Every finding on record at Cardinal Home Healthcare Solutions, Inc.

Emergency Preparedness Survey At the time of the emergency preparedness survey completed on 07/29/22, Cardinal Home Healthcare Solutions is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey An entrance conference was conducted with administrative staff on 07/26/22 at 11:00 AM, an exit conference was conducted with administrative staff on 07/29/22 at 10:30 AM. The following deficiencies are based on the partial extended recertification survey completed on 07/29/22. Cardinal Home Healthcare Solutions 368094, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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 medical record review, facility policy review, observation and patient and staff interview, the home health agency failed to ensure staff nurses conducted a review of all medications for three of seven patients reviewed (Patient #1, Patient #2, and Patient #3). The agency's census was 88 patients. Findings include: 1. The medical record of Patient #1 was reviewed on 07/27/22. Patient #1 was admitted for services of the agency on 10/08/21 with diagnoses that included cutaneous abscess of groin, peripheral vascular disease, hypertension, and amputation of left leg below the knee. The skilled nurse had orders for twice a week for one week and three times a week for eight weeks. The certification period reviewed was 06/29/22 through 08/27/22. Bactrim 400 milligrams (mg)-80 mg (antibiotic) one tablet every 12 hours for 30 days by mouth was listed on the plan of care as an active medication. The medication profile noted a start date of 06/28/22 for this medication. The plan of care also listed Synthroid (medication that helps restore thyroid levels) 50 micrograms (mcg) one tablet by mouth daily. A skilled nurse home visit was conducted on 07/27/22 at 3:00 PM. During the home visit, the patient's medications were reviewed. A bottle of medication labeled Bactrim was noted. The bottle was full. The patient was asked if she was aware of what the medication was used for and she replied: "I think this is supposed to improve my appetite." The patient stated that she had not taken any of the prescribed medication because she did not feel there was anything wrong with her appetite. The staff registered nurse (Staff C) explained to the patient that the medication was an antibiotic used to treat an infection. Further review of the patient's medications revealed there was no Synthroid. The patient was asked if she was currently taking Synthroid and the patient replied that she was not taking this medication. 2. The medical record of Patient #2 was reviewed on 07/26/22. Patient #2 was admitted for services of the agency on 05/19/22 with diagnoses that included type 2 diabetes mellitus, nicotine dependence, hypertension, and major depressive disorder. The skilled nurse had orders for a visit once a week for nine weeks. The certification periods reviewed were 05/19/22 through 07/17/22 and 07/18/22 through 09/15/22. Symbicort (bronchodilator) 160 mcg 4.5 mcg two puffs twice a day was ordered on both plans of care. Albuterol (bronchodilator) 90 mcg two puffs every 4-6 hours as needed was also an active medication listed on the plan of care and the medication profile. A skilled home visit was conducted on 07/27/22 at 10:30 AM. A review of the patient's medications was conducted during the visit. The patient was asked if she used any inhalers. Although the patient retrieved an Albuterol inhaler from a kitchen drawer, there was no Symbicort noted in the home. The patient reported that she had not used this medication for more than a year. 3. The medical record of Patient #3 was reviewed on 07/28/22. Patient #3 was admitted for services of the agency on 04/30/15 with diagnoses that included type 2 diabetes and bilateral amputations above the knee. The home health aide had orders for visits three times a week for one week, seven times a week for seven weeks, and once a week for one week. The skilled nurse had orders for a visit once every 60 days. The certification period reviewed was 07/22/22 through 09/19/22. There was no medication for pain listed on the plan of care or as an active medication or discontinued medication on the medication profile. A home health aide home visit was conducted on 07/27/22 at 8:00 AM. The patient's medications were reviewed during the visit. The patient was asked if she had been prescribed any medication for pain and she replied that she took Percocet for phantom pain from bilateral amputations. The patient stated she had been taking Percocet for approximately one year. The undated agency policy titled, Medication Profile, was reviewed on 07/27/22 at 4:20 PM. According to the policy the registered nurse or therapist is required to complete a medication profile for each patient at the time of admission. A complete list of all medications the patient is taking and an evaluation of the patient's knowledge of the effects of these medications should be documented. The provider should be promptly notified of any identified problems. Staff B was interviewed on 07/28/22 at 11:00 AM. It was confirmed the medications listed on the client medication reports for Patient #1, Patient #2, and Patient #3 did not match medications observed in the home.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on QSO memo 22-09-ALL REVISED, staff vaccination record review, facility policy review, and staff interview, the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. The active census was 88. Findings include: Review of QSO memo 22-09-ALL REVISED, dated 01/14/22 and revised 04/05/22, revealed within 30 days of issuance of this memorandum, the home health agency must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Review of staff vaccination records revealed 100% of staff were vaccinated. Staff B was interviewed on 07/26/22 at 11:55 AM and asked to provide the facility policy for COVID-19 vaccination. The undated agency policy titled, Cardinal Home Healthcare Solutions - COVID-19 Policy, was reviewed on 07/28/22 at 11:53 AM. According to the policy, the home health agency will ensure employees wear face masks or a higher level of respiratory protection. In order to minimize the spread of COVID-19, the agency instituted various housekeeping, social distancing, and other practices that all employees are required to follow. Additionally, employees are expected to report to their managers if they are experiencing signs and symptoms of COVID-19. The word vaccination did not appear in the policy. Staff B was interviewed on 07/28/22 at 3:00 PM. Staff B stated this policy was created at the beginning of the COVID-19 pandemic and there had been no policy created to address vaccination. Staff A and Staff B were interviewed on 07/28/22 at 4:00 PM. It was confirmed that the agency lacked policies and procedures as described in the QSO memo.