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)
G0714 Patient and caregiver education
CFR(s): 484.75(b)(5)

Patient and caregiver education;


This ELEMENT is not met as evidenced by:
Based on agency policy and procedure, medical record (MR) review and interviews it was determined the agency failed to ensure patients / caregivers were provided education and/or a return demonstration was obtained to ensure competency of wound care and disease processes per the physician order.




This affected 2 of 13 records including Home Visit (HV) # 2 and MR # 7 and had the potential to affect all patients served by the agency.




Findings include:

Agency Policy: Patient Education




Policy Number: 3.001




Revised Date: 11/01/17




Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety.




Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety...




Procedure:




…3. The patient and caregiver receive ongoing information specific to the identified needs...




…b. Patient/caregiver plan of care responsibilities




…7. Using the progress/visit note, the clinician documents the level of patient/caregiver comprehension, patient/caregiver return demonstration of skill(s) taught, compliance and any follow-up with team members...


1. 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 Home Health Certification (HHC) and Plan Of Care (POC) dated 5/16/22 to 7/14/22 revealed a Skilled Nurse (SN) frequency of 2wk1 (twice a week for one week) then 1wk8 (once a week for 8 weeks) and an order for "SN to instruct on Hypertension to include disease process, signs and symptoms, complications, and management."




Review of the SN VNR dated 5/25/22 revealed documentation the "SN instructed patient on role patient and caregiver has in the Hypertension POC..." There was no documentation of the specific education the SN provided the patient and caregiver on Hypertension.




An interview was conducted on 6/16/22 at 1:48 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation of the specific education the SN provided the patient and caregiver on Hypertension.




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 orders for "SN to provide instructions on Chronic Obstructive Pulmonary Disease (COPD) to include disease process, signs and symptoms, complications, and management."




Review of the SN VNR dated 12/1/21 revealed documentation the SN "instructed patient/caregiver on signs/symptoms of acute exacerbation of COPD and when to call home health nurse/physician or emergency personnel." There was no documentation the SN instructed the patient and/or caregiver on the COPD disease process, complications and management of COPD and of the specific signs and symptoms of COPD the SN educated the patient and/or caregiver on at the visit.




Review of the SN VNR's from 12/1/21 to 12/20/21 revealed no documentation the SN instructed the patient and/or caregiver on the COPD disease process, complications and management of COPD.




An interview was conducted on 6/16/22 at 1:55 PM with EI # 9, PCM, who confirmed there was no documentation the SN instructed the patient and/or caregiver on the COPD disease process, complications and management of COPD and of the specific signs and symptoms of COPD the SN educated the patient and/or caregiver on at the visit on 12/1/21.