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 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)
G0802 Duties of a HH aide
CFR(s): 484.80(g)(3)

The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), agency Train Aide's Guide to Home Visits and interviews with the staff it was determined the Home Health Aide (HHA) failed to follow the aide plan of care for documentation of the the patient's last BM (bowel movement). This affected two of three patients receiving HHA services and did affect Home Visit (HV) # 7 and MR # 1 and had the potential to negatively affect all patients receiving HHA services.


Findings include:


Agency Train: An Aide's Guide to Home Visits


Number: None


Date: 2016


This checklist is a guide to assist the Home Health Aide in all the necessary steps to completing the HHA visit.


HHA Aide Checklist:


Indicate each ADL (Activity of Daily Living) or IADL (Instrumental Activities of Daily Living) Tasks, input/output, precautions and other special instructions as complete or incomplete.


Aide Care Plan Job Aid:


Registered Nurses, Physical Therapists, Occupational Therapists and Speech Therapists will use this job aide as a guide in developing a Home Health Aide (HHA) care plan when a HHS is indicated and the physician has ordered the services. The HHA will only perform duties which they have been deemed competent to perform by a Registered Nurse or Therapist. The HHA plan of care is a comprehensive plan directing the HHA on specific personal care and services to provide during the patient visit...


Intake and Output:


Intake and output monitoring captures data to ensure the patient is receiving the required/ordered amount of fluids, and to record Urinary and/or Bowel output and elimination information.


Date of Last BM





2. MR # 1 was admitted to the agency 4/19/23 with admitting diagnoses including Other Osteoporosis with Current Pathological Fracture, Left Femur, Subsequent Encounter for Fracture with Routine Healing and Age Related Osteoporosis with Current Pathological Fracture, Left Forearm, Subsequent Encounter for Fracture with Routine Healing.


Review of the HHC and POC dated 4/19/23 revealed orders the HHA was to visit two times per week for two weeks effective 4/23/23.


Review of the Aide Care Plan Report revealed the following under Intake/Output:


Date of last BM every visit.


Review of the Aide Visit Note Report dated 5/2/23 revealed under category Intake/Output EI # 8 documented Y for yes and failed to document the date of the last bowel movement per the Aide Care Plan Report.


An interview was conducted on 5/11/23 at 10:20 AM with EI # 1, who confirmed the aide failed to follow the Aide Plan of Care and document the date of the last bowel movement.

1. HV # 7 was admitted to the agency on 4/27/23 with admitting diagnoses of Hemiplegia Following Cerebral Vascular Accident Right Dominant Side, and Aphasia Following Cerebral Infarction.


Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/27/23 revealed the Home Health Aide (HHA) was to visit 2 times a week for 3 weeks beginning on 4/30/23.


Review of the Aide Care Plan Report revealed the following under Intake/Output:


Date of Last BM (Bowel Movement) every visit.


Review of the Aide Visit Note Reports dated 5/4/23 and 5/9/23 revealed under category: intake/output, Employee Identifier (EI) # 8, Home Health Aide, documented "Y" for yes and failed to document the date of the last bowel movement per the Aide Care Plan Report.


An interview was conducted on 5/11/23 at 10:47 AM with EI # 1, Executive Director, who confirmed the aide failed to follow the Aide Plan of Care and document the date of the last bowel movement.