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)
G0714 Patient and caregiver education
CFR(s): 484.75(b)(5)

Patient and caregiver education;


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 ensure patients / caregivers were provided education and/or a return demonstration was obtained to ensure competency of:

1. Wound care.

2. New Medication.

3. Nebulizer use.

4. Oxygen Safety

5. Pressure Ulcer Prevention

This affected 5 of 17 records including Home Visit (HV) # 6, MR # 7, MR # 4, MR # 6, HV # 5, and had the potential to affect all patients served by the agency.

Findings include:

Agency Policy: Patient Education

Policy Number: 3.001

Revised Date: 11/01/17

Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety.

Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety...

Procedure:

...3. The patient and caregiver receive ongoing information specific to the identified needs...

...b. Patient/caregiver plan of care responsibilities

...4. The patient and caregiver receive ongoing safety information specific to the identified needs...

a. Basic home safety within the patient information admit packet, including:

v. Home Oxygen Safety...

5. Patients and caregivers receive...information on equipment safety specific to the identified needs...Including:

a. medical gases:

i. Storage of medical gases in a stable, protected area

ii. Protection from heat extremes

iii. Response to accidents and emergencies.

b. Medical equipment:

i. Purpose, operating instructions, troubleshooting, and correct use of supplies/accessories...

6. ...On medication education to include:

a. Dosage, route, duration.

b. Description, purpose, expected actions.

c. Potential side effects, contraindications, avoidance of interactions, reactions to report.

...e. Appropriate mixing...storage, safeguards against contamination.

f. Self-administration and monitoring techniques

...k. High alert medications...

7. Using the progress/visit note, the clinician documents the level of patient/caregiver comprehension, patient/caregiver return demonstration of skill(s) taught, compliance and any follow-up with team members...


5. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified ad Encounter for Attention to Cystostomy.

Review of the Physician Order dated 8/22/21 revealed wound care to wound # 4 right buttocks and wound # 5 left buttocks as follows: Cleanse with saline and gauze, pat dry with gauze, apply hydrocolloid dressing using clean technique. Change weekly and PRN (as needed) soiling or dislodgement.

Review of all VNRs by the nurse dated 8/22/21, 8/26/21 and 9/2/21 revealed no documentation of teaching wound care with a return demonstration by the caregiver.

Further review of the VNR by the nurse dated 9/2/21 revealed, "wound care not provided:" (for wound # 4 and wound # 5) "Caregiver completed care."

An interview conducted on 10/20/21 at 3:45 PM with EI # 5 confirmed there was no documentation of teaching wound care with a return demonstration by the caregiver prior to the caregiver providing the wound care.

4. MR # 6 was admitted on 5/27/21 and recertified from 7/26/21 to 9/23/21 with diagnoses including Pressure Ulcer of Other site, Stage 1, Diffuse Large B-Cell Lymphoma, and Neoplasm Related Pain.

Review of the HHC and POC dated 5/27/21 revealed orders for the “Skilled Nurse to provide skilled teaching to prevent pressure ulcers, instruct on factors that contribute to skin breakdown, areas prone to breakdown and principles of skin care.”

Review of the VNR, Braden Risk Assessment, dated 5/27/21 revealed the Braden Score was 15 indicating the patient was at risk for developing pressure ulcers.

Further review of the POC dated 5/27/21 revealed orders for SN frequency of 1 wk 9 (1 x week x 9 weeks).

Review of the SN VNR from week 1 through week 9 revealed no documentation of patient or caregiver teaching to prevent pressure ulcers.

Review of the SN VNR dated 6/3/21 revealed the nurse documented MR # 6 had only one wound which was a Stage 1 Pressure Ulcer (PU) to the Mid-Perineum measuring 1 cm (centimeter) in length (L) x 1 cm width (W), and 1 cm depth (D).

Review of the SN VNR dated 7/24/21 revealed the nurse documented the patient had wound # 1 Mid-Perineum PU Stage 1 measuring 4.2 L x 2.5 W x 0.2 D, wound # 2 Right lower buttock, unstageable PU measuring 0.9 L x 0.8 W x 0.1 D, and wound # 3 Left lower buttock, unstageable PU, measuring 3.0 L x 1 W x 0.2 D.

In an interview conducted on 10/21/21 at 11:25 AM EI # 1, Executive Director, confirmed there was no documentation of patient or caregiver teaching of measures to prevent pressure injuries.




3. 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 Home Health Certification (HHC) and Plan of Care (POC) dated 5/22/21 to 7/20/21 revealed physician orders for "SN for instruction of administration of inhalation therapy and care for equipment...SN to instruct on new...medications...high risk medications...SN to instruct patient/caregiver on administration of insulin including proper storage, preparation of medication, rotation of injection sites, and sharps disposal." The ordered SN frequency was once a week for 1 week, twice a week for 1 week, then once a week for 8 weeks.

Review of the Client Medication Report (CMR) revealed documentation of Humalog Insulin 15 Units three times a day subcutaneous and Tresiba Flex touch 40 Units daily subcutaneous.

Review of the 12 SN Visit Note Report (VNR) reports dated from 5/22/21 to 7/27/21 revealed documentation the patient was prescribed insulin. There was no documentation the patient or caregiver provided a return demonstration of the subcutaneous administration of the Humalog Insulin and the Tresiba Flex touch.

Review of the Physician Order dated 5/27/21 revealed documentation of "new med (medication) found in home" and Ipratropium 0.5 mg (milligram) - Albuterol 3 mg/3 ml (milliters) nebulization solution 3 ml dose 4 times daily as needed.

Review of the SN VNR dated 5/27/21 revealed documentation of the Ipratropium 0.5 mg - Albuterol 3 mg/3 ml nebulization solution being added to the patient CMR. There was no documentation the SN educated the patient and/or caregiver on the Ipratropium - Albuterol medication or how to administer the medication via nebulizer.

Review of the 9 SN VNR from 6/2/21 to 7/27/21 revealed documentation the patient was on Oxygen 2 Liters/minute, which was documented as both continuously and intermittently. There was no documentation the patient and/or caregiver was provided education on Oxygen Storage, protection from heat, and response to accidents and emergencies.

An interview was conducted on 10/21/21 at 10:49 AM with EI # 1 who confirmed there was no documentation of the patient and/or caregiver education received education on Ipratropium - Albuterol medication or how to administer the medication via nebulizer, Oxygen Storage, protection from heat, and response to accidents and emergencies or provided a return demonstration of the subcutaneous administration of the Humalog Insulin and the Tresiba Flex touch.

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.

Review of the MR revealed no documentation the paid caregiver was instructed in the wound care procedure and no documentation the SN observed a return demonstration of wound care to confirm competency in providing the care.

An interview conducted 10/20/21 at 4:15 PM with EI # 5, Clinical Manager, confirmed there was no documentation the caregiver was instructed in the wound care procedure and no return demonstration was documented.

2. 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 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 SN admission visit note dated 9/29/21 revealed multiple "copious draining wounds" to the lower extremities and the SN provided wound care as ordered. There was no documentation the SN instructed the patient or caregiver in the wound care procedure and no documentation a return demonstration was observed to verify competency in the wound care procedure which was ordered twice weekly. The next SN visit was 7 days later on 10/6/21.

An interview conducted 10/20/21 at 4:20 PM with EI # 1, Executive Director, confirmed there was no documentation the patient or caregiver was instructed in the wound care procedure and no return demonstration was documented.