Statement of Deficiencies

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)

G0606

Integrate all services
CFR(s): 484.60(d)(3)

Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines.

This ELEMENT is not met as evidenced by:
Based on medical record (MR) reviews, agency policy and procedure and interviews, it was determined the agency staff failed to ensure all initial evaluations were completed to meet patient needs and according to agency policy. This included physical therapy (PT) services and affected MR # 4 which was 1 of 10 records reviewed with therapy.

This had the potential to affect all patients who received therapy services.

Findings include:

Policy: Patient Assessment, Initial and Reassessment

Policy Number: 2.1.002

Revised Date: 10/1/18

"Purpose: To describe the process of patient assessments

...Procedure:

3...

c. Physical Therapist, .... may make initial evaluations of the patient status to determine the need for specific therapies. This initial discipline specific evaluation(s) will occur within 5 days from the referral or sooner if medically necessary..."

1. 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 PT documentation of a missed PT Visit on 11/3/17 with reason documented as "no answer door/phone."

Further record review revealed no documentation the PT attempted an evaluation visit within the 5 days period or communicated with MR # 4 regarding delay in PT services.

Review of the PT evaluation Visit Note Report revealed the PT evaluation was completed and PT plan of care established on 11/7/17, which was 14 days following the physician's order.

An interview was conducted on 12/6/18 at 8:06 AM with EI # 1, RN (Registered Nurse) Director of Nursing, who verbalized there was "no documentation of why the evaluation was not attempted prior" and "We (agency) should do it within 5 days of the order."