Every finding on record at Tender Loving Care Health Care Services Southeast, LLC

The District of Columbia State Agency conducted an unannounced Federal Recertification Survey on behalf of the Centers for Medicare and Medicaid Services at Amedisys Home Health Agency from 08/12/2025 to 08/19/2025. The survey resulted in noncompliance with Emergency Preparedness regulations with the following Condition and Standard level citations.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on policy review, supporting documentation review, personnel record review, and interview, the Home Health Agency failed to maintain a comprehensive Emergency Preparedness program as evidenced by the following: · The home health agency failed to maintain the Emergency Preparedness plan. See Tag E0004. · The Home Health Agency failed to update and complete hazard vulnerability assessments. See Tag E0006. · The home health agency failed to inform local emergency preparedness officials regarding homebound patients in need of evacuation from their residence at any time during an emergency. See Tag E0019. · The home health agency failed to maintain a current communication plan for the readily identification and notification of on duty staff. See Tag E0021. · The Home Health Agency failed to (1) provide education on emergency preparedness for one out of ten employees sampled (Employee #3) and (2) test the Emergency Preparedness plan annually. See Tag E0036.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on policy review, supporting documentation review, and interview the home health agency failed to maintain the Emergency Preparedness plan. A review of the agency’s ‘Preparation Education and Testing’ policy, last reviewed 05/22/2024, revealed: Annual review of Emergency Management Plan- The agency must review and update policies and procedures at least annually.” A review of the agency’s Emergency Preparedness Plan for the years 2023 to 2025 revealed the following: -No documentation of an updated plan for the years of 2023 and 2024. On 08/13/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 acknowledged the above findings.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on policy review, supporting documentation review, and interview the Home Health Agency failed to update and complete hazard vulnerability assessments. Findings Include: A review of the agency’s ‘Risk Assessment Analysis Planning Priorities’ policy, last reviewed 12/05/2023, revealed: “The Hazard Vulnerability Risk Assessment/ Analysis/Planning Priorities must be completed by the care center during the development of the plan, care center relocation, and reviewed and updated annually” and “Document the agency emergency plan for mitigating risk of incidents/emergencies with the highest risk.” A review of the agency’s Emergency Preparedness Plan for the years 2023 to 2025 revealed the following: -There is no documentation of hazard vulnerability assessments completed for the years of 2023 and 2024. -There is no documentation of emergency mitigation plan for identified high risks in the 2025 hazard vulnerability assessment. On 08/13/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 acknowledged the above findings.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on policy review, supporting documentation review, and interview, the home health agency failed to inform local emergency preparedness officials regarding homebound patients in need of evacuation from their residence at any time during an emergency. Findings Include: A review of the agency’s ‘Communication Plan Components’ policy, last reviewed 12/12/2023, revealed: “The Emergency Management Committee should evaluate the following community contacts for specific local/ state plans (in the event of an emergency) and document the required information in the Communication Plan; agencies should initiate contact with any local and state resources necessary to complete the emergency planning process : Local Health Department, Fire Departments in agency service area, Police Departments in agency service area, and Emergency Medical Services Organizations.” A review of the agency’s Emergency Preparedness Plan for the years 2023 to 2025 revealed the following: -No documentation of communication with local emergency services and public health department for the years 2023, 2024, and 2025. On 08/13/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 acknowledged the above findings.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on policy review, supporting documentation review, and interview the home health agency failed to maintain a current communication plan for the readily identification and notification of on duty staff. Findings Include: A review of the agency’s ‘Communication Policy’ policy, last reviewed 12/18/2023, revealed: “The agency will establish a protocol for contacting staff, emergency resources and/or outside agencies in the event of an emergency. Each office will keep and maintain a current list of contact information for staff, patients, physicians, volunteers, entities providing services under arrangements, vendors, (federal, state, tribal, regional and local) emergency services, other appropriate community resources, and other home health and hospice providers. The agency will establish a system to rapidly notify and disseminate information to staff including support/debriefings ongoing throughout all phases of the disaster plan.” A review of the agency’s Emergency Preparedness Plan for the years 2023 to 2025 revealed the following: -No documentation of employee contact information for the years 2023, 2024, and 2025.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on policy review, personnel record review, supporting documentation review, and interview, the Home Health Agency failed to (1) provide education on emergency preparedness for one out of ten employees sampled (Employee #3) and (2) test the Emergency Preparedness plan annually. A review of the agency’s ‘Preparation Education and Testing’ policy, last reviewed 05/22/2024, revealed: “All agency personnel will receive initial training and education on the preparedness plan and policies to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. This education will then be conducted on an annual basis.” and “The agency will participate in a full-scale Community-based exercise annually; If a community-based exercise is not accessible, an individual, facility/agency-based drill will be conducted.” 1)A review of Employee #3’s personnel record revealed that they were hired on 06/03/2024 for the position of Registered Nurse. Further review of Employee #3’s personnel record revealed the following: -No documentation of emergency preparedness education completed. 2) A review of the agency’s Emergency Preparedness plan for the years 2023 to 2025 revealed no documentation of testing of the Emergency Plan for the years of 2023 and 2024. On 08/13/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 acknowledged the above findings.

