G 0000 - secure.in.gov

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

04/21/2021PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46214

157606 03/31/2021

AVEANNA HEALTHCARE

2629 WATERFRONT PKWY E DR STE 150

00

G 0000

Bldg. 00

This visit was for a federal complaint investigation

at a deemed home health agency.

Complaint #: IN 00345786; substantiated with

findings

Survey Dates: 3-30 and 3-31-2021

Facility #: 007136

CCN #: 157606

MCD #: 200869820

Quality Review Completed on 4/6/21 by Area 3

G 0000

484.60(a)(2)(i-xvi)

Plan of care must include the following

The individualized plan of care must include

the following:

(i) All pertinent diagnoses;

(ii) The patient's mental, psychosocial, and

cognitive status;

(iii) The types of services, supplies, and

equipment required;

(iv) The frequency and duration of visits to be

made;

(v) Prognosis;

(vi) Rehabilitation potential;

(vii) Functional limitations;

(viii) Activities permitted;

(ix) Nutritional requirements;

(x) All medications and treatments;

(xi) Safety measures to protect against

G 0574

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FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: N6RP11 Facility ID: 007136

TITLE

If continuation sheet of 23

(X6) DATE




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injury;

(xii) A description of the patient's risk for

emergency department visits and hospital

re-admission, and all necessary interventions

to address the underlying risk factors.

(xiii) Patient and caregiver education and

training to facilitate timely discharge;

(xiv) Patient-specific interventions and

education; measurable outcomes and goals

identified by the HHA and the patient;

(xv) Information related to any advanced

directives; and

(xvi) Any additional items the HHA or

physician or allowed practitioner may choose

to include.

Based on record review and interview, the agency

failed to ensure the frequency and hours of care

visits were individualized on the plan of care to

meet the patients needs as identified in the

comprehensive assessment for 2 of 3 (Patients #1

and 2) patients whose clinical record was

reviewed.

The findings included:

1. Review of a policy, "Plan of Care," last

reviewed/ revised 5-28-2020, evidenced the policy

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 ... It is

developed based on the initial assessment, goals,

problems, and patient care needs .... "

2. Review of the clinical record of patient #1,

evidenced a start of care date of 10-12-2020, and

contained a plan of care for certification periods

10-12-2020 to 12-10-2020, and 12-11-2020 to

2-8-2021. Patient #1's primary diagnosis was

G 0574 Pt. #1 was discharged on

February 3, 2021

Pt. #2 HHA Care Plan was review

and revised to ensure the

frequency and hours of care were

individualized and met the needs

of the patient as identified in the

comprehensive assessment.

Changes were communicated to

the home health aides providing

care to ensure understanding and

compliance with the plan of care.

All changes in frequency/hours,

that will reflect a change in

physician orders, will be

communicated to the Parent or

Caregiver within 30 minutes of the

office receiving a call off and this

will be documented in the patient’s

medical record. Documentation of

the call in the medical record to

include time/date and person to

whom the clinician or designee

communicated with. Other

clinicians will be contacted to

04/15/2021 12:00:00AM

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quadriplegia, and plan of care orders included

home health aide (HHA) care visits 7-9 hours a

day, 4-7 days a week to perform activities of daily

living, to include bed bath and incontinence care,

and instrumental activities of daily living.

Review of the comprehensive assessments dated

10-12-2020 and 12-4-2020, evidenced patient #1

was bedbound, and lived with only an elder

mother who was unable to provide patient #1's

care. Diagnoses included quadriplegia,

generalized anxiety disorder, cystitis (bladder

infection), and suprapubic catheter (a catheter

placed through the abdominal skin into the

bladder to drain urine.) Patient #1 had sensation

to mid-chest and used a mouth stick to operate

remote controls for telephone and television, and

patient #1 was totally dependent on caregivers for

all needs/ care. Patient #1's mother was identified

as a caregiver, but was noted not to be able to

reposition or bathe patient #1. The plan of care

failed to be individualized to meet patient #1's

needs as a quadriplegic for care visits 7 days a

week to provide continence care, bed bath several

times each week, repositioning patient each 2

hours during care visits to ensure relief of

pressure from left buttock wound & dressing, to

provide hydration and meals, linen changes, and

to assist patient #1 with oral care, etc.

Review of the prior authorization document, dated

10-15-2020, evidenced 8 hours a day of home

health aide visits, 7 days a week, were authorized

by Medicaid.

On 3-31-2021, at P.M., when the administrator and

acting clinical manager, employee B, were queried

about the agency's choice in the plan of care for

HHA visits 4-7 days a week, rather than 7 days a

week, the administrator stated the agency had

cover the shift/visit if agreeable by

the caregiver/parent. If there is no

other clinical support that can

cover the shift/visit the

caregiver/parent will be notified by

preferred method of

communication (telephone, fax,

email). If the parent/caregiver

refuses another caregiver this will

be documented in the file and the

identified trained backup caregiver

will assume responsibility of the

care that needs to be provided.

