Every finding on record at Cornerstone Home Health, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 11/28/23 to 11/29/23. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 11/28/23 to 11/29/23. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons for administrative issues and Staff C was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the survey. Glossary: OT Occupational Therapy PT Physical Therapy POC Plan of Care SN skilled nurse

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure administrative policy information related to agency grievance procedures were included in patient rights admission information for all patients. Findings: A review of administrative records showed no agency policy/processes indentifying the agency’s grievance procedures included in patient rights admission information for patients. On 11/29/23 at 11:30 a.m., Staff B stated the patient information booklets did not contain agency administrative policy/process information related to agency grievance procedures for the patients.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure OSDH complaint hotline contact information was included as a part of the agency’s grievance and complaint procedures in the patient admission information packets for all patients. Findings: A review of administrative records showed no OSDH complaint hotline contact information included in patient rights admission information packets. On 11/29/23 at 11:30 a.m., Staff B stated the agency’s administrative grievance policies/processes and the OSDH complaint hotline contact information were not included in patient admission booklets for the agency.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure initial patient assessment occurred within 48 hours of referral and showed no coordination between the agency and physician for one (Patient #1) of eight patients. Findings: Patient #1 A review of a plan of care dated 10/20/23 to 12/18/23 showed a primary diagnosis of Diabetes Mellitus Type II. Documentation showed a referral date of 10/17/23 and an initial assessment/start of care date of 10/20/23. Documentation showed no patient/caregiver refusal for initial assessment/start of care and no coordination of care communications with the physician related to delay in initial assessment/start of care for agency services. On 11/29/23 at 10:50 a.m., Staff B stated the clinical record showed no documentation of delay of care /initial assessment for agency services or coordination of care communications with the physician for patient #1.

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 individualized patient POC included: 1. Identification of wound sites and wound care interventions for two (Patient #2 and #3) of eight and; 2. Skilled nursing intervention goals for one (Patient #4) of eight patients. Findings: Patient #2 A review of the POC dated 09/22/23 to 11/20/23 showed orders for SN for wound care management assessment and instruction. POC documentation showed no identified wound sites or ordered wound care interventions. Documentation showed no physician notifications and no change in orders. On 11/29/23 at 10:55 a.m., Staff C stated POC for patient #2 did not identify the wound care sites or wound care interventions. Patient #3 A review of the POC dated 10/06/23 to 12/04/23 showed orders for SN for wound care management assessment each visit. POC documentation showed no identified wound sites or ordered wound care interventions. Documentation showed no physician notifications and no change in orders. On 11/29/23 at 11:10 a.m., Staff C stated POC for patient #3 did not identify the wound care sites or wound care interventions. Patient #4 A review of the POC dated 10/06/23 to 12/04/23 showed orders for SN visit frequency of one time a week for three weeks, zero time a week for two weeks, one time a week for one week, zero time a week for one week, then one time a week for three weeks to assess and instruct disease management processes. POC documentation showed no skilled nursing intervention goals. Documentation showed no SN visits were conducted between 10/08/23 and 11/25/23. Documentation showed no patient/caregiver refusal of care, physician notifications and no change in orders. On 11/29/23 at 11:10 a.m., Staff C stated POC for patient #4 did not include skilled nursing intervention goals.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure an OT evaluation with implementation of a subsequent treatment plan was ordered for one (Patient #3) of eight patients. Findings: Patient #3 A review of a POC dated 10/06/23 to 12/04/23 showed no ordered OT evaluation. Documentation showed an OT evaluation with subsequent OT treatment plan implementation on 11/02/23. Documentation of the OT evaluation and OT visits were not available for review in the clinical record. Documentation showed no orders for OT evaluation and treatment and no physician notification of the OT evaluation and approval of the treatment plan. On 11/29/23 at 11:10 a.m., Staff C stated a physician’s order for OT evaluation and treatment should have been obtained prior to the implementation of OT services.