Every finding on record at Pediatric Services of America LLC

A complaint investigation 2025016843 was conducted at Aveanna Healthcare on 1/08/26 through 1/09/26. The facility was not in compliance with the Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

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, interviews, and patient's medical file reviews, the home health agency failed to ensure 2, (patient #1 and # 2), of 3 sampled patients were provided care as ordered by the physician and remained free from injuries which required immediate higher level of care. Review of the healthcare agency job description documented Licensed Practical Nurses (LPN) are responsible for the delivery and coordination of quality patient care in compliance with physician orders, continuously observes and assesses patient condition and care needs and reports changes in condition to the supervisor and / or physician as appropriate, …recognizes changes in patient needs and responses requiring intervention and implements care to prevent risk or reduce risk, accepts responsibility for personal and professional accountability by complying with agency policies, state and federal regulations… The clinical Manager and LPN, Staff A, signed the job description on 6/11/25. Review of LPN, Staff A’s, Skilled Nurse Orientation Competency Demonstration form completed 6/11/25 documented “verbalizes when to perform a respiratory assessment, demonstrates placement of a pulse oximeter probe, and demonstrates use of the Plan of care and identifies components.” Review of LPN, Staff B’s, Skilled Nurse Orientation Competency form completed 10/22/25 documented, “Demonstrates safe practices of enteral feedings including infection control, and bolus/ continuous feedings, demonstrates procedure for checking the balloon, tube placement and changing a gastrostomy button.” Review of agency policy titled Leadership and Management: Employee Evaluation / Supervision revised on 7/7/2025 documented, “Employees will be evaluated / supervised by appropriate skilled professional discipline or qualified professional per state regulations to ensure competency, compliance and support… Nursing Services: All LPN/ LVN’s function under the direction and oversight of the Registered Nurse (RN).” Review of agency policy titled Patient Event Reporting revised 7/1/2025 documented, “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… External reporting to an accredited body or agency will be based on recommendation from Area Clinical and Operations leadership, consistent with applicable state and federal law and/or regulation. The policy review revealed the home health agency neglected to adhere to their policy of notifying the designated state authorities about incidents involving employee neglect. A review of Patient #1’s Plan of Care revealed a start of care day of 6/23/25. The Plan of Care noted Patient #1 is a child with multiple medical needs, involving respiratory challenges requiring a pulse ox monitor and nutritional support via gastrointestinal feeding tube. The plan of care also included parameters to which the doctor is to be notified. The patient's doctor ordered 112 hours a week skill nursing services. The nurse is to monitor the patient's oxygen blood level and provide 2L (liters) of oxygen per nasal cannula when needed, for saturation levels of 88% or less, if there is no improvement call 911. (emergency services) On 1/8/26, review of the medical record revealed that the nurse failed to notify the physician of changes in Patient #1's condition, she deactivated the pulse oximeter alarm system and failed to document the patient's vital signs and altered status change in his condition. Review of Patient #1’s medical record revealed the incident occurred through the night of 9/15/25 during LPN Staff A’s scheduled shift. The morning of 9/16/25 mother entered Patient #1’s room and found he was in distress having difficulty breathing. She proceeded to give the child oxygen, called the patient's doctor and was instructed to call Emergency Medical Services. The patient was transported and admitted to the hospital. On 1/8/26 at 11:00 a.m., during an interview, the Executive Director said LPN, Staff A, was caring for Patient #1on 9/15/25, the night of the incident. The Nurse failed to follow the Plan of Care, physician’s orders, did not notify the parents or the doctor of the child’s change in condition. She failed to document vital signs and failed to document a narrative noting the child’s change in condition. She cut off the oximeter alarm. Review of the hospital emergency room records showed the triage nurse documented the patient was wheezing and had a low blood oxygen saturation. On 1/9/26, at 1:00 p.m., the Director of Nursing (DON) said the patient is 2 years old, the Pulse Oximeter belongs to the mother. Periodically the probe has to be changed. During the night of the incident the DON said LPN Staff A had said Patient #1’s oxygen levels kept changing. She thumped his back and chest, and the alarm was going off frequently. LPN Staff A changed the probe, and repositioned the patient, she failed to record Patient #1’s vital signs, failed to wake the patient's parent and failed to call the patient's doctor. A review of Patient #2 Plan of Care revealed 3/1/19 as the start of care. Patient #2 is a child with multiple medical needs, involving nutritional support via gastrointestinal feeding tube and a vesicostomy button. A vesicostomy button is a small device surgically placed in the bladder to help drain urine when a child can’t empty their bladder normally. The patient's doctor ordered 140 hours a week of skilled nursing services. The medical record review of Patient #2 revealed on 11/2/25 morning LPN Staff B incorrectly administered the