Enhabit Home Health

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to enforce its grievance policy requiring timely review, investigation, and response to patient complaints for one of three inactive patients (Patient #4) in that: Patient #4’s complaints were not documented or investigated until 8 days after Patient #4’s requested discharge from agency.Field staff and supervising nurse were aware, however no timely action was taken to investigate or resolve Patient #4’s complaints.This failure placed Patient #4 at risk of delay in healing and emotional distress. The findings included: RR HHA policy document titled, Patient Rights, revised date 7/23/25, read in part... 2.1.4 Voice grievances (complaints) regarding treatment or care that is furnished…without fear or discrimination or reprisal for doing so 2.1.4.1 that the agency must investigate all complaints 3.3.1.1 During the process of care delivery... Staff members protect and promote the exercise of the patient’s rights RR HHA policy document titled, Patient complaints and grievances dated 11/10/25 read in part... …3.2 The Agency investigates all complaints… 3.3.2.1 Staff reports to the Branch Director care delivery situations, which may indicate patient dissatisfaction 3.3.2.2 Patient or representative complaints. 4.2 The person taking the complaint ..will initiate a complaint form immediately. 4.2.1 Initiates problem-solving process to deal with patient concerns …4.2.1.7 Informs patient that the concern has been investigated and corrective action has been implemented RR of the HHA’s 2025 complaint log on 1/27/26 at 12:45pm. There was no documentation of Patient #4’s complaints logged. RR of clinical record of Patient #4. The clinical record contained POC for the certification period 7/8/25 – 9/5/25 with a SOC date of 7/8/25. The POC included a primary diagnosis of Disruption of Surgical Wound (surgical complication where a previously closed incision reopens), Chronic Pain Syndrome (pain that persists longer than three months), Malignant Neoplasm of Breast (cancer that originates in the breast tissue). Frequency of visits: SN twice a week for 9 weeks The order for discipline frequency noted SN twice a week for 9 weeks. The POC read in part, …SN to perform wound care to abdomen cleanse with normal saline pat and dry well then apply black foam and cover with foam dressing (sponge used in wound care) using clean technique (steps to reduce the number of germs during the dressing change process) twice weekly using pressure vacuum (specialized vacuum cleaner for a wound that removes waste, reduces swelling, and pulls the edges of the wound together). RR revealed SN visits: SOC performed by RN A on 7/8/25, wound care visit performed by RN A on 7/11/25 and wound care visit performed by LVN A on 7/14/25. Patient #4 discharged per Patient #4 request on 7/15/25, discharge summary sent to physician on 7/23/25. RR Patient #4 clinical record revealed a document titled, “Complaint Report” dated 7/23/25 read in part … Identifying Person: RN A., Patient #4.. Description: 1. Both nurses sent to do wound care seemed inexperienced in wound vac dressing applications 2. Clinicians late to appointments, affected care already taken pain pill (for premedication prior to wound care) 3. LVN A said she was not given a wound care kit 4. Nurses asked “How Did the Doctor do parts of the wound care” 5. ADON/CTL referred to doctor, but doctor not involved only NP and PA Intervention: Will discuss with case manager today Prevention: Other Change in Staff Assignment Processed by: Adm Date processed 7/30/25 Patient #4 requested discharge. Discharge completed… Interview conducted on 1/28/26 09:50am with Complainant. Complainant stated that she called the HHA on 7/8/25, 7/11/25, 7/14/25 and 7/15/25 when she spoke with PSC and CTL/ADON. Complainant stated she reported to CTL/ADON that on 7/8/25 RN A had come to admit her only and wound care would be done the next day at the wound care clinic which it was. Complainant stated on 7/11/25 she spoke with CTL/ADON to report that RN A was late, RN A told her that she was late because she was pulled to go to another person, problem was that the complainant had already premedicated for SN wound care and RN A did not call to tell her she would be late. Complainant also reported on the same call that RN A opened five wound care kits to get the tape out to stop the air leak alarm from the wound vac machine (specialized vacuum cleaner for a wound that removes waste, reduces swelling, and pulls the edges of the wound together). Complainant called the HHA after the 7/14/25 SNV of LVN A and spoke with CTL/ADON and told her LVN A arrived with no supplies, and LVN A asked the patient how to perform the wound care because she was new. On 7/15/25 she called the HHA and spoke with PSC and CTL/ADON to report, ..At Patient #4’s pain clinic visit the clinic saw that her (Patient #4) dressing was falling apart and leaking. Complainant further stated that she was upset and disappointed and told the HHA on 7/15/25 that she wanted to terminate because service had not been