Every finding on record at Lifod Home Health Care LLC

Reference Number: 112582 A Complaint Survey was conducted at LIFOD Home Health Care LLC on 02/04/25 and 02/05/25 to determine compliance with the following Condition of Participation related to home health care: - 42 CFR 484.50 Patient Rights - 42 CFR 484.58 Discharge Planning - 42 CFR 484.60 Care Planning, Coordination of Services, and Quality of Care - 42 CFR 484.70 Infection Prevention and Control - 42 CFR 484.80 Home Health Aide Services - 42 CFR 484.100 Compliance With Federal, State, and Local Laws and Regulations Related to the Health and Safety of Patients - 42 CFR -484.110 Clinical Records A statement of deficiency was generated as a result of the investigation of this complaint.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on records reviewed and interviews, for two of three sampled Patients (Patient #2 and Patient #3), the Home Health Agency failed to ensure that for their individual care needs per the Plan of Care, that interventions and/or goals were identified, as required. Findings include: Review of the Policy titled Plan of Care, dated August 2024, indicated each patient would receive home health services that are written in an individualized plan of care that identified patient-specific measurable outcomes and goals. 1) Patient #2 was admitted to the Agency in November 2024, diagnoses included anxiety, hypertension, and Human Immunodeficiency Virus infection. Review of Patient #2’s Home Health Certification and Plan of Care, dated effective 01/22/25 through 03/22/25, completed by the Director of Nursing (DON) indicated although his/her individual Care Needs and associated interventions were documented, there was no documentation to support goals were identified for the care needs related to the following: - Potential for abuse or neglect - Alterations in coping of patient/family/caregiver - Bowel elimination incontinence - Impaired communication - Medication administration 2) Patient #3 was admitted to the Agency in November 2024, diagnoses included hyperlipidemia, chronic pain, and hypertension. Review of Patient #3’s Home Health Certification and Plan of Care, dated 01/22/25 through 03/22/25, completed by the DON indicated his/her care needs included impaired communication and education limitations. There was no documentation to support interventions were identified related to the care need of impaired communication and education limitations, and no documentation to support goals were identified for his/her fall risk. During an interview on 02/04/25 at 1:10 P.M., the Administrator said every patient should have documentation related to identification of interventions and goals based on their care needs within their plans of care. During an interview on 02/04/25 at 2:00 P.M., the Director of Nursing (DON) said Patient #2’s Plan of Care did not include goals for each identified care area, but should have, and Patient #3’s Plan of Care did not include interventions and goals for each identified care area but should have.