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)
G0590 Promptly alert relevant physician of changes
CFR(s): 484.60(c)(1)

The HHA must promptly alert the relevant physician(s) or allowed practitioner(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 Medical Records (MR), agency policy and procedure and interviews it was determined the agency staff failed to notify the physician with changes in:




1. Edema




2. Pain



3. Wound measurements




This deficient practice affected 2 of 5 Home Visits (HV) conducted, including HV # 4 and HV # 2, and had the potential to affect all patients served by the agency.



Findings include:



Agency Policy: Coordination of Care, From Admit through Discharge



Policy Number: 2.1.017



Revised Date: 8/1/19



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...



Procedure:



...4. Coordination of care with physician: At admission, throughout care...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. 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), Physical Therapy (PT) 1wk1, 2wk2, then 1wk2 and physician order for pain above a 6 on a 1-10 scale to be reported to the physician by the Licensed Professional.



Review of the PT Visit Note Report (VNR) dated 5/12/22 revealed documentation the patient reported pain in the right shoulder at a 9 on a 1-10 scale. There was no documentation the PT notified the physician of the patient's pain outside of ordered parameters.



Review of the SN VNR dated 5/16/22 revealed documentation the patient had 2 + pitting edema to the bilateral lower extremities.




Review of the SN VNR dated 5/25/22 revealed documentation the patient had 3 + pitting edema to the Lower Left Extremity, there was no documentation of the Right Lower Extremity. There was no documentation the SN notified the physician of the increased Left Lower Extremity edema from the previous SN visit on 5/16/22.



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 the physician was notified of the increased edema to the Left Lower Extremity on 5/25/22 and the PT failed to notify the physician of increase in pain.




2. HV # 2 was admitted to the agency on 5/16/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris and Essential (Primary) Hypertension.




Review of the HHC and POC dated 5/16/22 to 7/14/22 revealed a SN frequency of 2wk1 then 1wk8.




Review of the SN VNR dated 5/20/22 revealed a new wound to the right Thoracic area due to the chest tube being removed by the physician, which measured 0.5 cm (centimeters) in length, 1.5 cm in width and 0.1 cm in depth.




Review of the SN VNR dated 5/25/22 revealed wound measurement to the right Thoracic wound as 0.5 cm in length, 2.5 cm in width and 0.1 cm in depth, which was a 1.0 cm increase in the width of the wound. There was no documentation the physician was notified of the increased width of the wound.




An interview was conducted with EI # 1, Executive Director, who confirmed there was no documentation the physician was notified of the increased right Thoracic wound width on 5/25/22.