NEW HOME IMPLEMENTATION

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NEW HOME IMPLEMENTATIONFACILITY INFORMATIONName of Facility:DBA:Address:Telephone Number:Administrator:( )Fax Number: ( )E-mailDirector of Nursing: E-MailAssistant D O N:E-MailIn-service Coordinator: E-MailMedical Director:E-MailIT Department Contact: E-MailDispensing Method:Start Date:Maximum Census:(licensed beds)NUMBER OF BEDSLTC:Current Dispensing Method:Todays Census:Asst Living:Other:Residential:Total Beds:Reports and Statements: Please provide name and emailWho should pharmacy contact to inform when triplicate is needed:A/R Statements sent to:Med Availability Report:Medicaid Pending report sent to:Weekly Facility Billing Pending report sent to:MTD reports:Page 1FAC13 Rev 1

Facility Name:NURSING STATIONSNameRoom (range)Contact Person Extension1.2.3.4.5.6.7.8.Page 2FAC13 Rev 1

FACILITY IMPLEMENTATION1. Will M Chest Pharmacy be using Therapeutic Interchange protocols? . . . . . . . . . . . . . . . . .2. Will M Chest Pharmacy be providing the flu vaccine?3. Will M Chest Pharmacy provide Hospice related medications?Yes No Yes No Yes No Name/Company/Email of consultant pharmacist:FACILITY SUPPLIESStandard E-kit . . . . . . . . . . . . . . . . . . . . . . . . .Yes No Location:Quantity: Narcotic E-kit . . . . . . . . . . . . . . . . . . . . .Yes No Location:IV E-kit . . . . . . . . . . . . . . . . . . . . . . . . . . .Quantity:Yes No Location:Quantity: Will M Chest Pharmacy provide OTC medications . . . . . . . . . . . . . . . . . . Yes No Stock Medications . . . . . . . . . . . . . . . . . . . . . . Yes No Location: Each Unit . . . . . . . . . . . . . . . . . . . . . . . Yes No Facility List . . . . . . . . . . . . . . . . . . . . . Yes No Central Location . . . . . . .Yes No Delivery date to facility of supplies:Page 3FAC13 Rev 1

NEW HOME IMPLEMENTATIONFACSIMILE MACHINE INFORMATIONName of Facility:Does facility own fax lines? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes No Location:Lines: ( )Location:Lines: ( )Location:Lines: ( )Location:Lines: ( )Location:Lines: ( )Location:Lines: ( )Location:Lines: ( )Location:Lines: ( )Anything special to dial out of building?NUMBERS TO BE PROGRAMMEDM Chest Main PhoneCurrent Pharmacy faxInstallation Date Needed By:Page 4FAC13 Rev 1

NEW HOME IMPLEMENTATIONFACILITY DELIVERY INFORMATIONName of Facility:Address:Telephone Number:( )Start Date:Delivery Entrance:Door Code:Number of Deliveries One TwoCut Off TimesRefills:New Orders / Admission or Re-AdmissionsRefills:New Orders / Admission or Re-admissionsWeekendsDelivery Locations InsideUnit:Unit:Unit:Unit:Unit:Unit:Unit:Unit:Page 5FAC13 Rev 1

NEW HOME IMPLEMENTATIONEQUIPMENT INFORMATIONType: BoxVialBingoMedication Carts . . . . . . . . . . . . . . . . . . . Yes No Quantity:OtherDividers . Yes No Tx Carts . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Quantity:Dividers . Yes No Cart Supplier:Notified . . . . . . . . . . . . . . . . . . . . . . . . . . . .Delivery Date:Yes No By: Date:New carts: Send information including pictures of current carts to Director of Operations to initiate quoteprocess if necessaryINSERVICING INFORMATIONFramework Link - training to be provided to: Schedule – time and place – routinely when scheduledTHERAPEUTIC SUBSTITUTIONS INFORMATIONTherapeutic substitution discussed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Point Person:Yes No Title:FACILITY SUPPLIESPolicy and Procedure ManualsIV ManualsQuantity:Quantity:Delivery date of Manuals:Medication Binders . . . . . . . . . . . . . . . .Yes No Qty:Dividers:Treatment Binders . . . . . . . . . . . . . . . .Yes No Qty:Dividers:Delivery Date of Binders:Page 6FAC13 Rev 1

