Cardinal Home Health Services Inc

The home health agency failed to ensure: the initial assessment was completed within 48 hours of referral (see tag G0514); the comprehensive assessment was completed within 5 days of the SOC (see tag G0520); the comprehensive assessment included the patient’s current health status (see tag G0528)…

The home health agency failed to ensure: the POC was reviewed by the physician, individualized and followed by all agency staff (See tag G0572), the POC included all required information / elements for the treatment of the patient (See tag G0574), all treatments provided by agency staff were…

The agency failed to ensure a process for collaboration and cooperation with local, state, and federal emergency preparedness officials in an effort to maintain an integrated response during an emergency.

The agency failed to ensure the communication plan included contact information for the physicians and all services provided under arrangement.

The agency failed to conduct exercises to test the emergency plan at least annually.

The agency failed to electronically transmit the completed Outcome and Assessment Information Set (OASIS) assessment to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of the completion of the patient assessment in 1 of 3 active clinical records reviewed with skilled…

The agency failed to ensure patients comprehensive assessment was updated, including collection of OASIS data elements, when patients' status deteriorated and developed a stage II wound, for 1 of 1 active record reviewed who received SN, PT, and OT services and was admitted without a documented…

The agency failed to develop the POC in conjunction with the physician and failed to provide services as directed in the POC in 5 of 5 active clinical records reviewed.

The agency failed to ensure the Governing Body approved the frequency and detail of the data collection and utilized quality indicator data from the OASIS Outcome and Assessment Information Set (OASIS) for the Quality Assessment Performance Improvement (QAPI) program.

The agency failed to ensure performance improvement activities focused on high risk and problem-prone areas.

The agency failed to ensure the HHA completed 12 hours of in-service training in a 12-month period for 3 of 3 HHA personnel records reviewed out of a total 3 HHA actively employed with the agency.

The agency failed to ensure the staff documented timely, into the clinical record, in 3 of 5 active clinical records reviewed.

The agency failed to ensure the patient was informed of and consent to care in advance of treatment and with any changes in care in 5 of 5 active clinical records reviewed.

The agency failed to conduct an initial assessment visit within 48 hours of the referral in 1 of 3 active clinical records reviewed with a SOC since 12/01/2024. (Patient #1) The findings include: A clinical record review for Patient #1 evidenced the Patient was referred on 12/20/2024 and the…

The agency failed to ensure the comprehensive assessment was completed within 5 days of the SOC in 1 of 1 active clinical record reviewed with OT services ordered at SOC since 01/01/2025. (Patient #5) The findings include: A clinical record review for Patient #5 evidenced a SOC physician order…

The agency failed to complete a comprehensive assessment to include the status of the wound in 1 of 1 active clinical records reviewed with a urinary catheter (a plastic tube inserted into the bladder to drain urine).

The agency failed to ensure the comprehensive assessment included a review of the medications to include drug interactions in 1 of 3 active clinical records reviewed with a SOC since 12/01/2024. (Patient #1) The findings include: A clinical record review for Patient #1 evidenced a SOC comprehensive…

The agency failed to ensure the comprehensive assessment included the assessment of the primary caregiver’s ability, willingness, and availability to provide care in 3 of 4 active clinical records reviewed with wounds.

The agency failed to ensure the POC was developed to include all the safety precautions, interventions, and measurable goals in 5 of 5 active clinical records reviewed.

The agency failed to ensure care was provided as directed by a physician in 2 of 4 active clinical records reviewed with a wound.

The agency failed to coordinate care with all healthcare providers providing care in 1 of 1 clinical record reviewed with another home care company providing care (Patient #1) and in 1 of 1 clinical record reviewed with a LPN providing services (Patient #2).

The agency failed to ensure the HHA provided services as directed in the care plan in 1 of 2 active clinical records reviewed with HHA services.

The agency failed to ensure the HHA was supervised no less frequently than every 14 days when HHA services were provided along with skilled services in 1 of 2 active clinical records reviewed with HHA services.

The agency failed to ensure the HHA supervision included the HHA followed the aide care plan in 1 of 2 active clinical records reviewed with HHA services.

The agency failed to provide to the physician the discharge summary within 5 business days of discharge from the agency in 2 of 2 closed records reviewed.