The District of Columbia State Agency conducted an unannounced Federal Recertification Survey on behalf of the Centers for Medicare and Medicaid Services at Amedisys Home Health Agency from 08/12/2025 to 08/19/2025. Of the 244 unduplicated skilled admissions, the sample size was 14 patients with eight record reviews and two home visits. The survey resulted in noncompliance with Home Health Agency regulations with the following Condition and Standard level citations

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on policy review, supporting documentation review, and interviews, the Home Health Agency failed to meet the Condition of Participation for Reporting Outcome and Assessment Information Set (OASIS) Information by failing to electronically report all OASIS data as evidenced by the following: The home health agency failed to encode individual client assessment data within 30 days for 77 out of 127 patients sampled. See Tag G-372.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on policy review, medical record review, verification of encoded Outcome and Assessment Information Set (OASIS) data, and interview, the home health agency failed to encode individual client assessment data within 30 days for 77 out of 127 patients sampled. Findings Include: A review of the agency’s ‘OASIS Outcome and Information Set’ policy, last reviewed 06/09/2025, revealed: “OASIS data are collected as part of the comprehensive assessment required by the Medicare conditions of participation. Collected OASIS data will be captured in the agency approved EMR [electronic medical record]/ software. The agency complies with Oasis data collection and submission requirements as outlined in the Conditions of Participation, electronically submitting Oasis data within 30 days of completing the Oasis assessment.” A review of the home health agency’s OASIS agency validation report for the reference range of 01/2024 to 08/2025 revealed 77 patients with the submission alert of ‘Record Submitted Late: The submission date is more than 30 days…’ On 08/18/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 confirmed that OASIS data is to be encoded within 30 days of the assessment. Employee #1 acknowledged the above late submissions.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, medical record review, and interview, the home health agency failed to document physician notification of delayed initial assessment and failed to comply with ordered initial assessment date for one out of eight patients sampled (Patient #5). Findings Include: A review of the agency’s ‘Initial Referral/Admission Process’ policy, last reviewed 06/09/2025, revealed: “3. The admitting clinician will perform the admission assessment within 48 hours of BOTH the facility discharge AND receipt of referral (unless state regulation is more stringent), unless specified otherwise by the physician/allowed practitioner. If the initial assessment visit cannot be performed within the proper time frame, the Physician/allowed practitioner/referral source is informed and there is documentation of the Physician/allowed practitioner/referral source notification, and any orders received.” A review of Patient #5’s medical record from 04/26/2025 to 08/15/2025 revealed that they were admitted to the home health agency for Skilled Nursing care and Physical Therapy treatment of left lower leg cellulitis. Further review revealed that Patient #5’s referral to initiate home health services was dated 06/16/2025. Further review of Patient #5’s Delay Start of Care note dated 06/17/2025 revealed that the Start of Care visit is to be delayed till 06/20/2025 due to a verbal order. There is no documentation of name of Physician who gave the verbal order. Further review of Patient #5’s medical record revealed that the Start of Care assessment occurred on 06/21/2025, not the ordered 06/20/2025. On 08/19/2025 at approximately 12:00 PM the surveyors conducted a face to face interview with Employee #1 Director of Operations. Employee #1 confirmed that the physician’s name must be documented for verbal orders to delay start of care. Employee #1 acknowledged that Patient #5’s documentation indicates the expected start of care should have been 6/20/2025.

