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)
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.