Every finding on record at Omnicare Home Health, Inc

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan, Agency policy and staff interview, it was determined the Agency failed to ensure the plan contained volunteers. This has the potential to affect all Pts. receiving services. Findings include: 1. The Emergency Preparedness plan last updated in "June 2020" was reviewed on 05/11/21 at 3:40 PM. The Plan lacked any volunteers. 2. The Agency's policy titled, "Communication Plan and Policy for Emergency Operations Plan (EOP) " was reviewed on 5/12/21 at 10:50 AM. The policy required: "...Procedure 1. The communication plan includes the following: Names and contact information for the ...Volunteers..." 3. During an interview with the Administrator, Clinical Manager and the RN/ Field Supervisor on 5/12/21 at 9:55 AM, the Clinical Manager confirmed the Agency failed to obtain volunteers for the Agency's Emergency Preparedness plan.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan, Agency policy and staff interview, it was determined the Agency failed to ensure the communication plan was complete. This has potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Emergency Preparedness plan last updated "June 2020" was reviewed on 05/11/21 at 3:40 PM. The Plan lacked the names and information that the staff and patients' physicians can be reached. 2. The Agency's policy titled, "Communication Plan and Policy for Emergency Operations Plan (EOP) " was reviewed on 5/12/21 at 10:50 AM. The policy required: "...Procedure 1. The communication plan includes the following: Names and contact information for the following: Staff... Patient's physicians..." 3. During an interview with the Administrator, Clinical Manager and the RN/ Field Supervisor on 5/12/21 at 9:55 AM, the Clinical Manager confirmed the Agency failed to ensure the communication plan was complete.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 5/13/21. Standard level deficiencies written. Abbreviations: Q = every # = number Tab = Tablet AM = morning PRN = as needed POC = Plan of care SOC = Start of care MG/mg = milligrams DC/ed = discontinued SN/Sn = Skilled Nurse PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients EOP = Emergency Operations Plan COVID/Covid-19 = Coronavirus disease 2019