The patient’s physician will be

notified by faxing over a missed

shift report noting that the care

was not provided by Aveanna.

confirmation of the fax will be

maintained that it was

successfully delivered.

Upon Admission to Aveanna a

“Contract For Participation In

Care” is signed by the

caregiver/parent. This document

states Aveanna requires

identification and availability of one

trained backup caregiver for care

to be provided or continued in the

event that care cannot be provided

for a specific period of time. This

information is maintained and is

utilized when there is a time that

care cannot be provided by

Aveanna. Aveanna is very aware

that care to their patients is

needed and we expect to fulfill our

role in caring for our clients and

meet their needs.

Patient number 2 as identified on

the survey currently is being





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often used ranges of visits per week, rather than a

discrete number. Neither disagreed with the

determination based on patient #1's

comprehensive assessments, the appropriate care

visits were at the maximum permitted by the prior

authorization of 8 hours, 7 days a week.

3. Review of the clinical record for patient #2,

evidenced a start of care date of 5-31-2017, date of

birth of 1-3-1998, evidenced diagnoses to include,

congenital deformity of spine and cerebral palsy,

and contained plans of care for certification

periods 1-18- to 3-18-2021, and 3-19 to 5-17-2021,

each with orders for home health aide 3-9 hours

per visit, 2-5 days per week "to assist with ADLs

(activities of daily living) and personal care tasks

and follow aide care plan ... Hygiene and

grooming; assist with shower, shampoo hair, hair

care, mouth care set up, shave legs, underarms,

and bikini area with electric razor, assist with

dressing, clean/file nails, foot care, skin care;

elimination: assist with toileting, assist with toilet

transfers ... Transfers: mobile wheelchair,

transfers pivot, pt. able to reposition self, HHA

may provide gentle PROM (passive range of

motion) to extremities as requested by patient ...

Meals: prepare meal, set up meal, patient may

assist with meal prep ... Housekeeping: change

bed linens, make bed, tidy room where care

provided, clean/dust surfaces, laundry ...

Medications: med reminders ... Safety: fall

precautions, hip precautions, glasses, regular

diet."

Review of the recertification comprehensive

assessment dated 3-12-2021, evidenced patient #2

lived at home with parents and other siblings and

required assistance with bathing, dressing,

toileting, transfers, meals, and medication

reminders.

staffed 8 hours per day 5 days per

week. An interim order was

obtained stating that care to be

provided was 8hrs. per day 5 days

per week. The Parent has

requested no weekend assistance

and Monday thru Friday 7-8 hours

per day. Medicaid authorization

has been revised to reflect the

individualized needs of the patient

as identified in the comprehensive

assessment.

The plan for monitoring to

prevent the likelihood of

recurrence of the deficient

practice:

100% HHA Care Plans were

reviewed and revised by the

Nursing Supervisor to ensure the





100% of patients receiving home

health aide services will be

reviewed on a monthly basis by

the Administrator/ Nursing

Supervisor or designee to ensure

that the needs of the patient ,as

identified in the comprehensive

assessment are being met.

· If at any point compliance

falls below the threshold then

weekly audits will be implemented

and the Clinical Director or

designee will provide additional

training and counseling for

individual staff. Recruiting will





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Review of HHA visit notes from 1-18-2021 to

3-29-2021, evidenced the home health aide was in

the home of patient #2 to provide the above

described care consistently for 8 hours, 5 days per

week. A range of visit hours of 3-9 hours was not

appropriate and individualized because it took the

HHA 8 hours to complete the care.

On 3-31-2021, at 10:58 A.M., the administrator and

acting clinical supervisor (acting nursing

supervisor), employee B, verified the plans of care

were not individualized and established to meet

the patients' identified needs. They indicated

patient #1's quadriplegia warranted the maximum

prior authorization permitted HHA hours and days

per week of visits. They indicated for patient #2,

the HHA visits took 8 hours to provide the

ordered care, and the range of 3-9 hours was not

individualized to meet patient #2's needs for care

of 8 hour visits.

continue for additional staff to

provide staffing when there are call

outs or resignations.

· If compliance is achieved

then 10 % of HHA clinical records

will be monitored through quarterly

record reviews.

· The Location Administrator

will monitor findings as stated

above to ensure ongoing

compliance is achieved ,deficiency

is corrected, and will not recur.

· Ongoing compliance will be

reported to the Administrator,

QAPI Committee and Governing

Body during regularly scheduled

meetings.

The title of the person

responsible for implementing

the plan of correction:

Administrator/ Nursing

Supervisor/Designee

484.80(g)(1)

Home health aide assignments and duties

Standard: Home health aide assignments

and duties.

