| 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) |
| G0608 | Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy, and interviews, it was determined the agency failed to ensure care was coordinated with the physician in relation to new medications and with outside agency at the time of discharge. This deficient practice affected one of four discharge records reviewed including MR # 8, and had the potential to affect all patients admitted to this agency. Findings include: Agency policy: Coordination of Care from Admit through Discharge Policy number: 2.1.017 Revised: 4/1/23 ...Policy: The agency provides care and services within an integrated continuum of care system... 4. Coordination of care with physician: At admission, thoughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician: a. when changes occur in the patients condition or response to treatment... 5. Coordination of care among disciplines: ... c...Significant changes in the patient's condition (... new or worsening symptoms, new or changed orders, or vital signs not within physician ordered parameters)... 6. Coordination of services with other organizations and community: When the patient receives services from other organizations and/or individual's care is coordinated to ensure that patient's needs are met efficiently... b. Communication with other health care providers when there are significant changes in patient care and/or condition... 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 10/26/22 revealed the SN documented the caregiver (cg) stated MR # 8 was treated for UTI (Urinary Tract Infection) two weeks earlier and the physician had called in an antibiotic. Further review of the HHC and POC dated 10/14/22 revealed no documentation of the new antibiotic. There was no documentation the physician was contacted to verify the new medication and no documentation the new medication was added to the CMR. Review of the RN (Registered Nurse) Discharge from Agency note dated 12/8/22 revealed the nurse documented the patient felt like his/her goals set on admission were not met. The nurse documented the Patient Care Manager would have to assess the care plan and patient's progress to see if he/she qualified for more visits and someone from the office would contact him/her. There was no documentation the agency office contacted MR # 8 about the discharge plans and possible recertification. An interview was conducted on 5/11/23 at 10:00 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation the physician was contacted to confirm the new medication and no documentation the office contacted the patient to discuss recertification. |