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 06/16/2022
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 or allowed practitioner orders.


This STANDARD is not met as evidenced by:
Based on Medical Record (MR) review, and staff interview it was determined the agency failed to ensure the staff was in conformance with physician orders for:



1. Wound care




2. Daily Weights every visit




3. Administration of Midodrine twice daily and as needed for blood pressure less then 120 systolic.



This deficient practice did affect 3 of 13 MRs reviewed, including Home Visit (HV) # 4, MR # 7, HV # 1 and had the potential to negatively affect all patient's served by the agency.








3. HV # 1 was admitted to the agency on 4/28/22 with admitting diagnoses of Abscess of Lung Without Pneumonia and Paroxysmal Arterial Fibrillation.




Review of the HHC and POC dated 4/28/22 revealed an order to instruct patient/caregiver on importance of obtaining weight and keeping a weight log at same time every day. SN to assess weight log each SN visit. Report to MD a weight loss 5 lbs. or greater over one week.




Review of the HHC and POC dated 4/28/22 revealed the SN to visit 2 times a week for 2 weeks and then 1 time a week for 7 weeks. Physical Therapy (PT) to visit 1 time a week for 1 week then 2 times a week for 4 weeks beginning 5/1/22. Beginning 5/29/22 Physical Therapy to visit 2 times a week for 1 week then 1 time a week for 3 weeks.




Review of the physician order dated 4/29/22 revealed an order for Midodrine 10 mg (milligrams) 1 tablet 2 times daily as needed for hypotension. Only take if blood pressure is less than 120 systolic.




Review of the SN visit note dated 4/29/22 revealed no documentation of a daily weight. Further review revealed in the interventions under obtain weight this visit the SN documented weight obtained , see results in vital signs (VS). Review of the VS area revealed no documentation of a weight.




Review of the SN visit note dated 5/2/22 revealed no documentation of a daily weight. Further review revealed in the interventions under obtain weight this visit the SN documented weight obtained , see results in vital signs. Review of the VS area revealed no documentation of a weight.




Review of the physical therapy visit notes dated 5/17/22 to 6/8/22 revealed the following patient blood pressures:




5/17/22 - 98/60




5/19/22 - 98/60




5/25/22 - 78/50




6/3/22 - 98/62




6/8/22 - 92/52




Review of the PT and PTA (Physical Therapy Assistant) notes dated 5/17/22, 5/19/22, 5/25/22, 6/3/22 and 6/8/22 revealed the patient's blood pressure was below the parameters of 120 systolic and should have taken the Midodrine as ordered per the MD. Further review of the PT and PTA visit notes dated 5/17/22, 5/19/22, 6/3/22 and 6/8/22 revealed no documentation by the therapist the patient had taken the Midodrine as ordered by the physician and no documentation the SN or the physician was notified of the low blood pressure.




Review of the therapy note dated 5/25/22 revealed the therapist notified the SN by voice mail and no follow up documentation the nurse received the notification and the physician was notified.




An interview was conducted on 6/16/22 at 2:30 PM with EI # 2, PCM, who confirmed the nurse failed to document the daily weights per the MD orders and the therapists failed to document if the patient was instructed to take the Midodrine as ordered per the physician orders and failed to document follow up with the SN or notification of the MD.




1. HV # 4 was admitted to the agency on 5/11/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Heart Disease with Heart Failure and Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/11/22 to 7/9/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week (1wk1), twice a week for 1 week (2wk1) then once a week for 7 weeks (1wk7).




Review of the Physician Order dated 5/31/22 revealed an order for "SN to cleanse new open areas to left lower leg with NS (Normal Saline) and pat dry with clean dry gauze. Apply Xeroform to open areas and wrap with kerlix and secure with tape during SN visit on 5/31/22..." as ordered.



Review of the SN Visit Note Report (VNR) dated 5/31/22 revealed no documentation wound care was provided to "...3 new open areas...to left lower leg..."



An interview was conducted on 6/16/22 at 2:17 PM with Employee Identifier (EI) # 2, Patient Care Manager (PCM), who confirmed the SN failed to document wound care was provided to the left lower leg wounds on 5/31/22.




2. MR # 7 was admitted to the agency on 8/23/21 and recertified for continued care from 10/22/21 to 12/20/21 with diagnoses including Other Intervertebral Disc Degeneration, Lumbosacral Region, Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris, Heart Failure, Unspecified and Chronic Obstructive Pulmonary Disease, Unspecified.




Review of the HHC and POC dated 10/22/21 to 12/20/21 revealed a SN frequency of once a week for 8 weeks and orders for the following:




a. SN to perform/instruct reinforce wound care to the # 1 Coccyx, Pressure Ulcer Stage III, # 2 upper buttock, pressure ulcer stage II, # 3 left lower buttock pressure ulcer stage II, # 4 Coccyx pressure ulcer stage II, # 5 right upper buttock pressure ulcer stage II and # 6 right lower buttock pressure ulcer stage II twice weekly by cleaning with vashe and sterile gauze, pat dry with sterile gauze, apply polymem to wound bed and secure with mefix tape.




b. SN to obtain weight every visit and notify the Registered Nurse/ Medical Doctor (MD) of weight gain or loss of 2 pounds (lbs) overnight or 5 lbs in one week.




Review of the SN VNR's dated 10/26/21, 11/1/21, and 11/9/21 revealed no documentation the SN obtained the patient's weight.




Review of the Physician Order dated 10/26/21 revealed documentation the "SN may use sacral foam border dressing until polymem in home...", which was not signed by the physician and was documented as not sent to the physician for signature.




Review of the SN VNR's dated 10/26/21 and 11/1/21 revealed documentation a sacral foam dressing was applied to wounds # 1, # 2, # 3, # 4, # 5 and # 6 instead of the ordered Polymem.




Review of the Supply Requisition Report dated 11/1/21 revealed documentation the Polymem was ordered for the patient's wound care.




Review of the Client Coordination Note Report dated 11/6/21 revealed documentation the Polymem was delivered to the patient's home "side door" on 11/4/21.




Review of the SN VNR's dated 11/16/21 and 11/27/21 revealed documentation a sacral foam dressing was applied to wounds # 1, # 2, # 3, # 4, # 5 and # 6 instead of the ordered and delivered Polymem.




Review of the SN VNR's dated 11/30/21 and 12/7/21 revealed documentation a sacral foam dressing was applied to wound # 1 instead of the ordered and delivered Polymem.




An interview was conducted on 6/16/22 at 1:55 PM with EI # 9, PCM, who confirmed there was no documentation the SN obtained the patient's weight on the above dates, the Polymem was reported as delivered on 11/6/21 per the agency documentation and the SN failed to use the ordered Polymem for the patient's wound care on the above dates.