Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017016 (X3) Date Survey Completed 12/06/2018
Name of Provider or Supplier Southeast Alabama Homecare, Llc Street Address, City, State 804 Glover Avenue, Enterprise, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G0572 Plan of care
CFR(s): 484.60(a)(1)

Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan.


This STANDARD is not met as evidenced by:
Based on review of agency policy, medical records (MR) and interviews, it was determined the agency staff failed to follow the physician ordered visit frequencies, including Occupational Therapy (OT) This affected 1 of 11 records reviewed, including Home Visit (HV) # 1 and had the potential to affect all patients admitted to this agency.



Findings include:



Agency Policy: Plan of Care (POC)

Effective date: 05/04/99

Revised: 01/01/18

Policy Number: 2.1.007



Purpose:

To assure an appropriate plan of care is developed and revised in a timely manner for each patient.

To ensure that physician's orders are followed.



Policy:

Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided.



Procedure:

1. A POC is developed for all patients and updated no less than every 60 days...



... 3. The qualified clinician develops and revises the POC under the direction of the physician...



5. Physician's orders are obtained to updated the POC and may include problems and goals...



7. Alterations to the POC are made only with the physician's approval...



1. HV # 1 was admitted to the agency on 9/26/18 with Cellulitis of Left Lower Limb, Venous Insufficiency (Chronic) (Peripheral), Non-pressure Chronic Ulcer of Left Calf with Fat Layer Exposed, Acute Embolism and Thrombosis of Left Popliteal Vein, Morbid Obesity and History of Falling.



Review of the Physician order dated 10/3/18 revealed physician orders for OT (Occupational Therapist) 1 time a week for 1 week effective the week of 9/30/18.



Review of the MR revealed no documentation OT visited the patient the week of 9/30/18.



An interview was conducted on 12/6/18 at 8:26 Am with Employee Identifier (EI) # 1, Director of Nursing, who verified the above findings.
G0578 Conformance with physician orders
CFR(s): 484.60(b)

Standard: Conformance with physician orders.


This STANDARD is not met as evidenced by:
Based on review of medical records (MR), agency policies and procedures, and interviews with agency staff, it was determined the agency failed to ensure:



1. Pain levels above physician ordered parameters were reported to physician.



2. Blood sugar levels (CBG) above physician ordered parameters were reported to physician



3. Patient weight was obtained as order by the physician.



4. Touch Down Weight Bearing was evaluated by Physical Therapy (PT) as ordered by the physician.



5. Oxygen Saturation was obtained as order by the physician.



This affected 6 of 11 records including, Home Visit (HV) # 5, MR # 1, MR # 4, MR # 3, MR # 5 and MR # 2 .



This had the potential to negatively affect all patients served by the agency



Findings include:



Policy: Coordination of Care, From Admit Through Discharge

Policy Number: 2.1.017

Revised Date: 1/1/18



"Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge



Policy:

...coordinating patient care among various disciplines to ensure that services are ...coordinated from admission through discharge.



Procedure:

...4. Coordination of care with physician:

At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician:

a. When changes occur in the patient's condition or response to treatment...

e. When there is a need to change the patient's plan of care...'



Policy: Pain Assessment

Policy Number: 2.1.011

Revised Date: 12/1/13



"Purpose: To provide pain assessment guidelines for clinicians...



Procedure: Standards indicate that once the presence of pain has been assessed, the appropriate intervention ordered on the Plan of Care will be initiated."



1. HV # 5 was admitted to the agency on 11/2/18 with diagnosis of Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 11/2/18 through 12/31/18 revealed the following physician order, 'Licensed Professional to report vital signs falling outside the following established parameters: ...Pain > (greater than) 3..." on a 1 (minimal) to 10 (severe) pain scale.



Review of the Occupational Therapy (OT) Visit Note Report dated 11/5/18 revealed documentation the patient reported a pain scale rating of "5."



Further review of the OT Visit Note Report dated 11/5/18 revealed no documentation the physician was notified of the pain scale > 3.



Review of the Skilled Nurse (SN) Visit Note Report dated 11/19/18 revealed documentation the patient reported a pain scale rating of "10."



Further review of the SN Visit Note Report dated 11/19/18 revealed the pain scale was repeated and patient reported a pain scale rating of "8."



Further review of the SN Visit Note Report dated 11/19/18 revealed no documentation the physician was notified of the pain scale > 3.



