Every finding on record at Recover Health of Wisconsin, Inc.

An unannounced onsite complaint survey was conducted on 01/07/2025 and 01/17/2025-01/21/2025 at Aveanna Home Health in La Crosse, WI in response to complaint #111530. Aveanna Home Health is in compliance with the Medicare Conditions of Participation 42 CFR 484 for Home Health Agencies. Complaint #111530 was substantiated. Citation issued at Standard Level.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to identify or implement additional actions to ensure on call clinical staff acknowledge messages received and failed to develop a comprehensive policy and procedure for notification of alternate clinical staff, in the event the designated on call nurse does not respond or is unavailable in response to 1 of 1 complaint involving lack of clinician response in a total of 12 complaint reports reviewed. Findings include: Review of agency policy titled, “On- Call: After Hours and Availability” dated 11/10/2023 revealed in part, “Qualified personnel will be made available to the patients and/or referral sources with 24-hour/7 days a week availability to respond to emergencies, answer questions, troubleshoot, and triage... All calls will be answered within 30 minutes … Primary call or non-clinical personnel who are receiving clinical calls will immediately contact the qualified licensed professional for intervention and response.” Review of agency procedure titled, “HCHB (Home Care Home Base) On call” dated 03/18/2024 revealed in part, “2. Clinician on call: 2. The on-call clinician will promptly (within 30 minutes) call the client/caregiver to respond to the clients/caregiver’s request for assistance…” There was no evidence the facility’s policies and procedures included guidance or expectations for staff to ensure on call clinical staff acknowledge messages received or a procedure to notify alternate clinical staff if the primary on call nurse does not respond or is unavailable. Record review of Patient #1’s “Client coordination notes report” dated 10/13/2024 revealed, “Note type: On call, Entered by: [Team Coordinator E], Note: Date of call: 10/13/2024, Time call received: 10:45 PM, Time call returned: N/A (not applicable) , Summary of call: [Complainant A] called stating they are having issues with oxygen, Resolution: Left on-call nurse a VM and gave access to chart.” Further review of Patient #1’s medical record revealed no documentation of LPN D follow up to Complainant A’s call. There was no documented evidence of further attempts by Team Coordinator E to ensure LPN D received the message. Record review of Patient #1’s “Complaint report” completed by Administrator B dated 10/14/2024 at 12:34 PM revealed, “Description: [Complainant A] called this writer, States: advertising says to call agency first, I did that last night because [Patient #1’s] oxygen level was very low…[Complainant A] never got a call back and left two voicemails…Intervention/Resolution Comments: 10/14/2024: Spoke with [LPN D] who states they did not receive VM (voicemail) regarding [Patient #1]. Spoke with [Team Coordinator E] who stated a voicemail was left for [LPN D] …Specific guidance given to both staff of the importance of responding in a timely manner to patient and caregiver after hour needs.” During an interview with Administrator B on 01/07/2025 at 12:35 PM, when asked for a timeline of events regarding this complaint, Administrator B stated, “I was notified of the complaint on 10/14/2024 from [Complainant A] by phone. Following the phone call with [Complainant A], spoke to [Team coordinator E] who stated they did receive the voice message from [Complainant A] and [Team Coordinator E] called [LPN D] and left a message about the call. I spoke to [LPN D] who stated they had no missed calls or messages, but [LPN D] stated was having phone issues.” When asked what interventions were completed to resolve this complaint and prevent further recurrence, Administrator B stated, “I reiterated the importance that [LPN D] ensure they do not have phone issues and the requirement to respond in a timely manner, also an email communication was sent out to staff in November 2024 re-educating about on-call policy.” There was no evidence found of additional action steps identified or implemented to ensure on call clinical staff acknowledge messages received by the 24/7 call center.