good and HHA responded ok, thank you, no transfer to DON or BD. Adm reported on 1/27/26 12:45pm that the former BD/DON moved to Canada, and HHA do not have her contact number when surveyor asked for former BD/DON phone number to reach for interview. Interview conducted on 1/28/26 at 5:00pm with RN A. Surveyor asked RN A what Patient #4 complained to her about. RN A stated, Patient #4 complained all the time, not in good mood, complained about times and visits. Surveyor asked RN A why she did not follow the agency complaint and grievance policy to report complaints of Patient #4. RN A stated, I called only the scheduler, but I did not report because I was helping that (branch) office, I worked the other (branch) office when Patient #4 was there. Surveyor asked RN A what the complaint policy. RN A did not answer, RN A responded, Yeah Ok. Interview with LVN A on 1/28/26 at 6:00pm. Surveyor asked LVN A did she notify a supervisor about Patient #4’s concerns. LVN A stated, she told PSC and previous DON after the visit that she would have declined the complex wound. Surveyor asked LVN A why she did not follow the HHA complaint and grievance policy. LVN stated, this was my first week on my own, I called them and told the PSC and scheduler. VPO reported on 1/29/26 11:00am that the former BD/DON moved to Canada, and HHA do not have her contact number when surveyor asked for former BD/DON phone number to reach for interview. Interview with PSC on 1/29/26 at 11:00am. Surveyor asked PSC was call the call on 7/14/25 from LVN A documented or escalated to supervisor the concern of the LVN A and Patient #4 wound care and clinician’s competency. PSC stated that she does not remember and there were no emails or notes from LVN A about Patient #4 complex wound concerns. Interview with Scheduler on 1/29/26 at 11:35 am. Surveyor asked did she recall conversation her and LVN A had on 7/14/25 when she stated client complained about competency of SN staff. Scheduler stated she does not recall, would have to wait on legal to release emails per the vice president of operations. Interview conducted on 1/29/26 at 12:05pm with CTL/ADON. Surveyor asked CTL/ADON if she documented and investigated the complaints per HHA policy. CTL/ADON stated, Patient #4 had a lot of complaints, they were not sensible., Patient #4 did not understand and we tried our best, but she was unreasonable. Surveyor asked were complaints related to care delivery. CTL/ADON stated, I am sure it did not matter what any nurse did...if the nurses came to me and I do not remember…every time I talked to Patient #4 it was her rambling in general…it would be our practice to put a note. Surveyor referred CTL/ADON the HHA’s policy regarding grievance to document and offer resolutions and asked CTL/ADON why this was not done. CTL/ADON stated, that it was the agency’s policy… I knew about it; Patient #4 wore RN A out so that was why we changed to LVN A not because she complained about quality. Interview with Adm on 1/29/26 at 12:35pm. Surveyor asked what the HHA patient complaint policy was. Adm stated, If I am taking the complaint I listen and let the client know I will give them a call back no later than 48 hours. I do not think the policy specifies the 48 hours. I call the clinician to get their side, look in the chart, do research, call the patient, offer resolution, and ask them if they feel it has been resolved.” Surveyor asked Adm why did Patient #4 request discharge from the agency. Adm stated, “we did not know this was a high acuity wound and Patient #4 felt that our nurses were incompetent. Surveyor asked what policy should have been followed. Adm stated, RN A should have called the office and said Hey guys the Patient #4 is saying this and that, CTL/ADON should have documented. Surveyor asked what actions were taken to resolve the client’s concerns prior to discharge. Adm stated, she did not take that complaint, I finished the complaint on 7/30/25. On 7/23/25 RN A called the office, told those complaints, and documented that. I processed it on 7/30/25 after Patient #4 was discharged. Surveyor asked why RN A, LVN A, CTL/ADON, who indicated complaints made during conversations with Patient #4 did not follow the HHA’s complaints and grievance policy. Adm stated, everything should have come up the chain about what was going on, how could we handle Patient #4 better. Surveyor asked Adm was the complaint policy prior to the 7/23/25 dated HHA Complaint policy. Adm stated, investigate and offer resolution.