An interview was conducted on 12/6/18 at 8:11 AM with Employee Identifier (EI) # 1, RN (Registered Nurse) Director of Nursing, who confirmed the previous findings.



2. MR # 1 was admitted to the agency on 12/27/17 with diagnoses of Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris.



Review of the HHC and POC dated 12/27/17 through 2/24/18 revealed a physician's order for the following blood sugar range, "CBG (capillary blood glucose) range is 60 mg/dl (milligrams per deciliter) to 200 mg/dl.



Review of the SN Visit Note Report dated 1/29/18 revealed a documented blood sugar of "285."



Further review of the SN Visit Note Report dated 1/29/18 revealed no documentation the physician was notified of the blood sugar above 200 mg/dl.



Review of the SN Visit Note Report dated 2/6/18 revealed a documented blood sugar of "229."



Further review of the SN Visit Note Report dated 2/6/18 revealed no documentation the physician was notified of the blood sugar above 200 mg/dl.



Review of the SN Visit Note Report dated 2/15/18 revealed a documented blood sugar of "208."



Further review of the SN Visit Note Report dated 2/15/18 revealed no documentation the physician was notified of the blood sugar above 200 mg/dl.



Review of the SN Visit Note Report dated 2/22/18 revealed a documented blood sugar of "241."



Further review of the SN Visit Note Report dated 2/22/18 revealed no documentation the physician was notified of the blood sugar above 200 mg/dl.



Review of the TIF (Transfer to Inpatient Facility) Visit Note Report dated 2/27/18 revealed documentation the patient was transferred to the hospital on 2/26/18 with the reason for hospitalization documented as, "...Respiratory Infection..." and "...Hypo/hyperglycemia (low/high blood sugar), Diabetes out of control."



Further review of the TIF Visit Note Report dated 2/27/18 revealed documentation of the last home visit as "2/22/18."



An interview was conducted on 12/6/18 at 8:08 AM with EI # 1, who confirmed the previous findings.



3. MR # 4 was admitted to the agency on 8/21/17 with diagnoses of Dorsalgia, Unspecified and Noninfective Gastroenteritis and Colitis, Unspecified.



Review of the Physician Order dated 10/24/17 revealed a physician's order for, "...PT to eval (evaluate) week of 10/29/17 per husbands request for touch down wt (weight) bearing..." following a Sacroiliac Fusion on 10/23/17.



Review of the Client Coordination Note Report dated 11/6/17 revealed a missed PT visit on 11/3/17.



Review of the Physician Order dated 11/7/17 revealed a physician's order to reschedule PT evaluation to the week of 11/5/17.



Review of the PT Visit Note Report(s) for the evaluation visit dated 11/7/17 through the PT discharge visit dated 11/30/17, revealed no documentation the patient's touch down wt bearing was evaluated, the patient and/or caregiver was provided education on touch down wt bearing, or a demonstration was provided by the patient of touch down wt bearing to ensure the patient's competency with touch down wt bearing.



An interview was conducted on 12/6/18 at 8:06 AM with EI # 1, who confirmed there was no documentation of the patient's touch down wt bearing status being evaluated or instructed by the PT during the PT visits.



4. MR # 3 was admitted to the agency on 12/9/17 with admitting diagnoses of Urinary Tract Infection, Site Not Specified, Muscle Weakness, Generalized.



Review of the Resumption of Care ( ROC) dated 1/22/18 revealed the following physician orders: " Skilled Nurse to obtain O2 (Oxygen) sat (saturation) on room air via pulse oximeter every visit..."



Review of the SN visit notes dated 1/23/18, 1/24/18, 1/25/18 and 1/29/18 revealed no documentation an O2 sat was performed per the physician's order.



An interview was conducted on 12/6/18 at 8:50 AM with EI # 1 who confirmed the above mentioned findings.



5. MR # 5 was admitted to the agency on 10/13/18 with admitting diagnoses of Malignant Neoplasm of Pancreases, Unspecified and Primary Generalized (Osteo) Arthritis.



Review of the HHC and POC dated 10/13/18 revealed a physician's order for the SN to obtain a weight every visit and notify RN (Registered Nurse) / MD (Medical Doctor) of weight gain or loss of 5 lbs (pounds) within 7 days.



Review of the SN visit notes dated 11/1/18 and 11/9/18 revealed no documentation a weight was performed.



An interview was conducted on 12/6/18 at 8:45 AM with EI # 1 who confirmed the above mentioned findings.