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 policy review, medical record review, and interviews, the home health agency failed to reconcile all medications during the creation of the Plan of Care for two out of eight patients sampled (Patient #5 and #7). Findings Include: A review of the agency’s ‘Plan of Care (POC)/Care Planning Process’ policy, last reviewed 01/31/2025, revealed: “6. The individualized plan of care must include the following: k. All medication and treatments.” A review of Patient #5’s medical record from 04/26/2025 to 08/15/2025 revealed that they were admitted to the home health agency for Skilled Nursing care and Physical Therapy treatment of left lower leg cellulitis. Further review of Patient #5’s referral information from 04/26/2025 revealed that Patient #5 is taking the following medications: -apixaban 5 milligrams (mg). -acetaminophen 1000 mg. -cholecalciferol 10 mcg. -ferrous sulfate 325mg. -gabapentin 100mg. Further review of Patient #5’s Plan of Care dated 06/24/2025 revealed no documentation of Patient #5 taking the following medications: -apixaban 5 milligrams (mg). -acetaminophen 1000 mg. -cholecalciferol 10 mcg. -ferrous sulfate 325mg. -gabapentin 100mg. A review of Patient #7’s medical record from 05/16/25 to 06/25/2025 revealed that they were admitted to the home health agency for Skilled Nursing care, Physical Therapy, Occupational Therapy, Speech Therapy, and Home Health Aide services for treatment of Sepsis due to urinary tract infection. Further review of Patient #7’s referral information dated 05/16/2025 revealed that Patient #7 is taking the following medications: -Gabapentin 100mg. -Acetaminophen 500mg. -Furosemide 40mg. Further review of Patient #7’s plan of care dated 05/21/2025 revealed no documentation of Patient #7 taking the following medications: -Gabapentin 100mg. -Acetaminophen 500mg. -Furosemide 40mg. On 08/15/2025 at approximately 1:30 PM the surveyor conducted a face to face interview with Patient #5 during the observed home visit. Patient #5 confirmed that they are taking apixaban, acetaminophen, cholecalciferol, ferrous sulfate, and gabapentin. On 08/19/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 acknowledged the finding and confirmed that medications from the referral are to be reconciled during creation of the Plan of Care to determine if the patient is taking them or not.

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: Based on policy review, medical record review, and interview, the home health agency failed to ensure timeframe of completion for plan of care goals for two out of eight patients sampled (Patient #1 and #5). Findings Include: A review of the agency’s ‘Guide for Requirements for Writing Therapy Goals (SMART Goals)’ procedure, last revised 07/2020, revealed: “Timebound- each goal must have a time frame, each plan of care must include both short term and long term goals.” A review of Patient #1’s medical record from 06/21/2025 to 08/19/2025 revealed that they were admitted to the home health agency for Skilled Nursing, Physical Therapy, and Occupational Therapy treatment for lobar pneumonia. Further review of Patient #1’s Plan of Care dated 06/21/2025 revealed under Physical Therapy Long Term Goal: “Patient will demonstrate improved ability to safely negotiate stairs from min A to CGA [acronyms] using handrails and SPC [acronym] order to safely.” There is no documentation of timeframe for when this goal is to be completed by. A review of Patient #5’s medical record from 04/26/2025 to 08/15/2025 revealed that they were admitted to the home health agency for Skilled Nursing care and Physical Therapy treatment of left lower leg cellulitis. Further review of Patient #5’s add on order from 07/23/2025 revealed that Patient #5 was ordered to receive Social Worker services. Further review of Patient #5’s Social Worker goal from 07/23/2025 revealed the following: “Patient/caregiver will demonstrate effective community resource planning, as evidenced by acceptance of assistance from those services for which they are eligible, extending the period of independence in the home.” There is no documentation of timeframe for when this goal is to be completed by. On 08/14/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 confirmed that all plan of care goals are to have timeframes for completion.

