Every finding on record at Cornerstone Home Health Care Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102, for home health agencies. Survey Dates: 05-16, 05-17, and 05-18-2022 Census: 48 At this Emergency Preparedness survey, Cornerstone Home Healthcare, was found to have been in compliance with the Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, including staffing and the implementation of staffing during a pandemic at 42 CFR 484.102. QR Completed 5/20/2022 A4

This visit was for a Federal Recertification survey of a home health provider. Survey Dates: 05-16, 05-17 and 05-18-2022 Home Care Census: 48 These deficiencies reflect State Findings cited in accordance with 410 IAC 17.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review, observation, and interview, the agency failed to secure clinical records for 3 of 3 survey days. The findings include: A policy received on 5-16-22 at 10:50 AM, titled, “CONFIDENTIALTY, STORAGE, AND RETENTION OF CLINICAL RECORDS”, contained but not limited to the following;” Purpose: to preserve the confidentiality, privacy, security…of client information. To comply with the requirements of the Health Insurance Portability and Accountability Act of 1996…, The clinical records(active/closed) are protected from loss, alteration, unauthorized use or damage and stored in a locked area away from public access. Clinical records shall not be displayed/left unattended in areas that are available to the public or unauthorized personnel. “ On 5-16-22 entered agency at 9:15 AM and observed boxes with names on the file folders and boxes on the floor of room adjacent to entrance. On 5-17-22 at 9:02 AM observed files in room adjacent to entrance on the floor, door ajar, and no employees in sight. On 5-17-22 at 3:15 PM the administrator confirmed that the boxes and files on the floor in the room observed, were patient records. She explained the records are to be moved to storage in the basement. On 5-18-22 at 8:58 AM observed boxes and patient records remained on the floor in the room adjacent to the entrance with door ajar. No employee was observed in room. On 5-18-22 at 10:40 AM, the Clinical Manager confirmed the charts on the floor are patient records (discharged patients) that are usually stored in the basement storage. She had them out of storage to review them. On 5-18-22 at 11:42 AM, the administrator confirmed location of file cabinets for storage of charts in basement. 5-18-22 at 11:52 AM, the administrator reported that the charts have been on the floor since the weekend for the clinical supervisor to review. 410 IAC 17-15-1(c)