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

Based on the findings of an onsite unannounced Medicare complaint survey conducted November 30,2023, December 1, 2023, December 6, 2023, December 20,2023 and offsite December 22, 2023, December 29, 2023, and onsite January 4, 2024. Aveanna Healthcare was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 patient record review, review of agency policy, and an interview with the executive administrator the agency failed to ensure physician orders were followed for three (3) of five (5) patient records reviewed (PR #1, 2 and 4). Findings include: Review of agency policy occurred on January 4, 2023, at approximately 12:05 PM and revealed the following: Policy titled: Medication Administration Guidelines "All medications for patients administration will be ordered by a licensed healthcare provider with the ability to prescribe. This includes prescribed, over the counter and homeopathic/home remedies, nutritional supplements..............All orders for medications will contain the name of the drug, concentration, dosage, frequency, duration and route of administration. All medications given during the visit/shift are documented on the Medication Administration Record (MAR)". Medications not given or withheld: Medications either withheld or not given shall be documented on the MAR or progress note the reason not given". Review of patient medication records took place on December 1, 2023, at approximately 9:02 am through 11:45 am and on January 4, 2024, at approximately 9:15 am through 10:57 am revealed the following: On the Home Health Certification and Plan of Care (485) contains medication orders and nutritional requirement were not followed per plan of care. Patient Record # 1 SOC 11-05-2020 certification period from 11/4/2023 to 1/2/2024, medication order: Fluticasone Propionate HFA (EQL Fluticasone Childrens) 50 mcg/act ml nasal give one spray in each nostril every morning. Medication not documented on the MAR on 11/4/23, 11/6/23, 11/7/23, 11/8/23 and 11/9/23 then patient was hospitalized. Polyethylene Glycol 3350 (Miralax) 17 GM/Scoop G-tube give 8.5 grams (one half scope dissolved in water daily, constipation). Medication not documented on the MAR on 11/9/23. Order for Nutritional requirement: Kate Farms 1.0 Peptide Formula 700 ml plus 600 ml free water, run continuously at 52 ml/hr. via G-tube. Monitor for signs and symptoms G-tube feeding intolerance. Position upright for feedings. Flush feeding tube with 10 ml water after meds and feeds. The nutritional flow rate order to run continuously at 52 ml/hr. was running at 56ml/hr. on 11/4/23, 11/6/23, 11/7/23, 11/8/23 and 11/9/23. Patient Record # 2 SOC 01/22/2018 certification period from 10/14/2023 to 12/12/2023, medication order. Fluticasone Propionate HFA (Flovent HFA) 44 mcg/act inhalation administer 2 puffs via spacer twice per day. Medication not documented on the MAR on the following dates: 10/14/23, 10/15/23, 10/22/23, 10/23/23, 10/28/23, 10/29/23,10/30/23, 11/4/23,11/5/23, 11/9/23, 11/11/23, 11/12/23, 11/14/23, 11/16/23, 11/25/23,11/26/23,11/27/23,11/28/23. Cetirizine HCL 1mg/ml G-tube administer 2.5mg (2.5 ml) twice per day. Medication not documented in the MAR for the entire certification period. Chlorhexidine Gluconate 0.12% ml Mouth/throat apply small amount to mouth daily. Medication not documented on the MAR on the following dates: 10/14/23, 10/16/23, 10/17/23, 10/18/23, 10/20/23, 10/26/23,10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/1/23,11/3/23,11/4/23,11/5/23,11/7/23,11/10/23,11/11/23,11/12/23,11/13/23,11/14/23,11/16/23,11/24/23,11/25/23,11/26/23,11/27/23,11/28/23. Patient Record # 4 SOC 02-01-2013 certification period from 10/14/2023 to 12/12/2023 medication order. Cetirizine HCL 1mg/ml G-tube administer 5mg (5 ml) daily. Medication not documented on the MAR on the following dates: 10/16/23, 10/18/23, 10/19/23, 10/20/23,11/29/23. An interview with the agency's administrator on January 4, 2024, at approximately 12:30 pm confirmed the above findings.