Brookestone Home Health & Hospice

“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 1, 2, 6, and 7). The census was 76. Findings are: A. Review of the agency policy and procedure titled 4.40 Medication Regime Review-Comprehensive, revised 5/3/23 revealed: 1. All comprehensive assessments will include a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, interactions, and duplicate drug therapy and noncompliance with drug therapy. 2. At the time of admission an accurate, current and complete list of all prescriptions and over-the-counter (OTC) medications taken by the patient will be maintained on the medication profile. 3. The list of medications must include the medication name, dose, route, and frequency. 4. The nurse must compare the list to those on the referral or other documents provided to the agency. 5. Any discrepancies will be reconciled with the physician or designee within 24 hours of the assessment. 6. The nurse will document this contact and any difficulties experienced in obtaining physician response within the 24- hour requirement. 7. Changes in the medication regimen will be documented in the clinical record as well as communicated to the patient and/or caregiver. 8. Review of the medication regimen will be on-going but done no less frequently than every 60 days. B. Review of Patient 1’s clinical record revealed: 1. The SOC was 5/5/26. 2. An Ambulatory referral to Home Health (Order 387162062) dated 5/4/26 from the patient’s attending physician. The referral form indicated the medications were current as of 4/30/26 and included orders for melatonin 5 milligrams (mg), take 3 tablets as needed nightly for sleep, clonazepam (an antianxiety medication) 0.5 mg at bedtime, as needed, albuterol HFA 90 microgram (mcg) actuation inhaler, inhale 2 puffs every 6 hours, as needed for wheezing, benzoate as needed for coughing, ondansetron as needed for nausea/vomiting, prochlorperazine as needed for nausea. Medications discontinued on the referral form included azelastine nasal spray and loratadine. 3. The Home Health Certification and Plan of Care (POC) for the certification period of 5/5/26 through 7/3/26 revealed: a. The following orders included on the POC varied from the orders on the ambulatory referral: melatonin 10 mg, take one daily, clonazepam 0.5 mg take one tablet daily as needed for anxiety, albuterol sulfate HFA Inhalation 108 (90 base) mcg/act 2 puffs every 4 hours as needed for shortness of breath. b. The following medications were not included on the Ambulatory referral: calcium- vitamins C and D 500/10/250 mg/mg/unit tablet daily, ascorbic acid 250 mg daily, mirtazapine (an antidepressant), sodium bicarbonate oral (used to treat heartburn, acid indigestion, and sour stomach), Renvela (a prescription phosphate binder used to lower high blood phosphate levels with chronic kidney disease on dialysis). c. The following orders which were listed as discontinued on the Ambulatory referral: azelastine nasal spray and loratadine. 4. There was no documentation that the differences in medications were identified or discussed with the patient’s physician, or the outcome of any discussion. 5. There was no documentation a discussion occurred with the patient regarding the discrepancies in medication/list. C. Review of Patient 2’s clinical record revealed: 1. The SOC was 2/23/26. 2. An untitled document from The Nebraska Medical Center Neurosciences Multidisciplinary Clinics (a visit note), received by the home health agency on 2/26/26, included patient information and medication orders. The following orders were included: Baclofen Oral 10 mg, take 2 tablets in the morning and 2 tablets before bedtime, ferrous sulfate, and ocrelizumab (medicine used to treat multiple sclerosis). 3. The POC for the certification period of 2/23/26 through 4/23/26 did not include orders for ferrous sulfate and ocrelizumab and did include an order for Baclofen Oral 20 mg by mouth at bedtime. 4. There was no documentation that the differences in medications were identified or discussed with the patient’s physician, or the outcome of any discussion. 5. There was no documentation a discussion occurred with the patient regarding the discrepancies in medication/list. D. Review of Patient 6’s clinical record revealed: 1. The SOC was 5/2/26. 2. A Patient Information packet received by the HHA on 5/1/26 with referral orders for home health care. The referral included orders for cath flow [sic] as needed (medicine used to clear blood clots stuck inside central venous access lines). 3. The POC for the certification period of 5/2/26 through 6/30/26 did not include the order for Cathflo. 4. There was no documentation that the differences in medications were identified or discussed with the patient’s physician, or the outcome of any discussion. 