FACILITY CREDENTIALS (SEND TO THE ATTENTION OF THE DIRECTOR OF NURSING)DEA LicensePharmacy LicenseLiability insuranceRPH in Charge LicenseDelivery date of Credentials:Dear Valued Customer, Thank you for choosing M Chest Pharmacy as your provider pharmacy. We appreciate yourconfidence in allowing us to service your facility. Enclosed you will find a list of credentials that may be needed duringDepartment of Health Survey.BILLING OFFICE INFORMATIONPlease note that the Billing Manager will contact the Billing Office to schedule a visit to review all billing procedures.Name of Facility:Contact Person:Title:Telephone Number:( )Ext:Contact person for private pay / Medicare charges review:Name of person responsible for sending daily census:Special specs/criteria for billing export:MED D INFORMATIONPoint Person:Fax Number:Title:Page 7FAC13 Rev 1

HIGH COST THRESHOLD INFORMATION (PRE-FILL)Dollar Amount:Approval Authorazation:If above not reachable:Send Full Amount Yes No Send Short Supply Yes No Number of days:INSURANCE NON-COVERED MEDICATION POLICYSend Short SupplyYes No Number of Days:Send Full AmountYes No Only Send if Under Certain Dollar Amount Yes No Dollar Amount:PRIVATE PAY MEDICATION POLICYSend Short SupplyYes No Number of Days:Send Full AmountYes No Only Send if Under Certain Dollar Amount Yes No Dollar Amount:Private Pay residents will be given up to 100 credit limit upon admission. Once the pharmacy receives the completedadmission packet, including responsible party information, insurance cards and credit card authorization, the creditlimit will be increased up to 1,000.Page 8FAC13 Rev 1

DRUG RETURN POLICYMChest Pharmacy Group, LLC and each of its subsidiaries (“Pharmacy”) accepts the return of unused prescriptionmedications that are still in their original packaging, have been delivered, and paid for by a facility (“Facility PaidItems”) if certain criteria are met. Prescription medications paid for by the patient or the patient’s insurance will onlybe returnable if the facility refuses to accept delivery of these medications because patient has discharged, is deceasedor the medication has been cancelled by the patient’s physician.Facility Paid Items will be evaluated using the criteria listed below to determine eligibility for return. If applicable,prescription medications that are covered by a per diem rate are considered returnable; however, no credit will begiven.DRUG CATEGORIESNon-Returnable ItemsThe following Facility Paid Items are not returnable after being delivered to the facility. Prescription medications that have not been returned to Pharmacy within 60 days from the dispense date(dispense date as printed on the prescription label) Controlled Substances (DEA Class CII-CV) Refrigerated/Frozen Items Special Order Medications (not stocked due to dispensing frequency and / or cost, determined by Pharmacy) OTC Products Compounded Medications (including IV’s) Prescriptions dispensed in partial tablets Partial prescriptions whose returnable value is less than the 5.00 restocking feeFull and/or Partial Quantity ItemsThe following Facility Paid Items are returnable in either full or partial quantities if they are not excluded by one ormore of the Non-Returnable categories listed above. A partial quantity is defined as any quantity less than thedispensed quantity. Solid/Oral Prescription Medications Single-Use Syringes (i.e. Enoxaparin) Individually Wrapped Patches (i.e. Exelon, Lidocaine, Rivastigmine)Full Quantity ItemsAll other Facility Paid Items that fall outside of the two categories listed above are returnable as long as themanufacturer’s seal has not been broken.Page 9FAC13 Rev 1

