Every finding on record at Home Health Agency - Central Philadelphia, LLC

Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 4/27/2023, Omni Home Care was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.

Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 4/27/2023, Omni Home Care was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of agency policy and procedure, facility observations (OBV) visits, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking and identify, and address significant side effects, drug interactions for three (3) of ten (10) patient (OBV1 MR3, OBV3 MR4 and MR6). Findings Included: Review of agency policy and procedures on 4/27/2023 at approximately 9:30 AM revealed, Monitoring Medications…Chapter: Medication Management Purpose: Tor provide a process to ensure continuous monitoring of medications in the patient’s home…PROCEDURE: 1. The discipline responsible for the drug regimen review will: a Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments, and medical marijuana (in states where legalized), to identify issues such as: i. Potential adverse effects and drug reactions: ii. Ineffective drug therapy; iii significant side effects; iv. Drug allergies; v. Contraindicated medications…2. All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient’s episode of care the following will occur a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies; ii. Collaborate with Patient Care Manager/case manager as needed; and iii. Have access to information about each patient in order to facilitate continuity of care. At a minimum, this information includes age, sex, current medications, diagnoses, co-morbidities, laboratory values, allergies, past sensitivities and as appropriate weight, height, or any other information for safe medication management. B. The Physician will be notified of discrepancies and discrepancies and documentation of notification must be evident in the medical record. 3. The patient will receive instruction on: a. Signs and symptoms of adverse drug reactions to report as applicable to patient and plan of care; and b. Proper storge of medications. 4. The completed medication list will be provided and communicated to any authorized service provider, within or outside the organization. The agency will provide the patient or transferring or accepting organization a complete reconciled medication list upon discharge or transfer…” (OBV1 MR3) was conducted on 10:01 AM on 4/26/2023, a review of the plan of care listed the start of care 4/4/2023 for a current certification period starting 4/4/2023 and ending 6/2/2023. The primary diagnosis was muscle wasting and atrophy, not elsewhere classified, right lower leg The agency “Client Medication Report” received on 4/24/2023 was compared to the facilities “Physician’s Orders” date printed 4/26/2023. The following medication was not listed on the agency medication profile. “ACETAMINOPHEN TAB 650MG ER TAKE ONE TABLET BY MOUTH THREE TIMES DAILY DX: ARTHRITIS PAIN…” (OBV3 MR4) was conducted on 4/26/2023 at approximately 11:38 AM, a review of the plan of care listed the start of care 4/10/2023 for a current certification period starting 4/10/2023 and ending 6/8/2023. The primary diagnosis was age-related osteoporosis with current pathological fracture, vertebra(e). The agency “Client Medication Report” received on 4/24/2023 was compared to the facilities “MAR” (medication administration record) date printed 4/26/2023. The following medication was not listed on the agency medication profile. “ALBUTEROL SUL 0.63 MG/3 ML SOL INHALE 1 UNIT DOSE VIA NEB EVERY 4 HOURS AS NEEDED…” “ONDANSETRON ODT 4 MG TAB ONE TABLET UNDER TONGUE THREE TIMES DAILY AS NEEDED FOR NAUSEA…” A chart review was conducted for MR6 on 4/25/2023 at approximately 1:40 PM, a review of the plan of care listed the start of care 2/28/2023 for a current certification period starting 2/28/2023 to 4/28/2023. The primary diagnosis was aftercare following joint replacement surgery. The agencies “Client Medication Report” list “Client Allergies NKA…” Review of the patient history and physical revealed “Review of patient’s allergies indicates: allergen Penicillin’s …Bactrim [Sulfamethoxazole-Trimethoprim]…” The following allergy was not listed on the agency medication profile: Penicillin’s and Bactrim. EMP1 was made aware of the medication information not matching for MR3, MR4 and MR6 on 4/27/2023 at approximately 10:15 AM. An exit interview was conducted with the administrator and improvement coordinator on 4/27/2023 at approximately 1:40 PM which confirmed the above findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on review of agency policy and procedure, observations (OBV) during home visits and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for two (2) of four (4) observations (OBV) providing direct care to patients (OBV1 and OBV2). Findings Included: Review of agency policy and procedures on 4/27/2023 at approximately 9:30 AM revealed, “iTRAIN Home Care Bag Protocol Job Aid, Field staff can use this job aid as a guide to home care bag use. The home care bag allows