| 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) |
| G0584 | Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on agency policy, medical record (MR) review and interview with staff it was determined the agency failed to ensure physician verbal orders were signed by the physician within 30 days. This affected 1 of 5 discharged records reviewed including MR # 10 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...and that order...signed/dated by the ordering physician. 4. The Plan of Care (POC), telephone and/or verbal orders must be signed by the physician...30 days. 1. MR # 10 was admitted to the agency 3/6/21 with diagnoses including Chronic Pain Syndrome and Low Back Pain and recertified for care 5/5/21 to 7/3/21. MR # 10 was discharged goals met on 7/1/21. Review of the MR revealed the following verbal physician orders were not signed and dated by the physician: a. Physical Therapy (PT) Add On Discipline dated 6/18/21 which included the Plan of Care and visit frequency. b. Occupational Therapy (OT) Add On Discipline dated 6/21/21 which included the Plan of Care and visit frequency. c. Skilled Nurse order dated 6/17/21 which included nurse visit frequency, PT and OT evaluation. An interview conducted 10/20/21 at 4:12 PM with Employee Identifier # 1, Executive Director, confirmed the physician orders were not signed within 30 days as directed in the agency policy. |