Home health aides are assigned to a specific

patient by a registered nurse or other

appropriate skilled professional, with written

patient care instructions for a home health

aide prepared by that registered nurse or

other appropriate skilled professional (that is,

physical therapist, speech-language

pathologist, or occupational therapist).

G 0798

Bldg. 00

G 0798 Pt #1 was discharged 04/15/2021 12:00:00AM





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Based on record review and interview, the

registered nurse failed to ensure the written care

instructions included the frequency a patient with

buttock wound and dressing should be

repositioned for 1 of 1 patient with wound (Patient

#1) and failed to ensure a minimum frequency for

bathing was established in relation to hygiene for

2 of 3 patients (Patients #1 and 2) whose clinical

record was reviewed.


1. Review of a policy, "Care Plan," last

reviewed/revised 5-28-2020, evidenced the policy

stated, " ... When aide services are provided,

written patient care instructions for the aide must

be prepared by the registered nurse ...

Assignments are designated based on patient

need and the utilization of "prn" [as needed] is

not to be associated with any task. Determination

of when tasks are performed are out of the scope

of practice for aides ... "

2. Review of the plan of care for patient #1, start

of care date of 10-12-2020, evidenced patient #1

was quadriplegic and totally dependent on

caregivers for ADLs (activities of daily living) and

IADLs (Instrumental Activities of Daily Living.)

Review of the home health aide (HHA) care plan

updated 12-4-2020, evidenced bed bath was

ordered "as requested." The HHA care plan failed

to include a minimum frequency of bed bath for

patient #1's hygiene needs.

3. Review of the plan of care for the certification

period of 3-19 to 5-17-2021 for patient #2,

evidenced diagnosis of congenital deformity of

the spine and cerebral palsy, with durable medical

equipment of bath/shower chair, and wheelchair.

February 3, 2021.

Pt. #2 Deficiencies

Addressed: The Home Health

Aide Plan of Care was reviewed

and revised on April 5th to ensure

all assignments are clear and

specific to the patient’s needs. All

task including repositioning and

hygiene , were revised to state a

minimal frequency based on

the patient’s needs . Utilization of

“prn” or as requested will not to

be associated with any task.

The home health aide was

re-educated on the changes, and

that Utilization of “prn” orders or

as requested will not to be

associated with any task and

evidenced understanding. An

interim physician’s order was

obtained .

1. Clinical staff were

re-educated that the HOME

HEALTH aide care plan is

developed by the registered nurse

, is individualized to the patient’s

need. The POC will be reviewed

and revised at least every 60 days

and more often as the needs of

the patient change.

2. All supervisory clinical staff

will be in-serviced on the Aide

Plan of Care and the review of the

aide plan to ensure all

assignments are clear and


task including hygiene task will

state a minimal frequency

based on the patient’s needs .

Utilization of “prn” or “as





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Review of the clinical record for patient #2, start of

care date of 5-31-2017, evidenced a home health

aide (HHA) care plan updated 9-15, 11-17-2020,

1-12, and 3-12-2021, with shower assistance to be

provided "as requested." Other HHA tasks

ordered "as requested" included mouth care set

up, toilet, pivot transfer, change linens, make bed,

tidy room, clean surfaces, and laundry. The HHA

care plan failed to establish a minimum frequency

for patient #2's hygiene needs and other HHA

tasks.

4. On 3-31-2021, at 10:58 A.M., the administrator

and acting clinical supervisor, employee B,

verified the home health aide care plans included

"as requested" for the frequency of bathing and

repositioning, and all HHA instructions should

have been specific to include a minimum

frequency.

requested” will not to be

associated with any task.

3. Education will be provided

to all aides to ensure

understanding of the care plan and

flowsheet. All tasks to be

performed by the aide will be

assigned as not to leave care to

the judgement of the aide which is

out of the home health aide scope

of practice. The home health aide

care plan will be reviewed during

the supervisory visit to ensure the

documentation reflects the duties

assigned , the frequency, how to

address” refusals”, and notification

to the Nursing supervisor.




practice:

· The Administrator/Alternate

Administrator or designee will

review 100% active patients

receiving Home Aide Services

weekly for 4 weeks to ensure

ongoing compliance. The

threshold for compliance is 90%.



weekly audits will continue and

the Administrator or designee will

provide additional training and

counseling for individual staff.


monitored through quarterly record

reviews of 10% of patient census

for the quarter.





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will monitor findings to ensure

ongoing compliance is achieved,

deficiency is corrected, and will

not recur.





meetings.




Administrator/ Clinical Director or

designee

484.105(a)

Governing body

Standard: Governing body.

A governing body (or designated persons so

functioning) must assume full legal authority

and responsibility for the agency's overall

management and operation, the provision of

all home health services, fiscal operations,

review of the agency's budget and its

operational plans, and its quality assessment

and performance improvement program.

