Every finding on record at Epic Homcare Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44290 Health Facilities Evaluator Nurse, Surveyor ID: 44802 Unduplicated Admissions: 627 Active Patients: 252 Sample Size: 13 Home Visits: 5

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 observation, interview and record review the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to maintain a current medication profile and check the medication's expiration dates for two of 13 sampled patients (Patients 3 and Patient 7). The deficient practice had the potential to placed Patients 3 and Patient 7 at risk for medication errors and ineffective treatment from expired mediation. Findings: b. A review of Patient 7’s Patient information sheet indicated a start of care (SOC) date of 9/13/2023. A review of Patient 7’s Plan of Care (POC), for the certification period from 11/12/2023 to 1/10/2024, indicated a start of care (SOC) date of 9/13/2023 with diagnoses that included encounter for change or removal of nonsurgical wound dressing and venous insufficiency (Improper functioning of the vein valves in the leg, causing swelling and skin change). The POC indicated a Skilled Nurse to visit twice a week for one, three times a week for two weeks, once a week for six weeks and to reassess after two weeks. The POC indicated a Physical Therapy evaluation. A review of Patient 7’s Medication Profile indicated for Furosemide (a medication used to used to treat fluid retention [edema]) 20 milligram (mg, unit of measurement), one tablet daily for fluid retention. On 1/3/2024 at 11 a.m., a joint home visit with the Physical Therapist (PT 2) was conducted at Patient 8’s residence. Patient 8 was alert, oriented and sitting on the sofa in the living room. PT 2 performed vital signs and physical therapy exercises with Patient 7. During a concurrent observation and interview on 1/3/2024 at 11:30 a.m., with PT 2, Patient 7’s medications were reviewed. There was no bottle observed for Furosemide. PT 2 stated that the nurse was at the house on 1/1/2024 and ordered the medication. During an interview on 1/4/2024 at 3:25 p.m., the Director of Patient Care Services (DPCS) stated that the visiting nurse is supposed to check the medications every visit to make sure the patient has it available and to check if there is any changes. The DPCS stated if there are changes, they will call the case manager to update the medications profile. The DPCS stated that it was important to have the medications on hand and available because the patient needs to take it daily. A review of home health agency’s policy and procedure titled, “Medication Profile”, dated 04/2021, indicated that patients receiving medications will have a current, accurate medications profile in the clinical record. The policy indicated that medication profile will be updated for each change to reflect current medications and new and/or discontinued medications. a. A review of Patient 3’s Plan of Care (POC: document that details the the type of care the patient is to receive from the agency) indicated a start of care (SOC) date of 1/24/2023, with a primary diagnosis of hypertensive heart disease (high blood pressure) and chronic kidney disease (kidneys are damaged and cannot filter blood properly) with heart failure (when the heart cannot pump enough blood for the body’s needs). According to the POC they patient was to have skilled nursing visits once a week for nine weeks and the nurse was to access medication compliance, educate the patient/caregiver on medication actions, uses, frequency, dose, side effects, interactions with all meds as needed with emphasis on new/changed meds. On 1/3/2024, at 2:04pm, a home visit was conducted at Patient 3’s home with Physical Therapist Assistant 2 (PTA 2) and Patient medications were reviewed. The following discrepancies were found… 1. Creon (a medication used to treat people who cannot digest food normally to help break down and digest fats, starch, and proteins in food) 12,000-38,000 units. Take one capsule by mouth three times a day with meals. Pharmacy fill date 12/15/23. This medication was not listed on the medication profile. 