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 017025 (X3) Date Survey Completed 06/28/2018
Name of Provider or Supplier Saad Enterprises, Inc. Street Address, City, State 1515 University Blvd, South, Mobile, 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)
G0516 Skilled professional performs assessment
CFR(s): 484.55(a)(2)

When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), agency policy and interviews with the staff it was determined the agency failed to ensure all admissions were completed within 48 hours of the referral date and/or documentation as to why the admission did not occur within the 48 hours of the referral date.



This affected 1 of 17 MR's reviewed and did affect MR # 9 and had the potential to negatively affect all patients served by the agency.



Findings include:



Policy: Oasis Based Admission and Resumption of Care Assessments

Last Review and Revision Date: 5/18



"Section 2: Policy



2.3 A Start of Care/Resumption of Care Form Utilizing OASIS, will be complete by an RN/PT within 48 hours of referral..."



*****



1. MR # 9 was admitted to the agency on 5/21/18 with a referral date of 5/16/18 and admitting diagnoses was Parkinson's Disease and Chronic Atrial Fibrillation.



Review of the Transitional Care Worksheet revealed the referral date was 5/16/18 and the admission date was 5/21/18.



Review of the Home Health Certification (HHC) and Plan of Care (POC) revealed an admission date of 5/21/18.



Review of the PT (Physical Therapy) Oasis Admission dated 5/21/18 revealed no documentation as to why the admission was completed 5 days after the referral date and not 48 hours per agency policy.



An interview was conducted on 6/28/18 at 10:35 AM with Employee Identifier # 1, Director of Nursing, who confirmed the above mentioned findings.