G 0942

Bldg. 00


governing body failed to establish written

guidelines and a procedure in relation to when,

how, and who must participate in the decision

whether to accept patients to agency service for 1

of 1 governing body.


G 0942 Pt #1 was discharged February 3,

2021.

Administrator and all internal staff

were educated on the admission

policy and procedure( 04.01.02)

which delegates responsibility for

determining whether to accept or

decline a referral to the location

administrator. This will be based

04/15/2021 12:00:00AM





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Review of the clinical record of patient #1,



10-12-2020 to 12-10-2020, and 12-11-2020 to







Review of the comprehensive assessment dated

10-12-2020, evidenced patient #1 was bedbound,

and lived with an elder mother. Diagnoses

included quadriplegia, generalized anxiety

disorder, cystitis (bladder infection), and

suprapubic catheter (a catheter placed through

the abdominal skin into the bladder.) Patient #1

was totally dependent on caregivers for all

needs/care. Patient #1's mother was identified as

a caregiver.



was bedbound, and lived with an elder mother.

Diagnoses included quadriplegia, generalized

anxiety disorder, cystitis (bladder infection), and





a caregiver.

Review of a document, "Backup Caregiver

Agreement," evidenced patient #1's brother and

sister as alternate caregivers. The document

stated, " ... I understand there may be times when

the agency's employees or contractors may be

unable to provide scheduled services ... " The

on admission criteria and ability of

the location to meet the patient’s

needs.

The Clinical Supervisor will assign

clinical personnel to conduct initial

assessments for eligibility of

services within 48 hours of

acceptance of referral information.

and/or discharge from referring

facility.

During the initial assessment visit,

the assigned RN will assess the

patient, review eligibility for home

care services according to the

admission criteria, and will

communicate her findings to the

location administrator. The

location administrator will then

determine if the referral will be

accepted or declined.

Upon admission an individualized

plan of care will be created to

meet the patient’s needs as


assessment and ordered by the

physician.

The Internal and clinical staff were

educated that Upon Admission to

Aveanna a “Contract For

Participation In Care” is signed by

the caregiver/parent. This

document states Aveanna requires













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document identified patient #1's brother and sister

as alternate caregivers and was signed by patient

#1's mother on 10-12-2020.

On 3-30-2021, the acting clinical manager,

employee B, indicated patient #1's brother and

sister did not reside with patient #1, but lived in

town. Employee B also stated patient #1's mother

was elderly and unable to bathe or reposition

patient #1.

Review of HHA visit notes during the 1st

certification period failed to evidence home health

visits the week of November 22 to November 28,

2020. During the week of November 29 to

December 5, a HHA care visit was made on

12-4-2020, from 12-5 P.M., and on 12-5-2020, from 9

to 10:30 P.M. The agency failed to meet the

ordered hours of care per visit, and failed to meet

the ordered frequency of visits.

Review of HHA visit notes during the 2nd


visits the week of January 3 to January 9, 2021.

The agency failed to meet the ordered hours of

care per visit, and failed to meet the ordered

frequency of visits.

On 3-31-2021, at 12:51 P.M., when asked about the

failure to provide visits, indicated patient #1's

brother, a designated alternate caregiver, did not

come to provide care when she requested due to

lack of agency staffing.

When the language on the Backup Caregiver

Agreement, " ... I understand there may be times

when the agency's employees or contractors may

be unable to provide scheduled services ... " was

read to the Administrator and the acting Clinical

Manager, employee B, both concurred this notice

Aveanna. - If there is a missed

shift the caregiver/parent will be

notified and this will be

documented in the patient’s

medical record. Other clinicians

will be contacted to cover the

shift/visit if agreeable by the

caregiver/parent. If there is no




preferred method of












If unable to staff the client due

to availability of staff the

following additional actions

will be taken and

communicated to the parent/

patient and physician:

PRN Staffing agencies will be

notified to see if they have staff

available.

Other agencies will be contacted

to see if they are able to meet the

identified staffing needs if

agreeable with the patient/family.




practice:





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was not intended to be used as an excuse for

chronic missed care visits.