2. Spiriva inhaler (a medication that relaxes the muscles around the airway so that they open up and you can breathe more easily) 18 micrograms (mcg: unit of measurement). This medication was not on the medication profile and there was no pharmacy label on the medication box. 3. Azelastine HCL (a nasal spray that is used to treat runny or stuffy nose, itching, sneezing and itchy, watery eyes) nasal solution 0.1%. This medication was not on the medication profile and there was no pharmacy label on the medication box. The box did not specify how much spray to use. 4. Flonase (a nasal spray that is used to treat runny or stuffy nose, itching, sneezing and itchy) nasal spray. 50 mcg per spray. This medication was not on the medication profile. The box did not specify how much spray to use. 5. Tramadol HCL (a controlled pain medication) 50 milligram (mg: unit of measurement) tablet. Take 1 tablet as needed (PRN) every 4-6 hours. This medication expired on 12/12/2020. 6. Torsemide (a medication to help take excess fluid out of the body) 5 mg take one tablet twice a day. The directions on the patient’s bottle indicated to take the medication every two days. During an interview on 1/3/2024, at 2:30pm, Patient 3’s caregiver (CG 1) stated that Patient 3 was no longer taking the Tramadol and has not taken it for months. CG 1 stated that he cannot remember when the last time he filled the prescription for Spiriva and the nasal sprays, but it has been a couple of weeks. A review of Patient 3’s medication profile for certification period 11/24/2023 to 1/22/2024, indicated that the last drug regimen review was done on 11/24/2023. During an interview on 1/4/2024, at 3:30pm, the Director of Patient Care Services (DPCS) stated that the nurses are supposed to check meds every visit. The nurses can call the case manager or update med profile and order the medications themselves. The nurses are supposed to ask the patient if they are taking anything new and verify with actual medications bottle and medication profile. The DPCS stated that they need to know what medications the patients are taking for their safety, because they can have side effects or drug interactions.

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: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to follow their discharge policy by not completing a discharge summary for one of 13 patients (Patient 13). This deficient practice had the potential to affect the patient's outcome and post discharge instructions. Findings: A review of Patient 13’s Patient information sheet indicated a start of care (SOC) date of 6/26/2023. A review of Patient 13's Plan of Care (POC), for the certification period from 10/24/2023 to 12/22/2023, indicated a start of care (SOC) date of 6/26/2023 with diagnoses that included a Stage 3 (full thickness tissue loss) pressure injury (the breakdown of skin integrity due to pressure) to the left hip. The POC indicated a Skilled Nurse to visit twice a week for four weeks and then once a week for four weeks. The POC indicated for a Physical Therapy evaluation. During an interview and record review on 1/4/2023 at 3:13 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 13’s Agency Discharge/Transfer Summary dated 12/4/2023. The discharge/transfer summary indicated that the reason for discharge/transfer as admitted to skilled nursing (SN) facility and the discharge instructions provided section was left blank. The DPCS stated that it was an error, the patient was transferred to hospice, not an SN facility. The DPCS stated the discharge summary should indicated that the patient was transferred to a hospice agency and the name of the agency where the patient was transferred. The DCPS stated that discharge instructions should had been included in the discharge summary to ensure continuity of care. A review of the HHA’s policy titled “Discharge Criteria and Process,” dated 4/2021 indicated that for a patient requiring continuing care, assistance will be given to the patient and family/caregiver in order to manage continuing care needs after the organization’s services and discontinue. Discharge instructions will be provided. A review of the HHA’s Policy titled, “Discharge Summary,” dated 4/2021 indicated that each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include, as appropriate: …C. The reason for discharge, including, as applicable, the name of the organization to which the patient is being transferred.

