| 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) |
| 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. |