Home Health of Columbus Community Hospital

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include an updated and accurate medication list for 2 of 2 (Patient 8 and Patient 9) patients who had a completed transfer summary sent to a receiving facility. The total sample size was 10. The census was 59. Findings are: A. Review of the agency policy and procedure titled Discharge/Transfer Summary, revised 3/2024, revealed upon transfer: 1. The home health nurse was to contact the receiving facility to verify acceptance. 2. The nurse was to provide information using SBART (not defined) to the accepting facility. 3. The transfer summary and any pertinent information will be shared with the facility receiving the patient. 4. The policy does outline information that is to be included for a discharge from the agency including medication reconciliation, utilizing the electronic medical record to review current medication and provide those to the patient. 5. The policy failed to include specifics about information needed for a transfer summary other than pertinent information. B. Review of Patient 8’s clinical record revealed a Discharge/Transfer Summary completed on 6/19/26. The discharge/transfer summary failed to include a current list of medications. C. Review of Patient 9’s clinical record revealed a Discharge/Transfer Summary completed on 6/5/26. The discharge/transfer summary failed to include a current list of medications. D. During an interview on 8/26/26 at 3:50 PM, the Director of Home Health confirmed the agency failed to include a current list of medications the patient was receiving on the transfer/discharge summary for Patient 8 and Patient 9.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to: 1) ensure the patient’s medication profile and/or plan of care contained current and accurate medications; 2) notify the patient’s physician when medication discrepancies were identified; and 3) document in the clinical record all corrective actions taken, and their outcomes, to resolve medication discrepancies for 4 of 10 patient records reviewed (Patient 4, 5, 6, and 7). The census was 59. Findings are: A. Review of the agency policy and procedure titled Medication and Drug Administration in the Home Policy, revised 12/2024, revealed: 1. A complete list of reconciled medications will be obtained from the transferring facility and/or medical office with transferal of approved provided-ordered medications to the Home Health Certification and Plan of Care (Form 485) (POC) for review by the approved provider for signature. 2. At the time of admission to home health a complete medication reconciliation review is to be completed by the registered nurse (RN) to include all prescription and nonprescription drugs, supplements, creams, and other treatments. 3. Reconciled medications list is to be completed at the start of care (SOC), resumption of care (ROC), updated after provider’s appointments, and with each medication addition, change, or discontinuation. 4. Any incomplete, illegible, or unclear medication orders are to be clarified with the prescribing provider by the nurse, whether per orders or prescriptions. 5. Reconciliation is to include identification and resolutions of omissions, duplications, changes, contraindications, and unclear information. The policy failed to require documentation of these findings in the clinical record. B. Review of Patient 4’s clinical record revealed: 1. The SOC was 8/6/26. 2. A ROC with a date of 8/18/26. 3. The ROC Home Medications list provided by the transferring facility included orders for ondansetron (Zofran) for nausea and vomiting, and simethicone 80 milligrams (mg), two tablet (160 mg) twice per day (BID). 4. The Customer Medication Profile, printed and current as of 8/24/26, failed to include the ondansetron. The simethicone was listed as simethicone 125 mg tablet take 1.5 tablets (187.5 mg) BID. 5. There was no documentation to clarify the discrepancies listed, if the physician was notified of the discrepancies, or if the discrepancies were identified. C. Review of Patient 5’s clinic record revealed: 1. The SOC was 7/30/26. 2. The Medication List provided to the agency for admission to home health included the following medications: 3. Ondansetron, dexamethasone 1 mg tablet take one tablet daily, dexamethasone 2 mg tablets daily, lorazepam (used for anxiety), oxycodone (a narcotic pain medication), bevacizumab (used to stop tumors from producing more blood vessels), Bactrim (an antibiotic) 800-160 mg tablet, take one tablet three times per week, and several intravenous (IV) medications used to treat adverse reactions to IV bevacizumab including epinephrine, diphenhydramine, famotidine, hydrocortisone, and methylprednisolone. 4. The POC for the certification period of 7/30/26 through 9/27/26 and the Medication Profile failed to include the following medications: ondansetron, oxycodone, bevacizumab, or the IV medications used to treat adverse reactions to IV bevacizumab. 5. The same POC included the following order differences: Bactrim 400-80 mg tablet take one tablet three times per week, dexamethasone 1.5 mg tablets, take two tablets (3 mg) daily. 