6. MR # 2 was admitted to the agency on 3/8/18 with diagnoses including Hypertensive Chronic Kidney Disease (CKD), Type 2 Diabetes Mellitus with CKD, CKD Stage 4 (Severe) and Long Term Use of Insulin.



Review of the HHC and POC dated 3/8/18 to 5/6/18 revealed physician orders for the patient's CBG testing to be completed 4 times a day with ranges between 70 ml/dl to 250 ml/dl and for the SN to assess CBG every visit and notify the physician if outside parameters.



Review of the SN Visit Note documentation dated 3/10/18 revealed this was a "Diabetes Phone Visit" conducted by the Licensed Practical Nurse (LPN) which revealed the LPN documented the patient's CGB was 303 that morning. There was no documentation the LPN notified the Registered Nurse (RN) and/or physician of the patient's CBG outside of the physician ordered parameters.



Review of the SN Visit Note Report dated 3/12/18 revealed no documentation the nurse assessed the patient's CBG.



An interview was conducted on 12/6/18 at 8:38 AM with EI # 1, who verified the above findings.
G0590 Promptly alert relevant physician of changes
CFR(s): 484.60(c)(1)

The HHA must promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.


This ELEMENT is not met as evidenced by:
Based on review of agency policy, medical records (MR) and interviews with agency staff, it was determined the agency staff failed to notify the physician of changes in patients' conditions including edema, hyperglycemia and unrelieved pain outside the specified parameters. This affected 3 of 11 MRs reviewed, including MR # 2, Home Visit (HV) # 4 and HV # 5 and had the potential to affect all patients admitted to this home health agency.



Findings include:



Agency Policy: Coordination of Care, From Admit through Discharge

Effective Date: 05/01/99

Revised date: 01/01/18

Policy Number: 2.1.017



Purpose:

To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge.



Policy:

The agency provides care and services within an integrated continuum of care system. This is accomplished by:

Identifying patient needs through assessment and communication with other health care providers...



Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge.



Procedure:



... 4. Coordination of care with physician:

At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician:



a. When changes occur in the patient's condition or response to treatment...



1. MR # 2 was admitted to the agency on 3/8/18 with diagnoses including Hypertensive Chronic Kidney Disease (CKD), Type 2 Diabetes Mellitus with CKD, CKD Stage 4 (Severe) and Long Term Use of Insulin.



Review of the SN (skilled nurse) Visit Note Report dated 3/8/18 revealed the nurse documented the patient had 2+ pitting edema to bilateral lower extremities. There was no documentation the nurse notified the physician of the 2+ pitting edema.



An interview was conducted on 12/6/18 at 8:38 AM with Employee Identifier (EI) # 1, Director of Nursing who verified the above findings.



2. HV # 4 was admitted to the agency on 11/23/18 with admitting diagnoses of Laceration Without Foreign Body, Left Lower Leg, Subsequent Encounter and Type 2 Diabetes Mellitus Without Specified Complications.



Review of the HHC (Home Health Certification) and POC (Plan of Care) dated 11/23/18 revealed the following orders: ...Skilled nurse to notify MD of pain level of 7 or higher on a 0 to 10 pain scale. Licensed professional to report vital signs falling out of the following established parameters: ...Pain greater then 7...



Review of the Physical Therapist (PT) visit notes dated 11/23/18, 11/28/18 and 12/4/18 revealed the patient rated his/her pain level a 7 out of 10 on the pain scale. Further review of the visit note revealed no documentation by the PT the physican was notified of the patient pain level.



Review of the Occupational Therapist (OT) visit note dated 12/4/18 revealed the patient rated his/her pain a 7 out of 10 on the pain scale. Further review revealed no documentation by the OT the physician was notified.



An interview was conducted on 12/6/18 at 8:40 AM with EI # 1 who confirmed the above mentioned findings.



3. HV # 5 was admitted to the agency on 11/2/18 with diagnosis of Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side.



Review of the HHC and POC dated 11/2/18 through 12/31/18 revealed the following physician order, 'Licensed Professional to report vital signs falling outside the following established parameters: ...Pain > (greater than) 3..." on a 1 (minimal) to 10 (severe) pain scale.



Review of the Occupational Therapy (OT) Visit Note Report dated 11/5/18 revealed documentation the patient reported a pain scale rating of "5."



Further review of the OT Visit Note Report dated 11/5/18 revealed no documentation the physician was notified of the pain scale > 3.



Review of the SN Visit Note Report dated 11/19/18 revealed documentation the patient reported a pain scale rating of "10."



