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 06/18/2025
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)
E0000 A recertification survey was conducted on 6/16/25 to 6/18/25 at Southeast Alabama Homecare. Southeast Alabama Homecare was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.
G0000 A recertification survey was conducted on 6/16/25 to 6/18/25 at Southeast Alabama Homecare. Standard level deficiencies were cited and will require a plan of correction.
G0564 Discharge or Transfer Summary Content
CFR(s): 484.58(b)(1)

Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care.


This STANDARD is not met as evidenced by:
Based on review of medical records (MR), agency policy and procedure, and interview with staff, it was determined the agency failed to ensure discharged patients medical information, and treatment preferences were sent to the health care practitioner for transition of care.

This deficient practice affected one of one patients reviewed with discharge to palliative care including MR # 3 and had the potential to negatively affect all patients referred for transition of care.

Findings include:

Policy Number: 2.1.017

Revised: 9/1/24

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.

Procedure: ...during time of ...discharge from the agency:

...3. a. Patients are referred to alternative agencies when the patient requires services that are unable to be met by the agency and/or for continuing needs.

 


1.MR # 3 was admitted on 8/12/24 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, and Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified.

Review of the Client Coordination Note Report dated 10/2/24 revealed the patient's caregiver requested to have patient evaluated by palliative care.

Further review of the Visit Note Report dated 10/2/24 revealed the Patient Care Manager and MD were notified of need for palliative care evaluation.

An interview was conducted on 6/18/25 at 10:30 AM with Employee Identifier # 1, Executive Director who confirmed there was no follow-up with palliative care after discharge.

 

 

 
G0580 Only as ordered by a physician
CFR(s): 484.60(b)(1)

Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner.


This ELEMENT is not met as evidenced by:
Based on review of Medical Records (MR) and staff interview the agency failed to follow physician orders for wound care.  

This deficient practice did affect one of four MRs reviewed with wounds, including MR # 2, and had the potential to negatively affect all patients with wounds served by the agency. 

Findings include: 


1. MR # 2 was admitted to the agency on 6/19/24 and recertified for continued care from 8/18/24 to 10/16/24 with diagnoses including Infection of Amputation Stump, Right Lower Extremity and Pressure Ulcer of Other Site, Stage 2.  

Review of the Physician Order dated 8/21/24 revealed orders to irrigate the right 3rd toe, wound # 3, with vashe (Brand of wound cleanser), cover with vashe moistened gauze, wrap foot with rolled gauze, then wrap with electric matrix wrap daily. Patient or caregiver to perform wound care once Skilled Nurse (SN) had observed a return demonstration of the wound care.  

Review of five of five SN visits dated 8/22/24 to 9/2/24 revealed the SN failed to performed wound care to wound # 3 per the physician's order and there was no documentation the patient and/or caregiver was provided education on the wound care. 

An interview was conducted on 6/18/25 at 9:40 AM with Employee Identifier # 2, Patient Care Manager, who confirmed wound care was not provided to wound # 3 per the physician's order. 
G0590 Promptly alert relevant physician of changes
CFR(s): 484.60(c)(1)

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


This ELEMENT is not met as evidenced by:
Based on medical record (MR) review, agency policy and procedure, and interviews it was determined the agency failed to ensure the provider was notified of significant changes in the patient condition and environment. 

This deficient practice affected one of eight MR's reviewed with Diabetes including MR # 1, and had the potential to negatively affect all patients admitted to this agency. 

Findings include:

Agency Policy: Coordination of Care, From Admit Through Discharge

Policy Number: 2.1.017

Revised: 9/1/24

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

Procedure: 

4. Coordination of care with physician:

...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...

b. When changes occur in caregiver support or the environment that affect patient treatment. 

In the event that a physician cannot be reached to communicate the status of a patient the following will occur:

Medical Director and/or Supervisor will be contacted for assistance with contacting physician...


1. MR # 1 was admitted to the agency on 8/13/24 with diagnoses including Essential (Primary) Hypertension and Type 2 Diabetes Mellitus with Hyperglycemia. 

Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/13/24 to 10/11/24 revealed orders for a skilled nurse (SN) frequency once a week for seven weeks, patient/caregiver to perform blood glucose testing daily with a therapeutic blood sugar range of 70 to 200, and to report vital signs, including a fasting blood sugar above 175 or random blood sugar above 225, outside of established parameters.  

Further review of the HHC and POC dated 8/13/24 to 10/11/24 revealed Lispro insulin 20 Units daily and Lantus Solostar insulin 30 Units twice daily was ordered for the patient. 

Review of the SN visit note report (VNR) dated 9/18/24 revealed the patient reported a blood sugar of 360 and the patient had not been taking the ordered insulin three times a day as ordered. There was no documentation the physician was notified of the patient's blood sugar and noncompliance with insulin. 

