plus two hundred fifty (250) ml of water to equal five hundred forty (540) ml to run at fifty (50) ml/hr for eleven (11) hours. Certification period: 4/15/23-6/13/23; Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/23; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023; medications: Omeprazole two (2) milligram(mg) per milliliter via G-tube sixteen (16) milligram (take one half-one hour before food) twice per day at 9:30 AM and 3:30 PM start effective date: 8/23/2021. a. Review of Physician orders no frequency dated 3/10/23 revealed: “Physician communication: New blood sugar orders post appointment earlier this week.”; Interventions: SN endocrine interventions: SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/2023; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023. The plan of care for certification period 4/15/23-6/13/23 was modified to show the change in blood glucose monitoring. b. Review of skilled nurse flow sheets between 2/14/23 and 3/9/23 revealed: Documentation on only four (4) days of blood glucose levels. c. No Documentation that the agency verified the order for G-tube feedings and blood glucose checks times or administration with the patient's physician for clarification (G-tube feedings ordered to run continuously from 9:30 AM-3:30 PM then to run overnight for eleven (11) hours; order to monitor blood glucose four (4) times daily between feedings) Certification period: 4/15/23-6/13/23; Skilled Nurse (SN)/Primary Caregiver (PCG) to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023; SN/PCG to notify medical doctor (MD)/Registered Nurse (RN) clinical supervisor of blood glucose less than fifty (50) start effective date: 2/13/2023; SN/PCG to monitor blood glucose as needed for signs/symptoms of metabolic crisis (vomiting, too hot or cold, lethargy) start effective date: 3/9/23; SN/PCG to monitor blood glucose four (4) times daily between feedings start effective date: 2/13/2023, met/discontinued date: 3/9/2023; medications: Omeprazole two (2) milligram(mg) per milliliter via G-tube sixteen (16) milligram (take one half-one hour before food) twice per day at 9:30 AM and 3:30 PM start effective date: 8/23/2021. a. Skilled nurse stated in his written statement dated 6/2/23: Skilled nurse did reveal that he did make a medication error involving the patient’s Omeprazole by administering the medication three (3) times a shift instead of the ordered two (2) times for several days in a row but did not give specific dates. Interviews held between 1:00 PM-1:30 PM with agency executive director and clinical manager throughout the onsite investigation on 6/1/23 revealed: “There are no blood glucoses documented for the week of the complaint, but the order was changed to as needed on March 9th.” An email response received from an agency clinical manager on 6/14/23 regarding blood sugar testing per physician’s orders from 2/13/23 through 3/9/23 after surveyor asked if there were any other blood sugars documented during that time frame besides the blood sugars that surveyor already had documentation revealed: “In regard to the blood sugars, those are the only documented blood sugars in those weeks.” “Skilled nurse did mention to us that the family had a little notebook that all the blood sugars were kept in when they were taken. We do not have a copy of this book but apparently it was sent along to school with the skilled nurse and the patient.” An email response received from an agency clinical manager on 6/15/23 at 2:00 PM in regard to medication error documentation revealed: “I have also attached the documentation for the medication error. We were never notified by complainant or skilled nurse in real time when this supposedly happened, and only learned of it during this investigation.” Review of incidents on the ERS system on May 31, 2023, prior to the survey, revealed no reported incidents in regard to complaint. Review of agency policy/procedure completed on 6/15/23 at 3:30 PM revealed: 1. Review of Aveanna Healthcare Patient Event Reporting revealed: Overview: The purpose of this policy is to guide the identification, reporting and intensive assessment of adverse Patient Events and Sentinel Events (collectively “Events”) in order to improve patient care, treatment and services and to reduce their probability of recurrence. “; Policy: “All personnel will promptly report Patient Events, Hospice Patient Events and Sentinel Events within 24 hours of becoming aware of such events; For purposes of this policy, all Patient Events and Sentinel Events refer to incidents that are (1) adverse to the patient; (2) potentially the result of a failure or action by an employee, caregiver, or agent of the company; and (3) not related to the natural course of the patient’s illness or medical condition; “Definitions: patient event: A patient event is an unexpected occurrence that involves potential, actual, or alleged injury to a patient that arises from the action or failure to act of employees, contractors, caregivers, family members, patients themselves or third parties and is not related to the natural course of the patient’s illness. Example: a medication error that results no harm to the patient or only in minor patient discomfort is a Patient event…” “General Overview of reporting process: The employee involved in or witnessing an Event should immediately seek whatever level of assistance is needed for the type of event in accordance with the guidelines below. Ensuring patient safety and attending to medical needs is always the first priority; The employee must notify their supervisor immediately or as soon as practical after the Event…” 2. Interviews held between 1:00 PM-1:30 PM with agency executive director and clinical manager throughout the onsite investigation on 6/1/23 revealed: “We didn’t enter an event report yet since our investigation is still ongoing.” An interview conducted with the agency executive director and clinical managers on 6/15/23 at approximately 2:00 PM confirmed the above findings.