| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 757287 | (X3) Date Survey Completed 11/03/2025 |
| Name of Provider or Supplier Summa Home Health Care, Inc. | Street Address, City, State 2500 E Foothill Blvd Unit 417, Pasadena, 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) |
| G0000 | The following reflects the findings of the California Department of Public Health (CDPH) during a complaint validation survey conducted from 10/30/2025 to 11/3/2025, at 2500 East Foothill Blvd. Unit 417, Pasadena, CA 91107. Complaint Intake # 2591188 Total Unduplicated Census: 94 Census: 14 Sample Size: 7 Home Visits: 3 Deficiencies were issued related to complaint number 2591188. IJ G580 On 11/3/2025, at 11:40 a.m., while onsite at the agency, the department called an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident), in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD), related to the Home Health Agency's (HHA, medically focused care provided by skilled professionals like nurses and therapists in a patient home) failure to ensure that Registered Nurse (RN 1) administered Ertapenem (medication used to treat bacterial infections) 1 gram IV on 8/5/2025 as ordered by the physician from General Acute Care Hospital (GACH) to treat Patient 1’s intra-abdominal abscess due to lack of staffing. This failure put Patient 1 at increased risk to have infection and develop sepsis (a life-threatening condition that occurs when the body’s immune system overreacts to an infection that could lead to widespread inflammation and organ damage) that could lead to hospitalization and death. On 11/3/2025, the HHA was unable to submit an IJ removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/3/2025 at 4 p.m., the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD) with the IJ situation not removed. On 11/12/2025, the HHA submitted an IJ removal plan which was reviewed and was accepted. The acceptable IJ removal plan included the following: Corrective Action Implemented / Immediate Jeopardy Removal Plan: 1. Patient 1 Status (Discharge): Patient 1 was discharged 08/11/2025 following hospitalization at the hospital and transferred to another home-health agency for post-discharge services. Patient 1 is no longer on Summa Home Health Care’s active census. 2. Leadership Oversight (11/7/2025) Completed Retraining Verification (11/8/2025): The Governing Body appointed a Registered Nurse Consultant / Compliance Officer to provide independent clinical oversight and verify staff competency in physician-order execution and reporting. The Administrator/DPCS continues in her role under mentoring and competency validation by the Compliance Officer. 3. Chart Audit (11/7/2025 – 11/10 2025): All 13 active patient records (Patients 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) were audited to confirm that medication and treatment orders were implemented and documented accurately. No harm, injury, or adverse event was found in any record. Any documentation deficiencies were corrected and verified with ordering physicians. Audit logs and QA verification are maintained in the QA binder. 4. Policy Implementation (11/10 / 2025): Policy #2025-11B Clinical Documentation Review and QA Verification were updated to require: -All OASIS to be completed within 48 hours for all payers (Medicare, Medicaid, Medi-Cal, HMO, Private). -Medication administration within 1 hour before or after the ordered time. Documentation must occur in real time, and the physician must be notified of any variance. -Any missed or delayed visit must be rescheduled immediately completed within 24 hours—when current staff are unavailable or late. -Nurse must notify the patient and office of changes and record this communication in the Communication Log. -Weekly chart audits for all patients from 11/01/2025 to 1/30/2026 (90 days) to verify OASIS timeliness, medication administration, and communication compliance. Results are logged and trended in Quality Assurance Performance Improvement (QAPI) Documentation Accuracy and Timeliness Initiative (DATI). -After January 30, 2026, audits transition to monthly based on sustained performance. -Two RNs and three LVNs are now on staff; new hire RN #2 is available for coverage as needed. The agency also has a contract with a staffing agency to provide per-diem nurses for restaffing. 5. Administrator/DPCS Retraining (11/10 2025): The Administrator/DPCS completed one-on-one education with the RN Consultant on physician-order compliance and documentation protocols. Competency was confirmed by return demonstration and written acknowledgement of the deficiency. 6. Staff Education (11/10 2025): A facility-wide in-service led by the RN Consultant addressed: -Physician-order execution and documentation timeliness. -Missed-visit escalation and chain of command. -Implementation of Policy #2025-11A. All staff attended, signed attendance roster, and completed competency validation. 7. Monitoring and QAPI Integration: The RN Consultant will audit Verbal Communication and Missed Visit Logs weekly for 12 weeks then monthly, reporting findings to the Administrator and Governing Body through the Documentation Accuracy and Timeliness Initiative (DATI) QAPI project. 