The following reflects the findings of the Department of Public Health during a Recertification Survey.Representing the Department of Public HealthSurveyor ID #- 25046 RN-HFEN Surveyor ID #- 22303 RN-HFEN Unduplicated Admissions -646Active Patients -249Sample Size - 13 PatientsHome Visit - 4

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 observation, interview and record review, the home health agency (HHA) failed to maintain an accurate, current medication profile for two of 11 patients (Patients 1 and 8). This failure has the potential risk to result in medication errors and adverse drug reactions. a. A review of Patient 1's clinical record indicated a start of care dated 7/21/21, with primary diagnosis of decubitus ulcer ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin).A review of Patient 1's plan of care from 11/18/21 to 1/16/22, included an order for SN (skilled nurse) visits of twice a week for three weeks, once a week for six weeks. The SN was to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication, and compliance. SN was also to instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). On 1/8/22, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 1. Patient 1 was observed sitting on the chair in the living room. During a review of Patient 1's medications indicated a bottle of Escitalopram (anti-depressive medication) 10 milligrams (mg) one tablet daily. During a review of Patient 1's clinical record indicated on evidence of a physician's order for the Escitalopram 10 mg medication in which the patient was regularly taking. On 1/8/22, at 12 p.m., during an interview with Caregiver 1 (sister), stated she has been administering the Escitalopram medication to Patient 1 for a year now. At 12:10 p.m., during an interview with LVN 1, stated she was not checking the patient's medications during her last three visits. On 1/9/22, at 1:30 p.m., during an interview with the DPCS (director of patient care services), she stated that LVN 1 should have been checking all the patient's medications during her visits. b. A review of Patient 8's clinical record indicated the start of care (SOC) date was 3/4/2021, with diagnoses of Stage II pressure ulcer (partial thickness skin loss due to pressure, which presents as a shallow open ulcer with red/pink wound bed) of sacral region and multiple sclerosis (a chronic disease affecting the central nervous system - the brain and spinal cord). A review of Patient 8's plan of care (POC) for certification period from10/30/2021 to 12/28/2021, indicated an order for the Skilled Nurse (SN) to visit two times a week for one week, three times a week for one week, two times a week for one week and once a week for one week (effective:11/30/2021). The SN was to assess all body system and assess medication compliance/provide teaching. On 1/8/2022 at 12:55 p.m., Patient 8's home visit was conducted at the assisted living facility with Licensed Vocational Nurse 1 (LVN 1). On 1/8/2022 at 1:15 p.m., Patient 7’s current medications were reviewed with LVN 1 and revealed the following medications not in the medication profile: Certavite senior ( multivitamins) dated 12/15/2021. Tivicay 50 mg. (antiviral- for treatment of HIV infection) dated 12/15/2021. The following medications were listed the in medication profile but were not available during the review: Sennosides 8.6 mg. (stool softener) Pyridoxine HCL 50 mg. (for Vitamin B6 deficiency) Dolutegravir Sodium 50 mg. (treat HIV infection) Isoniazid 300 mg. (antibiotic by stopping the growth of bacteria) On 1/8/2022 at 1:35 p.m., during an interview with LVN 1 (after reviewing the assisted living facility’s medication record), stated Sennosides 8.6 mg, Pyridoxine HCL 50 mg, Dolutegravir Sodium 50 mg, and Isoniazid 300 mg, were not listed in the assisted living facility’s medication record, and were no longer used. On 1/9/2022, at 10:30 a.m., during an interview with the Director of Patient Care Services (DPCS) she stated the agency’s nurse should have checked Patient 7’s medications every visit and updated the medication profile. A review of the agency’s policy titled “Medication Profile” revised in April 2021 indicated the Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: By Young Kang Based on interview and record review, the agency staff failed to follow the written plan of care established by the physician that included vital signs and Stage II wound assessments for one of 13 sampled patients (7). This deficient practice has the potential in the delay of healthcare response, treatment, and intervention that could result to complications to an already compromised patient's health status. By Young Kang A review of Patient 7's clinical record disclosed a start of care (SOC) of 7/21/2021, with diagnoses which included Stage II pressure ulcer (partial thickness skin loss due to pressure, which presents as a shallow open ulcer with red/pink wound bed) of sacral region (triangular shaped bone at the bottom of the spine), urinary tract infection, and hypertension (high blood pressure). A review of the Outcome and Assessment Information Set (OASIS - is officially the data collection tool used by Medicare to ensure standard quality care is being provided by home health agencies across the U.S.) dated 11/17/2021, indicated Patient 7 had one Stage II pressure ulcer on the sacrum measuring 1.5 cm x1 cm x 0.1 cm. The POC for the certification period from 11/18/2021 through 1/16/2022, included order for Skilled Nurse (SN) frequency once a week for one week, twice a week for one week and once a week for 7 weeks. SN was to continue assessment and observation, check vital signs, and Stage II pressure ulcer care: clean with normal saline, pat dry, apply xeroform cover with bordered foam dressing. The SN was to measure wound weekly. A review of Patient 7’s Skilled Clinical Note dated 12/29/2021, indicated the space for the vital signs (temperature, pulse, respiration, and blood pressure) were blank. A review of Skilled Clinical Notes from 11/28/2021 to 12/4/2021, and from 12/12/2021 to 12/18/2021, indicated there was no documented evidence Patient 7’s Stage II pressure ulcer was measured. During an interview with the Director of Patient Care Services (DPCS) on 1/9/2022, at 9:55 a.m., she was not able to provide the documented evidence the vital signs were assessed on 12/29/2021 and the Stage II pressure ulcer was assessed that included measurements from 11/28/2021 to 12/4/2021, and from 12/12/2021 to 12/18/2021. A review of the agency’s undated policy titled “Skilled Nursing Services” indicated the skilled nursing services will be provided by a registered nurse or a Licensed Practical/Vocational Nurse in accordance with a medically approved Plan of Care (physician’s orders). A review of the agency’s policy of “Ongoing Assessment” dated April 2021 indicated the clinician will assess the patient for blood pressure, pulse, respiration, and temperature. A review of the agency’s undated policy titled “Wound Assessment and Documentation” indicated to assess the wound location and its size; measure the length, width, and depth.