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 policy review, personnel file review, observation, and interview, the home health agency failed to (1) complete pre employment infection prevention screenings and interventions for four out of ten employees sampled (Employee #2, # 3, #6, and #8) and (2) failed to ensure patient care items were not expired. Findings Include: 1a) A review of the agency’s ‘Personnel File Requirements for Agency Staff’ policy, last reviewed 07/01/2024, revealed: “The Confidential/Medical Files may include but are not limited to the following documents as appropriate to the job functions: Health Assessment/MD Statement of Good Health Condition and free of communicable disease. TB [tuberculosis] screening questionnaire and TB Test on hire, Annual TB screening questionnaire, Hepatitis B Vaccine Declination/Acceptance, and Evidence of Hepatitis B Vaccine Administration if employee consents to receiving.” 1b) A review of Employee #2’s personnel record revealed that they were hired on 01/30/2024 for the position of Social Worker. Further review of Employee #2’s personnel record revealed the following: -No documentation of a health screening indicating that Employee #2 is in good health and free from communicable diseases. -TB initial screening is dated 2/2/2024. There is no documentation of one done at hire on 1/30/2024. -Hepatitis B vaccine signed 01/19/2024 revealed that Employee #2 consented to receiving the vaccine. There is no documentation of the Hepatitis B vaccine being administered. 1c) A review of Employee #3’s personnel record revealed that they were hired on 06/03/2024 for the position of Registered Nurse. Further review of Employee #3’s personnel record revealed the following: -There is no documentation of a Hepatitis B vaccination offered to Employee #3 by the home health agency. 1d) A review of Employee #6’s personnel record revealed that they were hired on 05/07/2025 for the position of Physical Therapist. Further review of Employee #6’s personnel record revealed the following: - Hepatitis B vaccine signed 04/24/2025 revealed that Employee #6 consented to receiving the vaccine. There is no documentation of the Hepatitis B vaccine being administered. 1e) A review of Employee #8’s personnel file revealed that they were hired on 09/06/2022 for the position of Speech Therapist. Further review of Employee #8’s personnel file revealed the following: -Employee #8’s health screening was completed on 10/01/2023. The form is not signed by a physician or other medical provider. There is no documentation of a health screening indicating that Employee #8 is in good health and free from communicable diseases prior to hire. 1f) On 08/13/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 acknowledged the findings. 2a) Review of the agency’s “Supply Room” process, date unknown shows “8) Supplies must be maintained in good condition and within date range. a) Expired supplies must be discarded…” 2b) The surveyors observed the following expired supplies in the supply room on 08/12/2025 at approximately 11:00 AM: -Six Saline Flush Syringes expired on 06/30/2025 -Four Sterile 0.9% Normal Saline 100 milliliters expired on 01/03/2025 (1 bottle) 06/01/2025 (3 bottles) -Sterile Wound Dressings expired on 06/28/2024 -Hydrocolloid Wound Dressings expired on 01/2025 -Four Intravenous catheters expired on 03/31/2025 -One hundred blood collection tubes expired on 08/31/2024 -Ninety-seven blood collection tubes expired on 02/28/2025 2c) A face to face interview was conducted with Employee #1 Director of Operations on 08/12/2025 at approximately noon. Employee #1 acknowledged the above-mentioned supplies had expired.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on policy reviews, medical record review, and interview, the home health agency’s infection control program failed to notify the medical provider of signs for infection for one patient and failed to document treatment of an infection for one out of four patients sampled (Patient #13). Findings Include: A review of the agency’s ‘Infection Prevention Program Overview’ policy, last reviewed 05/12/2025, revealed: “d. Monitoring and Surveillance: Infection data is collected using infection reports…” and “Documentation must include at a minimum: i. On the infection report: the date the infection was detected, the patient’s name, primary diagnosis, signs/symptoms, type of infection. ii. In the medical record: pathogens identified (if culture done) and treatment.” A review of the agency’s ‘Plan of Care (POC)/Care Planning Process’ policy, last reviewed 01/31/2025, revealed: “6. The individualized plan of care must include the following: k. All medication and treatments.” A review of Patient #13’s medical record from 03/03/2025 to 03/27/2025 revealed that they were admitted to the home health agency for Skilled Nursing care, Physical Therapy, Occupational Therapy, and Home Health aide services for chronic kidney disease with heart failure. Further review of Patient #13’s Physical Therapy note dated 03/18/2025 revealed the following under narrative: “Patient now reports being diagnoses with UTI [urinary tract infection]. She reports the pharmacy only had a few pills and was unable to fill the entire prescription. Her aide is to pick up the remaining doses of the prescription this week.” Further review of Patient #13’s Skilled Nursing note dated 03/27/2025 revealed the following under narrative: “Patient discharged from SN [Skilled Nursing] service