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 05/12/2022
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)
G0536 A review of all current medications
CFR(s): 484.55(c)(5)

A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), facility policy, and interviews, it was determined the agency failed to ensure medication profiles were updated for all patients.




This affected 2 of 7 Home Visits (HV) conducted, and did affect HV # 1, HV # 6, and had the potential to affect all patients served by the agency.




Findings include:




Facility Policy: Medication Profile Process




Policy number: None listed




Date revised: 01/21




...Section 2: Policy




2.1 A Plan of Care with Medication Profile will be completed on every patient upon admission to the agency and verified with physician for accuracy. All disciplines with the exception to Home Health Aides will reconcile medications every visit and as needed for medication changes and updates...











2. HV # 6 was admitted to the agency on 3/10/22 with diagnoses including Essential (Primary) Hypertension and Acute Embolism and Thrombosis Unspecified Deep Veins of Unspecified Lower Extremity.




A HV was conducted on 5/11/22 at 9:40 AM to observe the SN (Skilled Nurse) provide care. During the visit, EI # 3, RN reviewed the medications with the patient, caregiver and surveyor and the following discrepancies were found:




Amlodipine 10 mg tablet daily listed on the CMR printed for the surveyor on 5/10/22 at 1:46 PM and per HV # 6 and the caregiver, was discontinued between July of 2021 and January of 2022 by "the Cancer doctor."




Lipitor 40 mg tablet daily at bedtime was listed on the CMR, but per HV # 6 and the caregiver, was discontinued March 21, 2022.




Magnesium Oxide 500 mg, one tablet twice daily found in the home and not on the CMR. The date on the bottle revealed October 20, 2021 and per HV # 6 and the caregiver, the medication was restarted about one month ago.




An interview conducted on 5/12/22 at 12:50 PM with EI # 9, Clinical Educator confirmed the medication profile was not updated per policy.







1. HV # 1 was admitted to the agency on 4/20/22 with diagnoses including Spinal Stenosis Lumbar Region without Neurogenic Claudication, and Muscle Spasm of Calf.




Review of the Home Health Certification and Plan of Care, dated 4/20/22 to 6/18/22, revealed orders for PT (Physical Therapy) 1WK (Week) 1, 2 WK 4, and OT (Occupational Therapy) effective 5/1/22, 2 WK 4.




A HV was conducted on 5/10/22 at 2:15 PM to observe care provided by EI # 5, Occupational Therapist. During the HV, the surveyor compared the current Client Medication Report (CMR), printed on 5/10/22 at 11:54 AM, with the medications in the home. The following discrepancy was observed:




Baclofen 10 mg (milligrams) tablet, 1 tablet, 3 times daily was listed on the CMR. The caregiver stated HV # 1 could not tolerate that dose, and the doctor's office had instructed to give 1/2 tablet, two times a day, on 5/1/22.




An interview was conducted on 5/12/22 at 12:54 PM with EI # 8, RN (Registered Nurse), Supervisor, who confirmed staff failed to update the medication profile.