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. SN conducted assessments of patients pain every visit and report to the physician pain level greater than 6 for one (Patient #1) of eight patients; 2. PT conducted evaluation and implemented treatment plan for one (Patient #1) of eight patients; 3. SN visits were conducted for four (Patients #2, 3, 4 and 5) of eight patient. Findings: Patient #1 A review of a plan of care dated 10/20/23 to 12/18/23 showed a primary diagnosis of Diabetes Mellitus Type II. Documentation showed a pain reporting parameter of greater than 6 and orders for a PT evaluation with implementation of subsequent treatment plan. Documentation showed during SN visit conducted on 10/20/23 a patient reported a pain level of eight. Documentation showed no physician notification and no changes in orders. Documentation showed no PT evaluation with implementation of subsequent treatment plan was conducted. Documentation showed no patient/caregiver refusal of PT evaluation, no physician notifications and no change in orders. On 11/29/23 at 10:50 a.m., Staff C stated the SN should have reported then patient’s reported pain level of 8 and the PT evaluation should have been conducted and/or any patient/caregiver refusal of the PT evaluation should have been documented with notification to the physician for a change in orders. Patient #2 A review of a POC dated 09/22/23 to 11/20/23, showed orders for a SN visit frequency of zero week one, one week one, zero week two, one week one, zero week one, one week one, then one time a week for two weeks. Documentation showed during the week 10/22/23 to 10/28/23 no SN visit was conducted (one visit ordered, no visit conducted or documented) and week 11/05/23 to 11/11/23 no SN visit was conducted (one visit ordered, no visit conducted or documented). Documentation showed no patient/caregiver refusal of the SN visits, no physician notifications and no change in orders. On 11/29/23 at 10:55 a.m., Staff C stated the SN should have conducted and documented the SN visit as ordered in the POC. Patient #3 A review of a POC dated 10/06/23 to 12/04/23, showed orders for a SN visit frequency of one week one, zero week one, one week one, then one time a week for six weeks. Documentation showed during the week 11/05/23 to 11/11/23 no SN visit was conducted (two visits ordered, no visit conducted or documented); 11/12/23 to 11/18/23 SN visit conducted by MD on 11/17/23 (two visits ordered, one visit conducted) and week 11/19/23 to 11/25/23 no SN visit was conducted (two visit ordered, no visit conducted or documented). Documentation showed no patient/caregiver refusal of the SN visits, no physician notifications and no change in orders. On 11/29/23 at 11:10 a.m., Staff C stated the SN should have conducted and documented the SN visit as ordered in the POC. Patient #4 A review of a POC dated 10/06/23 to 12/04/23, showed orders for a SN visit frequency of one week three, zero week two, one week one, zero week one, then one time a week for three weeks. Documentation showed during the week 10/08/23 to 10/14/23 no SN visit was conducted (one visits ordered, no visit conducted or documented); 10/15/23 to 10/21/23 no SN visit conducted (one visits ordered, one visit conducted); week 11/05/23 to 11/11/23 no SN visit was conducted (one visit ordered, no visit conducted or documented) and week 11/19/23 to 11/25/23 no SN visit was conducted (one visit ordered, no visit conducted or documented). Documentation showed no patient/caregiver refusal of the SN visits, no physician notifications and no change in orders. On 11/29/23 at 11:15 a.m., Staff C stated the SN should have conducted and documented the SN visit as ordered in the POC. Patient #5 A review of a POC dated 05/27/23 to 07/25/23, showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed during the week 07/16/23 to 07/22/23 no SN visit was conducted (one visits ordered, no visit conducted or documented). Documentation showed no patient/caregiver refusal of the SN visits, no physician notifications and no change in orders. On 11/29/23 at 11:20 a.m., Staff C stated the SN should have conducted and documented the SN visit as ordered in the POC.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit notes were started, completed and authenticated for one (Patients #1) of eight patients. Findings: Patient #1 A plan of care dated 10/20/23 to 12/18/23 documented a principal diagnosis of Diabetes Mellitus Type II. Documentation showed a SN visit frequency of two times a week for one week, then one times a week for eight weeks. Documentation showed SN visits notes on 11/24/23 were not started (blank), completed and authenticated by the SN. On 11/29/23 at 10:50 a.m., Staff B stated visit notes are to be accepted by the staff at the start of the visit and completed and signed by staff within one day of the visit.