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)
G0580 Only as ordered by a physician
CFR(s): 484.60(b)(1)

Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner.


This ELEMENT is not met as evidenced by:
Based on Medical Record (MR) review, agency policy and procedure and staff interview it was determined the agency failed to ensure the Skilled Nurse performed wound care only as ordered by a signed physician order.



This deficient practice did affect 1 of 6 MRs reviewed with wounds, including MR # 7 and had the potential to negatively affect all patient's served by the agency with wounds.




Findings Include:




Agency Policy: Wound Assessment, Documentation and Photography




Policy Number: 2.2.001




Revised Date: 12/1/21




Procedure:




...3. Document the following in the medical record:




...i. Exact wound care performed, following physician orders.




4. Redress the wound using appropriate wound care dressing procedure following physician orders...








1. 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 Home Health Certification and Plan Of Care dated 10/22/21 to 12/20/21 revealed orders for the Skilled Nurse (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.




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 documented as not sent to the physician for signature.




Review of 5 of 5 SN Visit Note Reports (VNR) dated from 10/26/21 to 11/27/21 revealed documentation the sacral foam dressing was applied to wounds # 1, # 2, # 3, # 4, # 5 and # 6 without a signed physician order.




Review of the SN VNR's dated 11/30/21 and 12/7/21 revealed documentation the sacral foam dressing was applied to wound # 1 without a signed physician order.




An interview was conducted on 6/16/22 at 1:55 PM with Employee Identifier # 9, Patient Care Manager, who confirmed there was no documentation the order dated10/26/21 was sent to the physician for signature.