Further review of the SN Visit Note Report dated 11/19/18 revealed the pain scale was repeated and patient reported a pain scale rating of "8."



Further review of the SN Visit Note Report dated 11/19/18 revealed no documentation the physician was notified of the pain scale > 3.



An interview was conducted on 12/6/18 at 8:11 AM with EI # 1, who confirmed the previous findings.
G0606 Integrate all services
CFR(s): 484.60(d)(3)

Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines.


This ELEMENT is not met as evidenced by:
Based on medical record (MR) reviews, agency policy and procedure and interviews, it was determined the agency staff failed to ensure all initial evaluations were completed to meet patient needs and according to agency policy. This included physical therapy (PT) services and affected MR # 4 which was 1 of 10 records reviewed with therapy.



This had the potential to affect all patients who received therapy services.



Findings include:



Policy: Patient Assessment, Initial and Reassessment

Policy Number: 2.1.002

Revised Date: 10/1/18



"Purpose: To describe the process of patient assessments



...Procedure:



3...

c. Physical Therapist, .... may make initial evaluations of the patient status to determine the need for specific therapies. This initial discipline specific evaluation(s) will occur within 5 days from the referral or sooner if medically necessary..."



1. MR # 4 was admitted to the agency on 8/21/17 with diagnoses of Dorsalgia, Unspecified and Noninfective Gastroenteritis and Colitis, Unspecified.



Review of the Physician Order dated 10/24/17 revealed a physician's order for, "...PT to eval (evaluate) week of 10/29/17 per husbands request for touch down wt (weight) bearing..." following a Sacroiliac Fusion on 10/23/17.



Review of the Client Coordination Note Report dated 11/6/17 revealed PT documentation of a missed PT Visit on 11/3/17 with reason documented as "no answer door/phone."



Further record review revealed no documentation the PT attempted an evaluation visit within the 5 days period or communicated with MR # 4 regarding delay in PT services.



Review of the PT evaluation Visit Note Report revealed the PT evaluation was completed and PT plan of care established on 11/7/17, which was 14 days following the physician's order.



An interview was conducted on 12/6/18 at 8:06 AM with EI # 1, RN (Registered Nurse) Director of Nursing, who verbalized there was "no documentation of why the evaluation was not attempted prior" and "We (agency) should do it within 5 days of the order."
G0716 Preparing clinical notes
CFR(s): 484.75(b)(6)

Preparing clinical notes;


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), agency policies and procedures and interviews with the staff it was determined the agency failed to ensure:



1. Wound vac ( negative pressure wound therapy) was performed per agency policy.



2. All documentation within the MR by the staff was consistent and documented according to the patients condition.



This affected 3 of 11 MR's reviewed and did affect MR # 3, Home Visit (HV) # 4, HV # 1 and and had the potential to negatively affect all patients served by the agency.



Findings include:



Policy: Negative Pressure Wound Therapy (NPWT)

Policy Number: 2.2007

Revised Date: 9/1/17



Purpose:

To promote wound healing and establish competency assessment guidelines with utilizing negative pressure wound therapy.



Policy:



The RN (registered nurse) performs a wound assessment at least once a week during therapy...



Procedure:



4. The clinician will document the number of foam/sponge pieces placed in the wound bed and the number of foam/sponge pieces removed from the wound...



Policy: Coordination of Care, From Admit Through Discharge

Policy Number: 2.1.017

Revised Date: 1/1/18



Purpose:



To establish processes and criteria so that the coordination of patient care will be optimal from admit to discharge.



Policy:



The agency provides care and services within an integrated continuum of care system. This is accomplished by:



Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge.



Procedure:



5. Coordination of care among disciplines:



Patient care is coordinated among various disciplines and services through care planning process to ensure continuity of care from admission to discharge...



i. ...Report will include:

Significant changes in the patient's condition...



1. MR # 3 was admitted to the agency on 12/9/17 with admitting diagnoses of Urinary Tract Infection, Site Not Specified, Muscle Weakness, Generalized.



Review of the SN (skilled nurse) visit note dated 2/15/18 revealed under the respiratory section of the note the nurse documented the patient had abnormal breath sounds to the left lower lobe and the right lower lobe of the lungs consisting of crackles. Further review of the SN visit note revealed under Care Coordination the SN documented the RN (Registered Nurse) was notified of "vital signs within normal limits and lungs clear to auscultation bilaterally..."



Review of the MR revealed there was conflicting documentation of the the breath sounds to the left and right lower lobes during the assessment.



