G 0000 - secure.in.gov
Transcript of 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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
Bldg. 00
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 Page 1 of 23
(X6) DATE
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 2 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 3 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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
frequency and hours of care were
individualized and met the needs
of the patient as identified in the
comprehensive assessment.
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 4 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 5 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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.
The findings included:
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
specific to the patient’s needs. All
task including hygiene task will
state a minimal frequency
based on the patient’s needs .
Utilization of “prn” or “as
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 6 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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.
The plan for monitoring to
prevent the likelihood of
recurrence of the deficient
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%.
· If at any point compliance
falls below the threshold then
weekly audits will continue and
the Administrator or designee will
provide additional training and
counseling for individual staff.
· Ongoing compliance will be
monitored through quarterly record
reviews of 10% of patient census
for the quarter.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 7 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
· The Location Administrator
will monitor findings 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/ 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
Based on record review and interview, the
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.
The findings included:
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 8 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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
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 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.
Review of the recertification comprehensive
assessment dated 12-4-2020, 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.
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
identified in the comprehensive
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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 9 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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
certification period failed to evidence home health
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
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.
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.
The plan for monitoring to
prevent the likelihood of
recurrence of the deficient
practice:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 10 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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
· The Administrator/Alternate
Administrator or designee will
review 100% of referrals on a
monthly basis x2 to ensure
compliance. The threshold for
compliance is 100%.
· If at any point compliance
falls below the threshold then
weekly audits will continue and
the Administrator or designee will
provide additional training and
counseling for individual staff.
· Ongoing compliance will be
monitored through quarterly record
reviews of 10% of patient census
to include admissions for the
quarter.
· The Location Administrator
will monitor findings to ensure
ongoing compliance is achieved
deficiency is corrected, and will
not recur.
The title of the person
responsible for implementing
the plan of correction:
Administrator/ Clinical Manager/ or
designee
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 11 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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
N 0442
Bldg. 00
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 12 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
affairs of the home health agency.
Based on record review and interview, the
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.
The findings included:
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
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 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.
Review of the recertification comprehensive
assessment dated 12-4-2020, 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
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
identified in the comprehensive
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
04/15/2021 12:00:00AM
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 13 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
was totally dependent on caregivers for all
needs/care. Patient #1's mother was identified as
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
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
certification period failed to evidence home health
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
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. - 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
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.
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
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 14 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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.
On 3-31-2021, at 10:58 A.M., 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
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.
The plan for monitoring to
prevent the likelihood of
recurrence of the deficient
practice:
· The Administrator/Alternate
Administrator or designee will
review 100% of referrals on a
monthly basis x2 to ensure
compliance. The threshold for
compliance is 100%.
· If at any point compliance
falls below the threshold then
weekly audits will continue and
the Administrator or designee will
provide additional training and
counseling for individual staff.
· Ongoing compliance will be
monitored through quarterly record
reviews of 10% of patient census
to include admissions for the
quarter.
· The Location Administrator
will monitor findings to ensure
ongoing compliance is achieved
deficiency is corrected, and will
not recur.
The title of the person
responsible for implementing
the plan of correction:
Administrator/ Clinical Manager/ or
designee
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 15 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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.
N 0524
Bldg. 00
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 16 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
(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.
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
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
N 0524 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
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
04/15/2021 12:00:00AM
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 17 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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
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
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.
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 18 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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.
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, employee B, verified the
plans of care were not individualized and
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
frequency and hours of care were
individualized and met the needs
of the patient as identified in the
comprehensive assessment.
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
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.
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 19 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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.
· 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
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.
N 0533
Bldg. 00
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 20 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
Based on record review and interview, the
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.
The findings included:
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
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
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
specific to the patient’s needs. All
task including hygiene task will
state a minimal frequency
based on the patient’s needs .
04/15/2021 12:00:00AM
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 21 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
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.
The plan for monitoring to
prevent the likelihood of
recurrence of the deficient
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%.
· If at any point compliance
falls below the threshold then
weekly audits will continue and
the Administrator or designee will
provide additional training and
counseling for individual staff.
· Ongoing compliance will be
monitored through quarterly record
reviews of 10% of patient census
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 22 of 23
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
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
for the quarter.
· The Location Administrator
will monitor findings 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/ Clinical Director or
designee
State Form Event ID: N6RP11 Facility ID: 007136 If continuation sheet Page 23 of 23