5. There was no documentation a discussion occurred with the patient regarding the discrepancies in medication/list. E. Review of Patient 7’s clinical record revealed: 1. The SOC was 4/9/26. 2. The Patient was hospitalized 6/4/26 through 6/10/26. 3. A NMC: Internal Medical Associates Discharge Summary received by the agency on 6/10/26 and a hospital After Visit Summary received by the agency on 6/10/26 both included the following medication changes: Baclofen 2.5 mg three times per day, furosemide 40 mg daily, carvedilol 12.5 mg by two times a day with meals, lactobacillus rhamnosus GG-inulin (Culturelle- a probiotic) and discontinue patiromer calcium sorbitex powder (oral powder medication used to treat high blood levels of potassium). 4. The Resumption of Care-Plan of Care (ROC-POC, the post hospitalization plan of care) 6/11/26, and the Medication Profile printed on 7/15/26, included the following orders: Baclofen Oral Tablet 10 mg- take one tablet in the morning and evening (10 mg) and 1/2 tablet in the evening (5 mg), furosemide 40 mg tablet take two tablets in the morning and two tablets before bedtime, Carvedilol Oral tablet 6.25 mg- take one tablet every 12 hours, patiromer calcium sorbitex 8.4 mg three times per week. The ROC did not include an order for the Culturelle. 5. There was no documentation that the differences in medications were identified or discussed with the patient’s physician, or the outcome of any discussion. 6. There was no documentation a discussion occurred with the patient regarding the discrepancies in medication/list. F. During an interview on 7/16/26 at 4:30 PM, the Administrator and the Quality Assurance Performance Improvement (QAPI) Coordinator 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 1, 2, 6, and 7.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review, policy and procedure review and staff interview, the agency failed to follow their policy and procedure to ensure verbal orders were put into writing when received, for authentication by the ordering physician for 2 of 10 (Patient 1 and 6) patient records reviewed. The census was 76. Findings are: A. Review of the agency policy and procedure titled 7.15 Plan of Care/Certified Provider Orders, revised 7/8/26, revealed: 1. The receiver of the verbal order is to write down the complete order immediately and, whenever possible, read it back and receive confirmation from the individual who gave the order. 2. The (receiving staff member) is responsible for recording and signing verbal orders and submitting for certified providers counter signature. B. Review of Patient 1’s clinical record revealed: 1. A Start of Care (SOC) Assessment form dated 5/6/26. On the assessment form the skilled nurse (SN) documented the physician was contacted to order nystatin (an antifungal) powder for reddened skin around a stoma (a surgically created opening on the surface abdomen—that connects the intestine or bladder, to the outside to allow waste to leave the body). 2. There was no documentation of a written physicians order for the nystatin powder ordered. C. Review of Patient 6’s clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 5/2/26 through 6/30/26 revealed the patient had a diagnosis of infection/inflammatory reaction due to internal right hip prosthetic and was status post interventional radiology procedure where a percutaneous (through the skin) catheter was placed using imaging guidance to drain an abnormal fluid collection or abscess. 2. On a SN Visit note dated 5/6/26, the nurse documented that the physician’s office was contacted regarding the drain dressing and orders were received to remove the tape on the hip and remove any staple, but to leave the drain dressing alone. The same note revealed the nurse also discussed the patient’s pain and was instructed to advise the patient to take tramadol (a pain medication). 3. There was no documentation of a written physicians order for the drain care ordered or the tramadol. D. During an interview on 7/16/26 at 4:30 PM the Administrator and the Quality Assurance Performance Improvement (QAPI) Coordinator confirmed the agency failed to ensure staff followed their policy and procedure to ensure verbal orders were put into writing, when received, for authentication by the ordering physician for Patient 1 and 6.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include on the updated/revised plan of care, information concerning the patient’s progress toward the measurable outcomes and goals identified by the Home Health Agency (HHA) and patient in the plan of care for 8 of 10 patients (Patient 1, 2, 3, 6, 7, 8, 9, and 10) who had a revised/updated plan of care. The census was 76. Findings are: A. Review of the agency policy and procedure titled 7.14 Physician Progress Reports/60 Day Summary/486, revised 7/8/26, revealed: 1. The home health agency (HHA) will provide an overall, comprehensive review of the patient’s total progress and/or current summary report no less frequently than every 60 days. 2. The Plan of Care/485 (POC) for each discipline will be updated/revised to include current information from the patient’s updated comprehensive assessment and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA. 3. A Progress Note/MD Summary will be sent to the physician along with the renewal of the orders in the Plan of Care. B. Review of Patient 1’s clinical record revealed: 1. The Start Care (SOC) was 5/5/26. 