Omni Home Care

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on review of policies and procedures, medical record reviews and staff (EMP) interview it was determined the skilled professional failed to provide ongoing medication monitoring for three (3) of ten (10) OBV’s and MR’s reviewed (OBV1 MR1, OBV3 MR3, and MR5). Findings Included: Review of the agency admission packet on 4/29/2026 at approximately 3:00 PM revealed, “PATIENT ASSESSMENT, INITIAL AND REASSESSMENT…PROCEDURE: 1. Upon admission and reassessment, the qualified clinician performs the following assessment activities and collects the following data…e. Review of all medications 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…l. Oxygen safety assessment, if applicable…” Review of the agency admission packet on 4/29/2026 at approximately 3:00 PM revealed, “MONITORING MEDICATIONS… POLICY: A drug regimen review will be performed on all patients in conjunction with a comprehensive assessment. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode…2. All clinicians participating in the patient’s care are responsible to assist with maintenance of accurate patient medication 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…b. The Physician will by notified of discrepancies and documentation of notification must be evident in the medical record…4. The completed medication list will be provided and communicated to any authorized service provider, within or outside the organization…” Review of the agency admission packet on 4/29/2026 at approximately 3:00 PM revealed, “COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE…PROCEDURE…4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of devices is promoted at admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: a. When changes occur in the patient’s condition or response to treatment b. When changes occur in caregiver support or the environment that affect patient treatment…f. When there is a need to change the patient’s plan of care…5. Coordination of care among disciplines and between in-person and virtual clinicians: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge…8. Coordination of Care for Updates to the Plan of Care: a. Revisions to the plan of care due to a change in patient’s condition will be communicated to: i. Patient ii. Patient’s representative, if any iii. Caregiver iv. All physicians/authorized practitioner issuing orders, as applicable. The responsible physician/authorized practitioner will be notified of any orders from the physician/authorized practitioner.” A (OBV1) MR1 was conducted on 4/24/2026 at approximately 9:05 AM at a facility, the start of care was 4/14/2026 which revealed the following. “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Certification period 4/14/2026 to 6/12/2026…” with a primary diagnosis of myopathy, unspecified. Listed under section allergies and the “Client Medication Report” was listed Aspartame, sulfa, trimethoprim. A medical record review revealed a referral document dated 2/18/2026 listed under the section “Allergies” section aspercream, sulfa, lactose, tetanus and tramadol. A review of the medication lists provided by two (2) facilities was conducted on 4/28/2026. The Home Health Certification and Plan of Care and Client Medication Report (dated 4/23/2026) was compared to the facilities “Physician’s Orders” (dated 4/24/2026). The following three (7) medications were not listed on the on the agency plan of care or client medication report. “ESCITALOPRAM TAB 5MG…Date Written: 15-Apr-2026 STIMULANT LX TAB 8.6-50 MG…Date Written: 8-Apr-2026 ATROPINE SUL SOL 1% OP… Date Written: 28-Mar-2026 hydroxyzine HCL Tablet 10 MG… Date Written: 10-Apr-2026 MORPHINE SUL SOL 100/5ML… Date Written: 28-Mar-2026 PREPARATION OIN H… Date Written: 8-Apr-2026 CALASOOTHE OIN… Date Written: 8-Apr-2026…” The following two (16) medications were not listed on the on the facilities physician’s order document. “ACETAMINOPHEN 500 MG…Date 3/13/2026 CRAN-MAX 500 MG CAPSULE…Date 3/13/2026 DONEPEZIL 10 MG TABLET…Date 3/13/2026 ELEQUIS 2.5 MG TABLET…Date 3/13/2026 FEROSUL 325 MG (65 MG IRON) TABLET…Date 3/13/2026 FUROSDEMIDE 20 MG TABLET…Date 3/13/2026 GABAPENTIN 300 MG CAPSULE…Date 3/13/2026 LEVOTHYROXINE 88MCG TABLET…Date 3/13/2026 MAGNESIUM OXIDE 400 MG TABLET…Date 3/13/2026 METOPROLOL TARTRATE 25 MG TABLET…Date 3/13/2026 MIRTAZAPINE 15 MG TABLET…Date 3/13/2026 QUETIAPINE 50 MG TABLET…Date 3/13/2026 ROSUVASTATIN 5 MG TABLET…Date 3/13/2026 VITAMIN B COMPLEX-ELECTROLYTES 0.4 MG TABLET…Date 3/13/2026 VITAMIN C 1,000 MG TABLET…Date 3/13/2026 VITAMIN D3 25 MCG (1,000 UNIT) CAPSULE…Date 3/13/2026…” The agency was notified of the findings. A review of MR3 (OBV3) was conducted on 4/23/2026 at approximately 11:13 AM, the start of care was 4/18/2026 which revealed the following. “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Certification period 4/18/2026 to 6/16/2026…” With a primary diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris. A document labeled “Visit Note Report…Visit Date: 04/20/2026…Assessment…INDICATE OXYGEN DELIVERY MODE AND FREQUENCY 2L O2 CONTIN NASAL…” Oxygen was not listed on the Home Health Certification and Plan of Care or Client Medication Report. A review of MR5 was conducted on 4/23/2026 at approximately 11:47 AM, the start of care was 2/4/2025 which revealed the following. “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Certification Period 6/4/2026 to 8/2/2026…” with a primary diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Listed under section allergies on the “Client Medication Report” listed Cymbalta, oxycontin, Percocet. Revealed during the medical record review was a referral document “PHYSICIAN ORDER(S)” dated 3/27/2025 which listed “ALLERGIES/NOTES Oxycontin, Cymbalta (Duloxetine HCL), Percocet (Oxycodone-Acetaminophen), Tiotropium…” EMP1 was notified of the findings on 4/28/2026. An exit interview was conducted on 4/24/2026 at approximately 2:45 PM with the executive director and (via phone) vice president of operations which confirmed the findings.”

