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 017050 (X3) Date Survey Completed 01/06/2023
Name of Provider or Supplier Central North Alabama Health Services, Inc. Street Address, City, State 1310 Pulaski Pike, Unit A, Huntsville, 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)
G0578 Conformance with physician orders
CFR(s): 484.60(b)

Standard: Conformance with physician or allowed practitioner orders.


This STANDARD is not met as evidenced by:
Based on Medical Record (MR) review, agency policy and procedure, and interview, it was determined the agency failed to notify the physician when unable to obtain ordered labs.





This deficient practice affected one of seven records reviewed, including MR # 4, and had the potential to affect all patients served by the agency.





Findings include:





Agency Policy: Physician Communication





Policy Number: HHS.030





Review Date: 11/16





Policy:





The agency will establish and maintain communication with the physician to ensure safe and appropriate care for the patient /client.





Standard Operating Procedures:





1. Professional agency personnel contact the patient's /client's physician:





...F. When there is any problem implementing the plan of care.





2. All conferences or attempt to communicate with physician will be documented in the clinical record.


1. MR # 4 was admitted to the agency on 3/18/22 with diagnoses including Pressure Ulcer of Sacral Region, Stage 3, Pressure Ulcer of Right Buttock, Stage 3, and End Stage Renal Disease.


Review of the Home Health Certification and Plan of Care dated 3/18/22 to 5/16/22 revealed an ordered Skilled Nurse (SN) visit frequency of one time a week for eight weeks, and two as needed (PRN) visits for cardiopulmonary or wound complications.


Review of physician order dated 3/23/22 revealed an order for the SN to perform venipuncture for monthly dialysis lab work using needle of choice beginning month of March 2022.


Review of the 3/23/22 SN visit Interventions revealed the SN documented he/she attempted to obtain the dialysis labs times four attempts. There was no documentation the SN notified the physician he/she was unable to obtain the ordered labs.


Review of the 3/29/22 and 4/5/22 SN visits revealed no documentation the ordered labs were obtained.


An interview conducted 1/6/23 at 3:13 PM with Employee Identifier (EI) # 1, Registered Nurse Administrator confirmed the ordered dialysis labs were not obtained, and the physician was not notified.