Every finding on record at Pediatric Services of America, LLC

Based on the findings of an onsite unannounced complaint investigation completed on November 17, 2021, Aveanna Healthcare was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on the review of clinical records (CR1), review of agency policy, and interview with agency staff, the agency failed to effectively document a resolution to a patient/patient representative complaint related to the agency delivery of healthcare services to patients in accordance with agency policy and/or regulatory requirements for the clinical record reviewed (CR1). Findings included: Review of agency policies 11/17/2021 revealed the following: “Complaints…Number: 4.06.02…Revised 10/11/2021…Process/Procedures…All complaints and grievances are noted on the Complaint/Concern Form maintained…complaints are documented along with the resolution…Director or designee will take the following steps…3. Communicate with involved individuals…4. Report status of activities to client and/or complainant…6. When a complaint cannot be resolved, within five (5) working days…Complaint/Concern Form is to be forwarded to the Director. 7. The Director will review the complaint and collect additional data/information…If the Director is unable to resolve…to the client’s/complainant’s satisfaction…will..submit the complaint documentation to the managers of Business Operations, who will make every effort to resolve…to the client’s satisfaction and will notify the client and appropriate management personnel of all actions taken on the client’s behalf…PA (Pennsylvania) State Specific…following will be collected…Participant’s name, Nature of complaint, Date of complaint, Actions to resolve complaint, Participant’s satisfaction…” Review of CR1 conducted at approximately 10:30 AM on 11/17/2021 revealed the following: Agency Plan of Care (POC), Start of Care 10/15/2021, certification period 10/15/2021 to 12/13/2021. “…Interventions…HHA (Home Health Aide) will provide 58 – 78.5 hours per week of unskilled care. 12 hrs (hours)/day M (Monday) – F (Friday) and 8 hrs/day on Saturdays and Sundays…” Home Health Aide care plan initiated and signed by supervising Registered Nurse (EMP3) 10/15/2021 “…Frequency 78hrs/week…” Review of HHA visits form 10/15/2021 to 11/13/2021 revealed the following missed visits: 10/20/2021, 10/24/2021, 10/25/2021, 10/26/2021, 11/1/2021, 11/2/2021, 11/5/2021, 11/6/2021, 11/7/2021, 11/12/2021. Agency “Complaint & Concern Form” reported date 10/19/2021 by CR1 family member. “Narrative: [family member] of patient…called to cancele (sic) second aide, [HHA2], due to her inability to staff shift times…informed [family member]…do not have anyone at this moment to replace HHA2.…Administrative Action and Resolution:..Narrative: Followed up on 10/20 with payer relations manager to inform…of issue and complaint. Payer relations manager confirmed…would contact…(CR1) case manager with these updates…Resolved…yes…Complainant Notified…Yes…Resolved by: [signed by EMP1]…10/20/2021.” There was no additional evidence of resolution to the family member complaint, namely, no documentation of patient case manager contact and/or no documentation of complainant response/satisfaction of resolution after notification. Surveyor unable to discern resolution to complaint based on lack of documented evidence. An exit conference was conducted on 11/17/2021 at approximately 1:10 PM directly with agency executive director (EMP1), director of operations (EMP2), clinical director (EMP3), quality manager (EMP4, and via phone conference with agency area directors (EMP7, EMP8). Above findings were reviewed.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on the review of clinical records (CR1), review of agency policies, and interview with agency staff, the agency failed to coordinate services and inform the physician and/or other personnel of changes in the patient's condition/needs and/or initiate plan of care revisions for the clinical record reviewed (CR1). Findings included: Review of agency policies 11/17/2021 revealed the following: “Missed Services…Number 04.27.03…Revised 6/14/2016…Overview…Because the frequency of services are ordered by the physician, a missed service affects the plan of care, which may need to be updated or changed…Process/Procedures…When scheduled services, visits, or shifts are not provided for any reason, the appropriate notification should be completed and sent to the physician or other appropriate entity in a timely manner. A copy of the notification is placed in the patient’s record to reflect the alteration of the plan of care…” “Physician Orders…Number 4/27.04…Revised 10/13/2021…Plan of Treatment/Plan of Care...The physician must be promptly alerted to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or the POC should be altered…” Review of CR1 conducted at approximately 10:30 AM on 11/17/2021 revealed the following: Agency Plan of Care (POC), Start of Care 10/15/2021, certification period 10/15/2021 to 12/13/2021. “…Interventions…HHA (Home Health Aide) will provide 58 – 78.5 hours per week of unskilled care. 12 hrs (hours)/day M (Monday) – F (Friday) and 8 hrs/day on Saturdays and Sundays…” Home Health Aide care plan initiated and signed by supervising Registered Nurse (EMP3) 10/15/2021 “…Frequency 78hrs/week…” Review of HHA visits form 10/15/2021 to 11/13/2021 revealed the following missed visits: 10/20/2021, 10/24/2021, 10/25/2021, 10/26/2021, 11/1/2021, 11/2/2021, 11/5/2021, 11/6/2021, 11/7/2021, 11/12/2021. CR1 did not contain documentation of the supervising registered nurse coordinating care delivery with the patient physician, patient/patient representative, and/or other personnel to revise/update the patient POC Home Health Aide interventions for patient. An exit conference was conducted on 11/17/2021 at approximately 1:10 PM directly with agency executive director (EMP1), director of operations (EMP2), clinical director (EMP3), quality manager (EMP4, and via phone conference with agency area directors (EMP7, EMP8). Above findings were reviewed.