E E Cornerstone Home Health Inc.

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document PIP(s) annually, for one (2022) of three years reviewed for PIP(s), that reflected the scope, complexity and past performance of the agency’s services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to patient health and safety concerns. Findings include: During the entrance conference interview on 07/14/2025 10:00 a.m., the surveyor requested all agency QAPI documents/reports/manuals. Review of agency’s undated QAPI manuals revealed the following: A PIP with a date identified of 01/19/2023. Review of the PIP revealed it was initiated for the agency not completing discharge summaries. Continued review of the PIP revealed an evaluation of the PIP was completed on 12/21/2023. A PIP with a date identified of 01/19/2024. Review of the PIP revealed that it was initiated for patient individualized plans of care. Continued review of the PIP was reviewed on 12/21/2024. Further review of the agency’s QAPI records did not reveal documentation that indicated the agency had: any quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress on achieving the projects for the calendar year of 2022. During an interview with the Admin/DON on 07/18/2025 at 3:58 p.m. the surveyor reviewed the findings and asked who was responsible for conducting the PIP(s). The Admin/DON replied, “Me.” The surveyor asked what the agency’s process was for conducting and documenting the projects. The Admin/DON stated that the agency reviewed the agency records and see what needed to be “done;” then the agency started “there” to initiate a solution. The surveyor asked why the agency had not conducted PIP(s) per federal regulatory requirements (to conduct and document the projects) for year 2022. The Admin/DON looked in the binders and stated, “I don’t know how I could have missed that.” The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON replied, “We don’t know exactly what is going on with the patient and we won’t know how to fix it in order to prevent complications.” Review of agency policy titled, “Quality Assessment Performance Improvement Plan” dated 01/29/2020 read in part: “...Performance Improvement Projects...The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects...””

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 6 and 7) of two inactive patient records reviewed. The agency failed to provide Patients # 6 and 7 with the Centers for Medicare and Medicaid form titled “Notice of Medicare Non-Coverage (NOMNC)”. The failure placed the patient’s health and safety at risk and could result in harm due to lack of consistent and continuing care in the patient’s post discharge needs. The failure caused the clients to not have written advance notice to appeal the discharge decision if desired. Findings include: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 6 as 01/24/2025 and Patient # 7 as 10/21/2025. Inactive Clinical Record # 6: Record review of the hard copy clinical record and EHR for Patient # 6 revealed an individualized POC with a SOC date of 07/29/2022. The POC had a certification period 11/26/2024 to 01/24/2025 and a primary diagnosis of hypertension (high blood pressure). The POC was signed by the Alt Admin/DON and dated 11/25/2024. Record review of the clinical records for Patient # 6 revealed a POC for the certification period of 08/26/2023 to 10/24/2023. Review of the POC revealed a start of care date of 08/22/2022 with a principal diagnosis of hypertension (high blood pressure). The POC contained an order for skilled nursing visits one time per week for nine and two as needed visits. Continued review of the records revealed a discharge summary and OASIS (outcome and assessment information set) signed by the Admin/DON and dated 01/24/2025. Review of the discharge summary revealed that Patient # 6 was discharged from the agency with “Condition at discharge: Needs Assistance. Goals not met…” Continued review of the discharge summary revealed that the reason for discharge was a change in health maintenance organization insurance. Further review of Patient # 6’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 01/24/2025. The record did not include a written NOMNC. Inactive Clinical Record # 7: Record review of the hard copy clinical record and EHR for Patient # 7 revealed an individualized POC with a SOC date of 09/06/2022. The POC had a certification period 08/26/2024 to 10/24/2024 and a primary diagnosis of bilateral primary osteoarthritis of knee (a joint condition where the cartilage in both knees wears away and causes pain, stiffness, and limited movement). The POC was signed by the Alt Admin/DON and dated 10/21/2024. The POC contained orders for skilled nursing interventions but did not include the frequency and duration of visits to be made. Continued review of the records revealed a discharge summary signed by the Admin/DON and dated 10/21/2024. Review of the discharge