8. Admissions Control, Suspension of Payment for New Admissions (SPNA): Per CDPH/CMS directive (11/7/2025), Summa Home Health Care remains under SPNA and will not accept new patients until substantial compliance is verified. Verification and Outcome: All 13 active patients (Patients 2–14) were audited daily; no harm or recurrence identified. Medication administration times and real-time documentation verified compliant through daily audit logs. Completion Date: 11/10/2025 Responsible Persons: Administrator/DPCS | RN Consultant – Compliance Officer | CEO-Chair On 11/12/2025 at 3:10 p.m., the survey team verified the implementation of the IJ removal plan during an on-site visit and the IJ was removed in the presence of the Administrator (ADM)/DPCS. IJ G-1012 On 11/3/2025, at 11:450 a.m., while onsite at the agency, the Department called an IJ, in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD), related to the HHA’s failure to maintain a clinical record containing past and current information of patient receiving home health services for one of seven sampled patient (Patient 1) by failing to: 1. Ensure Patient 1 GACH Discharge order to administer Ertapenem (medication used to treat bacterial infections) Intravenous (IV- a way of giving a drug or other substance through a needle or tube inserted to a vein) every 24 hours was included to Patient 1’s plan of care. 2. Ensure Patient 1 medication and treatment orders were included on Patient’s 1 plan of care. 3. Ensure License staff document all interventions, including medication administration, treatments and services and responses to the interventions for Patient 1. 4. Ensure license staff completed an initial evaluation using the Outcome and Assessment Information Set (OASIS)on 8/3/2025 for Patient 1. 5. Ensure Patient 1 had a plan of care developed to outline the specific plan for medical, rehabilitation, and supportive services a patient needs at home. 6. Ensure Patient 1 had nursing notes completed for nursing visit conducted on 8/3/2025 and 8/4/2025. 7. Ensure to complete Oasis discharge comprehensive assessment for Patient 1. These failures had a potential to result with miscommunication within the interdisciplinary team (a group of professionals from different fields who collaborate to address complex issues, such as patient care), medication error, inappropriate treatment and services that could cause patient suffering severe harm, hospitalization and death. On 11/3/2025, the HHA was unable to submit an IJ removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/3/2025 at 4 pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD) with the IJ situation not removed. On 11/12/2025, the HHA submitted an IJ removal plan which was reviewed and was accepted. The acceptable IJ removal plan included the following: Corrective Action Implemented / Immediate Jeopardy Removal Plan: 1. Patient 1 Status (Discharge): Patient 1 was discharged 08/11/2025 from Summa Home Health Care following hospitalization and was redirected to another home-health agency for continuing care. No further services are being provided to this patient by Summa Home Health Care. 2. Leadership Oversight (11/7 2025): A Registered Nurse Consultant/ Compliance Officer assumed responsibility for auditing clinical records and mentoring the Administrator/DPCS on documentation standards and QA procedures. 3. Comprehensive Record Audit (11/7 -11/10 2025): All 13 active patient records (Patients 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) were audited to ensure required elements (OASIS, POC, orders, notes, discharge summaries) were complete and accurate. Any missing entries were corrected and verified with the ordering physician. No harm or injury was identified in any record. 4. Policy Implementation (11/10 2025): Policy #2025-11B- "Clinical Documentation Review and QA Verification" was implemented, requiring review of each record within 48 hours of completion for accuracy and completeness, with dual sign-off by clinician and QA reviewer. 5. Administrator/DPCS Retraining (11/10 2025): The Administrator/DPCS completed targeted training conducted by the RN Consultant on proper record maintenance, OASIS submission timeliness, and QA tracking. Competency was demonstrated by return demonstration and signed acknowledgement of the deficiency. 6. Staff Education (11/10 2025): A facility-wide in-service training was conducted by the RN Consultant covering documentation accuracy, timeliness, and CMS record standards under §484.60(b) and §484.110. All staff attended and completed competency validation and attendance sign-in. On 11/12/2025 at 3:10 p.m., the survey team verified the implementation of the IJ removal plan during an on-site visit and the IJ was removed in the presence of the Administrator ADM)/DPCS. The following Conditions of Participation (COP) were not met: §484.55 Comprehensive Assessment of patients §484.60 Care planning, coordination of services, quality of care §484.110 Clinical Records |