2. The revised/updated POC for the certification period of 7/4/26 through 9/1/26 did not include information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient. C. Review of Patient 2’s clinical record revealed: 1. The SOC was 2/23/26. 2. The revised/updated POC for the certification period of 4/24/26 through 6/22/26 and 6/23/26 through 8/21/26 did not include information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient. D. Review of Patient 3’s clinical record revealed: 1. The SOC was 3/16/26. 2. The revised/updated POC for the certification period of 5/15/26 through 7/13/26 and 7/14/26 through 9/11/26 did not include information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient. E. Review of Patient 6’s clinical record revealed: 1. The SOC was 5/2/26. 2. The revised/updated POC for the certification period of 7/1/26 through 8/29/26 did not include information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient. F. Review of Patient 7’s clinical record revealed: 1. The SOC was 4/9/26. 2. The revised/updated POC for the certification period of 6/8/26 through 8/6/26 did not include information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient. G. Review of Patient 8’s clinical record revealed: 1. The SOC was 12/12/25. 2. The revised/updated POC for the certification period of 2/10/26 through 4/10/26 and 4/11/26 through 6/9/26 did not include information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient. H. Review of Patient 9’s clinical record revealed: 1. The SOC was 1/15/26. 2. The revised/updated POC for the certification period of 3/16/26 through 5/11/26 did not include information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient. I. Review of Patient 10’s clinical record revealed: 1. The SOC was 12/4/25. 2. The revised/updated POC for the certification period of 2/2/26 through 4/2/26 did not include information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient. J. During an interview on 7/14/26 at 3:00 PM, the Quality Assurance Performance Improvement (QAPI) Coordinator confirmed the revised/updated POC’s for Patients 1, 2, 3, 6, 7, 8, 9, and 10, as well as any other patient’s updated/revised POC’s did not include information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient.”

“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 complete and send a transfer summary to the receiving provider, once the agency was notified of a transfer for 1 of 3 (Patient 7) patients who had an unplanned transfer to another provider/facility. The total sample size was 10. The census was 76. Findings are: A. Review of the agency policy and procedure titled 4.49 Transfer Patient, revised 5/3/23, revealed: 1. The Home Health Agency (HHA) will contact the receiving entity to give a summary of the patient’s medical condition, services provided, psychosocial status and any existing advanced directives, coordinate the transfer date and patient care, establish any specific transfer conditions and document the communication of this information. 2. The discharge/transfer summary/order and current plan of care will be sent to the receiving entity when transfer is confirmed. 3. The HHA will document that the information was sent. 4. When a transfer is unexpected, and discovered in a timely manner, staff will share transfer information with the appropriate person at the receiving hospital and the intake nurse at a hospital. B. Review of Patient 7’s clinical record revealed: 1. A Communication Note dated 6/9/26 by the patient’s Registered Nurse Case Manager (RNCM) revealed that the HHA informed the RNCM that the patient had a hospital visit and possible admission. The RNCM documented that the hospital and attending physician would be notified. 2. There was no documentation in the clinical record that transfer information was provided. 3. There was no documentation in the clinical record of a transfer summary on 6/9/26, once the agency was notified the patient had an unplanned transfer. C. During an interview on 7/16/26 at 4:00 PM, the Administrator and the Quality Assurance Performance Improvement (QAPI) Coordinator confirmed the agency failed to document that a transfer summary was completed and sent to the receiving provider once the agency became aware that Patient 7 had an unplanned transfer to another provider (hospital).”