gastrointestinal feeding to the patient via the vesicostomy button. The nurse failed to verify proper tube placement before administering the nutritional feeding. Feeding into the wrong body cavity can be life threating. On 1/8/26, at 12:16 p.m., the Executive Director said, LPN Staff B at the end of her visit connected the feeding and informed the father the feeding was connected then left for the day. On hearing the machine alarm beep the father entered the room and he noticed the feeding was connected to the vesicostomy. On 1/8/25 when Patient #2’s mother came home the child was taken to the hospital. The mother called and told me about the incident, and he was admitted to the hospital. The Executive Director said, “I did not chart the communication.” On 1/8/26, at 1:55 p.m., during an interview the Area Operations Director said she was not covering Fort Myers during that time. She was not sure if these two incidents were reported to the State, or who made the determination not to report to the State. On 1/8/26 at 2:50 p.m., during an interview LPN Staff B said she will never forget the incident. The patient had two access sites, a gastrostomy feeding tube and a vesicostomy button. The morning of the incident the patient was sitting in crunched up in a Jerry Chair. (supportive chair for disabled individual). She continued to say she picked up the tube she thought was the gastrostomy tube and connected the feeding bag. She confirmed she did not have visual sight of the two tubes. On 1/8/26 at 3:00 p.m., the DON said LPN Staff B presently does not have an assignment from us. She is listed as taking patients with less acuity. She was given instruction and will be assigned to patient with less acuity On 1/9/26 at 2:20 p.m., the Home Health Agency did not provide the information noting the two incidents of neglect with unprovided care as ordered resulting in hospitalization had been reported to the State Agency.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on policy review and interviews, the agency failed to properly report the neglect and mistreatment of patients 2, (Patient #1 and #2), of 3 sampled patients, to the appropriate State agency. The home health agency failed to promptly report negligence, within the states reporting guidelines. Review of agency policy titled Patient Event Reporting revised 7/1/2025 documented, “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… External reporting to an accredited body or agency will be based on recommendation from Area Clinical and Operations leadership, consistent with applicable state and federal law and/or regulation. The policy review revealed the home health agency neglected to adhere to their policy of notifying the designated state authorities about incidents involving employee neglect. Review of agency policy titled Leadership and Management: Employee Evaluation / Supervision revised on 7/7/2025 documented, “Employees will be evaluated / supervised by appropriate skilled professional discipline or qualified professional per state regulations to ensure competency, compliance and support… Nursing Services: All LPN/ LVN’s function under the direction and oversight of the Registered Nurse (RN).” A review of Patient #1’s Plan of Care revealed a start of care day of 6/23/25. The Plan of Care noted Patient #1 is a child with multiple medical needs, involving respiratory challenges requiring a pulse ox monitor and nutritional support via gastrointestinal feeding tube. The plan of care also included parameters to which the doctor is to be notified. The patient's doctor ordered 112 hours a week skill nursing services. The nurse is to monitor the patient's oxygen blood level and provide 2L (liters) of oxygen per nasal cannula when needed, for saturation levels of 88% or less, if there is no improvement call 911. (emergency services) On 1/8/26, review of the medical record revealed that the nurse failed to notify the physician of changes in Patient #1's condition, she deactivated the pulse oximeter alarm system and failed to document the patient's vital signs and altered status change in his condition. Review of Patient #1’s medical record revealed the incident occurred through the night of 9/15/25 during LPN Staff A’s scheduled shift. The morning of 9/16/25 mother entered Patient #1’s room and found he was in distress having difficulty breathing. She proceeded to give the child oxygen, called the patient's doctor and was instructed to call Emergency Medical Services. The patient was transported and admitted to the hospital. On 1/8/26 at 11:00 a.m., during an interview, the Executive Director said LPN, Staff A, was caring for Patient #1on 9/15/25, the night of the incident. The Nurse failed to follow the Plan of Care, physician’s orders, did not notify the parents or the doctor of the child’s change in condition. She failed to document vital signs and failed to document a narrative noting the child’s change in condition. She cut off the oximeter alarm. Review of the hospital emergency room records showed the triage nurse documented the patient was wheezing and had a low blood oxygen saturation. On 1/9/26, at 1:00 p.m., the Director of Nursing (DON) said the patient is 2 years old, the Pulse Oximeter belongs to the mother. Periodically the probe has to be changed. During the night of the incident the DON said LPN Staff A had said Patient #1’s oxygen levels kept changing. She thumped his back and chest, and the alarm was going off frequently. LPN Staff A changed the probe, and repositioned the patient, she failed to record Patient #1’s vital signs, failed to wake the patient's parent and failed to call the patient's doctor. A review of Patient #2 Plan of Care revealed 3/1/19 as the start of care. Patient #2 is a child with multiple medical