Every finding on record at Epic Health Services (De), LLC

This report includes the details of an unannounced complaint survey at Aveanna Healthcare, completed on June 11, 2024. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 484- Conditions of Participation for Home Health Agencies. An Immediate Jeopardy (IJ) was identified on June 10, 2024 at 12:22 PM and removed on June 11, 2024 at 1:38 PM after verification from the State Survey Agency that the home health agency had implemented immediate corrective actions addressing the IJ.

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on a review of facility documents, review of medical records, and staff interviews, it was determined that the facility failed to keep patients free from neglect (G430). Cross Reference: §484.50(c) Patient rights: Rights of the patient On June 10, 2024 at 12:22 PM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included staff education, a decrease in the patient/caregiver ratio, a re-evaluation of patient needs, and modified referral requirements. These interventions were implemented and verified by the State Agency, and the IJ was removed on June 11, 2024 at 1:38 PM.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on document review, medical record review, personnel record review, interview with staff, and interview with local police, it was determined that the agency failed to keep 1 out of 10 patients (Patient #6) in the sample free from neglect. Patient Rights and Responsibilities document provided to Patient # 6 on 3/11/2024 stated, "As a patient, member of a patient's family, or significant other, you have the following rights...To have personnel possess the necessary skills and knowledge required to do their job...To be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect, and misappropriation of property..." Medical record review revealed: Patient #5 Admitted on 3/12/2024 DOB: 3/31/2017 Diagnoses: autistic disorder, expressive language disorder, and other developmental disorders of speech and language Patient #6 Admitted on 3/12/2024 DOB: 3/31/2017 Diagnoses: Autism, Arthrogryposis multiplex congenita Patient #7 Admitted on 3/12/2024 DOB: 4/10/2015 Diagnoses: moderate intellectual disabilities, unspecified lack of expected normal physiological development in childhood, and other speech disturbances On 6/5/2024, Patient #6 (a seven-year-old child) who was under the care of the agency, was found deceased by emergency medical personnel. At the time of the patient's death, Employee # 9 (CNA) was assigned to care for Patient #6 along with their two siblings (Patient #5 and Patient #7). The agency summary of events indicated the following information: Two of the children (Patients #'s 6 and 7) were playing in the backyard with the gate closed. The aide went into the house to help one of the children (Patient # 5) get dressed. When the aide returned, approximately 10 minutes later, to the backyard it was noted that the gate was open and Patient # 6 was not visible. The aide ran to the playground and pond and was notified by someone walking their dog that a child went into the pond. The aide did not see Patient #6 in the pond and went back to the home to lock Patient #5 and Patient #7 in the house. The aide went back to the pond and emergency personnel arrived. EMS recovered Patient #6 and took them to the hospital where they were pronounced deceased. During a phone interview with a local police detective on 6/6/2024 between 4:25 PM and 4:34 PM a timeline of events was provided which included the following information: On 6/5/2024, Employee # 9 was watching the three siblings (Patient #5, 6, and 7) from 3:00 PM to 6:00 PM. Employee #9 had taken all three children to the park. Across from the park is a retention pond. It was stated that one of the children pointed at the pond and attempted to go towards it. At that time, Employee #9 took all three children back to the house. After arriving back at the house, two of the children (Patient #6 and Patient #7) played in the backyard while Employee #9 took Patient # 5 into the house to use the bathroom. When Employee #9 came back outside to the backyard she noticed Patient # 6 was missing. Employee # 9 locked the other two children (Patient #5 and Patient #7) into the home and ran towards the park. A bystander saw a boy fitting Patient #6's description swimming in the pond. Employee #9 went looking in the pond for Patient #6 but was unable to locate him. Emergency personnel arrived and located Patient #6 in a deep part of the retention pond. He was transported to the hospital where he was pronounced deceased. During an interview with Employee # 1, Employee # 4, and Employee #8 on 6/10/2024 between 9:50 AM and 10:10 AM, follow-up questions were asked related to the incident with Patient #6. Employee #8 confirmed that all of the children were on elopement precautions. When asked about what specific elopement precautions were in place for the three children, Employee # 8 stated that the care plan for Patient #6 indicated that the doors and windows were to be locked. Employee #8 stated that if there was any more specific information regarding elopement precautions it would have been discussed verbally when the nurse went over the case-specific information with the aide. When asked if there was a lock on the gate