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)
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 medical record (MR) review, observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure agency policy for infection prevention was followed. 

This deficient practice affected one of seven home visit (HV) patients including HV # 7 and had the potential to affect all patients receiving wound care. 

Findings include:

Agency Policy: Hand Washing Indications

Policy Number: 11160.20

Revised: 2/2022

Section 1: Purpose/Objective

1.1 To prevent nosocomial infections...

...4.6 Employees should sanitize their hands before and after touching inanimate sources that are likely to be contaminated with virulent or infections microorganisms...

 


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.

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

EI # 8 performed hand hygiene, donned gloves, retrieved measuring tape, cotton swab, and marking pen from clean barrier, then dropped the marking pen onto the floor. EI # 8 picked up the marking pen with a gloved hand then continued to measure the open wound with the measuring tape and cotton swap. 

EI # 8 failed to remove gloves and perform hand hygiene after touching contaminated surface. 

An interview was conducted on 4/3/25 at 10:30 AM with EI # 1, Director of Nursing, who confirmed the agency failed to ensure the agency policy for infection prevention was followed.