needs, involving nutritional support via gastrointestinal feeding tube and a vesicostomy button. A vesicostomy button is a small device surgically placed in the bladder to help drain urine when a child can’t empty their bladder normally. The patient's doctor ordered 140 hours a week of skilled nursing services. The medical record review of Patient #2 revealed on 11/2/25 morning LPN Staff B incorrectly administered the gastrointestinal feeding to the patient via the vesicostomy button. The nurse failed to verify proper tube placement before administering the nutritional feeding. Feeding into the wrong body cavity can be life threating. On 1/8/26, at 12:16 p.m., the Executive Director said, LPN Staff B at the end of her visit connected the feeding and informed the father the feeding was connected then left for the day. On hearing the machine alarm beep the father entered the room and he noticed the feeding was connected to the vesicostomy. On 1/8/25 when Patient #2’s mother came home the child was taken to the hospital. The mother called and told me about the incident, and he was admitted to the hospital. The Executive Director said, “I did not chart the communication.” On 1/8/26, at 1:55 p.m., during an interview the Area Operations Director said she was not covering Fort Myers during that time. She was not sure if these two incidents were reported to the State, or who made the determination not to report to the State. On 1/8/26 at 2:50 p.m., during an interview LPN Staff B said she will never forget the incident. The patient had two access sites, a gastrostomy feeding tube and a vesicostomy button. The morning of the incident the patient was sitting in crunched up in a Jerry Chair. (supportive chair for disabled individual). She continued to say she picked up the tube she thought was the gastrostomy tube and connected the feeding bag. She confirmed she did not have visual sight of the two tubes. On 1/8/26 at 3:00 p.m., the DON said LPN Staff B presently does not have an assignment from us. She is listed as taking patients with less acuity. She was given instruction and will be assigned to patient with less acuity. On 1/9/26, at 2:15 p.m., the Area Operation Director said she attempted today to notify the State Agency of the incidents but was not able. On 1/9/26 at 2:45 p.m., the Home Health Agency did not provide the information noting the two incidents of neglect with unprovided care as ordered resulting in hospitalization had been reported to the State Agency.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on Plan of Care record reviews and interviews, the agency failed to ensure 2, (Patient #1 and #2), of 3 sampled patients received the treatments, services, and ensure drugs/nutrition are administered as ordered by the physician. Review of the healthcare agency job description documented Licensed Practical Nurses (LPN) are responsible for the delivery and coordination of quality patient care in compliance with physician orders, continuously observes and assesses patient condition and care needs and reports changes in condition to the supervisor and / or physician as appropriate, …recognizes changes in patient needs and responses requiring intervention and implements care to prevent risk or reduce risk, accepts responsibility for personal and professional accountability by complying with agency policies, state and federal regulations… Review of LPN, Staff A’s, Skilled Nurse Orientation Competency Demonstration form completed 6/11/25 documented “verbalizes when to perform a respiratory assessment, demonstrates placement of a pulse oximeter probe, and demonstrates use of the Plan of care and identifies components.” Review of LPN, Staff B’s, Skilled Nurse Orientation Competency form completed 10/22/25 documented, “Demonstrates safe practices of enteral feedings including infection control, and bolus/ continuous feedings, demonstrates procedure for checking the balloon, tube placement and changing a gastrostomy button.” A review of patient #1 Plan of Care physician orders revealed the start of care day of 6/23/25. The Plan of Care notes Patient #1 is a child with multiple medical needs, involving respiratory challenges requiring a pulse ox monitor and nutritional support via gastrointestinal feeding tube. The plan of care also included parameters to which the doctor is to be notified. The patient's doctor ordered 112 hours a week skilled nursing service. The nurse is to monitor the patient's oxygen blood level and provide 2L (liters) of oxygen per nasal cannula when needed, for saturation levels of 88% or less, if there is no improvement call 911 (emergency services). The skilled nurse completes a comprehensive assessment as allowed by scope of practice at the beginning and end of every shift and as needed, the skilled nurse may administer medication as ordered. Review of Patient #1’s medical record revealed on 9/15/25 Licensed Practical Nurse (LPN) Staff A did not follow the physician’s orders. The Skilled Nurse Flow Sheet time in 10:00pm and signed 9/16/25 at 7:52am signed by the patient’s representative. A review of the Flow Sheet fails to provide evidence of the nurse documenting the start of the shift and end of shift narrative. Failed to document the patient’s vital signs, failed to document the patient’s blood oxygen saturation. On the morning of 9/16/25 the patient was taken to the hospital. The hospital pediatric emergency department note stated the patient was wheezing and had a low blood oxygen level. The Skill Nurse Flow Sheet failed to show evidence of the nurse following the physician’s orders, failed to notify the physician of Patient #1’s change in condition. On 1/8/26 at 11:00 a.m., during an interview, the Executive Director said LPN, Staff A, was caring for Patient #1on 