6. There was no documentation to clarify the discrepancies listed, if the physician was notified of the discrepancies, or if the discrepancies were identified. D. Review of Patient 6’s clinical record revealed: 1. The SOC was 7/25/26. 2. The Columbus Community Hospital Discharge Medication Reconciliation Order Report included orders for ciprofloxacin (an antibiotic) 500 mg tablets, start evening of 7/25, then BID 7/25/26 until gone. It did not include an order for Vitamin D3. 3. The POC for the certification period of 7/25/26 through 9/22/26 failed to include the order for the ciprofloxacin. It did include an order for Vitamin D3 25 micrograms (mcg) every day. 4. There was no documentation to clarify the discrepancies listed, if the physician was notified of the discrepancies, or if the discrepancies were identified. E. Review of Patient 7’s clinical record revealed: 1. The SOC was 8/1/26. 2. A Patient Visit Note, dated 7/27/26, with orders to admit to home health included the following medications: a. Ibuprofen as needed 2 (handwritten on page), b. atropine sulfate 0.01% ophthalmic solution as needed for drooling, c. hydrocodone-acetaminophen 5-235 mg oral tablet- 5 days, no refills, d. ondansetron, e. magnesium glycinate (120 mg capsule- take 250 mg daily; this is crossed out, and handwritten on page is, 300 mg), f. Aleve 200 mg oral tablets as needed, g. digestive enzymes three times per day. 3. The POC for the certification period of 8/1/26 through 9/29/26 included the following differences: a. Ibuprofen 200 mg, take 3 tablets 2-3 times per day as needed, b. Atropine 0.01% eye drops, take 3 drops by mouth every two hours for drooling, c. Hydrocodone -acetaminophen 5-325 mg take one tablet every 4 hours as needed d. Magnesium glycinate 120 mg, take one capsule every day e. Ondansetron, digestive enzymes, and Aleve were not included on the POC. 4. There was no documentation to clarify the discrepancies listed, if the physician was notified of the discrepancies, or if the discrepancies were identified. F. During an interview on 8/26/26 at 3:50 PM, the Director of Home Health confirmed the agency failed to: 1) ensure the patient’s medication profile and/or plan of care contained current and accurate medications; 2) notify the patient’s physician when medication discrepancies were identified; and 3) document in the clinical record all corrective actions taken, and their outcomes, to resolve medication discrepancies for Patient 4, 5, 6, and 7.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to send a transfer summary to the receiving facility, once the agency was notified of an unplanned transfer, and failed to maintain documentation of the completed transfer summary for 2 of 4 (Patient 4 and Patient 10) patients who had an unplanned transfer from the agency. The total sample size was 10. The census was 59. Findings are: A. Review of the agency policy and procedure titled Discharge/Transfer Summary, revised 3/2024, revealed: 1. The home health nurse was to contact the receiving facility to verify acceptance. 2. The nurse was to provide information using SBART (not defined) to the accepting facility. 3. The transfer summary and any pertinent information will be shared with the facility receiving the patient. 4. The policy does outline information that is to be included for a discharge from the agency including medication reconciliation, utilizing the electronic medical record to review. 5. The policy failed to include timelines for completion of transfer summaries to the receiving facilities as required by this regulatory requirement. B. Review of Patient 4’s clinical record revealed: 1. A Case Communication Report with an entry dated 8/14/26. The skilled nurse documented that due to patient symptoms, the patient should be transported to the emergency department for evaluation. 2. A Case Communication Report with an entry date of 8/15/26, indicated the patient was currently being treated at the hospital in an observation status. 3. There was no documentation that a transfer summary was completed and sent to the receiving facility. C. Review of Patient 10’s clinical record revealed: 1. A Case Communication Report, with an entry dated late entry for 5/18/26, entered on 6/19/26. The entry indicated the patient was hospitalized on 5/18/26. 2. A Fax cover sheet with a date of 5/18/26 sent to Acute Care. There was no information on, or attached to, the Fax cover sheet form to indicate what information was faxed to Acute Care on 5/18/26. 3. A second Fax cover sheet stamped as faxed on 5/18/26. The form had a check mark in the section indicating the patient had been transferred to Columbus Community Hospital (CCH), date section was blank. The form indicated an attached Transfer Summary was sent. 4. There was no documentation of a completed transfer summary for 5/18/26. 5. A Discharge/Transfer Summary, printed on 8/24/26, revealed it was a transfer summary. This transfer summary included, as part of the documentation, that the patient discharge date was 6/17/26. D. During an interview on 8/26/26 at 3:50 PM, the Director of Home Health confirmed the agency failed to send a transfer summary to the receiving facility, once the agency was notified of an unplanned transfer, and failed to maintain documentation of the completed transfer summary for Patient 4 and Patient 10.”