Review of the SN VNR dated 9/25/24 revealed the patient now lived alone, had several unused insulin bottles in the refrigerator, and the patient was unable to successfully administer insulin after education by the SN. There was no documentation the physician was notified of the change in the patient's living situation and inability to administer insulin due to the change in the living situation.

An interview was conducted on 6/18/25 at 9:16 AM with Employee Identifier (EI) # 2, Patient Care Manger, who confirmed there was no documentation the physician was notified of significant changes in the patient condition and environment.

 
G0682 Infection Prevention
CFR(s): 484.70(a)

Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.


This STANDARD is not met as evidenced by:
Based on medical records (MR), observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure agency policies and procedures for infection prevention were followed.

This deficient practice affected two of five home visits (HV) reviewed including HV # 1 and HV # 2, and had the potential to negatively affect all patients admitted to this agency.

Findings include:

Agency Policy: Cleaning of Re-Useable Equipment

Policy Number: 8.006

Revised: 6/1/25

Purpose: To ensure equipment required for patient care is clean and sanitized to prevent the spread of infections.

Definition: Semi-Critical Items: Equipment that comes in contact with mucous membranes or non-intact skin...All other semi-critical items will undergo intermediate level disinfection.

Definition: Intermediate-Level Disinfection: destroys vegetative bacteria, mycobacterium tuberculosis and most fungi. it neutralizes most viruses but does not kill bacterial spores.

Agency Policy: Hand Hygiene

Policy Number: 8.004

Revised: 5/1/19

Purpose: To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines.

Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact. Hand hygiene will be performed using soap and water or an alcohol-based hand sanitizer.

Procedure:

1.Staff performs hand hygiene by handwashing with soap and water or using an alcohol based hand sanitizer: 

...f. before and after removal of personal protective equipment (PPE).

...4. When using an alcohol based hand sanitizer, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are day...

Agency Policy: Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters (PICC)

Policy Number: 10.027

Revised: 10/01/16

Purpose: To keep insertion sites clean, stabilize catheters, and minimize the risk of infection. 

Policy: ...Sterility will be maintained throughout this procedure. 

...Procedure: 

...10. Allow solution to air dry completely...

 


2.HV # 2 was admitted to the agency on 5/21/25 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complication, Acute Hematogenous Osteomyelitis, Right Ankle and Foot, and Non-pressure Chronic Ulcer of Other Part of Right Foot with Necrosis of Bone.

A HV was conducted on 6/16/25 at 2:00 PM with EI # 5, Registered Nurse, to observe site care to the Peripherally Inserted Central Catheter (PICC) line. EI # 2, Patient Care Manager, was present during the HV. 

During the HV, EI # 5 failed to perform hand hygiene after removing gloves and donning clean gloves five times, failed to allow hands to dry following performing hand hygiene twice prior to donning clean gloves, and failed to cover all surfaces of the hands and fingers when using hand sanitizer once. 

While cleaning the PICC site with chlorprep, EI # 5 held the PICC line (outside of the sterile dressing site) with the left sterile gloved hand then obtained the stabilizing device and used both hands to place the device on the patient's skin. EI # 5 then obtained the antimicrobial disc, placed the disc around the PICC insertion site then held the disc in place with the left hand. EI # 5 failed to maintain sterility by using the contaminated left handed glove to place and/or hold the stabilizing device and antimicrobial disc. 

An interview was conducted on 6/18/25 at 9:29 AM with EI # 2 who confirmed the staff failed to ensure agency policies and procedures for infection prevention were followed.

 

1.HV # 1 was admitted on 6/13/25 with diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer.

Review of the Home Health Certification and Plan of Care dated 6/13/25 revealed physician's orders for Skilled Nurse (SN) three visits per week for one week, two visits per week for eight weeks, and one visit per week for one week to perform procedure of wound care to wound # 1, left plantar foot ulcer.

A HV was conducted on 6/16/25 with Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN) to observe wound care.

EI # 3 performed hand hygiene, donned gloves, removed soiled bandage from patient's left foot wound with bandage scissors, and placed scissors on dirty side of barrier.

EI # 3 removed gloves, performed hand hygiene, donned gloves, picked up bandage scissors from barrier, cut clean wound dressing, and applied to wound bed on left foot.

EI # 3 failed to cleanse the bandage scissors after removing soiled bandage, and prior to cutting wound dressing.

An interview was conducted on 6/18/25 at 10:25 AM with EI # 1, Executive Director (ED) who confirmed staff failed to follow the agency policy for cleaning of re-useable equipment.
G0706 Interdisciplinary assessment of the patient
CFR(s): 484.75(b)(1)

Ongoing interdisciplinary assessment of the patient;


This ELEMENT is not met as evidenced by:
Based on medical record (MR) review, agency policy, and interview with staff, it was determined the agency failed to ensure:

1.Midline catheter exposed catheter length and arm circumference were measured per the physician order. 