On 3-31-2021, the administrator and acting clinical

manager, employee B, when queried if the agency

had established written guidelines and a

procedure in relation to acceptance of patients to

agency service, both replied, "No." When

queried to explain the patient intake process, the

acting clinical manager, employee B, indicated

once the referral was received, a following

physician was verified, and source of payment

was confirmed, the registered nurse made an

appointment with referred patient to establish a

start of care, obtain consents, teach patient rights,

COVID-19 and general infection

prevention/control, and conduct a combined

initial and comprehensive assessment. The acting

clinical manager indicated often identifying

important needs for service and aspects of care at

the initial/comprehensive assessment, which had

not been included in the patients' referral. In

relation to patient #1, employee B stated

discovering a lot about care needs only after

going to the home to admit patient #1, to include

observing mother of patient was not physically

able to complete the tasks of repositioning and

bathing patient #1. Employee B, the acting clinical

manager, stated being unaware of any procedure

or written guidelines to follow to determine if

patients should be accepted to agency services,

with the responsibility to then meet the patients

needs for ordered care visits. The acting clinical

manager, employee B, when asked if the agency

had ever considered conducting an initial

assessment, and then conferring with appropriate

personnel, prior to establishing a start of care and

accepting a patient to agency services, replied

"No." When asked if the agency could again find

itself having admitted a patient and then not



review 100% of referrals on a

monthly basis x2 to ensure

compliance. The threshold for

compliance is 100%.










to include admissions for the

quarter.



ongoing compliance is achieved


not recur.




Administrator/ Clinical Manager/ or

designee





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having the staff to meet the ordered care visits,

the administrator and the acting clinical manager,

employee B, stated, "Yes." The administrator and

the acting clinical manager, employee B, indicated

the agency needs a way to address this concern.

N 0000

Bldg. 00

This visit was for a state licensure complaint

investigation of a home health agency.

Complaint #: IN 00345786; substantiated with

findings

Survey Dates: 3-30 and 3-31-2021

Facility #: 007136

CCN #: 157606

MCD #: 200869820

Quality Review Completed on 4/6/21 by Area 3

N 0000

410 IAC 17-12-1(b)

Home health agency

administration/management

Rule 12 Sec. 1(b) A governing body, or

designated person(s) so functioning, shall

assume full legal authority and responsibility

for the operation of the home health agency.

The governing body shall do the following:

(1) Appoint a qualified administrator.

(2) Adopt and periodically review written

bylaws or an acceptable equivalent.

(3) Oversee the management and fiscal

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State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet of 23




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affairs of the home health agency.


governing body failed to establish written

guidelines and a procedure in relation to when,

how, and who must participate in the decision

whether to accept patients to agency service for 1

of 1 governing body.


Review of the clinical record of patient #1,



10-12-2020 to 12-10-2020, and 12-11-2020 to







Review of the comprehensive assessment dated

10-12-2020, evidenced patient #1 was bedbound,

and lived with an elder mother. Diagnoses

included quadriplegia, generalized anxiety

disorder, cystitis (bladder infection), and





a caregiver.



was bedbound, and lived with an elder mother.

Diagnoses included quadriplegia, generalized

anxiety disorder, cystitis (bladder infection), and



N 0442 Pt #1 was discharged February 3,

2021.

Administrator and all internal staff

were educated on the admission

policy and procedure( 04.01.02)

which delegates responsibility for

determining whether to accept or

decline a referral to the location

administrator. This will be based

on admission criteria and ability of

the location to meet the patient’s

needs.

The Clinical Supervisor will assign

clinical personnel to conduct initial

assessments for eligibility of

services within 48 hours of

acceptance of referral information.

and/or discharge from referring

facility.

During the initial assessment visit,

the assigned RN will assess the

patient, review eligibility for home

care services according to the

admission criteria, and will

communicate her findings to the

location administrator. The

location administrator will then

determine if the referral will be

accepted or declined.

Upon admission an individualized

plan of care will be created to

meet the patient’s needs as


assessment and ordered by the

physician.

The Internal and clinical staff were

educated that Upon Admission to

Aveanna a “Contract For

Participation In Care” is signed by

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a caregiver.

Review of a document, "Backup Caregiver

Agreement," evidenced patient #1's brother and

sister as alternate caregivers. The document

stated, " ... I understand there may be times when

the agency's employees or contractors may be

unable to provide scheduled services ... " The

document identified patient #1's brother and sister

as alternate caregivers and was signed by patient

#1's mother on 10-12-2020.

On 3-30-2021, the acting clinical manager,

employee B, indicated patient #1's brother and

sister did not reside with patient #1, but lived in

town. Employee B also stated patient #1's mother

was elderly and unable to bathe or reposition

patient #1.

Review of HHA visit notes during the 1st


visits the week of November 22 to November 28,

2020. During the week of November 29 to

December 5, a HHA care visit was made on

12-4-2020, from 12-5 P.M., and on 12-5-2020, from 9

to 10:30 P.M. The agency failed to meet the

ordered hours of care per visit, and failed to meet

the ordered frequency of visits.

Review of HHA visit notes during the 2nd


visits the week of January 3 to January 9, 2021.

The agency failed to meet the ordered hours of

care per visit, and failed to meet the ordered

frequency of visits.

