Every finding on record at Cornerstone Health Care, Inc.

The Oklahoma State Department of Health Conducted an unannounced Medicare Emergency Preparedness Program survey at the agency 11/18/25. A deficiency was cited as a result of the Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the community-based risk assessment (All Hazards Risk Assessment) was updated every two years for all patients and employees. Findings: A review of administrative records showed a community-based risk assessment which addressed the agency and its patient population for the calendar year of 2023. No community-based risk assessment was provided for the calendar year of 2025. On 11/18/25 at 11:16 am, Staff A stated they were unable to provide documentation of an all-hazards risk assessment for the calendar year of 2025.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification and complaint survey (98779) at the agency 11/18/25. The entrance conference was held with Staff A. The survey process was explained. Questions were answered. Staff B was identified as the contact person for administrative issues and no staff was identified for clinical issues. Findings were discussed during an informal exit conference with Staff A and B. No deficiencies were cited related to the complaint. The following condition level deficiencies were cited as a result of the re-certification survey. §484.65 Quality assessment/performance Improvement. §484.105 Organization and administration of services. §484.110 Clinical records. Glossary: HHA - Home Health Agency PIP - Performance Improvement Plan QAPI - Quality Assessment and Performance Improvement

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. This failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. (See G644). Based on record review and interview, the agency failed to develop performance improvement activities that focused on high-risk problem areas. This failed practice had the potential to place all patients at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. (See G646). Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for all patients and employees. This failed practice had the potential to place the agency, all patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. (See G658). Based on record review and interview, the agency failed to ensure an ongoing, comprehensive QAPI program was monitored by the governing body. This failed practice had the potential to place all patients and all employees at increased risk for unresolved and unidentified health, safety and organizational issues. (See G660).

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. This failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: A review of administrative records showed no collection of data, the frequency the data should have been collected, and the indicators to be monitored for the calendar year 2025. Requests for QAPI records for the calendar year 2025 were unmet and the agency was unable to provide documentation, records or data to be utilized in the agency's QAPI Program for calendar year 2025. On 11/18/25 at 11:13 am, Staff B stated, no QAPI was started or completed for 2025.

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop performance improvement activities that focused on high-risk problem areas. This failed practice had the potential to place all patients at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. A review of administrative records showed no QAP, I no processes in place for program development or implementation for the calendar year of 2025. Requests for QAPI records for the calendar year of 2025 were unmet. On 11/18/25 at 11:13 am, Staff B stated, no QAPI program or activities was completed for 2025.

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 ensure the initiation and review of a PIP through their QAPI Program for all patients and employees. This failed practice had the potential to place the agency, all patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. Findings: A review of QAPI records showed no initiation, review, data analysis, or PIPs from January 01, 2025, through 11/18/25. On 11/18/25 at 12:40 pm, Staff A stated they had not completed a PIP for 2025.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an ongoing, comprehensive QAPI program was monitored by the governing body for all patients and employees. This failed practice had the potential to place all patients and all employees at increased risk for unresolved and unidentified health, safety and organizational issues. Findings: A review of administrative records showed a lack of ongoing governing body oversight of the QAPI Program. No governing body documentation showed that the agency had ceased QAPI activities for the calendar year of 2025. On 11/18/25 at 11:13 am, Staff B stated, no QAPI activities were completed for 2025.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the governing body failed to ensure a supervising nurse and alternate supervising nurse was hired to provide clinical oversite for all staff. This failed practice placed all employees and patients at risk for unidentified health and safety issues. (See G952). Based on record review and interview, the governing body failed to ensure pre-designation of staff to act in the administrator's absence. This failed practice placed all employees and patients at risk of inadequate care as a result of poor oversight. (See G954).

