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 04/03/2025
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), observations, agency policy, and interviews with staff, patients and caregivers, it was determined the agency failed to ensure the medications were reconciled per agency policy to include all current medications.

This deficient practice did affect five of seven Home Visit (HV) patients including HV # 1, HV # 2, HV # 5. HV # 7, and HV # 6, and had the potential to affect all patients admitted to this agency.

Findings include:

Agency Policy: Medication Profile Process

Policy Number: Not Listed

Revised: 2/2025

Purpose/Objective:

1.1 To provide a source of information for all patients/clients receiving drug therapy.

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 of Home Health Aides (CNA), will reconcile medication every visit and as needed for medication changes and updates...

 


4. HV # 7 was admitted on 2/23/25 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, and Type One Diabetes Mellitus with Diabetic Chronic Kidney Disease. 

A HV was conducted on 4/1/25 at 9:45 AM to observe wound care provided by EI # 8, Registered Nurse (RN).

A review of the medications in the home was conducted with EI # 8 and HV # 7's cg and compared to the CMR dated 4/1/25. The following is a list of the medication discrepancies observed:

a. Amitriptyline 100 mg take one and one-half tablets at bedtime, prescription dated 1/28/25, was in the home but not listed on the CMR. The cg stated HV # 7 is currently taking the medication each night. 

b. Methocarbamol 500 mg take one tablet twice a day as needed, prescription dated 1/30/25, was in the home but not listed on the CMR. The cg stated HV # 7 is currently taking the medication daily for pain. 

c. Ramelteon 8 mg, take one tablet at bedtime, prescription dated 3/4/25, was in the home but not listed on the CMR. The cg stated HV # 7 currently takes the medication each night for rest.

d. Hydralazine 25 mg, take one three times a day as needed, prescription dated 3/8/25, was in the home but not listed on the CMR. The cg stated HV # 7 is currently taking the medication daily as needed. 

An interview was conducted on 4/3/25 at 11:05 AM with EI # 1 who confirmed the agency failed to ensure the medications were reconciled per agency policy. 

5. HV # 6 was admitted on 3/10/25 with diagnoses including Atherosclerotic Heart Disease, Type 2 Diabetes Mellitus, and Repeated Falls. 

A HV was conducted on 4/1/25 at 1:00 PM to observe care provided by EI # 7, Physical Therapist Assistant (PTA), 

A review of the medications in the home was conducted with HV # 6 and compared to the CMR dated 4/1/25. The following medication discrepancies were observed:

a. Montelukast 10 mg take one daily, prescription dated 1/3/25, was in the home but not listed on the CMR. HV # 6 confirmed he/she was currently taking the Montelukast daily.

b. Collagen + C (brand name) 2,500 mg over the counter (OTC) bottle was in the home but not listed on the CMR. HV # 6 stated he/she had been taking the vitamin daily for over a year.

c. Quercetin 500 mg OTC bottle was in the home but not listed on the CMR. HV # 6 stated he/she had been taking the vitamin daily for over a year. 

d. Vitamin D 3 (brand name) 200 mg OTC bottle was in the home but not listed on the CMR. HV # 6 stated he/she had been taking the vitamin for over a year.

An interview was conducted on 4/3/25 at 11:05 AM with EI # 1 who confirmed the agency failed to ensure the medications were reconciled per agency policy.

 

2. HV # 2 was admitted on 12/4/2024 and recertified on 2/2/2025 to 4/2/2025 with diagnoses including Parkinsonism Unspecified and Dysphagia, Oropharyngeal Phase.

A HV was conducted on 4/1/25 at 11:20 AM to observe care provided by EI # 3, Occupational Therapist.

A review of the medications in the home was conducted with HV # 2's cg and compared to the CMR dated 4/1/25.

T3 (Liothyronine) 30 mcg (micrograms) / T4 (Levothyroxine) 76 mcg (Methocel) E4M caps with instructions to take one cap each morning. Filled date 3/17/25. The CG reported HV # 2 has been taking the medication for a very long time. There was no documentation of the T3/T4 caps on the agency CMR. 

An interview was conducted on 4/3/25 at 10:31 AM with EI # 1 who confirmed the agency failed to ensure the medications were reconciled per agency policy.

3. HV # 5 was admitted on 2/14/25 with the diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputee and Type Two Diabetes with Diabetic Peripheral Angiopathy with Gangrene.

A HV was conducted on 4/1/25 at 2:02 PM to observe care provided by EI # 6, Health Aide.

A review of the medications in the home was conducted with HV # 5 and the cg and compared to the CMR dated 4/1/25. The following medications were on the CMR, but not in the home:

a. Aspirin 81 mg tablet, delayed release, one tablet daily. HV # 5 stated, I should be taking aspirin, but never started the medication.

b. Farxiga 10 mg tablet one tablet daily. HV # 5 and the cg reported they were unaware of the medication.

c. Miralax 17 gram dose oral powder twice daily. HV # 5 and the cg reported they were unaware of the medication. 

An interview was conducted on 4/3/25 at 10:25 AM with EI # 1, who confirmed the agency failed to ensure the medications were reconciled per agency policy. 

1. HV # 1 was admitted to the agency on 3/7/25 with diagnoses including Cerebral Infarction due to Embolism of Bilateral Carotid Arteries and Nonrheumatic Aortic (Valve) Stenosis. 

A HV was conducted on 4/1/25 at 11:26 AM to observe wound care provided by Employee Identifier (EI) # 2, Speech Therapist.

A review of the medications in the home was conducted with EI # 2 and HV # 1's caregiver (cg) and compared to the Client Medication Report (CMR). The following is a list of the medication discrepancies observed:

a. Atorvastatin 40 milligram (mg) one tablet daily, prescription dated 3/14/25, was in the home. The cg verbalized the patient had been taking the 40 mg dose since returning home on 3/6/25. Atorvastatin 10 mg one tablet at bedtime was on the agency CMR.  

b. Miralax 17 grams daily was on the agency CMR. The cg verbalized Miralax was discontinued three weeks prior. 

c. Omega 3-6-9 1200 mg daily was on the agency CMR. The cg verbalized Omega 3-6-9 was discontinued prior to the patient returning home on 3/6/25. 

An interview was conducted on 4/3/25 at 10:49 AM with EI # 1, Director of Nursing, who confirmed the agency failed to ensure the medications were reconciled per agency policy.