On 3-31-2021, at 12:51 P.M., when asked about the

failure to provide visits, indicated patient #1's

the caregiver/parent. This

document states Aveanna requires









Aveanna. - If there is a missed

shift the caregiver/parent will be

notified and this will be

documented in the patient’s

medical record. Other clinicians

will be contacted to cover the

shift/visit if agreeable by the

caregiver/parent. If there is no




preferred method of












If unable to staff the client due

to availability of staff the

following additional actions

will be taken and

communicated to the parent/

patient and physician:

PRN Staffing agencies will be





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brother, a designated alternate caregiver, did not

come to provide care when she requested due to

lack of agency staffing.

When the language on the Backup Caregiver

Agreement, " ... I understand there may be times

when the agency's employees or contractors may

be unable to provide scheduled services ... " was

read to the Administrator and the acting Clinical

Manager, employee B, both concurred this notice

was not intended to be used as an excuse for

chronic missed care visits.


acting clinical manager, employee B, when queried

if the agency had established written guidelines

and a procedure in relation to acceptance of

patients to agency service, both replied, "No."

When queried to explain the patient intake

process, the acting clinical manager, employee B,

indicated once the referral was received, a

following physician was verified, and source of

payment was confirmed, the registered nurse

made an appointment with referred patient to

establish a start of care, obtain consents, teach

patient rights, COVID-19 and general infection

prevention/control, and conduct a combined

initial and comprehensive assessment. The acting

clinical manager indicated often identifying

important needs for service and aspects of care at

the initial/comprehensive assessment, which had

not been included in the patients' referral. In

relation to patient #1, employee B stated

discovering a lot about care needs only after

going to the home to admit patient #1, to include

observing mother of patient was not physically

able to complete the tasks of repositioning and

bathing patient #1. Employee B, the acting clinical

manager, stated being unaware of any procedure

or written guidelines to follow to determine if

notified to see if they have staff

available.

Other agencies will be contacted

to see if they are able to meet the

identified staffing needs if

agreeable with the patient/family.




practice:



review 100% of referrals on a

monthly basis x2 to ensure

compliance. The threshold for

compliance is 100%.










to include admissions for the

quarter.



ongoing compliance is achieved


not recur.




Administrator/ Clinical Manager/ or

designee





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patients should be accepted to agency services,

with the responsibility to then meet the patients

needs for ordered care visits. The acting clinical

manager, employee B, when asked if the agency

had ever considered conducting an initial

assessment, and then conferring with appropriate

personnel, prior to establishing a start of care and

accepting a patient to agency services, replied

"No." When asked if the agency could again find

itself having admitted a patient and then not

having the staff to meet the ordered care visits,

the administrator and the acting clinical manager,

employee B, stated, "Yes." The administrator and

the acting clinical manager, employee B, indicated

the agency needs a way to address this concern.

410 IAC 17-13-1(a)(1)

Patient Care

Rule 13 Sec. 1(a)(1) As follows, the medical

plan of care shall:

(A) Be developed in consultation with the

home health agency staff.

(B) Include all services to be provided if a

skilled service is being provided.

(B) Cover all pertinent diagnoses.

(C) Include the following:

(i) Mental status.

(ii) Types of services and equipment

required.

(iii) Frequency and duration of visits.

(iv) Prognosis.

(v) Rehabilitation potential.

(vi) Functional limitations.

(vii) Activities permitted.

(viii) Nutritional requirements.

(ix) Medications and treatments.

(x) Any safety measures to protect

against injury.

(xi) Instructions for timely discharge or

referral.

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(xii) Therapy modalities specifying length of

treatment.

(xiii) Any other appropriate items.

Based on record review and interview, the agency

failed to ensure the frequency and hours of care

visits were individualized on the medical plan of

care to meet the patients needs as identified in the

comprehensive assessment for 2 of 3 (Patients #1

and 2) patients whose clinical record was

reviewed.


1. Review of a policy, "Plan of Care," last


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 ... It is

developed based on the initial assessment, goals,

problems, and patient care needs ...

2. Review of the clinical record of patient #1,



10-12-2020 to 12-10-2020, and 12-11-2020 to







Review of the comprehensive assessments dated

10-12-2020 and 12-4-2020, evidenced patient #1

was bedbound, and lived with only an elder

mother who was unable to provide patient #1's

care. Diagnoses included quadriplegia,

generalized anxiety disorder, cystitis (bladder

N 0524 Pt. #1 was discharged on

February 3, 2021

Pt. #2 HHA Care Plan was review

and revised to ensure the





Changes were communicated to

the home health aides providing

care to ensure understanding and

compliance with the plan of care.

