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)
G0966 Assure patient needs are continually assessed
CFR(s): 484.105(c)(4)

Assuring that patient needs are continually assessed, and


This ELEMENT is not met as evidenced by:
Based on agency policy, review of on-call message documentation, medical records (MR) and interviews it was determined the agency failed to ensure staff assessed the after hours needs of the patient and responded within 30 minutes of the call as directed in agency policy. This affected 3 un-sampled patients including Un-sampled Patient (UP) # 1, UP # 2 and UP # 3 and had the potential to affect all patients served by the agency.

Findings include:

Agency Policy: On-Call Process (To Include During and After Hours Care)

Policy Number: 5.008

Revised Date: 03/01/19

Purpose:

To establish guidelines to promote continuity of care.

Procedure:

4. The respective answering service will contact the on-call clinician immediately after the patient related call is received. The total response time from patient/caregiver call to patient/caregiver contact by clinician will be no longer than 30 minutes...

5. Clinicians will document responses and outcomes of appropriate call on the On-Call Event Coordination note.

6. Clinicians will submit the On-Call Event Coordination Note and any supporting patient documentation by the next business day...


Review of a random sampling of 5 on-call events revealed the following:

1. UP # 1 caregiver called the answering service on 9/25/21 at 10:28 AM with message "retaining water/extreme tightness both legs." UP # 1 called the answering service three more times, 10:57 AM, 11:21 AM and 11:58 AM. There was no documentation the on-call nurse contacted the patient / caregiver. A visit was conducted by the Licensed Practical Nurse (LPN) on 9/25/21 at 1:31 PM, 3 hours and 3 minutes later, which revealed Blood Pressure (BP) 94/78, Pulse 133 and weight 229.2 pounds. UP # 1 was transported the the Emergency Room (ER) via ambulance.

UP # 1 caregiver called the answering service on 10/3/21 at 6:06 PM with message "wound vac (Vacuum Assisted Closure) message/blockage." There was no documentation the on-call nurse contacted the patient / caregiver. A visit was conducted the following day (10/4/21) at 9:46 AM, 15 hours and 40 minutes later.

An interview conducted 10/20/21 at 12:18 PM with Employee Identifier (EI) # 5, Clinical Manager, confirmed there was no documentation the on-call nurse contacted the patient / caregiver as directed in agency policy.

2. UP # 2 contacted the answering service 9/19/21 at 12:03 AM with message "tightness/numbness/pressure in legs/ requested nurse assistance." There was no documentation the on-call nurse contacted UP # 2. A visit was conducted 9/19/21 at 12:23 PM, 12 hours and 20 minutes later, by the LPN which revealed a 17 pound weight gain. The physician was contacted and recommended the patient go to the ER.

An interview conducted 10/20/21 at 3:55 PM with EI # 1, Executive Director, confirmed there was no documentation the on-call nurse contacted the patient as directed in agency policy.

3. UP # 3 contacted the answering service 9/24/21 at 6:11 PM with message "wound vac will not stay on/tape tore patient skin/needs to be covered/needs supplies for wound vac/urgent request for nurse visit 9/24/21."

There was no documentation the on-call nurse contacted UP # 3. A visit was conducted at 9:35 PM, 3 hours and 24 minutes later.

An interview conducted 10/20/21 at 3:55 PM with EI # 1, Executive Director, confirmed there was no documentation the on-call nurse contacted the patient as directed in agency policy.