| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017037 | (X3) Date Survey Completed 10/10/2018 |
| Name of Provider or Supplier Alabama Homecare Of Montgomery, Llc | Street Address, City, State 400 South Union Street Suite 285, Montgomery, 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. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency procedure, and interviews with agency staff, it was determined the agency failed to ensure Physician orders were obtained for all wound treatments provided. This affected 1 of 6 records reviewed with wounds and did affect Home Visit (HV) # 1 , and had the potential to negatively affect all patients served by the agency Findings include: Policy: 2.2.001 Subject: Wound Assessment, Documentation, and Photography Revised: 9/1/2017 Purpose: To ensure the accurate and consistent assessment and documentation of wounds Procedure: ...2. Perform wound care according to LHC adopted clinical skills guidelines and physician orders... ...4. Redress the wound using appropriate wound care dressing procedure following physician orders... 1. HV # 1 was admitted to the agency on 8/27/18 with diagnoses including, Encounter for Orthopedic Aftercare Following Surgical Amputation. Review of the Physician Order dated 8/29/18 revealed the following physician's order: "Skilled Nurse (SN) to provide/instruct/reinforce to client/caregiver wound care to # 3, # 4, and # 5 Right Leg Closed Surgical Incisions daily as follows: Cleanse with wound cleanser and gauze. Gently pat dry with gauze. Cover with dry dressing..." Review of the Visit Note Report(s) dated 9/3/18, 9/5/18, 9/7/18, and 9/10/18 revealed a wound # 6 Mid Thigh, Medial, Rt (Right), Surgical Incision with the following wound care performed, "...Cleansed with wound cleanser and patted dry with gauze. Covered with dry dressing. Patient tolerated well." Review of the MR physician order(s) from 8/27/18 through 9/10/18 revealed no documentation of a physician's order for wound care to wound # 6. The agency staff provided wound care to wound # 6 without a physician's order. Further review of the Visit Note Report dated 9/10/18 revealed documentation of "Inactivate Wound - Completely Epthelialized" under change in status of wounds # 3, # 4, # 5, and # 6 Further review of the Visit Note Report dated 9/10/18 revealed no documentation that the physician was notified and order obtained to inactivate wound # 3, # 4, # 5, and # 6. Review of the Visit Note Report dated 9/12/18 revealed the following documentation under wound care provided to wounds # 3, # 4, # 5, and # 6: "Wound care not provided: Healed" Further review of the Visit Note Report dated 9/12/18 revealed no documentation that the physician was notified of wound # 3, # 4, # 5, and # 6 being healed and order obtained to discontinue wound care. An interview was conducted on 10/10/18 at 1:19 PM with Employee Identifier # 1, Executive Director, who confirmed the previous findings. |