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)
G1024 Authentication
CFR(s): 484.110(b)

Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry.


This STANDARD is not met as evidenced by:
Based on Medical Record (MR) review, The Alabama Board of Nursing 610-X-6-.06 Documentation Standards,  and staff interviews it was determined the agency failed to ensure the staff documented accurately in the patient record. 

This deficient practice did affect MR # 2, one of two indwelling catheter charts reviewed, and had the potential to affect all indwelling catheter patients served by this agency.

Findings include:

Alabama Board of Nursing
Chapter 610-x-6: Standards of Nursing Practice

Supp (Supplement): 12/31/21

610-X-6-.06 Documentation Standards


(1) The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format.
(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient... "


1. MR # 2 was admitted to the agency on 7/13/23 and recertified for continued care on 11/4/24 to 1/2/25 with a primary diagnosis of Pressure Ulcer of Sacral Region Stage Four. 

A  review of the Home Health Certification and Plan of Care dated 11/4/24 to 1/2/25 revealed an order for the SN one time a week for nine weeks, for the Skilled Nurse (SN) to perform an insertion of a 24 French 10 cubic centimeter balloon, suprapubic catheter every month, and as needed for dislodgement or blockage.

 A review of the skilled nurse visit note dated 11/13/24 revealed documentation of the suprapubic catheter change.

A review of the SN visit notes revealed the nurse documented on 11/8/24,11/22/24, 11/29/24, 12/6/24, and 12/12/24 inaccurate dates for the insertion of the suprapubic catheter.

An interview was conducted on 3/27/25 at 12:08 PM, with Employee Identifier # 1, Area Administrator, who confirmed the nurse failed to accurately document the insertion date of the suprapubic catheter.