with all goals met. Patient denies any pain or burning upon urination. Per patient, she have completed the antibiotic for her UTI.” Further review of Patient #13’s medical record revealed no updating of the medical record to capture antibiotic use. A review of the agency’s infection report for Patient #13 dated 03/18/2025 revealed the following: -Under the prompt ‘Signs/Symptoms: “Changes in urine character, odor, blood, sediment.” -The prompt ‘antibiotic name’ is unanswered. -There is no documentation of the provider being notified. A review of the agency’s Antibiotic use report revealed no capturing of Patient #13’s antibiotic use during their certification period. On 08/14/2025 at approximately 1:00 PM the surveyors conducted a face to face interview with Employee #1 Director of Operations. Employee #1 confirmed that if a patient has signs of an infection the provider is to be notified. Employee #1 confirmed that if a patient is prescribed an antibiotic during their certification period an administration order can be placed to track their use in the plan of care.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on policy review, personnel file review, and interview, the Home Health Agency failed to provide employee infection control education for one out of ten employees sampled (Employee #3). Findings Include: A review of the agency’s ‘Infection Prevention Program Overview’ policy, last reviewed 05/12/2025, revealed: “. Education: Infection Prevention education is provided to employees upon hire and annually.” A review of the agency’s ‘Competency Plan- RN/LPN [Registered Nurse/ Licensed Practical Nurse]’ policy, last reviewed 10/16/2024, revealed: “Orientation to the care center or department includes, but is not limited to: OSHA [Occupational Safety and Health Administration] requirements.” A review of Employee #3’s personnel record revealed that they were hired on 06/03/2024 for the position of Registered Nurse. Further review of Employee #3’s personnel record revealed the following: -No documentation of infection control or OSHA related education completed. On 08/13/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 confirmed that education on infection control and OSHA requirements were missing from Employee #3’s personnel file.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, medical record review, and interview, the agency’s nursing staff failed to adhere to medical orders for weight assessment for one out of eight patients sampled (Patient #5). Findings Include: A review of the agency’s ‘Plan of Care (POC)/ Care Planning Process’ policy, last reviewed 01/31/2025, revealed under purpose: “To provide physician/allowed practitioner ordered care, treatment, and services through an organized process and plan.” A review of Patient #5’s medical record from 04/26/2025 to 08/15/2025 revealed that they were admitted to the home health agency for Skilled Nursing care and Physical Therapy treatment of left lower leg cellulitis. Further review of Patient #5’s Plan of Care dated 06/24/2025 revealed under Order of Discipline and Treatments: “Heart Failure…observe patient ability to monitor and record daily weights and vital signs.” And “ Record patient reported weight, or weigh patient as needed.” Further review of Patient #5’s vital signs trending report revealed no documentation of daily weights from 06/24/2025 to 08/15/2025. There is no documentation of Patient #5’s ability to perform daily weights. On 08/19/2025 at approximately 12:30 PM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 acknowledged the above findings. Employee #1 confirmed that nursing staff can perform daily weights if the patient is unable to do it themselves.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on policy review, personnel file review, medical record review, supporting documentation review, and interview, the Home Health Agency failed to meet the Condition of Participation for Organization and Administration of Services by failing to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs as evidenced by the following: The Home Health Agency failed to ensure competence of personnel for five out of ten employees sampled. Subsequently this failed practice contributed to patient injury for one out of eight patients sampled. See Tag G-952.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on policy reviews, personnel file review, medical record review, supporting documentation review, and interview, the Home Health Agency failed to ensure competence of personnel for five out of ten employees sampled (Employee #3, #5, #6, #8, and #11). Subsequently this failed practice contributed to patient injury for one out of eight patients sampled (Patient #9). Findings Include: A review of the agency’s ‘Competency Plan- RN/LPN [Registered Nurse/ Licensed Practical Nurse]’ policy, last reviewed 10/16/2024, revealed:” Orientation to the care center or department includes, but is not limited to: Oasis [Outcome and Assessment Information Set ] training and documentation training.” And “Annually, clinician competency is evaluated and documented on the Annual Skills Competency Checklist – knowledge, skills and abilities defined by Federal, State and accrediting body requirements, and company policies to be completed on an annual basis. Once completed, the skills competency checklist is filed and maintained in the employee’s personnel file. Applicable skills competency elements may be evaluated during an annual onsite observation