you to safely transport basic equipment and supplies necessary to perform a standard home visit. Use the home care bag to prevent the potential spread of infection among staff, patients, and the community. The contents of the home care bag is dictated by each disciplines care requirements Adherence to this protocol is mandator. Discuss and questions regarding proper bag technique with your manager. HOME CARE BAG PROTOCOL…7. After entering the patient’s home, place the bag on a clean, dry surface and a barrier placed between the bag and the surface. Avoid placing the bag on furniture or surfaces that are visibly soiled/contaminated. Avoid soiled areas such as kitchen counters with soiled dishes and food items. Do not hag bag on doorknobs or backs of chairs…” Visit (OBV1) on 4/26/2023 at approximately 8:41 AM patient care was conducted for (MR3) revealed, EMP5 provided direct patient care. EMP5 placed a chuck/barrier on a small table with the nursing/supply bag on top of the chuck/barrier. The strap from the healthcare bag was laying against a lamp base located on a tabletop. Visit (OBV2) on 4/26/2023 at approximately 10:01 AM patient care was conducted for (MR2) revealed, EMP6 provided direct patient care. EMP5 placed a chuck/barrier on a dining table with the nursing/supply bag on top of the chuck/barrier. Part of the strap from the healthcare bag was laying off the barrier and on a tabletop. An exit interview was conducted with the administrator and improvement coordinator on 4/27/2023 at approximately 1:40 PM which confirmed the above findings.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on a review of agency contracts, policy and procedure, direct observation (OBV) and staff (EMP) interview, it was determined that the agency failed to safeguard against loss or unauthorized use of staff and administrative information for one (1) of one (1) facility tour. Findings included: Review of agency policy and procedures on 4/27/2023 at approximately 1:00 PM revealed, “EMPLOYMENT RECORDS…POLICY NUMBER: 2-3-002…PURPOSE: To describe the content of a process utilized for maintaining employment records. POLICY: Employment records are maintained on all active and inactive employees. PROCEDURE: 1. Original employment records should be maintained at the facility/agency or at the home office in a secured area. 2. All employment records are maintained confidentially and security to prevent unauthorized access…3. Employment records responsibilities…f. Inactive employment records are sent to the Home Office Human Resources department for offsite storage…” Review of agency policy and procedures on 4/27/2023 at approximately 1:00 PM revealed, RECORDS RETENTION POLICY…POLICY NUMBER: 8.1.006…F. Responsibilities 1. The Company’s Legal Department has overall responsibility for developing, implementing and maintaining Company-wide records retention policy in accordance with requirement set forth in this Policy…2. Managers within each department and facility are responsible for assisting with the records retention policy and ensuring compliance. Such responsibilities generally include: a. Supporting preparation and maintenance of the Retention Schedule; b. Identifying, packaging, documenting and transferring applicable records to the offsite storages; c. Retaining only those records for which they have custodial responsibility…g. Ensuring that only authorized persons with a need-to-know gain access to records stored in offsite storage facilities; and h. Ensuring that stored records are retained, protected, retrieved, returned to storage, reviewed, and destroyed in accordance with the provisions of this Policy…I. Acquisition of an Agency/Facility 1. In the event of an acquisition of one or more agencies or facilities, the Legal Department must ensure that the applicable transactional documents secure the company’s right to access the seller’s records as appropriate to ensure the continuity of patient care, to support operations, and to defend the Company in connection with any retained liability. Active patient and billing records should remain with the facility to ensure continuity of patient care. 2. In the event of stock or asset purchase, the Legal Department is responsible for coordinating a review of the seller’s records. All acquired records should be retained and/or disposed of in accordance with this Policy.” During review of the agency contracts/agreements with other agencies on 4/27/2023 at approximately 11:40 AM. Review of a contract for janitorial services was observed. The surveyor was located in a conference room which contained filing cabinets. Upon inspection the filing cabinets contain two shelves of inactive staff files, and one shelf of a payroll file was observed. At approximately 11:48 AM the surveyor asked EMP1 if staff were able to lock the filing cabinet at night when cleaning staff are present? EMP1 was not able to locate the keys to lock the filing cabinet. An exit interview was conducted with the administrator and improvement coordinator on 4/27/2023 at approximately 1:40 PM which confirmed the above findings.