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 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)
G0520 5 calendar days after start of care
CFR(s): 484.55(b)(1)

The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care.


This ELEMENT is not met as evidenced by:
Based on interview and record review, the Home Health Agency (HHA) failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 1).

 

This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being.

 


During a review of Patient 1’s GACH (hospital) discharge order dated 8/2/2025, indicated to a physician’s order to infuse Ertapenem 1 gram in Normal Saline 100 milliliters over 30 minutes via IV access every 24 hours via rate-flow/mini-bag every 24 hours until 8/24/2025 for intra-abdominal abscess. 

 

During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix , a small finger-shaped organ attached to the large intestine, becomes inflamed and ruptured.   

 

During a phone interview with Family Member (FM 1) 10/29/2025, at 12 p.m., FM 1 stated she was very upset that Registered Nurse (RN 1) did not show up on her scheduled visit day (FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that resulted to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there were a lot of patients needing help.  

 

During a review of Patient 1’s electronic medical record (EMR) indicated that HHA did not complete the initial evaluation using the Outcome and Assessment Information Set (OASIS) dated 8/3/2025. 

 

During an interview with RN 1 on 10/29/2025, at 1:30 p.m., she stated she did not complete the OASIS assessment because the HHA’s biller told them there was a problem with the patient’s insurance and the HHA would not get paid for services rendered.  RN 1 also stated the comprehensive assessment must be completed no later than 5 calendar days after the start of care.

  

 During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2020, the P&P indicated a comprehensive patient assessment will be completed within five (5) calendar days of the patient start of care. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs.