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)
G0800 Services provided by HH aide
CFR(s): 484.80(g)(2)

A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), observation and staff interviews, it was determined the agency failed to ensure the Home Health Aide (HHA) notified the nurse when he/she was not able to follow the Plan of Care (POC).

This deficient practice affected 1 of 7 MRs reviewed receiving HHA services and did affect HV # 5 and had the potential to affect all patients receiving HHA services.

Findings include:





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

Review of the Aide Care Plan Report dated 8/21/21 included the following Activities of Daily Living (ADL) assignments:

Stand-by assistance with ambulation: every visit

Bathing (Chair): every visit

Review of 17 Visit Note Reports by the Aide dated from 8/24/21 to 10/18/21 revealed documentation by the Aide, "Stand-by assistance with ambulation completed."

A HV was conducted on 10/19/21 at 11:10 AM to observe Employee Identifier (EI) # 8, HHA perform care.

During the visit the patient remained in his/her chair and the aide was observed providing a chair bath, but did not provide stand-by assistance with ambulation.

Review of the Visit Note Report completed by EI # 8, HHA included the following documentation:

Service: "Stand-by assistance with ambulation completed."

An interview conducted on 10/20/21 at 3:45 PM with EI # 5 Clinical Manager confirmed, the patient is unable to stand and ambulate and the aide documented incorrectly on the Visit Note Reports.