FACILITY IMPLEMENTATION30 DAYS PRIOR TO START1.2.3.4.5.6.7.8.9.Send signed contract to the pharmacySet date and time for in-service (see pg. 6 )Face sheets and orders send to the pharmacyPhysician list to include Name – Address – Telephone – DEA – License NumberCurrent censusObtain a copy of latest SIGNED physician’s orders for each residentProvide facility with conversion letter to be sent to all residentsMake a copy of the E-kit license (blue) and DPS Narcotic license and put copies in place of the original at thefacility. Mail originals to the pharmacyProvide designated agent forms to the DON and instructions on getting one filled out for each prescriber7 DAYS PRIOS TO START1.2.3.4.5.Pharmacy will requests face sheets of all new admits prior to start dateFacility to provide SIGNED Designated Agent FormsFacility to provide SIGNED Therapeutic Interchange formsFacility to print current copy of physician orders and send to M Chest Pharmacy (unless integrated)Complete census to be provided dailyPage 10FAC13 Rev 1

NEW HOME IMPLEMENTATIONNAME OF FACILITY:I hereby certify that I have reviewed the information contained in this packet and verify theinformation as accurate.Signature of facility representative: Title:Page 11FAC13 Rev 1

Dear Resident and / or Family Member:Thank you for choosing M Chest Pharmacy as your pharmacy service provider! The entire team here knowswhat an important role pharmacy services provides in caring for you or your loved one and we hope to takea few minutes to explain some of the services to you as well. While you may be used to working with a retailpharmacy in the past, M Chest is very different from that experience, but yet very cost competitive as youwill see. Here are a few of the services that are being provided and go above and beyond your typical retailpharmacy: 24 hours /7 days a week/ 365 days a year service Numerous deliveries a day at no charge to you Staff in-servicing and education Knowledgeable Billing Department to assist you in all aspects of pharmacy drug coverage Emergency medication systems “in-house” for prompt medication accessIn order to establish an account with M Chest Pharmacy, we will need the following information returned tous. Upon receipt of basic resident information and a copy of your prescription insurance cards (typicallysubmitted by the facility staff) and prior to receiving the Pharmaceuticals Purchase Agreement andAssignment of Benefits forms, M Chest Pharmacy will setup a temporary account for you that will be limitedto 100 in total charges and these charges will be due upon receipt of your invoice at the end of each month.Once MChest has received all of your signed forms, your account credit limit will be increased to 1,000 andyou will be setup with 30 day payment terms. This means your monthly invoice will be due 30 days after theinvoice date.COPY & SENDResident Information (form provided or facility may send on separate form)Prescription Insurance Card(s)SIGN & RETURNPharmaceuticals Purchase AgreementAssignment of BenefitsPlease feel free to contact our billing office at 1-800-734-9105 if you have any questions or concerns. Inaddition, if you feel we do not have current or accurate insurance information, we will gladly accept theinformation over the phone, or by fax at (469) 206-5937.We thank you again for the opportunity to serve you or your family member!Sincerely,M Chest PharmacyPage 12FAC13 Rev 1

E-KIT USAGE NOTIFICATIONFacilityWingPatientDatePhysicianTime AM /PMMedicationStrengthDirectionsQty Used/Remaining///////Nurse’s SignaturePLEASE FAX COMPLETED FORM TO THE PHARMACY EVERY TIME A MEDICATIONIS REMOVED FROM THE ER KIT.Page 13FAC13 Rev 1

TEMPLATECONTROL E-KIT LISTDrug NameALPRAZOLAM TAB 0.5MGAPAP/CODEINE TAB 30030MGCLONAZEPAM TAB 0.5MGDIAZEPAM TAB 2MGDIPHEN/ATROP TAB 2.5MGLORAZEPAM TAB 0.5MGLYRICA CAP 25 MGZOLPIDEM TAB 5MGHYDROCODONE 5/325HYDROCODONE 10/325TRAMADOL HCL TAB 50MGOXYCODONE 5/325OXYCODONE 10/325Page 14QTY8848484466864FAC13 Rev 1

