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 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)
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 agency policy and procedure, medical record (MR) review and interviews it was determined the agency failed to notify the physician of deterioration of wounds affecting 1 of 6 records with wounds including MR # 7. This had the potential to affect all patients with wounds served by the agency.

Findings include

Agency Policy: Coordination of Care From Admit Through Discharge

Policy Number: 2.1.017

Revised Date: 8/1/19

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:

a. When changes occur in the patient's condition or response to treatment.


1. MR # 7 was admitted to the agency 9/29/21 with diagnoses including Chronic Ulcer Left Foot and Type 2 Diabetes Mellitus.

Review of the Home Health Certification and Plan of Care dated 9/29/21 revealed the skilled nurse (SN) was to visit 1 time the first week then 2 times per week. SN to perform and instruct patient/caregiver in the wound care procedure to wounds # 13 - right pretibial venous stasis ulcer, # 18 - left foot mid-dorsum pressure ulcer (PU) stage 2, # 19 left heel PU stage 2, # 20 - right great toe PU stage 1, and # 21 - right heel PU stage 2. Perform twice weekly: cleanse with Vashe (wound cleanser), pat dry, apply silver sulfadiazine cream to wound bed, cover with xeroform gauze, wrap with roll gauze and Coban (a compression wrap) using clean technique.

Review of the MR revealed the following changes in wound status:

Wound # 13 venous stasis ulcer 9/29/21: scant amount of serosanguinous exudate - deteriorated to small amount of purulent drainage on 10/19/21 and measured 6 cm (centimeters) length (L), by 6 cm width (W), by 0.25 cm depth (D). This was the first measurement of Wound # 13 documented. There was no documentation the physician was notified of the change in exudate or the size of the wound.

Wound # 18 left foot PU 9/29/21: moderate amount of purulent exudate with moderate odor measured 2 cm by 8.5 cm by 0.3 cm. continued to have purulent exudate on 10/6/21, 10/8/21, and 10/15/21. There was no documentation the physician was notified of the purulent exudate.

Wound # 19 left heel PU 9/29/21: small amount of serosanguinous exudate with moderate odor, measured 5 cm by 5 cm by 0.2 cm - deteriorated to purulent exudate, small amount on 10/19/21. There was no documentation the physician was notified of the purulent exudate.

An interview conducted 10/20/21 at 4:20 PM with Employee Identifier (EI) # 1, Executive Director, confirmed there was no documentation the physician was notified of the changes in wound status.