in the backyard, Employee #8 stated there was a latch, but not a lock. It was asked if it was common for the aide to take the children out of the house to the playground, and whether that was part of the care plan. Employee #8 stated that they were not sure but "It was probably verbalized with the aide, and it was probably at mom's request as well". The Aide Care plan for all three patients (Patients # 5, 6, and 7) indicated that the children were on elopement precautions. No information was found regarding whether the children were permitted to leave the premises with the aide. The "Case Specific Orientation" forms for all three patients located in Employee # 9's personnel file indicated "Maintain elopement risk" and "Doors and windows locked for elopement risk". The agency's personnel were unable to provide a policy on elopement precautions when requested. Policy titled "Aide Services, Training and Competency" dated 8/11/2023 stated, "...All aide personnel will demonstrate competency prior to being assigned to care for a patient...An individual may furnish home health services on behalf of the company only after that individual has successfully completed a competency evaluation program..." Policy titled "Skills/Knowledge Assessment: Pre-Hire and New Hire" dated 1/30/2023, stated, "...All required testing/evaluations must be completed and graded prior to or at the time of hire. All incorrect answers will be remediated by the appropriate clinician...If the test score is less than 80%, the candidate must be remediated and rested..." A review of Employee # 9's personnel record revealed: Date of Hire: 2/27/2024 Employee scored less than 80% for 8 of 18 new hire knowledge assessment topics completed on 2/27/2024. There was no evidence that Employee #9 received remediation for the deficient topics. During an interview with Employee #1, Employee #4, and Employee #8 on 6/10/2024 between 9:50 AM and 10:10 AM, it was confirmed that Employee #9 did not achieve a passing score on 8 out of 18 tested topics. Employee # 1 stated that it is the normal process for anyone who scores less than 80% in an area to have remediation and a re-test that would be filed in the employee file. Employee # 1 confirmed that no evidence of remediation or re-test was available for Employee # 9. HLS

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, document review, medical record review, and interview with staff, it was determined that for 1 out of 2 patients (Patient #1) in the sample, the agency failed to revise the plan of care after a significant change in patient condition. Policy titled " Comprehensive Assessment" dated 8/14/2023, stated, "...Each patient will receive a patient specific, comprehensive assessment. The comprehensive assessment will accurately reflect the patient's status and will include...The patient's current health, psychosocial, functional, and cognitive status...Update of the Comprehensive Assessment...The Comprehensive Assessment must be updated and revised as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status..." Policy titled "Aide Assignments and Duties (Care Plan)" dated 5/23/2023, stated, " An individualized care plan will be developed by the appropriate personnel to ensure that care and services are appropriate to the patient's specific needs/problems... The care plan is evaluated and updated on an ongoing basis as patient condition, problems and goals change..." An event report for Patient #1 indicated that the patient had a fall with injury on 5/13/2024. The patient was seen in the Emergency Room and found to have a closed fracture of the right forearm which required the placement of a cast. A review of the medical record for Patient #1 revealed: "Plan of Care" was last reviewed by the RN Supervisor on 4/17/2024. No review or update to the plan of care was completed after the patient's injury on 5/13/2024. During an interview on 6/11/2024 between 10:34 AM and 10:45 AM with Employee #4 and Employee #8, the above findings were confirmed. Employee #4 stated that normal practice would be to complete an evaluation and adjust the plan of care as necessary after a significant change in a patient's condition.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on the review of Agency policies and documents and staff interviews, it was determined for 9 of 12 employees sampled, the Agency failed to follow policies related to ensuring direct care staff had appropriate competencies before being assigned to care for a patient. Findings include: Agency policy titled "Aide Services, Training and Competency" revised 8/11/23 stated, "...All aide services must be provided by individuals who meet personnel...requirements...All aide personnel will demonstrate competency prior to being assigned to care for a patient...An individual may provide home health services...only after that individual has successfully completed a competency evaluation program...If an aide is going to perform a task for which he or she was rated as unsatisfactory, the task must be performed under the supervision of a registered nurse until the aid achieves [an] evaluation of satisfactory..." Agency policy titled "Skills/Knowledge Assessment: Pre-Hire and New Hire" revised 1/30/23 stated, "...All required testing/evaluations must be completed and graded prior to or at the time