STANDARD E-KIT LISTItemsANTIBIOTICSAMOX/K CLAV TAB 500-125AMOX/K CLAV TAB 875-125AMOXICILLIN CAP 250MGAZITHROMYCIN TAB 250MGCEFDINIR CAP 300MGCEFUROXIME TAB 250MGCEPHALEXIN CAP 250MGCIPROFLOXACN TAB 250MGCLINDAMYCIN CAP 150MGDOXYCYCL HYC CAP 100MGFLUCONAZOLE TAB 50 MGLEVOFLOXACIN TAB 250MGLINEZOLID 600 MGMETRONIDAZOL TAB 250MGNITROFUR MAC CAP 50MGNITROFURANTN CAP 100MGSMZ/TMP DS TAB 800-160Page 15Qty772820714142814141228101471414FAC13 Rev 1

STANDARD E-KIT LISTALBUTEROL NEB 0.083%ALLOPURINOL 100 MGAMIODARONE TAB 200MGAMLODIPINE TAB 5MGATORVASTATIN TAB 10MGBENZONATATE CAP 100MGCARBAMAZEPIN TAB 200MGCARB/LEVO ER TAB 25-100MGCARVEDILOL TAB 3.125MGCITALOPRAM TAB 20MGCLONIDINE TAB 0.1MGCLOPIDOGREL TAB 75MGCYCLOBENZAPR TAB 5MGDIGOXIN TAB 0.125MGDIVALPROEX CAP 125MGDIVALPROEX TAB 250MG DRDIVALPROEX TAB 250MG ERDONEPEZIL 5 MGDULOXETINE CAP 30MGESOMEPRA MAG CAP 40MG DRFLUOXETINE CAP 20MGFOLIC ACID TAB 1MGFUROSEMIDE TAB 20MGGABAPENTIN CAP 100MGGLIPIZIDE TAB 5MGGLUCOSE CHW 4GMGLYBURIDE TAB 2.5MGPage 1610688466984643386663444312333FAC13 Rev 1

STANDARD E-KIT LISTHALOPERIDOL TAB 0.5MGHYDRALAZINE TAB 25MGHYDROXYZ HCL TAB 25MGHYDROCHLOROT TAB 25MGIPRATROPIUM SOL 0.02%INHIPRATROPIUM-ALBUTEROL 0.5 - 3 MG UDVIALISOSORB MONO TAB 30MG ERLACTULOSE SOL 10GM/15LANSOPRAZOLE CAP 30MG DRLEVOTHYROXIN TAB 100MCGLEVOTHYROXIN TAB 50MCGLISINOPRIL TAB 5MGMEMANTINE TAB HCL 5MGMETFORMIN TAB 500MGMETHYLPRED TAB 4MGMETOCLOPRAM TAB 5MGMETOLAZONE TAB 2.5MGMETOPROL TAR TAB 25MGMETOPROLOL TAB 25MG ERMIRTAZAPINE TAB 15MGMONTELUKAST TAB 10MGNITROGLYCERN SUB 0.4MGOLANZAPINE TAB 2.5MGOMEPRAZOLE CAP 20MGONDANSETRON TAB 4MGPANTOPRAZOLE TAB 20MGPANTOPRAZOLE TAB 40MGPHENAZOPYRID TAB 100MGPage 1736331010344444488123846416812446FAC13 Rev 1

STANDARD E-KIT LISTPHENYTOIN EX CAP 100MGPOT CHLORIDE CAP 10MEQ ERPOT CL MICRO TAB 20MEQ ERPREDNISONE TAB 5MGPREDNISONE TAB 20 MGPROMETHAZINE TAB 25MGQUETIAPINE TAB 25MGRISPERIDONE TAB 0.25MGSERTRALINE TAB 50MGSIMVASTATIN TAB 20SPIRONOLACT TAB 25MGSPS SUS 15GM/60TAMSULOSIN CAP 0.4MGTRAZODONE TAB 50MGWARFARIN TAB 1MGWARFARIN TAB 2.5MGWARFARIN TAB 3 MGPage 189661281266646436666FAC13 Rev 1