visit by a qualified clinician.” And “Clinicians are not considered competent until successful observation of skills and testing (as applicable to task) is completed. Skills will not be independently performed until the skill has been observed, evaluated and documented.” A review of the agency’s ‘Competency Plan-PT, OT, ST [Physical Therapy, Occupational Therapy, Speech Therapy]’ policy, last reviewed 06/11/2025, revealed: “New Hire competencies: Newly hired clinicians receive a skills competency assessment conducted by a qualified clinician with equal or greater competency in the applicable skill. The skills competency assessment is documented on the new hire skills competency checklist (appropriate to job title/role) during their new hire/orientation period and filed in the employee’s personnel file.” A review of the agency’s ‘Competency Plan-HHA [Home Health Aide]’ policy, last reviewed 12/06/2024, revealed: “An Annual Competency/ Skills Assessment of the home health aide is completed by a Registered Nurse.” A review of Employee #3’s personnel record revealed that they were hired on 06/03/2024 for the position of Registered Nurse. Further review of Employee #3’s personnel record revealed the following: -No documentation of completion of OASIS training. A review of Employee #5’s personnel record revealed that they were hired on 03/14/2014 for the position of Home Health Aide. Further review of Employee #5’s personnel record revealed the following: -Most recent annual competency training is dated 11/16/2022. There is no documentation of annual skills competency done for the years 2023, 2024, or 2025. A review of Employee #6’s personnel record revealed that they were hired on 02/24/2025 for the position of Physical Therapist. Further review of Employee #6’s personnel record revealed the following: -Skills checklist completed 02/27/2025 is incomplete with no documentation of Clinician Self-Assessment, Evaluation Method, and Initials/Date Validated for 11 out of 15 skill prompts. A review of Employee #8’s personnel record revealed that they were hired on 09/06/2022 for the position of Speech Therapist. Further review of Employee #8’s personnel record revealed the following: -Skills checklist completed on 11/06/2022 is incomplete with no documentation of Evaluation Method, Result of Evaluation, or Initals/Date Validated for 16 out of 28 skill prompts. -There is no documentation of Skills Checklists completed for the years 2023, 2024, or 2025. A review of Employee #11’s personnel record revealed that they were hired on 04/14/2004 for the position of Registered Nurse. Further review of Employee #11’s personnel record revealed the following: -Skills checklist completed 12/22/2022 revealed that the skill prompt ‘Urinary Catheter Insertion Male’ was evaluated as “NA =Does Not Apply” -There is no documentation of annual skill checklists completed for the years 2023, 2024, or 2025. A review of Patient #9’s medical record from 07/02/2025 to 08/06/2025 revealed that they were admitted to the home health agency for Skilled Nursing care for treatment of Parkinson’s Disease and management of an indwelling urinary catheter. Further review of Patient #9’s nursing note from 07/25/2025 revealed that Employee #11 changed Patient #9’s urinary catheter. A review of the agency’s incident log from 08/06/2025 revealed the following: “[Patient #9’s] spouse called to complain regarding [Employee #11] causing hospitalization D/T [due to] traumatic insertion of foley [catheter]…” A review of Patient #9’s Hospitalization discharge record from 07/25/2025 to 07/30/2025 revealed that they were admitted to an acute care facility for management of hematuria secondary to traumatic foley insertion. On 08/18/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #1 Director of Operations. Employee #1 acknowledged the above findings. Employee #1 confirmed that staff are to have skills evaluated annually to ensure competency.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, medical record review, and interview, the home health agency failed to secure physician signatures within 30 days for authentication of plans of care for two out of eight patients sampled (Patient #1 and #3) Findings Include: A review of the agency’s ‘Plan of Care (POC)/ Care Planning Process’ policy, last reviewed 01/31/2025, revealed: “4. The Plan of Care will be forwarded to the physician/allowed practitioner for his/her review and should be received with dated signature within thirty (30) days.” A review of Patient #1’s medical record from 06/21/2025 to 08/19/2025 revealed that they were admitted to the home health agency for Skilled Nursing, Physical Therapy, and Occupational Therapy treatment for lobar pneumonia. Further review of Patient #1’s Plan of Care dated 06/21/2025 revealed it is unsigned by the physician. A review of Patient #3’s medical record from 06/30/2025 to 08/28/2025 revealed that they were admitted to the home health agency for Skilled Nursing, Physical Therapy, and Occupational Therapy treatment for Calculus of Kidney. The surveyor reviewed Patient #3’s Plan of Care, dated 06/30/2025, on 08/13/2025; however the document was not signed nor dated by the Attending Physician during the time of the review. On 08/14/2025 at approximately 2:00 PM the surveyors conducted a face to face interview with Employee #1 Director of Operations. Employee #1 acknowledged the missing signatures and confirmed that Plans of Care are to be signed by the physician within 30 days.

