| 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) |
| G0800 | Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on review of agency policies and procedures, medical record (MR) review and staff interview, it was determined the agency failed to ensure the Home Health Aide (HHA) provided care as ordered in the plan of care. This deficient practice affected 2 of 4 MR’s reviewed receiving HHA services and did affect MR # 11, and HV (Home Visit) # 3, and had the potential to negatively affect all patients receiving HHA services. Findings include: Agency Policy: Home Health Aide Date Revised: 1/21 Procedure: The role of the HHA includes… The HHA is responsible for reporting any abnormal issues to the Clinical Supervisor at time of visit. Agency Policy: Supervision for Home Health Aide Date Revised: 3/20 Agency Policy: Section 2 Policy 2.1 All HHA shall … carry out assigned responsibilities … Procedure: Section 4: Procedure 4.5 The HHA Care Plan will be utilized by the Aide and maintained by the Nurse to ensure that the care provided follows an Established Plan of Care. Agency Policy: Home Health Aide Date Revised: 1/21 HHA is responsible for reporting any abnormal issues to the Clinical Supervisor at time of visit. 2. HV # 3 was admitted to the agency on 12/28/21, and recertified for care 4/27/22 to 6/25/22, with diagnoses including Encounter for Attention to Gastrostomy, and Dysphagia Following Cerebral Infarction. Review of the Home Health Certification and Plan of Care dated 4/27/22 to 6/25/22 revealed a HHA effective 5/1/22, 1 WK (Week) 7. Review of the Aide Plan of Care, effective date 4/27/22, included orders for perineal care, every visit. A HV was conducted on 5/10/22 at 12:30 PM to observe care provided by EI # 6, HHA. During the visit, the CG stated she/he had recently changed the patient's briefs. EI # 6 did not perform perineal care. Review of the Aide Visit Note dated 5/10/21 revealed the aide documented the following for perineal care, "N" (No) CG (caregiver) changed briefs and washed perineal and bottom areas." There was no documentation the aide notified the nurse of tasks not performed, per policy. An interview was conducted on 5/12/22 at 8:14 AM with EI # 1, Director of Nursing, who confirmed the aide failed to notify the nurse of tasks not completed. 1. MR # 11 was admitted on 4/7/2020 and recertified on 4/7/22 with diagnoses including Type 2 Diabetes Mellitus Without Complications and Unspecified Osteoarthritis, Unspecified Site. Review of the Home Health Certification and Plan of Care dated 4/7/22 to 6/5/22 revealed orders for HHA services once a week for eight weeks and to provide assistance with personal care and Activity of Daily Living (ADL)… Review of the Aide Care Plan report dated 4/7/22 revealed orders of Foley catheter care every visit and empty urinary drainage bag per patient request. Review of the aide visit note reports dated 4/8/22, 4/13/22, 4/20/22 and 5/5/22 revealed Foley catheter care and empty urinary drainage bag was completed. Review of the Skill Nurse (SN) Visit Note Reports dated 4/13/22, 4/20/22, 4/27/22 and 5/9/22 revealed there was no documentation that the patient had a Foley catheter. An Interview conducted on 5/12/22 at 11:30 AM with Employee Identifier (EI) # 8, Registered Nurse Supervisor confirmed the HHA failed to notify the nurse MR # 11 did not have a Foley catheter. EI # 8 also confirmed the HHA documented incorrectly that Foley catheter care was provided, and urinary drainage bag was emptied. |