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)
G0716 Preparing clinical notes
CFR(s): 484.75(b)(6)

Preparing clinical notes;


This ELEMENT is not met as evidenced by:
Based on review of agency policy, medical records (MR) and interviews, it was determined the agency failed to ensure medical record documentation was accurate and complete with all events, and treatments administered which included OASIS (Outcome and Assessment Information Set) documentation and …..




This affected 1 of 12 active MRs including MR # 9, and 1 of 4 discharge records including MR # 4, and had the potential to negatively affect all patients served by this agency.




Agency Policy: OASIS Based Admission and Resumption of Care Assessments




Last Review & Revision: 1/20




Section 2: Policy




2.3 A Start of Care/Resumption of Care Form Utilizing OASIS, will be completed by an RN/PT/ST (Registered Nurse/Physical Therapist/Speech Therapist) within 48 hours of referral or on the physician ordered start of care date (admission)...




Section 5: Documentation




5.1 Documentation on assessments for Start of Care... are to be complete and adequately describe the patients/client’s condition.





1. MR # 9 was admitted to the agency on 4/4/22 with diagnoses including Other Chronic Pain and Pain in Left Knee and Joints of Left Foot.




Review of the Transitional Care Worksheet revealed the referral date was 3/30/22.




Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 4/4/22 to 6/2/22 revealed, "PT: 2wk4,1wk1 (2 times a week for 4 weeks, then 1 time a week for 1 week).




Review of the PT OASIS Admission dated 4/4/22 revealed the PT documented "4/4/22" to the question, "Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA (Home Health Agency)". The PT failed to accurately document the date of referral, which was 3/30/22.




An interview was conducted on 5/12/22 at 10:58 AM with Employee Identifier (EI) # 8, RN Supervisor, who confirmed the referral date was 3/30/22 and the PT failed to accurately document the date of referral in the OASIS Start of Care Assessment as directed per agency policy.




2. MR # 4 was admitted to the agency on 9/15/21 with diagnoses including Unilateral Primary Osteoarthritis Right Knee and Presence of Right Artificial Knee Joint.




Review of the HHC and POC dated 9/15/21 to 11/13/21 revealed, "PT: 2wk1,3wk1,1wk1.




Review of the 9/29/21 PT Discharge From Agency Visit Note revealed, "Yes" to the question, "Has this patient been treated for a urinary tract infection (UTI) in the past 14 days?". There was no documentation in the medical record that MR # 4 had been treated for a UTI in the past 14 days.




An interview was conducted 5/12/22 at 12:38 PM with EI # 9, Clinical Educator, who stated MR # 4 had not been treated for a UTI in the past 14 days. EI # 9 confirmed the PT failed to accurately document in the MR per agency policy.