| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017027 | (X3) Date Survey Completed 05/22/2025 |
| 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) |
| G0580 | Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedures, and interview, it was determined the home health agency failed to ensure the skilled nurse (SN) obtained a physician order to include the strength of medication being administered intravenously at each SN visit. This deficient practice affected MR # 5, one of one MR's reviewed with a mediport (an implanted central venous catheter), and had the potential to affect all patients receiving medications intravenously. Findings include: Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 10/01/23 Policy: No medications...will be administered without the order of a qualified physician or authorized practitioner... Procedure: ...11. Orders containing medication must be entered into the software system or written legibly in ink and at a minimum include: a. Name of medication, dose, dilution... ...c. Dosage expressed in metric system except when it must be expressed otherwise as in units. Agency Policy: Medication Administration Policy Number: 10.002 Revised Date: 12/01/23 Purpose: To provide a process to ensure safe administration of medications in the home. Procedure: 1. The physician's order will contain: a. Name of medication, dose, dilution.. b. Dosage expressed in metric system except when it must be expressed otherwise as in units... 2. The nurse will observe the 'five rights" when administering or preparing medications. ... (2) right dose 1. MR # 5 was admitted for home health services on 4/23/25 with a primary diagnosis of Malignant Neoplasm of Rectum. Review of the Home Health Certification (HHC) and Plan of Care (POC) for certification period 4/23/25 to 6/21/25 revealed orders for the SN to visit one time for one week, then one visit every two weeks for eight weeks with two additional visits as needed for IV (intravenous) complications. Continued review of the HHC and POC revealed orders for the SN to instruct the patient and caregiver on administering one liter of normal saline every other Wednesday and flush the IV site with ten milliliters (ml) of normal saline before infusion and again after infusion followed by Heparin 5ml. Review of the 4/23/25 OASIS (Outcome and Assessment Information Set) Admission Visit Note Report revealed the SN documented under "Infusion Access," that MR # 5 had a mediport to the left chest. The SN also documented under, "Indicate Heparin Flush Strength and Number of ML/CC," (cubic centimeters) that he/she administered 5ML. There was no documentation of the strength of Heparin Flush administered. The SN failed to contact the physician and obtain an order to clarify the strength of Heparin to be administered. An interview was conducted on 5/22/25 at 1:59 PM with Employee Identifier # 1, Executive Director, who confirmed there was no order for the strength of Heparin to be administered, and the SN failed to contact the physician for an order to clarify the strength of Heparin. |