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 observation, interview and record review, the skilled nurses failed to administer drugs and treatments as ordered by the physician for two of 13 patients (Patient 1 and 8). SN failed to provide wound care treatment for both Patient 1 and 8. This deficient practice had potential for causing delayed wound healing or worsening of the pressure ulcer. a. A review of Patient 1's clinical record indicated a start of care dated 7/21/21, with primary diagnosis of decubitus ulcer ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin).A review of Patient 1's plan of care from 11/18/21 to 1/16/22, included an order for SN (skilled nurse) visits of twice a week for three weeks, once a week for six weeks. SN to provide wound care to right buttocks Stage II pressure sore as follows: clean with Normal Saline, pat dry, apply Xeroform dressing, cover with bordered foam dressing, perform two times a week and as needed when soiled. On 1/8/22, at 11 a.m., a joint home visit was made to Patient 1's residence with LVN 1. During a wound care observation on 1/8/22, at 11:20 a.m., Patient 1 was observed standing while leaning on his walker next to his chair with a Stage II right buttocks pressure sore without drainage nor odor. On 1/8/22, at 11:35 a.m., during an interview with LVN 1, stated she provided wound care treatment and documented it in the nursing notes. A review of Patient 1's Skilled Nursing notes from dates 11/18/21 to 1/6/22, indicated no documented evidence the visiting nurse provided wound care treatment every visits. On 1/9/22, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated LVN 1 should document every treatment they provide to the patient in their nursing notes. b. A review of Patient 8's clinical record indicated the start of care (SOC) date was 3/4/2021, with diagnoses of Stage II pressure ulcer (partial thickness skin loss due to pressure, which presents as a shallow open ulcer with red/pink wound bed) of sacral region and multiple sclerosis (a chronic disease affecting the central nervous system - the brain and spinal cord). A review of the Outcome and Assessment Information Set (OASIS - is officially the data collection tool used by Medicare to ensure standard quality care is being provided by home health agencies across the U.S.) dated 11/30/2021 indicated Patient 8 had one Stage II pressure ulcer on the sacrum sized 4 cm x 3 cm x 0.2 cm with red surrounding tissue (size was not indicated) A review of Patient 1's plan of care (POC) for certification period from10/30/2021 to 12/28/2021, indicated an order for the Skilled Nurse (SN) to visit two times a week for one week, three times a week for one week, two times a week for one week and once a week for one week (effective:11/30/2021). The POC indicated to clean Stage II pressure ulcer with normal saline, pat dry, apply triple antibiotic to the wound, apply mixture of Calmoseptine and A&D ointment to surrounding redness, and cover with bordered foam dressing. The POC indicated to perform daily and as needed for soiled/dislodged dressing by able/willing caregiver and by SN every visit (start effective 11/30/2021). On 1/8/2022 at 12:55 p.m., a home visit was conducted with Licensed Vocational Nurse 1 (LVN 1) at the assisted living facility where Patient 8 lived. Patient 8 was observed lying on a low air loss mattress, alert and oriented. Patient’s personal caregiver was in the room with the patient. On 1/8/2022 at 1:50 p.m., LVN 1 performed wound care to the pressure ulcer on the sacral area. It was observed the pressure ulcer was a Stage II (sized 2 cm by 1.5 cm) with