The agency failed to develop and implement individualized emergency preparedness plans for the patients which provided appropriate instructions, in the event of an emergency in 5 of 5 active clinical records reviewed.

The agency failed to ensure the plan of care was individualized and services were provided to the patient as directed in the plan of care in 3 of 5 active clinical records reviewed.

The home health agency failed to ensure all employees practiced standard/universal precautions to prevent the transmission of infections and failed to follow agency infection control policies and procedures in 2 of 3 home visits.

The home health agency failed to ensure the home health aides had complete, patient-specific written patient care instructions to be performed by the home health aides in 3 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure the entries in the clinical record were signed and dated in 4 of 7 clinical records reviewed.

The agency failed to ensure the patient was discharged because the physician responsible for the plan of care and the agency agreed the measurable goals and outcomes set forth in the plan of care had been achieved in 1 of 1 closed clinical record reviewed with a discharge reason of goals met.

The agency failed to ensure the comprehensive assessment reflected the patient’s current health status in 1 of 2 clinical records reviewed with a comprehensive assessment completed after 4/1/2022. (#4) The findings include: Review of an agency policy obtained 4/19/2022, titled “Initial…

The agency failed to ensure the patient’s medication was reviewed to identify any potential adverse effects, drug interactions, and duplicative drug therapy in 2 of 5 active clinical records reviewed.

The agency failed to ensure the plan of care was individualized to include all medications, services, nutritional requirements, treatments, and patient-specific interventions in 5 of 5 active clinical records reviewed.

The agency failed to ensure treatments and services were provided as ordered by the physician in 2 of 5 active clinical records reviewed.

The agency failed to ensure the plan of care was revised to reflect the patient’s current status in 1 of 3 active clinical records reviewed with wounds.

The agency failed to coordinate care of services provided to the patient in 4 of 5 active clinical records reviewed.

The agency failed to provide the patient and caregiver in writing with a copy of the visit schedule to include the personnel acting on behalf of the agency in 2 of 3 home visits conducted.

The agency failed to provide the patient and caregiver in writing with a copy of the medication schedule and instructions in 2 of 3 home visits conducted.

The agency failed to provide the patient and caregiver in writing with the treatments to be administered by agency personnel in 1 of 3 home visits conducted.

The physical therapist (PT) failed to develop the plan of care in 1 of 1 active clinical record reviewed with PT services.

The agency failed to ensure the skilled nurse provided services as ordered by the physician in the plan of care in 3 of 5 active clinical records reviewed.

The skilled nurse failed to accurately prepare clinical notes in 3 of 5 active clinical records reviewed (#3, #4, #6).

The home health aide failed to report changes in the patient’s condition to a registered nurse or other appropriate skilled professional in 1 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure the clinical record contained clinical notes for 2 of 5 active clinical records reviewed.

The home health agency failed: to develop and maintain an emergency preparedness plan which included a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or…

The home health agency failed to ensure: the plan of care was reviewed by the physician, individualized and followed by all agency staff (See tag G0572); the plan of care included all required information / elements for the treatment of the patient (See tag G0574); services and treatment were…

The quality assurance and performance improvement (QAPI) program: failed to ensure the performance improvement activities considered incidence, prevalence and severity of problems (see tag G0650); failed to ensure the performance improvement activities lead to an immediate correction of any…

The home health agency failed to ensure: the agency followed accepted standards of practice for standard/universal precautions to prevent the transmission of infections (see tag G0682); staff was educated on infection control (see tag G0686); and policies and procedures were developed and…

The skilled professional failed to ensure the following: failed to develop and evaluate the plan of care (See tag G0708); failed to provide the services as indicated in the plan of care (See tag G0710); failed to provide the patient and caregiver education (See tag G0714); failed to prepare…

The home health agency failed to ensure: all home health aide care plans were completed and contained frequency of tasks to be performed (See tag G0798); all home health aides followed the aide care plan tasks developed by the skilled professional (See tag G0800); all home health aides reported…

The agency failed to ensure an emergency preparedness plan was developed and maintained to include a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency…

The agency failed to ensure a policy included the agency must inform state and local officials of on-duty staff and patients that are unable to be reached in the event of an emergency.

The agency failed to ensure a policy included a system for medical documentation that preserves patient information, protects patient confidentiality, and secures and maintains availability of records in the event of an emergency.

