| 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. |