| 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) |
| 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 review of medical records (MR), agency policy, and interviews, it was determined the agency failed to ensure all treatments were ordered by the physician. This deficient practice affected two of six MR's reviewed of patients with wounds including MR # 8 and MR # 3, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Physician Orders Policy number: 2.1.008 Revised: 4/01/23 ...Policy: No medications, treatments, diagnostic studies or therapies will be administered without the order of a qualified physician... 2. MR # 3 was admitted to the agency 4/18/23 with admitting diagnoses Chronic Obstructive Pulmonary Disease, Unspecified and Acute and Chronic Respiratory Failure with Hypoxia. Review of the HHC and POC dated 4/18/23 revealed the orders for SN visits two times a week for one week and one time a week for six weeks. Review of the the SN Visit Note Report (VNR) dated 4/18/23 in the narrative- "Patient has a PEG Tube that is clamped but SN needs specified orders to perform PEG management." The SN VNR dated 4/24/23 revealed under heading Integumentary- PEG Tube site." Educated patient's son on cleaning the PEG Tube site and returned demonstration." In the narrative-" SN educated the patient and son on cleaning around the PEG Tube site. Using Saline solution, a q-tip and gauze to pat dry, apply a split gauze under the plastic ring and tape around the gauze to hold it in place. Dressing changes twice a day." Further review of the HHC and POC and Physician's orders dated 4/18/23 revealed no documentation of orders for the PEG Tube. An interview was conducted on 5/11/23 at 10:42 AM with EI # 1, who confirmed the agency failed to ensure all treatments were ordered by the physician. 1. MR # 8 was admitted on 6/16/22 and recertified for home care from 10/14/22 to 12/12/22 with diagnoses including Non Pressure Chronic Ulcer of Left Lower Leg, Essential (Primary) Hypertension, and Paroxysmal Atrial Fibrillation. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 10/14/22 revealed orders for SN (Skilled Nurse) one visit per week for eight weeks. Review of the SN Visit Note dated 11/23/22 revealed the SN documented a new Stage II pressure ulcer to the left distal lateral posterior calf measuring 0.6 cm (centimeters) length x 0.3 cm width x 0.1 cm depth with scant serosanguous exudate. Further review of the SN Visit Note dated 11/23/22 revealed the SN documented the new wound was cleansed with wound cleanser and gauze, patted dry, petroleum gauze applied, covered with ABD (abdominal) pad and Kerlix, and secured with tape. Review of the physician orders revealed no documentation of wound care orders for the pressure ulcer. An interview was conducted on 5/11/23 at 10:00 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there were no physician orders for the wound care that was provided to the new pressure ulcer. |