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 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)
G0682 Infection Prevention
CFR(s): 484.70(a)

Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.


This STANDARD is not met as evidenced by:
Based on agency procedure, observation, and interviews it was determined the staff failed to maintain sterile technique for the drainage of a vacuum bottle system and dispose of drained pleural fluid per the agency procedure.


This deficient practice did affect Home Visit (HV) # 2, one of one observation conducted to observe drainage of a PleurX drain (Pleural Catheter and vacuum bottle System), and had the potential to affect all patients requiring a PleurX drain at the agency.


Findings include:


Agency Procedure: Drainage with a Vacuum Bottle System


Procedure Number: Not documented


Procedure Date: Not documented


...Drainage with a Vacuum Bottle System.


...12. Remove gloves and perform hand hygiene.


13. ...Place the catheter on a clean, waterproof absorbable pad and discard the cap.


14. Prepare a sterile field.


...16. Undo the paper tape on the drainage line and lay the access tip on the sterile field...


17. Perform hand hygiene and don sterile gloves.


18. Open the sterile package containing the catheter valve cap and place the cap on the sterile field.


...22. Disinfect the catheter valve opening with an alcohol pad, using a vigorous motion. Allow to dry...


23. Insert and securely lock the vacuum bottle access tip into the catheter valve...


39. Flush the contents of the drainage bottle down the toilet.





1. An observation was conducted on 11/20/24 at 9:08 AM with Employee Identifier (EI) 4, Registered Nurse (RN), to observe the drainage of HV # 2's PleurX catheter with a vacuum bottle system. EI # 2, Patient Care Manger, was present during the observation.


EI # 4 removed old dressing from the PleurX catheter site then placed the catheter on the patient's pants, failing to place the catheter on a clean, waterproof absorbable pad.


EI # 4 then performed hand hygiene, donned gloves, opened the PleurX vacuum bottle, removed the paper tape on the drainage line and vacuum bottle access tip, removed the old catheter valve cap of the the PleurX catheter, inserted the vacuum bottle access tip into the catheter valve cap and drained pleural fluid into the vacuum bottle. EI # 4 failed to prepare a sterile field, remove gloves used to open sterile field, perform hand hygiene, don sterile gloves, and disinfect the catheter valve opening with alcohol.


EI # 4 then opened the sterile field, using the same gloves used to drain the pleural fluid, removed gloves, picked up the right sterile gloves inside of the sterile field, placed the right sterile glove back down on top of the left sterile glove inside the sterile field which contaminated the sterile gloves and sterile field, performed hand hygiene, then donned the sterile gloves inside of the sterile field. EI # 4 failed to maintain sterile technique by opening a sterile field with previously used gloves, entering the sterile field without hand hygiene, then donning contaminated sterile gloves.


EI # 4 then used contaminated sterile gloves to disinfect the catheter valve cap and perform PleurX catheter site care.


EI # 4 placed the vacuum bottle with drained pleural fluid inside a regular trash bag and left it beside the patient's trash can for the caregiver to place in the outside trash. EI # 4 failed to flush the drained pleural fluid down the toilet.


An interview was conducted with EI # 1, Executive Director, and EI # 2 who confirmed the agency staff failed to maintain sterile technique for the drainage of a vacuum bottle system and dispose of drained pleural fluid per the agency procedure.