STANDARD E-KIT LISTINJECTABLESCEFTRIAXONE INJ 1GMCEFEPIME INJ 1 GMCIPROFLOXACIN 400MG/200 MLCYANOCOBALAM INJ 1000MCGDIPHENHYDRAM INJ 50MG/MLENOXAPARIN INJ 60 MG/MLENOXAPARIN INJ 40 MG/MLEPINEPHRINE INJ 1MG/MLFUROSEMIDE INJ 10MG/MLGENTAMICIN INJ 40MG/MLGLUCAGEN INJ HYPOKITHALOPER LAC INJ 5MG/MLHEPARIN SOD INJ 5000/MLKENALOG-40 INJ 40MG/MLLEVOFLOX/D5W INJ 250/50MLLIDOCAINE INJ 1%METHYLPR SS INJ 125MGNALOXONE INJ 0.4MG/MLOLANZAPINE INJ 10MGONDANSETRON INJ 4MG/2MLPIPER/TAZOBA INJ 3-0.375GPROMETHAZINE INJ 25MG/MLVANCOMYCIN 1 GM VIALVANCOMYCIN 500 MG VIALVITAMIN K1 INJ 10MG/MLPage 193321222224212123241434222FAC13 Rev 1

STANDARD IV KIT1" GRIPPERBUTTERFLY NEEDLECLAVE EXTENSION SET 7.25"CLAVE INJECTION SITE CONND5W/NACL INJ 0.45%D5W/NACL INJ 0.9%DEXTROSE INJ 5%DIAL-A-FLODRESSING CHANGE TRAYFILTER SET (MACROBORE)HEPARIN LOCK INJ 10UNT/MLIV START KITSAF-T-INTIMA 20GSAF-T-INTIMA 22GSAF-T-INTIMA 24GSOD CHLORIDE INJ 0.45%SOD CHLORIDE INJ 0.9%SODIUM CHLORIDE 0.9% SYGSTERIL WATER INJVOLUMAT SETPage 20FAC13 Rev 1

STANDARD REFRIGERATOR E-KITDrug NameLANTUS INJ 100/MLLEVEMIR INJNOVOLIN INJ 70/30NOVOLIN R INJ U-100NOVOLOG INJ 100/MLPage 21QTY11111FAC13 Rev 1

Determine with the DON/Administrator the number and types of med / treatment carts neededM3 – 350 CARDSCart SizeM4 – 450 CARDSQtyColorChoose Cart SizeGreenChoose ColorChoose Cart SizeChoose ColorGreenChoose Cart SizeChoose ColorGreenChoose Cart SizeChoose ColorGreenChoose Cart SizeChoose ColorGreenChoose Cart SizeChoose ColorGreenChoose Cart SizeChoose ColorGreenChoose Cart SizeChoose ColorGreenChoose Cart SizeChoose ColorGreenChoose Cart SizeChoose ColorGreenM5 – 550 CARDSSoufletteTrashSharpsTREATMENT CARTSingleDoubleLock Box Lock BoxPlease send all Med Carts pictures and needs to the Director of Operations, Pharmacy Manager and AmandaHerrick. Cart appearance may differ from images above at based on supplier chosen by M Chest.Page 22FAC13 Rev 1

Jan 23, 2018 · amlodipine tab 5mg 8 atorvastatin tab 10mg 4 benzonatate cap 100mg 6 carbamazepin tab 200mg 6 carb/levo er tab 25-100mg 9 carvedilol tab 3.125mg 8 citalopram tab 20mg 4 clonidine tab 0.1mg 6 clopidogrel tab 75mg 4 cyclobenzapr tab 5mg 3 digoxin tab 0.125mg 3 divalproex cap 125mg 8 divalproex tab

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