The State Agency conducted an unannounced Federal Recertification Home Health Agency Survey from 04/25/2022 through 04/27/2022 for compliance with Emergency Preparedness requirements for Home Health Agencies. The Home Health Agency's total active census was 158 patients. Based on interview with the Home Health Agency's staff, the surveyor found the Home Health Agency in compliance with the requirements for Emergency Preparedness Program. No deficiencies were cited.

The State Agency conducted an unannounced Federal Medicare/Medicaid Home Health Agency Recertification Survey from 04/25/2022 through 04/27/2022. The agency reported that their number of unduplicated admissions for skilled services during the most recent 12-month period was 1,035 patients. The sample consisted of seventeen (17) clinical records, and 13 personnel records. On the first day of the survey, the Home Health Agency reported the total active census was 158 patients. Standard level deficiencies were cited based on observations, interviews with agency staff, patients' caregivers, review of clinical records, and the agency's policies. Glossary ADL's - Activities of Daily Living BP - Blood pressure CFR- Code of Federal Regulations CMS - Centers for Medicare and Medicaid Services COVID-19 - Coronavirus Disease 2019 DC- District of Columbia D/C - discontinue; discharge DCMR - District of Columbia Municipal Regulations DME - Durable Medical Equipment HHA - Home Health Aide HHA- Home Health Agency IU - International System of Units mg - milligram(s) mg/dL - milligrams per deciliter ml - milliliter(s) NPH - Insulin/ Humulin (Novolin) [Intermediate acting] PCA - Personal Care Aide PRN - As Needed REG- Regulation RN - Registered Nurse SN - Skilled Nurse (ing) SOC - Start of Care VP-Vice President wk- week (s) www - World Wide Web % - Percentage

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on clinical record review, policy review, and staff interviews, the Home Health Agency staff failed to complete comprehensive assessments to accurately reflect the patient's current health status in one (1) of twelve (12) active clinical records receiving skilled services. (Patient #2). Findings included: The Home Health Agency's policy titled, "Patient Assessment/Reassessment," dated 03/03/2022, shows "the comprehensive assessment will be completed, and consistent with the patient's immediate needs." The surveyor reviewed the clinical record on 04/26/2022 at approximately 10:20 AM that showed a Plan of Care for skilled services with a Start of Care date of 08/03/2021 and a Recertification Period of 03/31/2022 to 05/29/2022. The diagnoses listed on the Plan of Care included Pressure Ulcer of Other Site, Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Chronic Kidney Disease, Stage 3B, Hyperlipemia, Long Term use of Insulin, History of Diabetic Foot Ulcer, and Acquired Absence of Right Great Toe. In addition, the Plan of Care, Orders of Discipline and Treatments showed the skilled nurse to report blood glucose readings "greater than or less than" to the physician. The parameters were blank. Further review of the clinical record showed Employee #5 conducted a recertification assessment dated 03/30/2022. The clinical record lacked documented evidence that the Home Health Agency staff provided a completed comprehensive assessment that accurately reflected Patient #2's current health status to include reportable parameters for blood glucose readings. The surveyor conducted a face-to-face interview with Employees #1 (Vice President of Operations) and #2 (Administrator). Both employees acknowledged and confirmed the finding on 04/27/2022 at approximately 3:30 PM.

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 clinical record review, policy review, and staff interviews, the Home Health Agency failed to ensure the clinician developed an individualized Plan of Care and included all required elements to have the psychosocial and cognitive status for two (2) of the twelve (12) active clinical records reviewed (Patients #2, and 3). Findings included: The Home Health Agency's policy titled "Physician Orders and Medical Supervision of the Plan of Care" showed each patient must receive an individualized written plan of care that must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment and include all pertinent diagnoses and the patients' mental, psychosocial and cognitive status. 1. The surveyor reviewed Patient #2's clinical record on 04/26/2022 at approximately 10:20 AM. The record showed a Plan of Care with a Start of Care date of 08/03/2021 and a Certification Period from 03/31/2022 to 05/29/2022. Patient #2's diagnoses on the Plan of Care included Pressure Ulcer of Other Site, Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Chronic Kidney Disease, Stage 3B, Hyperlipemia, Long Term use of Insulin, and History of Diabetic Foot Ulcer, and Acquired Absence of Right Great Toe. A review of Patient #2's Plan of Care did not include the psychosocial and cognitive status. 2. The surveyor reviewed Patient #3's clinical record on 04/26/2022 at approximately 11:17 AM. The record contained a Plan of Care with a Start of Care date of 12/08/2021 and a Recertification Period from 04/07/2022 to 06/05/2022. Patient #3's diagnoses on the Plan of Care included Pressure Ulcer of the Sacral Region, Stage 4, Osteomyelitis of Vertebra and Sacral Region, Quadriplegia, Hypertension, Anoxic Brain damage, Epilepsy, Intellectual Disabilities, Urinary Device, Tracheostomy, and Gastrostomy. A review of the clinical record visit note report dated 03/04/2022 showed Patient #3 on Oxygen via Tracheostomy at 3.5 liters/minute. Further review of the clinical record and client coordination note report showed Patient #3 on Oxygen via Tracheostomy in place at 3.5 liters/min. Additionally, a review of Patient #3's Plan of Care did not include the following: A diagnosis of Oxygen Management, and The psychosocial and cognitive status The Plan of Care lacked documented evidence of completion of all required elements, including pertinent diagnoses and psychosocial and cognitive status for all patients identified. The surveyor conducted a face-to-face interview with Employees #1 (Vice President of Operations) and #2 (Administrator) on 04/27/2022 at approximately 3:30 PM. Both employees acknowledged the findings.