summary and OASIS revealed reveal the reason for discharge was for a change in health maintenance insurance and the “patient health status unchanged. Goals unmet.” Further review of Patient # 7’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 10/21/2024. The record did not include a written NOMNC. During an interview on 07/18/2025 at 4:15 p.m. with the Admin/DON, the surveyor reviewed the findings and asked who at the agency was responsible for providing the discharge notices. The Admin/DON stated she was responsible. The surveyor asked why the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6 and 7. The Admin/DON stated that she thinks it was because they had health maintenance organization insurance. Review of agency policy titled, “Patient Discharge” dated 01/29/2020 read in part: “ ...The Agency will deliver the Notice of Medicare Non-Coverage…to the patient (or representative), at least 2 calendar days before Medicare covered services end or the second to last day of service if care is not provided daily...””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure that the individualized plan of care for five (Patients # 1, 3, 4, 5, and 7) of seven records reviewed included the frequency and duration of visits to be made. The failure placed the patients at risk to have missed visits and to not receive necessary care and services to maintain their health and safety. Findings include: Patient # 1: Record review of the hard copy clinical record and EHR for Patient # 1 revealed an individualized POC with a SOC date of 03/24/2025. The POC had a certification period 05/23/2025 to 07/21/2025 and a primary diagnosis of Type two diabetes mellitus with hyperglycemia (a disease where insulin is not effectively used in the body which leads to elevated level of sugar in the blood). The POC was signed by the Admin/DON and dated 05/20/2025. The POC did not include the frequency and duration of visits to be made. Patient # 3: Record review of the hard copy clinical record and EHR for Patient # 3 revealed an individualized POC with a SOC date of 03/06/2025. The POC had a certification period 07/04/2025 to 09/01/2025 and a primary diagnosis of Chronic Obstructive Pulmonary Disease (a lung disease that causes breathing problems due to obstructed airflow in the lungs). The POC was signed by the Admin/DON and dated 07/03/2025. The POC did not include the frequency and duration of visits to be made. Patient # 4: Record review of the hard copy clinical record and EHR for Patient # 4 revealed an individualized POC with a SOC date of 03/24/2025. The POC had a certification period 05/23/2025 to 07/21/2025 and a primary diagnosis of Type two diabetes mellitus with hyperglycemia (a disease where insulin is not effectively used in the body which leads to elevated level of sugar in the blood). The POC was signed by the Admin/DON and dated 05/20/2025. The POC did not include the frequency and duration of visits to be made. Patient # 5: Record review of the hard copy clinical record and EHR for Patient # 5 revealed an individualized POC with a SOC date of 03/24/2025. The POC had a certification period 05/23/2025 to 07/21/2025 and a primary diagnosis of Type two diabetes mellitus (a disease where insulin is not effectively used in the body which leads to elevated levels of sugar in the blood). The POC was signed by the Admin/DON and dated 05/20/2025. The POC did not include the frequency and duration of visits to be made. Patient # 7: Record review of the hard copy clinical record and EHR for Patient # 7 revealed an individualized POC with a SOC date of 09/06/2022. The POC had a certification period 08/26/2024 to 10/24/2024 and a primary diagnosis of bilateral primary osteoarthritis of knee (a joint condition where the cartilage in both knees wears away and causes pain, stiffness, and limited movement). The POC was signed by the Admin/DON and dated 008/21/2024. The POC did not include the frequency and duration of visits to be made. During an interview on 07/18/2025 at 2:05 p.m. with the Alt Adm/DON, the surveyor asked who at the agency was responsible for ensuring the individualized POCs included the required frequency and duration of visits to be made. The Admin/DON stated that (the Admin/DON) was responsible. The surveyor reviewed the findings and asked why the patients POC (s) did not include the frequency and duration of visits to be made. The Admin/DON replied, “Honestly, speaking I don’t know how that happened.” The surveyor asked how the failure could adversely affect the patients. The Admin/DON stated that the patients could have missed visits because the visits would not populate on the visit schedule. Review of agency policy titled “Care Planning Process” dated read in part: “…Procedure…III. Each patient/client must receive an individualized written plan of care…A. The individualized plan of care must include the following…4. The frequency and duration of visits to be made…””