| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017024 | (X3) Date Survey Completed 10/21/2021 |
| Name of Provider or Supplier Southeast Alabama Homecare, Llc | Street Address, City, State 3813 Ross Clark Circle, Suite 300, Dothan, 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) |
| G0574 | Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy and procedure, review of medical records (MR) and interview with staff it was determined the agency failed to ensure the plan of care wound care orders included the frequency of dressing changes. This affected 2 of 6 records reviewed with wound care including Home Visit (HV) # 6, MR # 9 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 02/01/20 Policy: No medications, treatments...will be administered without the order of a qualified physician... Procedure: 10. Services are provided according to the most recent orders updating the patient's Plan of Care. 1. HV # 6 was admitted to the agency 9/21/21 with diagnoses including Paraplegia and Essential Hypertension. Review of the physician's order dated 9/27/21 revealed the skilled nurse (SN) was to visit 1 time per week to perform wound care and instruct the wound care procedure to the patient / caregiver. Wound care to the left lateral foot was ordered as follows: clean with normal saline, pat dry, apply Medihoney, cover with foam dressing using clean technique. The order failed to include how often the dressing was to be changed. A HV observation was conducted 10/19/21 at 12:30 PM to observe Employee Identifier (EI) # 7, Licensed Practical Nurse, perform wound care. During the visit the surveyor asked how often the dressing was changed and the patient and nurse stated every day, performed by the paid caregiver. An interview conducted 10/21/21 at 4:15 PM with EI # 5, Clinical Manager, confirmed the wound care order failed to include how often the dressing was to be changed. 2. MR # 9 was admitted to the agency 11/17/21 and recertified on 1/16/21 with diagnoses including Pressure Ulcer of Sacral Region Stage 2 and Pressure Ulcer of Left Buttock Stage 2. Review of the Plan of Care dated 1/16/21 revealed wound care to wound # 5, left buttock, and wound # 8. right inner buttock: clean with normal saline and gauze pads, pat dry, apply skin prep to periwound, then hydrocolloid. The order failed to include how often the dressing was to be changed. An interview conducted 10/20/21 at 4:00 PM with EI # 1, Executive Director, confirmed the order failed to include how often the dressing was to be changed. |