Cornerstone Health Care, Inc.

The agency failed to ensure a patient centered QAPI Program for all patients and employees.

The hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for one patient and all employees.

The agency failed to ensure the physician was notified of pain ratings outside of ordered parameters for one (Patient #3) of seven patients.

The agency failed to ensure a patient centered QAPI Program for all patients and employees.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program for one patient and all employees.

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.

The agency failed to ensure improvement activities were identified and focused on high-risk problem-prone areas for one current patient.

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.