All changes in frequency/hours,

that will reflect a change in

physician orders, will be

communicated to the Parent or

Caregiver within 30 minutes of the

office receiving a call off and this

will be documented in the patient’s

medical record. Documentation of

the call in the medical record to

include time/date and person to

whom the clinician or designee

communicated with. Other

clinicians will be contacted to

cover the shift/visit if agreeable by

the caregiver/parent. If there is no




preferred method of







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infection), and suprapubic catheter (a catheter

placed through the abdominal skin into the

bladder to drain urine.) Patient #1 had sensation

to mid-chest and used a mouth stick to operate

remote controls for telephone and television, and

patient #1 was totally dependent on caregivers for

all needs/care. Patient #1's mother was identified

as a caregiver, but was noted not to be able to

reposition or bathe patient #1. The plan of care

failed to be individualized to meet patient #1's

needs as a quadriplegic for care visits 7 days a

week to provide continence care, bed bath several

times each week, repositioning patient each 2

hours during care visits to ensure relief of

pressure from left buttock wound & dressing, to

provide hydration and meals, linen changes, and

to assist patient #1 with oral care, etc.

Review of the prior authorization document, dated

10-15-2020, evidenced 8 hours a day of home

health aide visits, 7 days a week, were authorized

by Medicaid.

On 3-31-2021, at P.M., when the administrator

and acting clinical manager, employee B, were

queried about the agency's choice in the plan of

care for HHA visits 4-7 days a week, rather than 7

days a week, the administrator stated the agency

had often used ranges of visits per week, rather

than a discrete number. Neither disagreed with

the determination based on patient #1's

comprehensive assessments, the appropriate care

visits were at the maximum permitted by the prior

authorization of 8 hours, 7 days a week.

3. Review of the clinical record for patient #2,

evidenced a start of care date of 5-31-2017, date of

birth of 1-3-1998, evidenced diagnoses to include,

congenital deformity of spine and cerebral palsy,

and contained plans of care for certification






confirmation of the fax will be

maintained that it was

successfully delivered.

Upon Admission to Aveanna a

“Contract For Participation In

Care” is signed by the

caregiver/parent. This document

states Aveanna requires









Aveanna. Aveanna is very aware

that care to their patients is

needed and we expect to fulfill our

role in caring for our clients and

meet their needs.

Patient number 2 as identified on

the survey currently is being

staffed 8 hours per day 5 days per

week. An interim order was

obtained stating that care to be

provided was 8hrs. per day 5 days

per week. The Parent has

requested no weekend assistance

and Monday thru Friday 7-8 hours

per day. Medicaid authorization

has been revised to reflect the

individualized needs of the patient

as identified in the comprehensive

assessment.





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periods 1-18- to 3-18-2021, and 3-19 to 5-17-2021,

each with orders for home health aide 3-9 hours

per visit, 2-5 days per week "to assist with ADLs

(activities of daily living) and personal care tasks

and follow aide care plan ... Hygiene and

grooming; assist with shower, shampoo hair, hair

care, mouth care set up, shave legs, underarms,

and bikini area with electric razor, assist with

dressing, clean/file nails, foot care, skin care;

elimination: assist with toileting, assist with toilet

transfers ... Transfers: mobile wheelchair,

transfers pivot, pt. able to reposition self, HHA

may provide gentle PROM (passive range of

motion) to extremities as requested by patient ...

Meals: prepare meal, set up meal, patient may

assist with meal prep ... Housekeeping: change

bed linens, make bed, tidy room where care

provided, clean/dust surfaces, laundry ...

Medications: med reminders ... Safety: fall

precautions, hip precautions, glasses, regular

diet."



lived at home with parents and other siblings and

required assistance with bathing, dressing,

toileting, transfers, meals, and medication

reminders.

Review of HHA visit notes from 1-18-2021 to

3-29-2021, evidenced the home health aide was in

the home of patient #2 to provide the above

described care consistently for 8 hours, 5 days per

week. A range of visit hours of 3-9 hours was not

appropriate and individualized because it took the

HHA 8 hours to complete the care.


acting clinical supervisor, employee B, verified the

plans of care were not individualized and




practice:

100% HHA Care Plans were

reviewed and revised by the

Nursing Supervisor to ensure the





100% of patients receiving home

health aide services will be

reviewed on a monthly basis by

the Administrator/ Nursing

Supervisor or designee to ensure

that the needs of the patient ,as


assessment are being met.



weekly audits will be implemented

and the Clinical Director or

designee will provide additional

training and counseling for

individual staff. Recruiting will

continue for additional staff to

provide staffing when there are call

outs or resignations.

· If compliance is achieved

then 10 % of HHA clinical records

will be monitored through quarterly

record reviews.


will monitor findings as stated

above to ensure ongoing

compliance is achieved ,deficiency

is corrected, and will not recur.





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established to meet the patients' identified needs.

They indicated patient #1's quadriplegia

warranted the maximum prior authorization

permitted HHA hours and days per week of visits.

