| 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) |
| G0590 | Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure the physician was notified of significant changes. This deficient practice did affect two of seven Home Visit (HV) patients including HV # 7 and HV # 6, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Physician Notification and Physician Orders Policy Number: Not Listed Revised: 2/2025 Section 1: Purpose/Objective 1.1 To ensure that the physician is notified of all changes in patient status ... Section 4: Procedure ...4.2 Reasons to obtain a new order, or provider physician notification, will include but are not limited to the following: ...e. Change in patient status and/or need for additional services. ...g. Any parameters outside those listed above... 1. HV # 7 was admitted on 2/3/25 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, and Type 1 Diabetes Mellitus with Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/23/25 revealed physician's orders for Skilled Nurse (SN) three visits per week for one week then two visits per week for seven weeks. SN to assess/evaluate co-morbid conditions including ... Diabetes Mellitus... Further review of the HHC and POC dated 2/23/25 revealed physician's orders for SN to perform blood sugar analysis every visit and to report to the physician blood glucose levels greater than 250 milligrams (mg)/decaliter (dl) or less than 70 mg/dl. Review of the SN Visit Note Report dated 3/4/25 revealed the SN documented the blood sugar reading was 435 mg/dl, patient asymptomatic. There was no documentation the physician was notified. An interview was conducted on 4/3/25 at 10:30 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to ensure the physician was notified. 2. HV # 6 was admitted on 3/10/25 with diagnoses including Atherosclerotic Heart Disease, Type 2 Diabetes Mellitus, and Repeated Falls. Review of the HHC and POC dated 3/10/25 revealed physician's orders for Physical Therapist (PT) two visits per week for four weeks. Review of the PTA Visit Note Report dated 4/1/25 revealed the patient's last bowel movement was on 3/27/25, which was greater than 3 days. Instructions under the Gastrointestinal section was to notify the Nurse Supervisor if greater than three days. Further review of the PTA Visit Note Report dated 4/1/25 revealed no documentation the physician was notified of the no bowel movement of greater than three days. An interview was conducted on 4/1/25 at 1:05 PM with EI # 1, who confirmed the agency failed to ensure the physician was notified of no bowel movement greater than three days. |