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the governing body failed to ensure a supervising nurse or an alternate supervising nurse was hired to provide clinical oversite for all staff. This failed practice placed all employees and patients at risk for unidentified health and safety issues. Findings: A review of the licensure application listed the name of a supervising nurse and did not list an alternate supervising nurse. The surveyor requested an employee roster with the names and titles of staff. On 11/15/25 at 10:30 am, Staff B stated: 1) There was no employee roster; 2) There was no supervising nurse or alternate supervising nurse employed under the license home health license.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the governing body failed to ensure pre-designation of staff to act in the administrator's absence. This failed practice placed all employees and patients at risk of inadequate care as a result of poor oversight. Findings: A review of administrative records from calendar years 2023 and 2024 did not list a pre-designated staff member to act in the administrator's absence. On 11/18/25 at 10:30 am, Staff B stated there were no employees under this home health license.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure that patient records could be accessed after the agency canceled the software contract for all former patients. This failed practice placed all patients at risk of not having continuity of care across the care continuum. (See G1012). Based on record review and interview, the agency failed to ensure that records would be accessible after it ceased to provide Medicare re-imbursed home health services for all former patients. This failed practice placed all former patients at risk of not having safe and necessary care delivered by another agency or entity. (See G1026). Based on record review and interview, the agency failed to ensure medical records could be provided upon the request of former patients or persons legally entitled to obtain a medical record from the agency for all former patients. This failed practice placed all former patients at risk of not being able to provide medical records to current providers ensuring their health care needs are met. (See G1030).

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that patient records could be accessed after the agency canceled the software contract for all former patients. This failed practice placed all patients at risk of not having continuity of care across the care continuum. Findings: A request for access to patient records was unmet.11/18/25 at 8:54 am. Patient records should have included: 1) Assessments; 2) Clinical notes; 3) Plans of Care: 4) Physician's orders. At 11:13 am the request for access to records was unmet, and records were inaccessible. On 11/18/25 at 11:13 Staff B stated: 1) A staff had cancelled the software contract (name omitted) in May or June of 2025; 2) The agency has no access to patient records at this time.

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that records would be accessible after it ceased to provide Medicare re-imbursed home health services for all former patients. This failed practice placed all former patients at risk of not having safe and necessary care delivered by another agency or entity Findings: A request for access to patient records was unmet. On 11/18/25 at 11:13 Staff B stated, we thought we would be able to access records after we cancelled the contract with the software company (name omitted).

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure medical records could be provided upon the request of former patients or persons legally entitled to obtain a medical record from the agency for all former patients. This failed practice placed all former patients at risk of not being able to provide medical records to current providers ensuring their health care needs were met. Findings: On 11/18/25 at 08/54 am the surveyor requested access to patient records. On 11/18/25 at 11:13 am access to patient records was unmet and the records inaccessible to the agency and surveyor. The surveyor asked how a patient or an authorized representative would obtain patient records. On 11/18/25 at 11:13 am Staff B stated: 1) A staff cancelled the software contract (name omitted) in May or June of 2025; 2) We have no access to patient records at this time; 3) We could not provide medical records if they were requested.

Clinical Manager CFR(s): 484.115(c) Standard: Clinical manager. A person who is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. This STANDARD is not met as evidenced by: Based on record review and Interview, the agency failed to ensure the agency had a staff member to act as Clinical Manager for all patients. Findings: The surveyor requested an employee roster with names and titles of staff 11/18/25 at 08:54 am. The request was repeated again 11/18/25 at 10:30 am. The request for an employee roster was unmet. On 11/18/25 at 10:30 am, Staff B stated: 1) There is no employee roster; 2) There were no staff employed under this home health license.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency from 10/24/22 to 10/25/22. A deficiency was cited as a result of the Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for one patient and all employees. A review of administrative records showed no community-based risk assessment which addressed the agency and its patient population for the calendar years of 2020, 2021 and January 01, 2022, to October 25, 2022. On 10/25/22 at 11:10 am, Staff B stated there was no documentation of an all-hazards risk assessment for the calendar years of 2020, 2021 and January 01, 2022, to October 25, 2022.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/24/22 to 10/25/22. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff B was identified as the contact person for administrative issues and clinical issues. Findings were discussed during an informal exit conference with Staff B and C. The following condition level deficiency was cited as a result of the re-certification survey: 484.65 Quality Assessment/Performance Improvement GLOSSARY: PIP Performance Improvement Project PIPs Performance Improvement Projects QAPI Quality Assessment and Performance Improvement