9/15/25, the night of the incident. The Nurse failed to follow the Plan of Care, physician’s orders, did not notify the parents or the doctor of the child’s change in condition. She failed to document vital signs and failed to document a narrative noting the child’s change in condition. She cut off the oximeter alarm. Review of Patient #2 Plan of Care revealed 3/1/19 as the start of care. Patient #2 is a child with multiple medical needs, involving nutritional support via gastrointestinal feeding tube and a vesicostomy button. A vesicostomy button is a small device surgically placed through the abdomen into the bladder to help drain urine when a child can’t empty their bladder normally. The patient's doctor ordered 140 hours a week skilled nursing services. The medical record review of Patient #2 revealed on 11/2/25 morning LPN Staff B incorrectly administered the gastrointestinal feeding to the patient via the vesicostomy button. The nurse failed to verify proper tube placement before administering the nutritional feeding. Feeding into the wrong body cavity can be life threating. On 1/8/26 at 2:50 p.m., during an interview LPN Staff B said she will never forget the incident. The patient had two access sites, a gastrostomy feeding tube and a vesicostomy button. The morning of the incident the patient was sitting in crunched up in a Jerry Chair. (supportive chair for disabled individual). She continued to say she picked up the tube she thought was the gastrostomy tube and connected the feeding bag. She confirmed she did not have visual sight of the two tubes. On 1/8/26 at 3:00 p.m., the DON said LPN Staff B presently does not have an assignment from us. She is listed as taking patients with less acuity. She was given instruction and will be assigned to patient with less acuity The Plans of Care were not followed by the nurses for Patients #1 and #2. Not following the physician’s signed Plan of Care/orders can lead to worsening health conditions and affect the patients’ well-being.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on personnel file review and interviews, the home health agency failed to ensure that 1, (Licensed Practical Staff B), of 3 sampled Licensed Practical Nurse (LPN) files reviewed had a case performance demonstration. LPN, Staff 's employee file failed to have evidence of a case specific evaluation on performance by a Registered Nurse to meet the patient needs before assigning the patient to the LPN Staff B. Review of the healthcare agency job description documented Licensed Practical Nurses (LPN) are responsible for the delivery and coordination of quality patient care in compliance with physician orders, continuously observes and assesses patient condition and care needs and reports changes in condition to the supervisor and / or physician as appropriate, …recognizes changes in patient needs and responses requiring intervention and implements care to prevent risk or reduce risk, accepts responsibility for personal and professional accountability by complying with agency policies, state and federal regulations… Review of the LPN’s Staff B’s personnel file revealed a hire date of 10/17/25, as a Licensed Practical Nurse. She completed the agency’s Nurse Orientation Competency Demonstration on 10/22/25. Review of LPN, Staff B’s, Skilled Nurse Orientation Competency form, completed 10/22/25, documented, “Demonstrates safe practices of enteral feedings including infection control, and bolus/ continuous feedings, demonstrates procedure for checking the balloon, tube placement and changing a gastrostomy button.” The demonstrations were performed in the office on a mannequin. The form was signed by the Director of Nursing. The medical record review of Patient #2 revealed on 11/2/25 morning LPN Staff B incorrectly administered the gastrointestinal feeding to the patient via the vesicostomy button. The nurse failed to verify proper tube placement before administering the nutritional feeding. Feeding into the wrong body cavity can be life threating. On 1/8/25, at 10:15 a.m., during an interview the Director of Nursing said, “The Case Specific Orientation sheet is an overview of the case and demonstrations that is performed in the home of the assigned patient. I did not perform the Case Specific Orientation with LPN Staff B.” LPN B’S Case Specific Orientation sheet is signed by another LPN, on 10/25/25, not by the Supervising Registered Nurse. On 1/8/26, at 12:16 p.m., the Executive Director said, LPN Staff B at the end of her visit connected the feeding and informed the father the feeding was connected then left for the day. On hearing the machine alarm beep the father entered the room and he noticed the feeding was connected to the vesicostomy. On 1/8/25 when Patient #2’s mother came home the child was taken to the hospital. The mother called and told me about the incident, and he was admitted to the hospital. The Executive Director said, “I did not chart the communication.” On 1/8/26 at 2:50 p.m., during an interview LPN Staff B said she will never forget the incident. The patient had two access sites, a gastrostomy feeding tube and a vesicostomy button. The morning of the incident the patient was sitting in crunched up in a Jerry Chair. (supportive chair for disabled individual). She continued to say she picked up the tube she thought was the gastrostomy tube and connected the feeding bag. She confirmed she did not have visual sight of the two tubes. On 1/8/26 at 3:00 p.m., the DON said LPN Staff B presently does not have an assignment from us. She is listed as taking patients with less acuity. She was given instruction and will be assigned to patient with less acuity. The Supervising Registered Nurse failed to ensure LPN B had the skills required to care for Patient #2.