An interview was conducted with Employee Identifier (EI) # 1 Registered Nurse (RN) Director of Nursing, who confirmed the above mentioned findings.



2. HV # 4 was admitted to the agency on 11/23/18 with admitting diagnoses of Laceration Without Foreign Body, Left Lower Leg, Subsequent Encounter and Type 2 Diabetes Mellitus Without Specified Complications.



Review of the SN visit notes dated 11/23/18 and 11/30/18 revealed the patient had a wound vac and the SN performed wound care during the visit. Further review of the visit note revealed the nurse failed to document the number of black foam pieces applied to the wound bed.



Review of the SN visit note dated 11/28/18 revealed the nurse failed to document the amount of black foam pieces removed from the wound bed and applied to the wound bed.



An interview was conducted on 12/6/18 with EI # 1 who confirmed the above mentioned findings.



3. HV # 1 was admitted to the agency on 9/26/18 with Cellulitis of Left Lower Limb, Venous Insufficiency (Chronic) (Peripheral), Non-pressure Chronic Ulcer of Left Calf with Fat Layer Exposed, Acute Embolism and Thrombosis of Left Popliteal Vein, Morbid Obesity and History of Falling.



Review of the SN Visit Note Report dated 9/26/18 revealed the SN documented there were 5 sutures to the incision site of the port located at the RIGHT anterior chest. Further review of the SN Visit Note Report dated 9/26/18 revealed the nurse documented incision site was closed with 4 sutures.



Review of the SN Visit Note Report dated 9/30/18 revealed the SN documented there were 4 sutures to the incision site of the port located at the RIGHT chest.



Review of the SN Visit Note Report dated 10/2/18 revealed the SN documented there were no sutures to the incision site of the port located at the RIGHT anterior chest.



Review of the SN Visit Note Reports dated 10/8/18 and 10/16/18 revealed the nurse documented in the wound assessment section of the note there were sutures (this portion of the note does not indicate the number of sutures) to the RIGHT subclavian surgical incision.



Review of the SN Visit Note Report dated 10/22/18 revealed the nurse documented there were 5 sutures to the incision site of the port located to the LEFT anterior chest below clavicle. Further review of the SN Visit Note Report dated 10/22/18 revealed the SN documented in the wound assessment section of the note there were sutures (this portion of the note does not indicate the number of sutures) to the RIGHT subclavian surgical incision.



Review of the SN Visit Note Report dated 10/30/18 revealed the SN documented in the wound assessment section of the note the surgical incision to the RIGHT subclavian was healed.



Review of the MR revealed there was conflicting documentation related to the number of sutures and the location of the surgical incision (left or right subclavian).



An interview was conducted on 12/6/18 at 8:26 AM with EI # 1 who verified the above findings.
G0808 Onsite supervisory visit every 14 days
CFR(s): 484.80(h)(1)(i)

If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in ยง484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR) agency policy and procedure and interviews with the staff it was determined the agency failed to ensure aide supervisory visits were conducted according to agency policy once ever 14 days. This affected MR # 5, 1 of 1 MR's with Home Health Aides (HHA) and had the potential to negatively affect all patients who receive HHA services by the agency.



Findings include:



Policy: Home Health Aide Supervision

Policy Number: 6.007

Revised Date: 4/1/18



Policy:



The Registered Nurse and/or Qualified Therapist, as appropriate, will supervise the Home Health Aides according to State and Federal Conditions of Participation to ensure the quality and appropriateness of the home health aides service.



Procedure:

...These visits are made according to specific state guidelines below:

Alabama: At least every 14 days, with or without aide present...



1. MR # 5 was admitted to the agency on 10/13/18 with admitting diagnoses of Malignant Neoplasm of Pancreases, Unspecified and Primary Generalized (Osteo) Arthritis.



Review of the Home Health Certification and Plan of Care dated 10/13/18 revealed the Home Health Aide was to visit 1 time a week for 1 week then 1 time every 2 week for 4 weeks and to start 10/21/18.



Review of the Skilled Nurse (SN) visit notes dated 10/26/18, 11/1/18 and 11/9/18 revealed no documentation the SN performed an aide supervisory visit on any of the mentioned dates. Further review revealed the first aide supervisory visit was conducted on 11/15/18 which was 21 days after the start of care by the aide.



An interview was conducted on 12/6/18 at 8:45 AM with Employee Identifier # 1, Registered Nurse, Director of Nursing, who confirmed the above mentioned findings.