Statement of Deficiencies

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)

G0716

Preparing clinical notes
CFR(s): 484.75(b)(6)

Preparing clinical notes;

This ELEMENT is not met as evidenced by:
Based on review of medical records (MR) and staff interviews, it was determined the agency failed to document correctly in the clinical record. This deficient practice did affect Home Visit (HV) # 5 and had the potential to affect all patients served by the agency.

Findings include:

1. HV # 5 was admitted to the agency on1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy.

Review of the Home Health Certification and Plan of Care dated 8/21/21 to 10/19/21 revealed orders for skilled nurse (SN) to insert 20 Fr (French) 10 cc (cubic centimeter) balloon suprapubic catheter using aseptic technique. Change every 4 weeks beginning week of 9/5/21 and PRN (as needed)...

Further review of the Home Health Certification and Plan of Care dated 8/21/21 to 10/19/21 revealed orders for SN to administer bladder irrigation/instillation with sterile water, 60 cc every week and PRN using aseptic technique.

Review of the Visit Note Report by the SN dated 8/21/21 revealed patient complains of leaking catheter....SN removed old catheter, inserted new 20 Fr Catheter using sterile technique.... There was no documentation of what size balloon was used or how much fluid was used to inflate the balloon and no documentation of urine return.

Review of the Visit Note Reports by the SN dated 8/26/21, 9/2/21, 10/4/21, 10/15/21 and 10/18/21 revealed, "Administration of bladder instillation/irrigation", instillation of 50 ml (milliliters) of sterile water...." There was no documentation of why 60 cc of sterile water was not used for irrigation as ordered.

Review of the Visit Note Report by the SN dated 9/16/21 revealed a Suprapubic Foley Catheter size 16 Fr was inserted on 8/21/21 and not a 20 Fr Catheter as stated in the 8/21/21 Visit Note Report.

Review of the Visit Note Report by the SN dated 9/29/21 revealed a Suprapubic Foley Catheter size 22 was inserted on 9/22/21.

Further review of the medical record from 8/21/21 to 10/19/21 revealed no SN visit documented for 9/22/21.

An interview conducted on 10/20/21 at 3:45 PM with EI (Employee Identifier) # 5 Clinical Manager confirmed the documentation was inaccurate and unclear.