| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017027 | (X3) Date Survey Completed 09/26/2018 |
| Name of Provider or Supplier Hga Homecare, Llc | Street Address, City, State 2050 Beltline Rd Sw, Decatur, 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) |
| G0584 | Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on review of medical records (MR) and interview with agency staff it was determined the agency failed to obtain and/or document verbal orders from the physician for all care provided for 2 of 17 records reviewed. This affected MR # 2 and # 4 and had the potential to negatively affect all patients receiving home health services. Findings include: 1. MR # 2 was admitted to the agency 2/9/18 with diagnoses including Traumatic Pneumothorax, Subsequent Encounter, Repeated Falls and Multiple Fractures of Ribs. Medical record review included a SN (skill nurse) Visit Note Report dated 3/16/18 which contained genitourinary system assessment documentation for dysuria and incontinence. The nurse documented obtained UA (urinalysis) via straight cath (catherization) due to dysuria. There was no physician's order documented for the SN to perform straight cath for UA collection. During an interview on 9/26/18 at 9:35 AM, Employee Identifier (EI) # 3, Performance Improvement Coordinator confirmed the aforementioned finding. 2. MR # 4 was admitted to the agency on 3/9/18 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Unspecified Severity. Review of the SN Visit Note Report dated 3/9/18 revealed narrative documentation of the Right Lateral Heel as "Spoke with (physician) and received for Doxycycline and wound culture..." Incomplete documentation in the MR, should say order for Doxycycline and wound culture. Review of the Visit Note Report dated 3/13/18 revealed narrative documentation of "C&S (culture and sensitivity) done and (physician identified) changed ABX (antibiotic) to Levofloxacin..." Record review of the physician verbal orders dated 3/9/18 through 3/13/18 revealed no documentation of a verbal order for the Culture of the Right Lateral Heel or the Doxycycline. The staff failed to document a complete physicians' order for wound culture to the Right Lateral Heel and Doxycycline in the medical record. An interview was conducted on 9/26/18 at 11:34 AM with EI # 1, Executive Director, who confirmed the previous findings. |