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 017035 (X3) Date Survey Completed 03/27/2025
Name of Provider or Supplier Infirmary Home Health Agency, Inc. Street Address, City, State 851 E I-65 Service Rd S, Suite 1000, Mobile, 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)
G0574 Plan of care must include the following
CFR(s): 484.60(a)(2)(i-xvi)

The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include.


This ELEMENT is not met as evidenced by:
Based on review of agency policy and procedure, medical records (MR), and staff interviews it was determined the agency failed to include patient specific interventions, measurable outcomes and goals for a peripherally inserted central catheter (PICC) in the plan of care (POC). 

This deficient practice did affect MR # 9, one of one MR reviewed with a PICC, and had the potential to effect all patients with a PICC served by the agency. 

Findings include: 

Agency Policy: POC

Policy Number: 2.1.007

Revised Date: 9/1/24

Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient...

Policy: Each patient has an individualized POC developed...that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. 

Procedure: 

...2. The POC includes: 

...i. Patient specific interventions...measurable outcomes and goals identified by the agency and patient. 

 


1. MR # 9 was admitted to the agency on 12/20/24, and recertified for continued care from 2/18/25 to 4/18/25, with diagnoses including Cellulitis of Left Lowers Limb and Disruption of External Operation (Surgical) Wound, Not Elsewhere Classified, Subsequent Encounter.

Review of the Home Health Certification (HHC) and POC dated 2/18/25 to 4/18/25 revealed an order for a skilled nurse (SN) frequency of once a week for eight weeks. There was no documentation of interventions, measurable outcomes, and goals for a PICC. 

Review of the Recertification nursing note (comprehensive assessment) dated 2/18/25 revealed the patient had a PICC to the right upper extremity. 

Review of six of six SN visits from 2/18/25 to 3/18/25 revealed site care, flushing, and/or blood was removed from the PICC line during the visit. 

An interview was conducted on 3/27/25 at 1:02 PM with Employee Identifier (EI) # 2, Clinical Director, who confirmed there was no interventions, measurable outcomes, and goals for a PICC on the patients POC.