| 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) |
| G0578 | Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: Based on, review of medical records (MR), review of agency policy and procedure, and staff interviews, it was determined the agency failed to ensure discipline visit frequencies were completed as ordered by the physician. This affected MR # 2, 1 of 17 records reviewed and had the potential to affect all patients admitted to the agency. Findings include: Policy: Physician Notification and Physician Orders Review and Revision Date: 01/14 "Purpose / Objective: 1.1 To ensure that the physician is notified of all changes in patient status and that all changes to the Plan of Care are addressed in a Physician Change Order. 1.2 To ensure that all disciplines follow all orders... Procedure: 4.2 Reasons to obtain a New Order, or provider physician notification, will include but are not limited to the following: d. Change in discipline frequency 4.3 Omission of a visit by any discipline will need a Missed Visit Notification Note in the Electronic Medical Record completed and Physician Notification will be faxed, mailed, or hand-delivered." ***** 2. MR # 2 was admitted to the agency on 5/26/17 with certification dates of 5/26/17 to 7/24/17 for diagnoses including Type 1 Diabetes Mellitus with Hyperglycemia. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/26/17 to 7/24/17, revealed Skilled Nurse (SN) order as "2 wk 2;1 wk 8" (twice a week for 2 weeks, once a week for 8 weeks) Review of the Physician Verbal Order dated 5/26/17 revealed an order for SNV (Skilled Nurse Visit) 5/27/17 to assess blood sugar and call significant findings to MD (Medical Doctor). Review of the Visit Note Reports revealed SNV for admission to agency on Friday 5/26/17. Further review of the Visit Note Reports revealed no documentation of a SNV on Saturday 5/27/17. Review of the MR revealed no documentation of a missed visit note or physician notification of the missed SN visit on 5/27/17. An interview was conducted on 6/28/18 at 11:09 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the previous findings. |