Brookestone Home Health & Hospice

“Based on record review, policy and procedure review, observation of the provision of care, and staff interview, the hospice failed to ensure the patients medication profile (form used by the agency to provide real-time list of medications utilized by the patient) included all medications initiated between assessment periods for 6 of 19 (Patient 1, 5, 6, 7, 8, and 12) records reviewed and the hospice failed to have a process to ensure standing orders (physician pre-approved, nurse-initiated protocols designed to manage symptoms promptly at the end of life) were incorporated into the medication profile once initiated. The census was 18. Findings are: A. Review of the agency policy and procedure titled Medication Profile, Policy No. 4-050.1, revised 11/2021, revealed:1. The medication profile will be updated for each change to reflect current medication, and new and/or discontinued medications. 2. The medication profile will be used as a care planning tool to ensure the patient, family/caregiver, and other clinicians understand the medication regime. 3. The medication profile is a communication tool for all other clinicians involved in the patients care. 4. A drug regime review will be completed upon initial assessment, comprehensive assessment, when updates occur, and with the addition of new medications. 5. The policy did not include a process to ensure staff were aware that medications/treatments from standing orders were to be included on the medication profile once initiated by the nurse. B. Review of Patient 1’s clinical record revealed:1. A skilled nurse (SN) note dated 1/2/26. The SN documented that the patient received new eye drops for glaucoma.2. The new eye drop order was not included in the patient’s medication profile. C. A home visit to the home of Patient 1, conducted on 2/23/24 at 2:30 PM, revealed a vial of Rhopressa eye drops. The patient confirmed these as the “new eye drops” that were ordered by the [patient’s] eye doctor for glaucoma (patient was not able to recall the date the physician ordered the eye drops). D. Review of Patient 5’s clinical record revealed:1. A SN note dated 2/15/26. The SN documented new orders received to start Zofran (an anti-nausea medication) 4 milligrams (mg) by mouth (po) every 6 hours, and acetaminophen 650 mg po every 4 hours as needed for fever greater than 100.4.2. The new orders for Zofran and acetaminophen were not included in the patient’s medication profile. E. Review of Patient 6’s clinical record revealed:1. A SN note dated 1/27/26. The SN documented the patient’s scopolamine patch (used to treat nausea) was changed from routine to as needed. 2. Scopolamine frequency was not updated on the patient’s medication profile. F. Review of Patient 7’s clinical record revealed:1. A SN note dated 2/2/26. The SN documented the patient’s caregiver reports administering Miralax (a laxative) every day and occasionally administering a suppository for bowel care. 2. A SN note dated 2/16/26. The SN documented the patient’s caregiver reports administering Miralax (a laxative) two times per day but will reduce to 1 time per day due to the patient having loose stools now. 3. Miralax and bowel suppository orders were not included on the medication profile when initiated, the changes verbalized by the caregiver on 2/2/26 and 2/16/26 were not updated on the medication profile. G. Review of Patient 8’s clinical record revealed:1. A SN note dated 2/4/26. The SN documented orders were received to discontinue Miralax, start senna-d (used for constipation and softening stools), and to schedule Zofran every 6 hours.2. The Miralax and Zofran orders were not updated on the medication profile. H. Review of Patient 12’s clinical record revealed:1. A SN note dated 2/19/26. The SN documented Fentanyl patch (a pain medication patch applied to the skin to release medicine over a specified time) was applied today.2. Fentanyl was not on the patient’s medication profile. I. During an interview on 2/25/26 at 5:00 PM, the Administrator confirmed the medication profile for Patient 1, 5, 6, 7, 8, and 12 was not updated when orders changed, started, or discontinued, and the hospice failed to have a process to ensure standing orders were incorporated into the medication profile once initiated.”

“Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure the registered nurse (RN) conducted a visit to the home of 2 of 3 patients (Patient 4 and Patient 14) who received hospice aide services every 14 days, to assess the quality of the hospice aide (HA) services and ensure the needs of the hospice patient were being met. The total sample size was 19. The census was 18. Findings are: A. Review of the policy and procedure titled Home Health Aide Supervisory Visit, revised 11/1/25, revealed:1. The RN will complete supervisory visits and document appropriately.2. The RN must visit the patient’s home no less frequently than every 14 days.3. The policy does not include the requirement that the RN is to assess the quality of care and services provided to the hospice patient, and to ensure the services are meeting the needs of the hospice patient, every 14 days. B. Review of Patient 4’s clinical record revealed:1. The Plan of Care for the certification period of 1/22/26 through 4/21/26 included orders for HA two times per week to provide a bed bath, and to change linens as needed. 2. The first HA visit occurred on 1/27/26.3. There was no visit by an RN to assess the quality of the HA services and ensure the needs of the hospice patient were being met from 1/27/26 through record review date of 2/24/26. C. Review of Patient 14’s clinical record revealed:1. The Plan of Care for the certification periods of 9/30/25 through 12/28/25 and 12/29/25 through 3/28/26 included orders for HA services 1 time per week to assist with bathing and linen changes. 2. There was no visit by an RN to assess the quality of the HA services and ensure the needs of the hospice patient were being met from 12/18/25 through 1/7/26 and from 1/22/26 through record review date of 2/24/26. D. During an interview on 2/25/26 at 5:00 PM, the Administrator confirmed he hospice failed to ensure the RN conducted a visit to the home of Patient 4 and Patient 14 every 14 days, to assess the quality of the HA services and ensure the needs of the hospice patient were being met.”

“Based on record review, policy and procedure review, and staff interview, the hospice failed to provide day-to-day administrative or direct patient care by volunteers to equal at least 5% of the total direct patient care hours provided by the hospice employees for 2024 and 2025 and to date for 2026. The census was 18. Findings are:A. Review of the hospice policy and procedure titled Volunteer Services, Policy N. 4-007.1, revised 11/2021 revealed the agency was to provide volunteer services to provide support to the patient and family/caregiver in an amount that exceeds 5% of the total patient care hours of paid and contracted hospice personnel. B. Review of the hospice’s cost-savings report for 2024 and 2025 provided by the agency administrator revealed 0% volunteer usage. C. During an interview on 2/25/26 at 8:30 AM, the Volunteer Coordinator confirmed there has been no volunteer usage to date for 2026. D. During an interview on 2/25/26 at 9:30 AM, the Administrator confirmed volunteer usage for 2024 and 2025 was 0%, and 0% to date for 2026.”