of hire...If the score is less than 80%, the candidate must be remediated and retest[ed]..." I. Competencies and Remediation of skills and knowledge A review of Agency documentation revealed: - Employee #9 is providing care for Patient #5 and #7. - Employee #14 is providing care for Patient #11. - Employee #15 is providing care for Patient #14. - Employee #17 is providing care for Patient #12 and #13. A review of the Agency's personnel files revealed: a. Employee # 9 scored less than 80% for 8 of 18 new hire knowledge assessment topics completed on 2/27/24. There was no evidence that Employee #9 received remediation for the deficient topics. b. Employee #14 scored less than 80% for 4 of 18 new hire knowledge assessment topics completed on 1/16/23. There was no evidence that Employee #14 received remediation for the deficient topics. c. No evidence that Employee #15 completed their orientation competency before being assigned to patient care. d. Employee #15 scored less than 80% for 4 of 18 new hire knowledge assessment topics completed on 2/22/24. There was no evidence that Employee #15 received remediation for the deficient topics. e. Employee #17 scored less than 80% for 2 of 12 annual knowledge assessment topics completed on 2/11/23. There was no evidence that Employee #17 received remediation for the deficient topics. During an interview on 6/11/24 between 11:30 and 11:40 AM, Employee #8 stated the annual knowledge assessment is usually completed on the Agency’s electronic education software “Workday Learning” and remediation is completed while the employee completes the education programs. Annual knowledge assessments completed on paper will not receive online remediation. Employee #4 stated the remediation may be documented in the annual skills checklist. Upon request, the Agency was unable to provide documentation for Employee #17 for scores less than 80% on their annual knowledge assessment. During an interview on 6/10/24 between 1:55 and 2:35 PM, Employee #1 confirmed there was no evidence that Employees #9, #14, and #15 demonstrated successful assessment of their knowledge and competency prior to being assigned to care for a patient and that there was no evidence that Employee #17 received remediation for their annual knowledge assessment topic scores of less than 80%. II. Annual evaluations and competencies Agency policy titled "Evaluations - Performance" revised 6/10/23 stated, "...It is the policy of the Company to have...regularly scheduled formal employee evaluations...Annual evaluations will be performed...anytime within the calendar year for caregivers...For these employees, reviews should be completed once each calendar year..." Agency policy titled "Education: Competency Evaluation" revised 11/10/23 stated, "...Competencies and skills are assessed prior to delivery of services and reviewed/performed at hire and updated annually...An individual may furnish home health aide services...only after that individual has successfully completed a competency evaluation program through direct observation or examination..." A review of the Agency's personnel files revealed: a. No evidence that Employee #10 (hired in 2022), #12 (hired in 2014), #14 (hired in 2022), #16 (hired in 2016), and #17 (hired in 2017) received an annual performance review in the calendar year of 2023 or 2024. b. No evidence that Employee #10 (hired in 2022), #12 (hired in 2014), and #14 (hired in 2022) completed an updated competency assessment in the past 12 months. During an interview on 6/10/24 between 1:55 and 2:35 PM, Employee #1 confirmed the above findings of no evidence of an annual performance review and/or an annual competency assessment. III. Case Specific Orientation Agency policy titled "Clinical Orientation" revised 11/9/23 stated, "...All direct caregiver staff are oriented...to their job responsibilities prior to assuming job duties...Case Specific Orientation (CSO) will be provided to every Private Duty Nursing Services (PDS) nurse/aide for each case they are assigned..." During an interview with Employee #8 on 6/10/2024 between 9:50 AM and 10:10 AM, it was stated that all caregivers receive a case-specific orientation before going to the patient's home. a. Review of Agency documentation revealed: - Employee #10 is providing care for Patient #1, #2, and #3. - Employee #12 is providing care for Patient #15. - Employee #14 is providing care for Patient #11. - Employee #15 is providing care for Patient #14. - Employee #17 is providing care for Patient #12 and #13. - Employee #19 provided care for Patient #4. - Employee #20 provided care for Patient #4. b. Review of Agency personnel files revealed: - No evidence Employee #10 received CSO for the care of Patient #1, #2, and #3. - No evidence Employee #12 received Case Specific Orientation (CSO) for the care of Patient #15. - No evidence Employee #14 received CSO for the care of Patient #11. - No evidence Employee #15 received CSO for the care of Patient #14. - No evidence Employee #17 received CSO for the care of Patient #12 and #13. - No evidence Employee #19 received CSO for the care of Patient #4. - No evidence Employee #20 received CSO for the care of Patient #4. During an interview on 6/10/24 at 4:00 PM, Employee #1 confirmed the finding of no evidence of CSO for the above employees and patients.