surrounding redness (17 cm by 8.5 cm). On 1/8/2022 at 2 p.m., during an interview with LVN 1 and Patient 8’s personal caregiver, both stated the wound treatment was only performed when the agency nurse visited the patient (1-3 times per week). The patient's caregiver stated the wound treatment was not done when the SN does not visit the patient. During an interview with the Director of Patient Care Services (DPCS) on 1/9/2022, at 10:40 a.m., she was not able to provide the documented evidence the agency staff had instructed the caregiver to perform wound care during non-SN visit days. The DPCS stated the agency nursing staff should have educated the caregiver regarding daily wound care, and the wound care should have been performed daily and as needed as the physician ordered. A review of the agency’s undated policy titled “Skilled Nursing Services” indicated the skilled nursing services will be provided by a registered nurse or a Licensed Practical/Vocational Nurse in accordance with a medically approved Plan of Care (physician’s orders). It also indicated the Registered Nurse was to counsel the client and family/caregiver in meeting their needs and supervises and teaches other nursing personnel and home health aides as appropriate.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the registered nurse (RN 1) failed to notify the physician promptly of the patient's change of condition for one out of 13 patients (Patient 3). Patient 3 had an existing pitting edema (the swollen part developed a "dimple or pit" when pressed for a few seconds) of both lower extremities. RN 1 failed to inform the physician of the patient's existing pitting edema. This deficient practice had the potential to place the patient at risk for serious complications that could affect the patient's overall health status and quality of care. A review of Patient 3's clinical record indicated a start of care (SOC) date of 9/2/21, with diagnosis of spondylolisthesis (a spinal disorder in which a bone slips forward onto the bone below it). A review of Patient 3's plan of care (POC) for the period of 11/1/21 to 12/30/21, included an order for the skilled nurse (SN) to visit once a week for 9 weeks. The SN was to assess all body systems with emphasis on cardiovascular status, to assess extremity color, temperature, swelling and pain and to notify the physician of significant change in patient's condition. On 1/8/22, at 1 p.m., a joint home visit was made to Patient 3's residence with RN 1. Patient 3 was observed sitting on the couch. It was further observed Patient 3 had pitting edema +2 (3-4 mm of depression in 15 seconds) on the right and left lower extremities (legs). On 1/8/22, at 1:20 p.m., Patient 3 when asked how long she had the swelling on her lower legs, stated she noticed the swelling for three weeks now. On 1/8/22, at 1:30 p.m., during an interview with RN 1, she stated she knew the patient had pitting edema and instructed patient to wear knee high compression stockings at night. A review of Patient 3's Skilled Clinical notes 12/9/21, 12/16/21, and 12/23/21, identified the patient had a pitting edema +2 on her right lower leg and +1 on her left lower leg. However, there was no documented evidence the physician was notified regarding the underlying condition. On 1/9/22, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated Patient 3's existing edema was a change of condition and the physician should have been notified. A review of Agency's policy "Reporting To Physician (undated)", indicated the patient's physician will be contacted on the same day when there is changes in the patient's condition.

