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 06/18/2025
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)
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 review of the agency policy and procedure, Medical Record (MR), and staff interviews the agency staff failed to provide patient education and/or document the patient or caregiver was able to provide a return demonstration to ensure competency of the following:  

 Urinary Traction infection. Self catheterization procedure. Wound care. Ordered bowel protocol. This did affect four of 13 MR's reviewed including MR # 4, MR # 2, Home Visit (HV) # 2, and HV # 3, and had the potential to affect all patients served by the agency. 

Finding include: 

Agency Policy: Patient Education

Policy Number: 3.001

Revised Date: 11/1/17

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. Patients receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency. 

Procedure: 

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

...b. Patient/caregiver plan of care responsibilities. 

...6. ...Patients and caregivers receive oral and/or written information on medication education...

7. Using the progress/visit note, the clinician documents...patient/caregiver return demostration of skill(s) taught...

 


1. MR # 4 was admitted to the agency on 9/6/24 with diagnoses including Wernicke's Encephalopathy and Type 2 Diabetes Mellitus with without complications. 

Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 9/6/24 to 11/4/24 revealed orders for a skilled nurse (SN) frequency of weekly for nine weeks to provide instruction associated with knowledge deficits including urinary retention. 

Review of the SN Visit Note Report (VNR) dated 9/6/24 revealed the patient provided a urine specimen to the physician office for suspected UTI (Urinary Tract Infection) and an antibiotic had been ordered following the discontinuation of a catheter. There was no documentation the patient and/or caregiver was provided education on UTI. 

Review of the SN VNR dated 9/9/24 revealed the patient was instructed to perform self catheterization following a physician visit for urinary retention. There was no documentation the patient and/or caregiver was provided education on how to perform self catheterization or a return demonstration to ensure competency. 

Review of the SN VNR dated 9/12/24 revealed the patient was performing a self catheterization nightly without the use of betadine. The SN instructed the caregiver on the proper way to perform a sterile intermittent self catheterization. The SN documented the caregiver reported the patient did have a UTI. There was no documentation the patient and/or caregiver was provided education on UTI. 

Review of the SN VNR dated 9/17/24 revealed there was no documentation the patient and/or caregiver was provided education on UTI and a return demonstration of the self catheterization procedure was obtained to ensure competency. 

Review of the SN VNR dated 9/27/24 revealed the patient was discharged from the agency. 

An interview was conducted on 6/18/25 at 9:36 AM with Employee Identifier (EI) # 2, Patient Care Manager, who confirmed there was no documentation the patient and/or caregiver was provided education on UTI and provided a return demonstration of the self catheterization procedure. 

2. MR # 2 was admitted to the agency on 6/19/24 and recertified for continued care from 8/18/24 to 10/16/24 with diagnoses including Infection of Amputation Stump, Right Lower Extremity and Pressure Ulcer of Other Site, Stage 2.  

Review of the Physician Order dated 8/21/24 revealed orders for the SN twice a week for one week, three times a week for one week, twice a week for six weeks, then once a week for one week to perform or instruct the patient or caregiver on the following new wound care:

a. Irrigate the right 3rd toe, wound # 3, with vashe (Brand of wound cleanser), cover with vashe moistened gauze, wrap foot with rolled gauze, then wrap with electric matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care.  

b. Cover the right 2nd toe, wound # 1, with dry gauze, wrap foot with rolled gauze, then wrap with elastic matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care. 

Review of five of five SN visits dated 8/22/24 to 9/5/24 revealed no documentation the patient and/or caregiver was provided education on the new wound care or provided a return demonstration of the wound care to wounds # 1 and # 3.

Review of the Physician Order dated 9/5/24 revealed orders for the SN to perform or instruct the patient or caregiver on the following new wound care:

a. Irrigate the right 3rd toe, wound # 3, with vashe, cover with Medi honey using a sterile applicator, cover with maxorb AG (silver alginate dressing) wrap foot with rolled gauze, then wrap with electric matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care.  

b. Cover the right 2nd toe, wound # 1, with dry gauze, wrap foot with rolled gauze, then wrap with elastic matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care. 

Review of the Physician Order dated 9/9/24 revealed orders for the SN to perform or instruct the patient or caregiver to irrigate the right 4th toe, wound # 5, with vashe, cover with Medi honey using a sterile applicator, cover with maxorb AG, wrap foot with rolled gauze, then wrap with elastic matrix wrap daily. Patient or caregiver to perform wound care once SN had observed a return demonstration of the wound care.  

Review of one of one SN visits dated 9/5/24 to 9/12/24, when patient was transferred to inpatient hospitalization, revealed no documentation the patient and/or caregiver was provided education on the new wound care or provided a return demonstration of the wound care to wounds # 1, # 3, and # 5.

An interview was conducted on 6/18/25 at 9:40 AM with EI # 2 who confirmed there was no documentation the patient and/or caregiver was provided education on the new wound care and/or provided a return demonstration of the wound care to wounds # 1, # 3, and # 5. 

3. HV # 2 was admitted to the agency on 5/21/25 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complication, Acute Hematogenous Osteomyelitis, Right Ankle and Foot, and Non-pressure Chronic Ulcer of Other Part of Right Foot with Necrosis of Bone.

Review of the HHC and POC dated 5/21/25 to 7/19/25 revealed orders for the SN twice weekly for eight weeks then once a week for one week to perform/instruct patient/caregiver to cleanse the right dorsal foot with wound cleanser, pat dry, apply Silvasorb gel, cover with gauze, secure with rolled gauze and tape daily.  

Review of five of five SN VNR's dated 5/21/25 to 6/5/25 revealed no documentation the patient and/or caregiver provided a return demonstration of the wound care to the right dorsal foot.

Review of the Physician Order dated 6/5/24 revealed orders for the SN to perform or instruct the patient or caregiver to cleanse the right dorsal foot with vashe, pat dry, apply drawtex, cover with gauze, and secure with tape three times a week. The patient or caregiver to perform wound care in the absence of the SN. 

Review of two of two SN VNR's dated 6/5/25 to 6/12/25 revealed no documentation the patient and/or caregiver was provided education on the new wound care or provided a return demonstration of the wound care to the right dorsal foot.

An interview was conducted on 6/18/25 at 9:20 AM with EI # 2 who confirmed there was no documentation the patient and/or caregiver was provided education on the wound care and/or provided a return demonstration of the wound care to the right dorsal foot wound. 

4. HV # 3 was admitted to the agency on 5/2/25 with diagnoses including Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety and Rheumatoid Arthritis with Rheumatoid Factor of Left Hand without Organ or Systems Involvement.

Review of the HHC and POC dated 5/2/25 to 6/30/25 revealed orders for SN once weekly for nine weeks and if patient exhibits signs or symptoms of constipation, ensure patient is taking any prescribed medications for condition. If not already prescribed then instruct to initiate 17 grams of MiraLAX daily and/or 15 milligrams of Senna twice daily until normal bowel regime resumes. If normal bowel movements do not resume in 2 days, contact physician for additional orders. 

Review of the SN VNR dated 6/5/25 revealed the patient's last bowel movement was on 6/1/25 and the normal pattern for bowel movements as "greater than 4 days - institute bowel protocol or contact practitioner for further orders as needed." There was no documentation the patient was provided education on the ordered bowel protocol. 

Review of the Medicine List, printed on 6/16/25, revealed no documentation of a medication prescribed for constipation. 

An interview was conducted on 6/18/25 at 9:12 AM with EI # 2 who confirmed there was no documentation the patient and/or caregiver was provided education on the ordered bowel protocol.