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 017009 (X3) Date Survey Completed 04/26/2018
Name of Provider or Supplier Eh Health Home Health Of Birmingham, Llc Street Address, City, State 1 Chase Corporate Drive, Suite 210 A, Hoover, 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)
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 reviews of the medical record (MR) and interview with agency administrative staff, it was determined the RN (Registered Nurse) failed to perform supervisory aide service no less than 14 days.



This affected 1 to 3 patients with home health aide services including MR # 4 and had the potential to negatively affect all patients served by the home health agency.



Findings include:



1. MR # 4 was admitted to home health on 12/4/17 with the diagnoses including Pressure Ulcer of Right Buttock, Stage III and Hypertensive Chronic Kidney Disease, Stage I - IV.



Review of the HHC and POC dated 12/4/17 to 2/1/18 revealed the discipline visit frequencies: Home Health Aide (HHA) effective 12/10/17 at 2x for 3 wks and 1x for 3 wks;.



Review of the Skilled Nurse (SN) Visit note 4/25/18 revealed no documentation a SVA (Supervisory Visit, Aide ) was performed the week of 1/7/18.



An interview was conducted on 4/26/18 at 9:00 AM with Employee Identifier (EI) #1, Branch Manager (BM) who confirmed the aforementioned findings.