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)
G0574 Plan of care must include the following
CFR(s): 484.60(a)(2)(i-xvi)

The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician may choose to include.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), and interview, it was determined the agency failed to ensure the staff obtained and documented physician's orders for oxygen in 1 of 3 records reviewed with oxygen. This affected MR # 7 and had the potential to affect all patients admitted to the agency.



Findings include:



1. MR # 7 was admitted to the agency on 5/22/18 with diagnoses including Unspecified Diastolic Heart Failure and Chronic Obstructive Pulmonary Disease.



Review of the 5/22/18 Registered Nurse Admission Visit Note Report documentation revealed oxygen was in use. There was no documentation of the flow rate, frequency and administration device.



Review of the 5/22/18 to 7/20/18 Home Health Certification (HHC) and Plan of Care (POC) included durable medical equipment and medications, but failed to contain oxygen.



Record review revealed Nurse documentation on the 6/7/18 Visit Note Report, the patient uses oxygen as needed for dyspnea. The nurse documented on 6/14/18 that oxygen 1-2 liters via nasal cannula was in use. On 6/19/18, the nurse documented the patient has been using oxygen more frequently.



There was no documentation on the HHC/POC or physician orders for the use of oxygen, the rate of flow, frequency and administration device.



An interview was conducted on 6/28/18 at 11:57 AM with Employee Identifier (EI) # 9, Registered Nurse, Clinical Manager who confirmed the above findings.