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 an individualized plan of care included interventions for the care and management of the primary diagnosis for six (Patients #1, 3, 4, 5, 6 and 7) of seven patients. Patient #1 A review of the plan of care dated 06/03/22 to 08/01/22 showed a primary diagnosis of a fracture of the left lower extremity. No interventions were outlined for the care and management of the primary diagnosis. Patient #3 A review of the plan of care dated 10/19/21 to 12/17/21 showed a primary diagnosis of aftercare following joint surgery. No interventions were outlined for the care and management of the primary diagnosis. Patient #4 A review of the plan of care dated 08/02/21 to 09/30/21 showed a primary diagnosis of aftercare following joint surgery. No interventions were outlined for the care and management of the primary diagnosis. Patient #5 A review of the plan of care dated 03/16/22 to 05/14/22 showed a primary diagnosis of aftercare following joint surgery. No interventions were outlined for the care and management of the primary diagnosis. Patient #6 A review of the plan of care dated 12/08/21 to 02/05/22 showed a primary diagnosis of aftercare following joint surgery. No interventions were outlined for the care and management of the primary diagnosis. Patient #7 A review of the plan of care dated 08/23/21 to 10/21/21 showed a primary diagnosis of aftercare following joint surgery. No interventions were outlined for the care and management of the primary diagnosis. On 10/25/22 at 12:20 pm, Staff B stated the plan of care for Patients #1, 3, 4, 5, 6 and 7 were not fully developed for the care and services to be provided for the management of the primary diagnosis.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was notified of pain ratings outside of ordered parameters for one (Patient #3) of seven patients. Patient #3 A review of the plan of care dated 08/02/22 to 09/30/22 showed orders to notify the physician of pain ratings greater than 6 on the classic 1-10 pain scale. A skilled nurse assessment dated 08/02/22 documented a pain rating of 8 with no notification to the physician. A physical therapy assessment dated 08/04/22 documented a pain rating of 9 with no notification to the physician. On 10/25/22 at 11:51 am, Staff B stated the physician should have been notified of the pain ratings above the ordered parameters for Patient #3

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program for all patients and employees. This failed practice had the potential to place one patient and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See G642. Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement. This failed practice had the potential to place one patient at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See G644. Based on record review and interview, the agency failed to ensure improvement activities were identified and focused on high-risk problem-prone areas for one current patient. This failed practice had the potential to place one current patient at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. See G648 Based on record review and interview, the agency failed to ensure conduction of a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees. The failed practice had the potential to place one patient and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See G656. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for one patient and all employees. This failed practice had the potential to place the agency, all patients and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See G658.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program for all patients and employees. This failed practice had the potential to place one patient and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. A review of administrative records showed no ongoing patient centered QAPI program and no QAPI data collected, monitored or evaluated by the agency for 2020, 2021 and January 1, 2022, through October 25, 2022. On 10/25/22 at 12:40 pm, Staff B stated there was no documentation of a QAPI program for 2020, 2021 and no current documentation of a QAPI program for 2020, 2021 and January 1, 2022, through October 25, 2022.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement. This failed practice had the potential to place one patient at risk of repeated agency mishaps, ineffective management of care and poor quality of care. A review of administrative records showed no data collection activities utilized in the agency's QAPI Program for calendar years of 2020, 2021 and from January 01, 2022, to October 25, 2022. On 10/25/22 at 12:40 pm, Staff B stated they had no analysis of data collected available that showed improved quality of patient care and program improvement data was not available for 2020, 2021 and from January 01, 2022, to October 25, 2022.

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure improvement activities were identified and focused on high-risk problem-prone areas for one current patient. This failed practice had the potential to place one current patient at risk of repeated unidentified, unexplored and unresolved agency problems that remained un-addressed within the QAPI program. A review of administrative records showed a plan for a QAPI Program with no record of data utilization or improvement efforts for 2020, 2021 and from January 01, 2022, to October 25, 2022. On 10/25/22 at 12:40 pm, Staff B stated there was no documentation of the QAPI program for 2020, 2021 and from January 01, 2022, to October 25, 2022.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient centered QAPI Program which measured and tracked agency performance strategies to ensure improvements were sustained for all patients and employees. The failed practice had the potential to place one patient and all employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. A review of administrative records showed no ongoing QAPI program activities which measured and tracked agency performance strategies to ensure improvements were sustained to improve the care, services, and operations of the agency for calendar years 2020, 2021 and January 01, 2022, to October 25, 2022. On 10/25/22 at 12:40 pm, Staff B stated they had no QAPI documentation for calendar years 2020, 2021 and January 01, 2022 to October 25, 2022.

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 ensure the initiation and review of a PIP through their QAPI Program for one patient and all employees. This failed practice had the potential to place the agency, one patient and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. A review of QAPI records showed no initiation, review, data analysis, or status of PIPs for the calendar years of 2020, 2021 and January 01, 2022, to October 25, 2022. On 10/25/22 at 12:40 pm, Staff B stated the agency had no documented PIP activities for 2020, 2021 and from January 01, 2022, to October 25, 2025.