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interviews, the home health agency failed to ensure agency staff provided optimal care to achieve the goals and outcomes identified in the patient’s plan of care for two of five Patients (#2 and #4) with a change in health condition or status, whose clinical records were reviewed, in that: 1. There was no coordination of care with the agency and the physician when Patient #2’s RN A assessed oxygen saturation (amount of oxygen in the blood) of 73% (low) on 1/2/26 SNV. 2. RN A and CTL/ADON did not inform Client #4’s physician until 7/23/25 that Patient #4’s last SN visit was 7/14/25 and that Patient #4 requested discharge on 7/15/25 (8 days later). These deficient practices of not coordinating services with the physician could place patients at risk of receiving inadequate treatment, hypoxia (low oxygen levels), and sepsis (infection of an unattended wound could cause a blood infection). The findings included: RR of document titled, Scope of Services, dated (no date), read in part…The registered nurse …3.4.7 Coordinates services …3.4.8 Informs the physician and other personnel of changes in client’s conditions and needs RR of document titled, Job Description of Clinical Team Leader, dated 11/01/23 signed by ADON on 5/6/25, read in part... …Administrative duties and responsibilities... …5. Process workflow, coordination notes, and administrative tasks timely …11. Review patient schedules…to ensure clinical skills of assigned staff meets patient requirements… …13. Remain up to date…and ensure company policies and procedures, standards of care and practice guidelines are met …Clinical:.. …3. Review and approve patient care assessment coordination notes. Contact physicians… ...11. Review and process vital signs reports; document follow up action and physician notification -Patient #2 RR SOC 11/7/25 certification period 11/7/25 – 1/5/26 certification period 11/7/25 – 1/5/26 revealed diagnosis of Lumbosacral Radiculopathy (condition characterized by pain, numbness, or weakness in the lower back and legs), Rheumatoid Arthritis (pain, swelling and stiffness in the lining of your joints) Asthma (airways narrow and swell may produce extra mucus can make breathing difficult), Chronic Obstructive Pulmonary Disease (lung disease that makes it hard to breathe), Benign Prostatic Hyperplasia (prostate enlarged in size), Prediabetes (blood sugar levels higher than normal)… Licensed Professional to report vital signs falling outside the following established parameters… Oxygen saturation (amount of oxygen in the blood) less than 90%. Frequency of visits: SN 1 time a week for 1 week, 1 time every two weeks for two weeks, 1 time a week for 6 weeks and PT 1 time a week for 1 week, 2 times a week for three weeks and 1 time a week for 4 weeks… Medications: Ipratropium 0.5 mg – Albuterol (medication for breathing problems) 3 mg (2.5 mg base)/3ml Inhalation (fine mist breathed into lungs through a mouthpiece or face mask) Reason: COPD (lung disease that makes it hard to breathe), Asthma (airways narrow and swell may produce extra mucus can make breathing difficult) RR of SNV dated 1/2/26 Narrative of RN A read in part… oxygen saturation reading of 73% (low), has secretions (thick, sticky liquid produced by your lungs and throat), some wheezing (whistling sound heard when lung airways are narrowed) over right lung, called 911, arrived, I placed nebulizer (machine that delivers fine mists of medication) with Albuterol (medication used to open lungs making it easier to breathe), oximeter (device that reports oxygen level in the body) 99%, felt better did not go to emergency room RR of SNV performed by RN A dated 1/2/26 revealed RN A called 911 for oxygen saturation reading of 73% (low). Adm reported on 1/27/26 12:45pm that the former BD/DON moved to Canada, and HHA do not have her contact number when surveyor asked for former BD/DON phone number to reach for interview. Interview with RN A on 1/28/26 at 5:00 pm. Surveyor asked RN A did she notify physician of 73% oxygen saturation on the 1/2/26 SNV. RN A stated she called the physician, but the SNV was after 5pm. Surveyor asked RN A why she did not follow up to report to physician oxygen saturation less than 90% and that she called 911. RN A stated, nebulizer treatment (fine medicine mist of Ipratropium-Albuterol breathed into lungs through a face mask used for breathing problems) brought oxygen saturation up to 99% and Patient #2 did not need to go to emergency department. Continued interview with RN A on 1/28/26 at 5:00 pm. Surveyor asked if she notified the physician of oxygen saturation of 73%. RN A stated, she did call the doctor, but no one answered. Surveyor asked RN A what the HHA policy was to notify the physician. RN A stated the staff was to call the doctor, leave a message and document in our clinical note and email manager to wait for reply from the doctor. Surveyor asked where the documented physician notification would be since no note was found in clinical record. RN A stated she did not see the clinical note in the client record. Surveyor asked RN A why she did not follow through with the POC to report oxygen saturation less than 90% which was 73%. RN A stated, she should have notified CTL/ADON, but I do not see it in the clinical record, I do not know why. Surveyor asked RN A what harm could occur to client when agency did not report less than 90% oxygen saturations. RN A did not answer and then stated, “I called and notified the CTL/ADON.” VPO reported on 1/29/26 11:00am that the former BD/DON moved to Canada, and HHA do not have her contact number when surveyor asked for former BD/DON phone number to reach