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: Based on observation, interview and record review, the license vocational nurse (LVN 1) failed to follow standard precautions during wound treatment for one of 13 patients (Patient 1). Patient 1 was provided wound care treatment to the right buttocks by LVN 1. LVN 1 failed to perform hand hygiene and change gloves in between dressing change. This failure had the potential for an increased risk of infection and cross contamination. A review of Patient 1's clinical record indicated a start of care dated 7/21/21, with primary diagnosis of decubitus ulcer ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin).A review of Patient 1's plan of care from 11/18/21 to 1/16/22, included an order for SN (skilled nurse) visits of twice a week for three weeks, once a week for six weeks, to provide wound care to right buttocks Stage II (skin breaks open or forms an ulcer) pressure sore as follows: clean with Normal Saline, pat dry, apply Xeroform dressing, cover with bordered foam dressing, perform two times a week and as needed when soiled. On 1/8/22, at 11 a.m., a joint home visit was made to Patient 1's residence with LVN 1. During a wound care observation on 1/8/22, at 11:20 a.m., Patient 1 was observed standing up, leaning on his walker next to his chair while LVN 1 provided wound care to the Stage II right buttocks pressure ulcer. LVN 1 was observed initially washing her hands, then putting on a new pair of gloves, picked up a clean pair of gauze, wet the gauze with normal saline and wiped the open wound with it. LVN 1 disposed the soiled gauze in the trash. Without changing gloves and hand hygiene performed , LVN 1 picked up a new pair of gauze, wet it with normal saline and wiped and cleaned the open wound again. LVN 1 then applied Xeroform dressing and covered the wound bed with bordered foam dressing using the soiled gloves. LVN 1 failed to remove her soiled gloves and wash her hands in between cleaning the wound and applying the prescribed medicated dressing.On 1/8/22, at 11:35 a.m., during an interview with LVN 1, she stated she forgot to remove her soiled gloves and wash her hands because she was too nervous.On 1/9/22, at 12 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated that LVN 1 should have changed her gloves and wash her hands as per the agency's policy. A review of the agency's policy and procedure " Infection control /exposure practices" dated 4/1/2002, indicated gloves are to be worn during a procedure such as wound care. The policy also indicated hands are to be washed prior to gloving and upon removal of disposable gloves.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: By YK Based on observation, interview and record review, the home health agency (HHA) failed to ensure the family/caregiver was provided instructions about placing acceptable layers on the low air loss mattress (LAL) mattress for a patient who had pressure ulcer on the sacral area for one of 13 sampled patients (8). This deficient practice had potential for causing delayed wound healing or worsening of the pressure ulcer. By Young Kang A review of Patient 8's clinical record indicated the start of care (SOC) date was 3/4/2021, with diagnoses of Stage II pressure ulcer (partial thickness skin loss due to pressure, which presents as a shallow open ulcer with red/pink wound bed) of sacral region and multiple sclerosis (a chronic disease affecting the central nervous system - the brain and spinal cord). A review of the Outcome and Assessment Information Set (OASIS - is officially the data collection tool used by Medicare to ensure standard quality care is being provided by home health agencies across the U.S.) dated 11/30/2021 indicated Patient 8 had one Stage II pressure ulcer on the sacrum sized 4 cm x3 cm x 0.2 cm with red surrounding tissue (size was not indicated) A review of Patient 8's plan of care (POC) for certification period from10/30/2021 to 12/28/2021, indicated an order for the Skilled Nurse (SN) to visit two times a week for one week, three times a week for one week, two times a week for one week and once a week for one week (effective:11/30/2021). The POC indicated to clean Stage II pressure ulcer with normal saline, pat dry, apply triple antibiotic to the wound, apply mixture of Calmoseptine and A&D ointment to surrounding redness, cover with bordered foam dressing. The POC indicated to perform daily and as needed for soiled/dislodged dressing by able/willing caregiver and by SN every visit (start effective 11/30/2021). The POC also indicated to assess/instruct the patient/primary caregiver regarding measures to prevent skin breakdown, pressure relief, incontinence care, and to encourage/teach off loading (wheelchair cushion, specialty bed/mattress for pressure reduction). On 1/8/2022 at 12:55 p.m., Patient 8's home visit was conducted at the assisted living facility with Licensed Vocational Nurse 1 (LVN 1). Patient 8 was lying on a low air loss (LAL) mattress, and Patient 8’s personal caregiver was next to the patient. On 1/8/2022 at 1:50 p.m., while LVN 1 provided wound care, Patient 8 was observed wearing an adult brief, and there was a one linen, one draw sheet and two chucks on the LAL mattress. During an interview with the personal caregiver, she stated she placed above layers under the patient because the patient urinated a lot. During an interview with LVN 1, she was not able to answer how many layers was to be place on the LAL mattress. On 1/9/2022, at 9:55 a.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence whether the family/caregiver was provided instruction about placing acceptable layers on the LAL mattress. A review of the manufacturer’s reference provided by the agency indicated that it is recommended to limit bed linens to one sheet in order to maximize the system’s performance, and “Breathable” incontinent pads are recommended.