The agency failed to ensure a policy included the use of volunteers or other emergency staffing in the event of an emergency.

The agency failed to ensure the communication plan included names and contact information for staff in the event of an emergency.

The agency failed to ensure the communication plan included a method for sharing information and medical documentation for patients under the agency’s care with other health care providers to maintain continuity of care, and in the event of an evacuation, a means of releasing patient information…

The agency failed to conduct exercises to test the emergency preparedness plan at least annually.

The agency failed to ensure the OASIS (Outcome and Assessment Information Set, a comprehensive assessment data collection tool) accurately reflected the patient’s status in 2 of 5 active clinical records reviewed.

The agency failed to ensure the comprehensive assessment was updated and revised to include new wounds in 1 of 3 active clinical records reviewed with wounds.

The home health agency failed to ensure the performance improvement activities analyzed the causes of adverse patient events and implemented preventive actions.

The home health agency failed to document a performance improvement project.

The agency failed to ensure staff was educated on infection control.

The agency failed to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19. The findings include: Review of an untitled binder on 2/14/2022 the alternate administrator identified as the infection program binder, evidenced an untitled, undated document…

The registered nurse (RN) failed to provide supervision of the licensed practical nurse (LPN) in 3 of 3 active clinical records reviewed with services provided by a licensed practical nurse.

The clinical manager failed to provide oversight of the storage of medication used to provide tuberculosis (TB; a contagious bacterial infection usually affecting the lungs) skin tests and influenza vaccination to agency personnel.

The agency failed to ensure the patients were provided the name of the administrator to receive complaints in 3 of 3 home visits conducted.

The agency failed to ensure the patient was informed of and consented to care in advance of the frequency of visits and changes in the care to be furnished in 2 of 7 clinical records reviewed.

The agency failed to ensure the patient was discharged because the patient refused services in 1 of 1 closed clinical record reviewed with a discharge reason of patient requested discharge.

The agency failed to ensure a registered nurse (RN) conducted the initial assessment to determine the immediate care and support needs of the patient in 1 of 1 partial clinical record reviewed.

The agency failed to ensure the clinician receiving the physician's verbal orders documented the order in the patient's clinical record to include a signature, date and time of the order and failed to ensure the verbal orders were authenticated and dated by the physician in 1 of 7 clinical records…

The agency failed to ensure the plan of care was reviewed by the physician responsible for the plan of care no less than every 60 days in 4 of 5 clinical records reviewed receiving agency services for at least 60 days.

The agency failed to ensure the physician was notified of changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or the plan of care should be altered in 4 of 7 clinical records reviewed.

The agency failed to ensure revisions to the plans for patient discharge were communicated to the physician responsible for the plan of care in 2 of 2 closed clinical records reviewed.

The agency failed to provide the patient and caregiver in writing with the name and contact information of the clinical manager in 3 of 3 home visits conducted.

The home health agency failed to ensure the performance improvement activities considered incidence, prevalence, and severity of problems.

The home health agency failed to ensure the performance improvement activities lead to an immediate correction of any identified problem that directly or potentially threatens the health and safety of patients.

The home health agency failed to measure the success of the performance improvement activities and track performance to ensure that improvements are sustained.

The licensed practical nurse (LPN) failed to educate the patient and caregiver on swelling and wound prevention measures in 2 of 3 active clinical records reviewed with services provided by a LPN.

The licensed practical nurse (LPN) failed to communicate with the physician with a patient’s change in status in 2 of 3 active clinical records reviewed with services provided by a LPN.

The agency failed to ensure skilled professionals participated in the agency’s quality assurance performance improvement (QAPI) program.

The home health agency failed to ensure the home health aides provided services that were ordered by the physician, included in the plan of care, and consistent with the aide care plan in 3 of 3 active clinical records reviewed with home health aide services.

The agency failed to ensure the home health aide (HHA) was supervised to ensure the aides furnished care that followed the patient’s plan of care in 1 of 3 active clinical records reviewed with home health aide services.

The administrator failed to be responsible for the day-to-day operations of the agency.

The clinical manager failed to provide oversight of patient and personnel assignments.

The home health agency failed to ensure the discharge summary was sent to the primary care physician in 1 of 2 active clinical records reviewed with a prior discharge from the agency (#5) and 2 of 2 closed clinical records reviewed.