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)
G0682 Infection Prevention
CFR(s): 484.70(a)

Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.


This STANDARD is not met as evidenced by:
Based on observations, facility policies and procedures, CDC (Centers for Disease Control and Prevention) Hand Hygiene Recommendations, and interviews, it was determined the facility failed to ensure staff:




1) Removed contaminated gloves and performed hand hygiene prior to cleaning non-disposable equipment.




2) Performed hand hygiene when performing wound care per agency policy.




This affected 3 of 7 Home Visits (HV) conducted, and did affect HV # 3, HV # 1, and HV # 5, and had the potential to affect all patients served by the agency.




Findings include:




Facility Policy: Hand Washing Indications




Policy number: 11160.20




Date revised: 01/22




Section 1: Purpose/ Objective




1.1 To prevent nosocomial infections.




...Section 2: Policy




2.1 All employees will follow CDC Hand Washing Recommendations...




Section 4: Procedure




...4.3. Employees should always sanitize their hands BEFORE and AFTER touching wounds.




4.4. Employees should sanitize theirs hands BEFORE and AFTER situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or bodily fluids, secretions, or excretions.




Source: CDC Website




Topic: Hand Hygiene Recommendations Guidance for Healthcare Providers about Hand Hygiene and COVID-19




Updated: May 17, 2020



Hand Hygiene Guidance




The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings.






Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:






Immediately before touching a patient




Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices




Before moving from work on a soiled body site to a clean body site on the same patient




After touching a patient or the patient’s immediate environment




After contact with blood, body fluids, or contaminated surfaces




Immediately after glove removal


3. HV # 5 was admitted to the agency on 3/25/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery of the Digestive System, Perforation of Intestine, and Peritoneal Abscess.




A HV was conducted on 5/10/22 3:05 PM to observe wound care provided by EI # 7, RN.




EI # 7 performed hand hygiene, donned gloves then removed the soiled surgical dressing from the abdomen. EI # 7 then applied wound cleanser to a clean 4 x 4 and cleaned the open wound site. EI # 7 then removed gloves and performed hand hygiene.




EI # 7 failed to remove gloves and perform hand hygiene after removing the soiled dressing.




In an interview conducted on 5/12/22 at 1:15 PM, EI # 8 confirmed the staff failed to follow agency policy for hand hygiene when performing wound care.













1. HV # 3 was admitted to the agency on 12/28/21 with diagnoses including Encounter for Attention to Gastrostomy, and Dysphagia Following Cerebral Infarction.




A HV was conducted on 5/10/22 at 12:30 PM to observe care provided by Employee Identifier (EI) # 6, HHA (Home Health Aide).




EI # 6 performed hand hygiene, donned gloves and checked HV # 3's blood pressure. Using the same gloves, EI # 6 cleaned the blood pressure cuff and stethoscope. Continuing with the same gloves, EI # 6 checked HV # 3's oxygen (O2) saturation, then cleaned the O2 monitor while wearing the same gloves. EI # 6 failed to remove contaminated gloves and perform hand hygiene prior to cleaning equipment used on HV # 3.




An interview was conducted on 5/12/22 at 11:41 AM with EI # 8, RN (Registered Nurse), Supervisor, who confirmed staff failed to remove gloves and perform hand hygiene prior to cleaning equipment.




2. 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.




A HV was conducted on 5/10/22 at 2:15 PM to observe care provided by EI # 5, Occupational Therapist.




EI # 5 performed hand hygiene, donned gloves, and checked HV # 1's blood pressure and pulse. Wearing the same gloves, EI # 5 cleaned the stethoscope and blood pressure cuff. EI # 5 failed to remove contaminated gloves and perform hand hygiene prior to cleaning equipment used on HV # 1.




An interview was conducted on 5/12/22 at 12:24 PM with EI # 8, who confirmed staff failed to remove gloves and perform hand hygiene prior to cleaning equipment.