Every finding on record at Clay Home Health Services

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 10/20/23. The Agency was in compliance with the Condition, 42 CFR 484.102, Emergency Preparedness for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 10/20/2023. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: E - employee Pt - patient HHA - Home Health Agency SOC - Start of Care POLST - Physician Orders for Life Sustaining Treatment DNR- Do not resuscitate POC - Plan of Care

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined in 1 of 3 (Pt #9) patient discharge charts reviewed, the Home Health Agency failed to provide the patient with resource information of other providers upon discharge. Findings include: 1. Pt #9 SOC: 5/23/2023 Diagnosis: Liver Transplant Pt #9’s chart was reviewed on 10/19/2023 at approximately 11:00 AM. During the certification period of 5/23/2023 thru 7/17/2023 Pt #9 was seen by the registered nurse 2 times a week for 7 weeks. Pt #7 was discharged on 7/17/2023 as Pt #7 had changed to an insurance provider that was out of network for the Home Health Agency. The home health agency failed to provide contact information for other community resources and/or HHA which may be able to provide services will be provided to patient if needed. 2. On 10/19/2023 at approximately 2:00 PM, the policy titled, “Discharge/Transfer of Patient (reviewed/updated 11/29/19) required, “In the event the agency initiates termination of services, the following steps will be taken:…Contact information for other community resources and/or HHA which may be able to provide services will be provided to patient if needed.” 3. On 10/19/2023 at approximately 2:30 PM, an interview was conducted with the Home Care Coordinator (E #2). E #2 reviewed Pt #9’s chart and confirmed the Agency failed to provide the required resource information to the patient upon discharge.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined in 2 of 2 (Pt #8 and Pt #11) records reviewed, the Agency failed to obtain a physician order/POLST order for the DNR status on the POC.. Findings include: 1.Pt #8 SOC: 8/25/2023 Diagnosis: Pyonephrosis. The clinical record was reviewed on 10/20/2023. The POC for the certification period dated 8/25/2023 to 10/23/2023, indicated a DNR order. Pt #8 record lacked a physician order/ POLST form. 2. Pt #11 SOC:2/25/2023 Diagnosis: Pleural Effusion. The clinical record was reviewed on 10/19/2023. The POC for the certification period dated 8/2/2023 to 10/22/2023, indicated a DNR order. Pt #11’s record lacked a physician order/POLST form. 3. The policy titled “Advance Directives” (review date 4/20) was reviewed on 10/20/2023. The policy required, “A copy of the advance directive is obtained from the patient (if available) and incorporated into the patient’s record." 4. An interview was conducted on 10/19/2023 with the Admission Nurse (E #3). E #3 reviewed both P #8 and Pt #11's clinical record and stated, “Our practice when we admit a patient, and the patient states they are a DNR, we are required to get a copy of the POLST and place it in patents chart. Otherwise we do not have a physician’s order for the DNR.”