2.Infusion access device site care was performed per the physician order. 

This deficient practice affected one of one MR reviewed with a infusion access device, including Home Visit (HV) # 2, and had the potential to negatively affect all patients served by the agency with a infusion access device. 

 


1.HV # 2 was admitted to the agency on 5/21/25 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complication, Acute Hematogenous Osteomyelitis, Right Ankle and Foot, and Non-pressure Chronic Ulcer of Other Part of Right Foot with Necrosis of Bone.

Review of the Home Health Certification and Plan of Care dated 5/21/25 to 7/19/25 revealed an order for Skilled Nurse (SN) twice weekly for eight weeks then once weekly for one week to perform site care to the infusion access device by cleansing the site with ChloraPrep, allow to dry, apply antimicrobial disc to insertion site, secure with stabilization device, cover with transparent dressing and measure midline catheter length exposed and arm circumference 5 centimeters above the insertion site with each weekly dressing change of the midline catheter.

Review of the SN Visit Note Reports (VNR) dated 5/27/25, 6/2/25, and 6/9/25 revealed site care to the midline catheter was performed. There was no documentation of the exposed catheter length or arm circumference. 

Further review of the SN VNR dated 6/9/25 revealed no documentation of what was used to cleanse the infusion access device site, no documentation of the application of the antimicrobial disc, and no documentation the stabilization device was placed. 

An interview was conducted on 6/18/25 at 9:20 AM with Employee Identifier # 2, Patient Care Manager, who confirmed the midline catheter exposed catheter length and arm circumference were not measured and the infusion access device site care was not performed per the physician order. 
G0714 Patient and caregiver education
CFR(s): 484.75(b)(5)

Patient and caregiver education;


This ELEMENT is not met as evidenced by:
Based on review of the agency policy and procedure, Medical Record (MR), and staff interviews the agency staff failed to provide patient education and/or document the patient or caregiver was able to provide a return demonstration to ensure competency of the following:  

 Urinary Traction infection. Self catheterization procedure. Wound care. Ordered bowel protocol. This did affect four of 13 MR's reviewed including MR # 4, MR # 2, Home Visit (HV) # 2, and HV # 3, and had the potential to affect all patients served by the agency. 

Finding include: 

Agency Policy: Patient Education

Policy Number: 3.001

Revised Date: 11/1/17

Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety. 

Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety. Patients receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency. 

Procedure: 

...3. The patient and caregiver receive ongoing information specific to the identified needs...including: 

...b. Patient/caregiver plan of care responsibilities. 

...6. ...Patients and caregivers receive oral and/or written information on medication education...

7. Using the progress/visit note, the clinician documents...patient/caregiver return demostration of skill(s) taught...

 


1. MR # 4 was admitted to the agency on 9/6/24 with diagnoses including Wernicke's Encephalopathy and Type 2 Diabetes Mellitus with without complications. 

Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 9/6/24 to 11/4/24 revealed orders for a skilled nurse (SN) frequency of weekly for nine weeks to provide instruction associated with knowledge deficits including urinary retention. 

Review of the SN Visit Note Report (VNR) dated 9/6/24 revealed the patient provided a urine specimen to the physician office for suspected UTI (Urinary Tract Infection) and an antibiotic had been ordered following the discontinuation of a catheter. There was no documentation the patient and/or caregiver was provided education on UTI. 

Review of the SN VNR dated 9/9/24 revealed the patient was instructed to perform self catheterization following a physician visit for urinary retention. There was no documentation the patient and/or caregiver was provided education on how to perform self catheterization or a return demonstration to ensure competency. 

Review of the SN VNR dated 9/12/24 revealed the patient was performing a self catheterization nightly without the use of betadine. The SN instructed the caregiver on the proper way to perform a sterile intermittent self catheterization. The SN documented the caregiver reported the patient did have a UTI. There was no documentation the patient and/or caregiver was provided education on UTI. 

Review of the SN VNR dated 9/17/24 revealed there was no documentation the patient and/or caregiver was provided education on UTI and a return demonstration of the self catheterization procedure was obtained to ensure competency. 

Review of the SN VNR dated 9/27/24 revealed the patient was discharged from the agency. 

An interview was conducted on 6/18/25 at 9:36 AM with Employee Identifier (EI) # 2, Patient Care Manager, who confirmed there was no documentation the patient and/or caregiver was provided education on UTI and provided a return demonstration of the self catheterization procedure. 

2. MR # 2 was admitted to the agency on 6/19/24 and recertified for continued care from 8/18/24 to 10/16/24 with diagnoses including Infection of Amputation Stump, Right Lower Extremity and Pressure Ulcer of Other Site, Stage 2.  

