Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 757280 (X3) Date Survey Completed 11/04/2025
Name of Provider or Supplier Rely Home Health, Inc. Street Address, City, State 100 N Brand Blvd Suite 401, Glendale, CA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G1008 Clinical records
CFR(s): 484.110

Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically.


This CONDITION 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 therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical records as follows: 


The Home Health Agency (HHA, agency that provides skilled health care services to patients in their own homes) failed:  

 



 



1. To ensure Licensed Vocational Nurse (LVN) 1 did not willfully falsify (knowingly make a false entry into a patient record) patient records for one of thirteen sampled patients (Patient 5) when LVN 1 copied LVN 2’s visit notes for Patient 5 on 10/15/2025 and 10/17/2025, that indicated wound care was provided to Patient 5 when wound care treatment was not actually provided by LVN 1. 

 



 



2. To ensure the Outcome and Assessment Information (OASIS, an assessment tool used to collect functional and clinical status data for patients) patient assessment, was authenticated with a signature of the staff who completed the OASIS form and dated for one of thirteen sampled patients (Patient 8). 



 

 



 3. To ensure Occupational Therapist (OT) 1, who was a contracted employee, used a unique identifier that included OT 1’s signature when completing the “Patient Assessment: OASIS (OASIS)” form for one of thirteen sampled patients (Patient 9).  

 



 



These failures affect data accuracy that could result in inappropriate guidance for the development of Patient 5, Patient 8 and Patient 9’s plan of care (POC), compromise patient safety, disrupt continuity of care, poor quality of care that could lead to adverse health outcome (any negative or suboptimal result affecting a person's physical or mental well-being, stemming from various factors including medical care, disease progression, or environmental exposure). (See G01024).

 

 

The cumulative effect of these practices resulted in the systemic failure of the HHA to deliver statutorily (decided and controlled by law) mandated compliance with the federal regulations for Clinical Records to ensure the clinical records contained accurate and completed clinical information to all patients certified to receive the home health benefits.