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: . A. Based on a review of clinical records, Agency Memo and staff interview, it was determined the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing Pt. care and services. This was found in 3 of 7 (Pts. #5, 4 and 7) clinical records reviewed, and has the potential to affect all Pts. served by the Agency. Findings include 1. Pt. #5. SOC 1/26/21. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 5/11/21 at 11:15 AM. The record contained the Medical Social Worker evaluation and discharge forms, both were dated 4/5/21. The record lacked documentation the Medical Social Worker screened the Pt. for COVID-19 symptoms, prior to providing service as required by the Agency. 2. Pt. #4. SOC 1/9/20. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 5/11/21 at 10:40 AM. The record contained documentation the Home Health Aide provided service on 6/11/20, 6/18/20, and 7/2/20. The record lacked documentation the Home Health Aide screened Pt. #4 for symptoms of COVID-19 prior to these visits. 3. Pt. #7. SOC 3/20/20. Primary Diagnosis: Encounter for Attention to Gastrostomy. The clinical record was reviewed on 5/11/21 at 12:45 PM. The record contained documentation the Speech Therapist provided service on 4/25/20, 5/2/20, 5/9/20, and 5/16/20. The record lacked documentation the Speech Therapist screened Pt. #7 for symptoms of COVID-19 prior to these visits. 4. During interviews with the Administrator, Clinical Manager, and the RN Field Supervisor on 5/12/21 at 9:55 AM and 11:00 AM, the Clinical Manager confirmed the above findings, and stated all clinicians must screen Pts. prior to home visits, and document the results of these screenings in the patient's clinical record.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, observation and interview during a home visit, Agency policy review and staff interview, it was determined the Agency failed to ensure medications contained in the clinical record were clear and/or accurate. This was found in 2 of 7 (Pts. #1 and 2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 8/23/19. Diagnoses: Encounter for Attention to Urostomy and Multiple Sclerosis. On 5/11/21, Agency staff presented a copy of the "Patient Medication Profile" form completed by the RN and effective 4/14/21; the form contained documentation that all medications were current/active. The clinical record was reviewed on 5/11/21 at 12:30 PM and contained the "Patient Medication Profile" form completed by the RN also effective 4/14/21; this form had "Butalbital/ Acetaminophen/ Caffeine 50-325-40 MG 1 Tab PO 4 Hours PRN for pain ----- DC/ed 5/5/2021" written on it. As of 5/10/21, the clinical record contained 2 conflicting Patient Medication Profile forms for Pt. #1. During an interview with the RN/ Field Supervisor on 5/12/21 at 10:45 AM, the RN/ Field Supervisor stated the patient's nurse stated, the medication indicated above was discontinued on 5/5/21. 2. Pt. #2. SOC 4/23/21. Primary Diagnosis: Diaper Dermatitis. The clinical record was reviewed on 5/10/21 at 1:45 PM. The record contained a Medication Profile form effective 4/23/21. The record lacked any further orders for changes in Pt. #2's medications. A home visit was conducted on 5/10/21 at 2:55 PM, along with E #5. During this home visit, Pt. #2's Caregiver presented Pt. #2's medications for review, which was compared to the Medication Profile. The Medication Profile contained Physician orders for the following medications: Memantidine 5 mg daily; Furosemide 20 mg daily; Multivitamin 1 tablet daily; Power C 282 mg 1 tablet daily, Donepezil 5 mg daily; and Allegra 180 mg daily. Pt. #2's Caregiver stated Pt. #2's Physician discontinued Memantidine on 4/26/21, and that Pt. #2 no longer takes Furosemide for "at least two weeks." Pt. #2's Caregiver also stated Pt. #2 takes two tablets of both the Multivitamin and the Power C daily. Pt. #2's Caregiver stated Pt. #2 takes Donepezil 7.5 mg daily "for the last 2 to 3 months." Pt. #2's Caregiver also stated Pt. #2 takes Allegra "only if needed, not daily." The Medication Profile was inaccurate. 3. The Agency policy titled, "Medication Reconciliation" was reviewed on 5/12/21 at 10:45 AM. The policy required: "The Agency will reconcile the Patient's medication at the time of admission and on an ongoing basis... Medications ordered while the Patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication..." 4. During interviews with the Administrator, Clinical Manager, and the RN Field Supervisor on 5/12/21 at 9:55 AM and 11:00 AM, the Clinical Manager confirmed the above findings, and stated the patient's medications should be reconciled with the Medication Profile, whenever the Pt./Caregiver reports changes in Pt. medications. The Physician would then be called for new orders, and the Medication Profile is updated with the changes.

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to forward a copy of the discharge summary to the Physician. This was found in 2 of 2 (Pts. #6 and 7) closed clinical records reviewed. Findings include: 1. Pt. #6. SOC 6/11/20. Primary Diagnosis: Right Side Lumbago with Sciatica. The clinical record was reviewed on 5/11/21 at 2:50 PM. The record contained the Agency's "Discharge Summary" form with a SOC date of 6/11/20. The form lacked the nurses's signature and the date the form was completed. The record lacked documentation a copy of the "Discharge Summary" was sent to the Physician. 2. Pt. #7. SOC 3/20/20. Primary Diagnosis: Encounter for Attention to Gastrostomy. The clinical record was reviewed on 5/11/21 at 12:45 PM. The record contained a Discharge Summary completed by the RN and dated 6/29/21. The record lacked documentation this Discharge Summary was sent to the Physician. 3. During an interview with the Administrator, Clinical Manager and the RN/ Field Supervisor on 5/12/21 at 10:45 AM, the Clinical Manager stated "the Agency doesn't send a copy of the Discharge Summary to the doctor, we send a Physician's order." 4. During interviews with the Administrator, Clinical Manager, and the RN Field Supervisor on 5/12/21 at 9:55 AM and 11:00 AM, the Clinical Manager confirmed the Agency failed to forward a copy of the Discharge Summary forms for Pts. #6 and 7 to the Physician.