for interview. Interview with CTL/ADON conducted on 1/29/26 at 12:05pm with CTL/ADON. Surveyor asked whether she received a call from RN A during SNV on 1/2/26 for Patient #2 and followed the POC to notify physician. CTL/ADON stated, she remembered telling RN A to send Patient #2 to the hospital. CTL/ADON stated she would have written a clinical note; but she did not see any notes. Surveyor asked why the physician was not notified according to POC for saturation less than 90%. The CTL/ADON stated if it was after 5pm, RN A should notify the physician. Surveyor asked what systems failed if physician was not notified as ordered in the POC for oxygen saturation less than 90%. CTL/ADON stated, if it was not done it should be an incident report. Surveyor asked if there was any documentation sent to the physician of the 1/2/26 SNV when RN A called 911 regarding saturation less than 90%. CTL/ADON stated, there was none. Surveyor asked potential harm for Patient #2’s oxygen saturation less than 90% and physician was not notified. CTL/ADON stated, the doctor cannot make decisions, cannot determine what was going on to tell the client to come in. Surveyor asked was it her responsibility to ensure RN A followed the POC. CTL/ADON stated, yes. Interview with Adm conducted on 1/29/26 at 12:35pm. Surveyor asked Adm what administrative systems were in place to ensure policies related to emergency escalation, and physician notification as ordered in the POC were implemented. Adm stated, there would have been a vital sign report that would have been faxed to the physician of the oxygen saturation of 73% in the coordination notes. Surveyor advised Adm the clinical record did not indicate this, RN A nor CTL/ADON notified the physician. Adm stated, if it was done it would be in the coordination notes and that gets sent to the physician, if RN A had documented 73% it would have prompted a care coordination note but she resolved it with the nebulizer treatment and oxygen went up to 99%. Surveyor asked what agency policies failed to ensure POC followed. Adm stated, this was a person failure, people did not follow, they all have the orientation and education, have the resources at hand, just not wanting to let the office know they do not know what they were doing. Surveyor asked potential harm of Patient #2 in physician not notified. Adm did not answer then stated, the saturation bounced back after the nebulizer but there should have been a notification to physician about the 73%. -Patient #4 RR SOC on 7/8/25 for the certification period 7/8/25 – 9/5/25 revealed diagnosis of Disruption of Surgical Wound (surgical complication where a previously closed incision reopens), Chronic Pain Syndrome (pain that persists longer than three months), Malignant Neoplasm of Breast (cancer that originates in the breast tissue). Frequency of visits: SN twice a week for 9 weeks The order for discipline frequency noted SN twice a week for 9 weeks. The POC read in part, SN to perform wound care to abdomen cleanse with normal saline pat and dry well then apply black foam and cover with foam dressing (sponge used in wound care) using clean technique (steps to reduce the number of germs during the dressing change process) twice weekly using pressure vacuum (specialized vacuum cleaner for a wound that removes waste, reduces swelling, and pulls the edges of the wound together) RR revealed SN visits: SOC performed by RN A on 7/8/25, wound care visit performed by RN A on 7/11/25 and wound care visit performed by LVN A on 7/14/25. RR revealed Patient #4 was discharged (patient no longer received services or care from agency) on 7/23/25. Interview conducted on 1/29/26 at 12:05pm with ADON/CTL. Surveyor asked if there was potential harm in discharging a client with a complex wound with last SNV on 7/14/25 and physician was not notified until 7/23/25. ADON/CTL did not answer and then stated, the Patient (#4) let the wound care clinic know. Interview with Adm 1/29/26 at 12:35 pm. Survey asked Adm what care coordination occurred with the physician for Patient #4. Adm stated, she believeed that the CTL/ADON put in the coordination note, she had spoken to the physician on the phone. CTL/ADON would have faxed a coordination note or should have faxed coordination to the physician if this is what happened that discharged per Patient #4 request on 7/15/25, within 48 hours we should have called and faxed the discharge summary of care and why we discharged the patient. Adm went on to state, the episode summary report was to be sent to the physician within 48 hours internally not in the electronic medical record, if there was a coordination note on 7/23/25 that was when the Dr was notified since the fax generated that note. Adm stated, there was no fax to MD before 7/23/25. Surveyor asked risk of harm for Patient #4 with complex wound discharged on 7/15, last SNV 7/14/25, physician not notified until 7/23/25. Adm stated, Patient #4 could get infected, get sepsis, and die that was the potential.