Review of the Physician Order dated 8/21/24 revealed orders for the SN twice a week for one week, three times a week for one week, twice a week for six weeks, then once a week for one week to perform or instruct the patient or caregiver on the following new wound care:

a. Irrigate the right 3rd toe, wound # 3, with vashe (Brand of wound cleanser), cover with vashe moistened gauze, wrap foot with rolled gauze, then wrap with electric matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care.  

b. Cover the right 2nd toe, wound # 1, with dry gauze, wrap foot with rolled gauze, then wrap with elastic matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care. 

Review of five of five SN visits dated 8/22/24 to 9/5/24 revealed no documentation the patient and/or caregiver was provided education on the new wound care or provided a return demonstration of the wound care to wounds # 1 and # 3.

Review of the Physician Order dated 9/5/24 revealed orders for the SN to perform or instruct the patient or caregiver on the following new wound care:

a. Irrigate the right 3rd toe, wound # 3, with vashe, cover with Medi honey using a sterile applicator, cover with maxorb AG (silver alginate dressing) wrap foot with rolled gauze, then wrap with electric matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care.  

b. Cover the right 2nd toe, wound # 1, with dry gauze, wrap foot with rolled gauze, then wrap with elastic matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care. 

Review of the Physician Order dated 9/9/24 revealed orders for the SN to perform or instruct the patient or caregiver to irrigate the right 4th toe, wound # 5, with vashe, cover with Medi honey using a sterile applicator, cover with maxorb AG, wrap foot with rolled gauze, then wrap with elastic matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care.  

Review of one of one SN visits dated 9/5/24 to 9/12/24, when patient was transferred to inpatient hospitalization, revealed no documentation the patient and/or caregiver was provided education on the new wound care or provided a return demonstration of the wound care to wounds # 1, # 3, and # 5.

An interview was conducted on 6/18/25 at 9:40 AM with EI # 2 who confirmed there was no documentation the patient and/or caregiver was provided education on the new wound care and/or provided a return demonstration of the wound care to wounds # 1, # 3, and # 5. 

3. HV # 2 was admitted to the agency on 5/21/25 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complication, Acute Hematogenous Osteomyelitis, Right Ankle and Foot, and Non-pressure Chronic Ulcer of Other Part of Right Foot with Necrosis of Bone.

Review of the HHC and POC dated 5/21/25 to 7/19/25 revealed orders for the SN twice weekly for eight weeks then once a week for one week to perform/instruct patient/caregiver to cleanse the right dorsal foot with wound cleanser, pat dry, apply Silvasorb gel, cover with gauze, secure with rolled gauze and tape daily.  

Review of five of five SN VNR's dated 5/21/25 to 6/5/25 revealed no documentation the patient and/or caregiver provided a return demonstration of the wound care to the right dorsal foot.

Review of the Physician Order dated 6/5/24 revealed orders for the SN to perform or instruct the patient or caregiver to cleanse the right dorsal foot with vashe, pat dry, apply drawtex, cover with gauze, and secure with tape three times a week. The patient or caregiver to perform wound care in the absence of the SN. 

Review of two of two SN VNR's dated 6/5/25 to 6/12/25 revealed no documentation the patient and/or caregiver was provided education on the new wound care or provided a return demonstration of the wound care to the right dorsal foot.

An interview was conducted on 6/18/25 at 9:20 AM with EI # 2 who confirmed there was no documentation the patient and/or caregiver was provided education on the wound care and/or provided a return demonstration of the wound care to the right dorsal foot wound. 

4. HV # 3 was admitted to the agency on 5/2/25 with diagnoses including Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety and Rheumatoid Arthritis with Rheumatoid Factor of Left Hand without Organ or Systems Involvement.

Review of the HHC and POC dated 5/2/25 to 6/30/25 revealed orders for SN once weekly for nine weeks and if patient exhibits signs or symptoms of constipation, ensure patient is taking any prescribed medications for condition. If not already prescribed then instruct to initiate 17 grams of MiraLAX daily and/or 15 milligrams of Senna twice daily until normal bowel regime resumes. If normal bowel movements do not resume in 2 days, contact physician for additional orders. 

Review of the SN VNR dated 6/5/25 revealed the patient's last bowel movement was on 6/1/25 and the normal pattern for bowel movements as "greater than 4 days - institute bowel protocol or contact practitioner for further orders as needed." There was no documentation the patient was provided education on the ordered bowel protocol. 

Review of the Medicine List, printed on 6/16/25, revealed no documentation of a medication prescribed for constipation. 

An interview was conducted on 6/18/25 at 9:12 AM with EI # 2 who confirmed there was no documentation the patient and/or caregiver was provided education on the ordered bowel protocol.