| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017016 | (X3) Date Survey Completed 06/18/2025 |
| 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 medical record (MR) review, agency policy and procedure, and interviews it was determined the agency failed to ensure the provider was notified of significant changes in the patient condition and environment. This deficient practice affected one of eight MR's reviewed with Diabetes including MR # 1, and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised: 9/1/24 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge... Procedure: 4. Coordination of care with physician: ...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... b. When changes occur in caregiver support or the environment that affect patient treatment. In the event that a physician cannot be reached to communicate the status of a patient the following will occur: Medical Director and/or Supervisor will be contacted for assistance with contacting physician... 1. MR # 1 was admitted to the agency on 8/13/24 with diagnoses including Essential (Primary) Hypertension and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/13/24 to 10/11/24 revealed orders for a skilled nurse (SN) frequency once a week for seven weeks, patient/caregiver to perform blood glucose testing daily with a therapeutic blood sugar range of 70 to 200, and to report vital signs, including a fasting blood sugar above 175 or random blood sugar above 225, outside of established parameters. Further review of the HHC and POC dated 8/13/24 to 10/11/24 revealed Lispro insulin 20 Units daily and Lantus Solostar insulin 30 Units twice daily was ordered for the patient. Review of the SN visit note report (VNR) dated 9/18/24 revealed the patient reported a blood sugar of 360 and the patient had not been taking the ordered insulin three times a day as ordered. There was no documentation the physician was notified of the patient's blood sugar and noncompliance with insulin. Review of the SN VNR dated 9/25/24 revealed the patient now lived alone, had several unused insulin bottles in the refrigerator, and the patient was unable to successfully administer insulin after education by the SN. There was no documentation the physician was notified of the change in the patient's living situation and inability to administer insulin due to the change in the living situation. An interview was conducted on 6/18/25 at 9:16 AM with Employee Identifier (EI) # 2, Patient Care Manger, who confirmed there was no documentation the physician was notified of significant changes in the patient condition and environment. |