| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017024 | (X3) Date Survey Completed 11/21/2024 |
| 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) |
| G0536 | A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, medical record (MR) review, agency policy, and interviews it was determined the agency failed to ensure an accurate medication list was maintained for each patient. This affected one of seven home visit (HV) patients including HV # 5 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised: 7/1/24 Purpose: To provide a process to ensure continuous monitoring of medications... 2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medications throughout the episode of care. During the patient's episode of care the following will occur: ...i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... HV # 5 was admitted on 10/22/24 with diagnoses including Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease, and Heart Failure. Review of the Home Health Certification and Plan of Care dated 10/22/24 revealed orders for SN one visit a week for nine weeks, Physical Therapy one visit for one week, two visits for three weeks, then one visit for one week, and Speech Therapy one visit a week for five weeks. A HV was conducted on 11/19/24 at 2:00 PM to observe care provided by Employee Identifier (EI) 9, Speech Therapist. EI # 7, Clinical Director, accompanied the surveyor on the HV. A review of the home medications with EI # 9 and the caregiver revealed the following current medications were in the home but were not listed on the Medicine List dated 11/19/24: Trospium Chloride 20 milligrams (mg) one tablet twice a day. The prescription was dated 10/21/24. Tizanadine 2 mg one tablet three times a day. The prescription was dated 10/21/24. Vitamin D3 25 mg take one tablet daily was listed on the Medicine List, the caregiver stated HV # 5 had been taking the Vitamin D3 twice a day since March of 2024. An interview was conducted on 11/21/24 at 9:20 AM with EI # 7 who confirmed the medication list not continuously updated per agency policy. |