| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017037 | (X3) Date Survey Completed 05/11/2023 |
| 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) |
| 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 medical records (MR), agency policy and staff interviews, it was determined the agency failed to provide an individualized plan of care (POC). This deficient practice affected one of 17 MR reviewed and had the potential to affect all patients admitted to the agency. Findings include: Agency Policy: Plan of Care Policy number: 2.1.007 Date revised 12/01/21 Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician's/authorized practitioner's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner and staff that integrates comprehensive assessment findings to address patient problems, needs and goals as well as to address specific services being provided. Procedure: 1. A POC is developed for all patients and updated... 2. The POC includes ...e. Nutritional requirements f. Medications and treatments... i. Patient specific interventions and education... n. all patient care orders... 3. The qualified clinician develops and revises the POC under the direction of the physician or authorized practitioner. The POC is established prior tp providing services. 1. MR # 3 was admitted to the agency on 4/18/23 with admitting diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified and Acute and Chronic Respiratory Failure with Hypoxia. Review of the Home Health Certification (HHC) and POC dated 4/18/23 revealed orders for skilled nurse (SN) visits two times a week for one week and one time a week for six weeks. The SN visit note report (VNR) dated 4/18/23 under the heading Nutrition- Nutritional approaches: check all of the nutritional approaches that apply- Feeding Tube- Percutaneous Endoscopic Gastrostomy (PEG). Further review of the SN VNR dated 4/18/23 revealed the SN documented in the narrative section - "The patient was recently hospitalized at ...Rehab Hospital from 3/17/23 to 3/22/23 for strengthening and PEG care... Patient has a PEG Tube that is clamped but SN needs specified orders to perform PEG management." Further review of the HHC and POC dated 4/18/23 revealed no documentation of a PEG Tube or physician's orders for care of a PEG Tube in the POC. An interview was conducted on 5/11/23 at 10:42 AM with EI # 1, Executive Director, who confirmed the agency failed to provide an individualized POC. |