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Findings included: RR of document titled, Job Description of Clinical Team Leader dated 11/01/23 signed by ADON on 5/6/25, read in part... …Clinical: …11. Review and process vital signs reports; document follow up action and physician notification RR of Patient #2 clinical record revealed a SOC on 11/7/25 for certification period 11/7/25 – 1/5/26, diagnosis of Lumbosacral Radiculopathy (condition characterized by pain, numbness, or weakness in the lower back and legs), Rheumatoid Arthritis (pain, swelling and stiffness in the lining of your joints) Asthma (airways narrow and swell may produce extra mucus can make breathing difficult), Chronic Obstructive Pulmonary Disease (lung disease that makes it hard to breathe), Benign Prostatic Hyperplasia (prostate enlarged in size), Prediabetes (blood sugar levels higher than normal)… Licensed Professional to report vital signs falling outside the following established parameters…Oxygen saturation (oxygen in the body) less than 90%. Frequency of visits: SN 1 time a week for 1 week, 1 time every two weeks for two weeks, 1 time a week for 6 weeks and PT 1 time a week for 1 week, 2 times a week for three weeks and 1 time a week for 4 weeks… RR of SNV performed by RN A dated 1/2/26 revealed RN A called 911 for oxygen saturation reading of 73% (very low) and MD was not notified of oxygen saturation outside of the given parameter (oxygen saturation less than 90%). During Interview with RN A on 1/28/26 at 5pm. Surveyor asked RN A did she notify physician of 73% oxygen saturation on the 1/2/26 SNV. RN A stated she called the physician, but the SNV was after 5pm. Surveyor asked RN A why she did not follow up to report to physician oxygen saturation less than 90% and that she called 911. RN A stated, nebulizer treatment brought oxygen saturation up to 99% and patient did not need to go to emergency department. Surveyor asked RN A was the physician notified of Patient #2’s oxygen saturation of 73%. RN A stated, yes she did call the doctor, but no one answered. Surveyor asked RN A what the HHA policy was to notify the physician. RN A stated we call the doctor, leave a message and document in our clinical note, and email the manager to wait for reply from the doctor. Surveyor asked where the documented physician notification would be since note in the clinical record review. RN A stated she does not see the clinical note in the client record. Surveyor asked RN A why she did not follow through with the POC to report oxygen saturation less than 90% which was 73%. RN A stated, I just had to notify CTL/ADON, but I do not see it in the clinical record, I do not know why. Surveyor asked RN A if harm to patient could occur when the agency does not report less than 90% oxygen saturations. RN A did not answer and then stated, I had to notify CTL/ADON. During interview conducted on 1/29/26 at 12:05pm with ADON/CTL. Surveyor asked whether a call from RN A from Patient #2’s home for supervisory support documented. ADON/CTL stated, yes I remember telling her to send Patient #2 to the hospital. I would have put a clinical note; I do not have any notes. Surveyor asked why the physician was not notified according to POC for saturation less than 90%. The ADON/CTL stated if it was after 5pm…RN A should do it to notify physician. Surveyor asked why the physician was not notified as ordered in the POC for oxygen saturation less than 90%. ADON stated, it was not done so it should be an incident report. Surveyor asked if there was any documentation sent to the physician of the 1/2/26 SNV when RN A called 911 regarding saturation less than 90%. ADON/CTL reported, none. Surveyor asked what the potential harm for Patient #2’s oxygen saturation less than 90% and physician was not notified. ADON/CTL stated, the doctor cannot make decisions, cannot determine what was going on to tell the client to come in. Interview with Adm conducted on 1/29/26 at 12:35pm. Surveyor asked Adm what administrative systems were in place to ensure policies related to emergency escalation, and physician notification as ordered in the POC were implemented. Adm stated, there would have been a vital sign report that would have been faxed to the physician of the oxygen saturation of 73% in the coordination notes. Surveyor advised Adm the clinical record did not indicate this, RN A nor CTL/ADON notified the physician. Adm stated, if it was done it would be in the coordination notes and that gets sent to the physician. Adm went on to state, If RN A had documented 73% it would have prompted a care coordination note, but RN A resolved it with the nebulizer treatment and oxygen went up to 99%. Surveyor asked what agency policies failed to ensure POC followed. Adm stated, this was a person failure, people did not follow, they all have the orientation and education, have the resources at hand, just not wanting to let the office know they do not know what they were doing. Surveyor asked potential harm of Patient #2 in physician not notified. Adm did not answer then stated, the saturation bounced back after the nebulizer but there should have been a notification to physician about the 73%.”