“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 review of agency policy, observation (OBV), medical records (MR) and staff (EMP) interviews, the agency failed to maintain an accurate medication profile and to ensure review of potential adverse effects for three (3) of ten (10) OBV’s and MR’s reviewed (OBV1 MR1, OBV3 MR3, and MR5). Findings included: Review of the agency admission packet on 4/29/2026 at approximately 3:00 PM revealed, “PLAN OF CARE (POC)…POLICY: Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided…PROCEDURE…2. The POC includes…f. Medications and treatments…7. Physician/authorized practitioner’s orders are obtained to update the POC and may include problems and goals. 8. Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner…” Review of the agency admission packet on 4/29/2026 at approximately 3:00 PM revealed, “PATIENT ASSESSMENT, INITIAL AND REASSESSMENT…PROCEDURE: 1. Upon admission and reassessment, the qualified clinician performs the following assessment activities and collects the following data…e. Review of all medications 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…l. Oxygen safety assessment, if applicable…” Review of the agency admission packet on 4/29/2026 at approximately 3:00 PM revealed, “MONITORING MEDICATIONS… POLICY: A drug regimen review will be performed on all patients in conjunction with a comprehensive assessment. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode…2. All clinicians participating in the patient’s care are responsible to assist with maintenance of accurate patient medication 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…b. The Physician will by notified of discrepancies and documentation of notification must be evident in the medical record…4. The completed medication list will be provided and communicated to any authorized service provider, within or outside the organization…” A (OBV1) MR1 was conducted on 4/24/2026 at approximately 9:05 AM at a facility, the start of care was 4/14/2026 which revealed the following. “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Certification period 4/14/2026 to 6/12/2026…” with a primary diagnosis of myopathy, unspecified. Listed under section allergies and the “Client Medication Report” was listed Aspartame, sulfa, trimethoprim. A medical record review revealed a referral document dated 2/18/2026 listed under the section “Allergies” section aspercream, sulfa, lactose, tetanus and tramadol. A review of the medication lists provided by two (2) facilities was conducted on 4/28/2026. The Home Health Certification and Plan of Care and Client Medication Report (dated 4/23/2026) was compared to the facilities “Physician’s Orders” (dated 4/24/2026). The following three (7) medications were not listed on the on the agency plan of care or client medication report. “ESCITALOPRAM TAB 5MG…Date Written: 15-Apr-2026 STIMULANT LX TAB 8.6-50 MG…Date Written: 8-Apr-2026 ATROPINE SUL SOL 1% OP… Date Written: 28-Mar-2026 hydroxyzine HCL Tablet 10 MG… Date Written: 10-Apr-2026 MORPHINE SUL SOL 100/5ML… Date Written: 28-Mar-2026 PREPARATION OIN H… Date Written: 8-Apr-2026 CALASOOTHE OIN… Date Written: 8-Apr-2026…” The following two (16) medications were not listed on the on the facilities physician’s order document. “ACETAMINOPHEN 500 MG…Date 3/13/2026 CRAN-MAX 500 MG CAPSULE…Date 3/13/2026 DONEPEZIL 10 MG TABLET…Date 3/13/2026 ELEQUIS 2.5 MG TABLET…Date 3/13/2026 FEROSUL 325 MG (65 MG IRON) TABLET…Date 3/13/2026 FUROSDEMIDE 20 MG TABLET…Date 3/13/2026 GABAPENTIN 300 MG CAPSULE…Date 3/13/2026 LEVOTHYROXINE 88MCG TABLET…Date 3/13/2026 MAGNESIUM OXIDE 400 MG TABLET…Date 3/13/2026 METOPROLOL TARTRATE 25 MG TABLET…Date 3/13/2026 MIRTAZAPINE 15 MG TABLET…Date 3/13/2026 QUETIAPINE 50 MG TABLET…Date 3/13/2026 ROSUVASTATIN 5 MG TABLET…Date 3/13/2026 VITAMIN B COMPLEX-ELECTROLYTES 0.4 MG TABLET…Date 3/13/2026 VITAMIN C 1,000 MG TABLET…Date 3/13/2026 VITAMIN D3 25 MCG (1,000 UNIT) CAPSULE…Date 3/13/2026…” The agency was notified of the findings. A review of MR3 (OBV3) was conducted on 4/23/2026 at approximately 11:13 AM, the start of care was 4/18/2026 which revealed the following. “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Certification period 4/18/2026 to 6/16/2026…” With a primary diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris. A document labeled “Visit Note Report…Visit Date: 04/20/2026…Assessment…INDICATE OXYGEN DELIVERY MODE AND FREQUENCY 2L O2 CONTIN NASAL…” Oxygen was not listed on the Home Health Certification and Plan of Care or Client Medication Report. A review of MR5 was conducted on 4/23/2026 at approximately 11:47 AM, the start of care was 2/4/2025 which revealed the following. “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Certification Period 6/4/2026 to 8/2/2026…” with a primary diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Listed under section allergies on the “Client Medication Report” listed Cymbalta, oxycontin, Percocet. Revealed during the medical record review was a referral document “PHYSICIAN ORDER(S)” dated 3/27/2025 which listed “ALLERGIES/NOTES Oxycontin, Cymbalta (Duloxetine HCL), Percocet (Oxycodone-Acetaminophen), Tiotropium…” EMP1 was notified of the findings on 4/28/2026. An exit interview was conducted on 4/24/2026 at approximately 2:45 PM with the executive director and (via phone) vice president of operations which confirmed the findings.”