| 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) |
| G0684 | Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of personnel files, agency policy and interview with staff it was determined the agency failed to provide Hepatitis B vaccine when requested. This affected 1 of 3 personnel files reviewed including Employee Identifier (EI) # 7, Licensed Practical Nurse (LPN) and had the potential to affect all staff at risk for exposure to blood- borne pathogens. Findings include: Agency Policy: Staff Screening, New Hire and Annual Policy Number: 6.002 Revised Date: 09/01/21 Purpose: To establish a process to ensure appropriate staff screening prior to hire and annually thereafter. Procedure: H. Staff at Risk for Exposure to Blood-Borne Pathogens...are offered the series of Hepatitis B Vaccines, which is documented on the Hepatitis B Vaccine Consent Form... EI # 7, LPN, was hired 3/2/21. Review of the personnel file revealed EI # 7 signed the Hepatitis B Vaccination Consent form on 9/20/21. There was no documentation the Hepatitis B Vaccine series had been provided An interview conducted 10/20/21 at 4:00 PM with EI # 1, Executive Director, confirmed the Hepatitis B Vaccine had not been started for EI # 7. |