They indicated for patient #2, the HHA visits took

8 hours to provide the ordered care, and the range

of 3-9 hours was not individualized to meet patient

#2's needs for care of 8 hour visits.





meetings.




Administrator/ Nursing

Supervisor/Designee

410 IAC 17-13-2

Nursing Plan of Care

Rule 13 Sec. 2(a) A nursing plan of care

must be developed by a registered nurse for

the purpose of delegating nursing directed

patient care provided through the home health

agency for patients receiving only home

health aide services in the absence of a

skilled service.

(b) The nursing plan of care must contain the

following:

(1) A plan of care and appropriate patient

identifying information.

(2) The name of the patient's physician.

(3) Services to be provided.

(4) The frequency and duration of visits.

(5) Medications, diet, and activities.

(6) Signed and dated clinical notes from all

personnel providing services.

(7) Supervisory visits.

(8) Sixty (60) day summaries.

(9) The discharge note.

(10) The signature of the registered nurse

who developed the plan.

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registered nurse failed to ensure the nursing plan

of care written care instructions included the

frequency a patient with buttock wound and

dressing should be repositioned for 1 of 1 patient

with wound (Patient #1) and failed to ensure a

minimum frequency for bathing was established in

relation to hygiene for 2 of 3 patients (Patients #1

and 2) whose clinical record was reviewed.


1. Review of a policy, "Care Plan," last


stated, " ... When aide services are provided,

written patient care instructions for the aide must

be prepared by the registered nurse ...

Assignments are designated based on patient

need and the utilization of "prn" [as needed] is

not to be associated with any task. Determination

of when tasks are performed are out of the scope

of practice for aides ... "

2. Review of the plan of care for patient #1, start

of care date of 10-12-2020, evidenced patient #1

was quadriplegic and totally dependent on

caregivers for ADLs (activities of daily living) and

IADLs (Instrumental Activities of Daily Living.)

Review of the home health aide (HHA) care plan

updated 12-4-2020, evidenced bed bath was

ordered "as requested." The HHA care plan failed

to include a minimum frequency of bed bath for

patient #1's hygiene needs.

3. Review of the plan of care for the certification

period of 3-19 to 5-17-2021 for patient #2,

evidenced diagnosis of congenital deformity of

the spine and cerebral palsy, with durable medical

N 0533 Pt # 1 was discharged on

February 3, 2021

Pt. #2 Deficiencies

Addressed: The Home Health

Aide Plan of Care was reviewed

and revised on April 5th to ensure

all assignments are clear and


task including repositioning and

hygiene , were revised to state a

minimal frequency based on

the patient’s needs . Utilization of

“prn” or as requested will not to

be associated with any task.

The home health aide was

re-educated on the changes, and

that Utilization of “prn” orders or

as requested will not to be

associated with any task and

evidenced understanding. An

interim physician’s order was

obtained .

1. Clinical staff were

re-educated that the HOME

HEALTH aide care plan is

developed by the registered nurse

, is individualized to the patient’s

need. The POC will be reviewed

and revised at least every 60 days

and more often as the needs of

the patient change.

2. All supervisory clinical staff

will be in-serviced on the Aide

Plan of Care and the review of the

aide plan to ensure all

assignments are clear and


task including hygiene task will

state a minimal frequency

based on the patient’s needs .

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equipment of bath/shower chair, and wheelchair.

Review of the clinical record for patient #2, start of

care date of 5-31-2017, evidenced a home health

aide (HHA) care plan updated 9-15, 11-17-2020,

1-12, and 3-12-2021, with shower assistance to be

provided "as requested." Other HHA tasks

ordered "as requested" included mouth care set

up, toilet, pivot transfer, change linens, make bed,

tidy room, clean surfaces, and laundry. The HHA

care plan failed to establish a minimum frequency

for patient #2's hygiene needs and other HHA

tasks.

4. On 3-31-2021, at 10:58 A.M., the administrator

and acting clinical supervisor, employee B,

verified the home health aide care plans included

"as requested" for the frequency of bathing and

repositioning, and all HHA instructions should

have been specific to include a minimum

frequency.

Utilization of “prn” or “as

requested” will not to be

associated with any task.

3. Education will be provided

to all aides to ensure

understanding of the care plan and

flowsheet. All tasks to be

performed by the aide will be

assigned as not to leave care to

the judgement of the aide which is

out of the home health aide scope

of practice. The home health aide

care plan will be reviewed during

the supervisory visit to ensure the

documentation reflects the duties

assigned , the frequency, how to

address” refusals”, and notification

to the Nursing supervisor.




practice:



review 100% active patients

receiving Home Aide Services

weekly for 4 weeks to ensure

ongoing compliance. The

threshold for compliance is 90%.














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for the quarter.



ongoing compliance is achieved,


not recur.





meetings.




Administrator/ Clinical Director or

designee


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