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 12/29/2021
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)
G0578 Conformance with physician orders
CFR(s): 484.60(b)

Standard: Conformance with physician or allowed practitioner orders.


This STANDARD is not met as evidenced by:
Based on review of agency policy and procedure, Medical Record (MR), and interviews with staff, it was determined the agency staff failed to follow facility policy and procedure for the administration of Intravenous (IV) medications.



This affected 2 of 2 MR's review with Intravenous (IV) administration. This affected MR # 1 and MR # 5 and had the potential to affect all patients who received IV administration by the agency.Findings include:Agency Policy: Administration of Medications and Fluids Through a Peripheral or Central Venous Access DevicePolicy Number:10.012Revised date: 5/1/18




Purpose: To administer medication or solutions safely through a peripheral IV or a central venous access device.




...Mid-Line catheters should be treated as peripheral IV catheters.




PICC (Peripherally Inserted Central Catheter) should be treated as central venous access devices...




Procedure:




...4. Document the following in the electronic health record...:




a. Name of drug




b. Dose




...d. Route of administration




e. Duration of infusion




f. Time administered and time disconnected





1. MR # 1 was admitted to the agency on 7/31/21, recertified for continued care from 9/29/21 to 11/27/21, with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Encounter for Orthopedic Aftercare Following Surgical Amputation.




Review of the Physician's order dated 10/17/21 revealed an order for Skilled Nurse (SN) to administer "Tygacil 50 mg (milligrams)/100 ml (milliliters) daily over 60 minutes vis (via) elastomeric kit..."




Review of the SN Visit Note Report(s) (VNR) dated 10/17/21, 10/18/21 and 10/19/21 revealed documentation the SN administered an IV infusion via a peripheral line. There was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected.




Review of the SN VNR dated 10/20/21, 10/21/21, 10/22/21 and 10/23/21 revealed documentation the SN administered an IV infusion via a mid- line. There was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected.




In an interview conducted on 12/29/21 at 1:42 PM, Employee Identifier (EI) # 1, Executive Director, confirmed there was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected on the above dates.




2. MR # 5 was admitted to the agency on 11/24/21 with diagnoses including Sepsis, Unspecified Organism and Severe Sepsis with Septic Shock.




Review of the Home Health Certification and Plan of Care dated 11/24/21 to 1/22/22 revealed an order for the SN to "...instruct patient/caregiver on administering the following medication Ancef 1 gram in 50 ml of Normal Saline every 8 hours x (times) 3 weeks beginning 11/24/21 via esometric ball..."




Review of the SN Admission Note dated 11/24/21 revealed documentation of "SN instructed ...on how to administer IV antibiotics and he/she provides correct return demonstration as follows: ...connects antibiotics to port, unclamps to allow to flow. At end of procedure he/she correctly flushes..." There was no documentation name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered.




In an interview conducted on 12/29/21 at 1:26 PM, EI # 1 confirmed there was no documentation of the name of the drug administered, dose of the drug administered, duration of the infusion and time the infusion was administered and disconnected on 11/24/21.