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 clinical record review, policy review, and staff interviews, the Home Health Agency staff failed to submit completed discharge summaries within five (5) business days of discharge to the primary care physicians for two (2) of five (5) closed record reviews. (Patients #16 and 17). Findings included … The Home Health Agency's policy titled "Discharge of Patients," dated 08/26/21, showed that "A completed discharge summary is sent to the primary care practitioner, receiving facility or other health care professional who will be responsible for providing care and services to the patient after discharge from the Home Health Agency (HHA) within five business days of the patient's discharge." A. The surveyor conducted a review of Patient #16's closed clinical record on 04/27/2022 at approximately 12:45 PM. The medical history included a Plan of Care for skilled nursing services with a Start of Care date of 01/10/2022 and a Certification Period from 01/10/2022 to 03/10/2022. The diagnoses included COVID-19, Hypertension, Abnormalities of Gait and Mobility, Hypothyroidism, Obesity, Dextrocardia, History of Malignant Neoplasm of the Breast, and History of Cerebral Infarction. A review of the physician's orders on the Plan of Care directed the physical therapist to visit Patient #16 to provide skilled therapeutic intervention, activity, education, and training twice (2) a week for three (3) weeks, then once (1) a week for five (5) weeks, to address bed mobility training, transfer training, gait training, therapeutic exercises, identify fall risk factors, and hypertension self-management. Further review of the closed clinical record, the Discharge-Transfer Summary Report showed a discipline discharge date of 03/01/2022. The Event-Stages History Report showed a process-appropriate summary to the physician with an end date of 04/05/2022. The closed clinical record review lacked documented evidence that the Home Health Agency staff submitted Patient #14's discharge summary to the primary care physician within five (5) business days. B. The surveyor conducted a review of Patient #17's closed clinical record on 04/27/2022 at approximately 1:15 PM. The medical history included a Plan of Care for skilled nursing services with a start of care date of 12/04/2021 and a recertification period from 02/02/2022 to 04/02/2022. The diagnoses included Flaccid Neuropathic Bladder, Retention of Urine, Type 2 Diabetes Mellitus, Low Vision Right Eye, Asthma, Hyperlipemia, Urinary Device, Long Term Use of Insulin, and Long Term Use of Oral Hypoglycemic Drugs. Physician's orders on the Plan of Care directed the skilled nurse to visit Patient #17 to provide skilled nursing services once (1) a week for one (1) week, three (3) times a week for five (5) weeks, once a week (1) for one (1) week, twice (2) a week for one (1) week, then three (3) times a week for one(1) week throughout the certification period for disease management, medication management, pain management, fall reduction management, genitourinary management, intermittent straight catheterization management and or change in condition. A review of the closed clinical record, Discharge-Transfer Summary Report, showed a discharge date of 03/25/2022. The Event-Stage History Report showed a process-appropriate summary to the physician with an end date of 04/06/2022. A review of the closed clinical record lacked documented evidence that the Home Health Agency staff submitted Patient #17's discharge summary to the primary care physician within five (5) business days. The surveyor conducted a face-to-face interview with Employees #1 (Vice President of Operations) and #2 (Administrator) on 04/27/22 at approximately 3:30 PM. Both employees acknowledged the findings.