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)
G0608 Coordinate care delivery
CFR(s): 484.60(d)(4)

Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.


This ELEMENT is not met as evidenced by:
Based on review of the Medical Records (MR) and agency policy and procedure the agency staff failed to ensure care was coordinated with the physician regarding patient's blood sugar monitoring and swallowing difficulty.

This deficient practice affected 3 of 17 MR's reviewed, including MR # 2, MR # 4, MR # 8 and has the potential to affect all the patient's 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: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's Physician..."


3. MR # 8 was admitted to the agency on 8/28/21 with diagnosis including Aftercare Following Surgery For Neoplasm and Malignant Neoplasm of Overlapping Sites of Right Female Breast.

Review of the HHC and POC dated 8/28/21 to 10/26/21 revealed orders for PT (Physical Therapy) effective 8/29/21 1WK1 (once per week times one week). PT to evaluate/assess and develop PT plan of care that will be approved by the physician prior to implementation.

Review of the PT VNR dated 8/31/21 revealed evaluation for PT completed and care coordinated with physician with plans for PT visits 1W4 focusing on endurance training, BLE (Bilateral Lower Extremity) strengthening, fall prevention, gait training and HEP (Home Exercise Program) Training.

Further review of the medical record revealed no PT physician orders were written for 1W4, no plan of care written and no visits were completed after the initial PT evaluation.

An interview conducted on 10/20/21 at 3:45 PM with EI # 5, Clinical Manager confirmed the PT did not complete the plan of care and orders for PT as discussed with the physician on 8/31/21 and MR # 8 did not receive PT as planned.

1. MR # 2 was admitted to the agency on 9/3/21 with a diagnosis of Type 2 Diabetes Mellitus Without Complications.

Review of the Home Health Certification (HHC) and Plan of Care (POC) revealed a physician order for "skilled nurse (SN) to instruct on Diabetes to include...management..." with a once a week SN frequency.

Review of the SN admission note dated 9/3/21 revealed documentation of "...is not currently ordered to check (his/her) blood sugar and just has A1C's (lab test) checked at (Physician identified) twice yearly..." There was no documentation the SN coordinated with the physician about the patient not monitoring Diabetic Blood Sugars in the home and determine if the physician wanted to order blood sugar monitoring.

Review of 7 of 7 SN visit note reports (VNR) between the next SN visit date of 9/7/21 through 10/19/21 revealed no documentation the SN coordinated with the physician about the patient not monitoring Diabetic Blood Sugars in the home and determine if the physician wanted to order blood sugar monitoring.

An interview was conducted on 10/21/21 at 10:57 AM with Employee Identifier (EI) # 1, Registered Nurse Executive Director, who confirmed there was no documentation the agency staff coordinated with the physician about the patient not monitoring Diabetic Blood Sugars in the home and determine if the physician wanted to order blood sugar monitoring.

2. MR # 4 was admitted to the agency on 5/22/21 with diagnoses including, Unspecified Asthma, Uncomplicated and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease.

Review of the SN VNR dated 6/9/21 revealed documentation of "patient not swallowing well. Has to do a barium swallow study on Friday" with a weight documented as 248 lbs (pounds).

Review of the MR from 6/9/21 through 7/20/21 revealed no documentation of a follow up with the physician on the results of the barium swallow study nor coordination of care about the patient not swallowing well and need for Speech Therapy (ST).

Review of the SN VNR dated 7/14/21 revealed documentation of "Patient reports low appetite and weight loss noted. Patient also reports that (her/his) CBG (Blood Sugar) monitor reads HI (High) instead of giving a number....MD (Medical Doctor) notified of...weight loss, CBGs..." There was no documentation of a physician return call to the SN and no documentation the SN attempted to follow up with the physician after not receiving a return call.

An interview was conducted on 10/21/21 at 10:49 AM with EI # 1 who confirmed there was no documentation of the above coordination of care with the physician.