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)
G0532 Continuing need for home care
CFR(s): 484.55(c)(3)

The patient's continuing need for home care;


This ELEMENT is not met as evidenced by:
Based on observation, interview, and record review, the Home Health Agency (HHA) failed to assess the patients' continuing need for home care services for two of 7 sampled patients (Patient 2, and Patient 3). 

This deficient practice resulted in the continued skilled nurse services to these patients lacking the comprehensive assessments to clearly demonstrate the continuing provision of the home health benefits.

 


a. During a review of Patient 2'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 date (SOC) date of 8/26/2025, with a diagnosis of diabetes mellitus type II ( high blood sugar levels due to the body’s inability to use insulin effectively). 

 

During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the re-certification period from 8/25/2025 to 10/24/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. 

 

During a joint home visit, on 10/31/2025, at 1 p.m., at Patient 2’s residence with the director of patient care services (DPCS), Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During an interview, Patient 2 she goes visit her physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and can managed her medication and diet regimen independently.

 

During a concurrent interview and record review, on 11/2/2025, at 11 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 2’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 8/25/2025 to 10/24/2025, Patient 2’s vital signs were within normal range, that he had no recent admissions to the hospital, no episodes of falls, no new medications, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 2 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 1 should have been discharged because her goals have been met and there was no need for skilled nursing services.  

 

b. During a review of Patient 3'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 date (SOC) date of 8/3/2025, with a diagnosis of hypertensive heart disease (a heart problem that develop from long term high blood pressure).

 

During a review of Patient 3’s Home Health Certification and Plan of Care (POC) for the certification period from 8/3/2025 to 10/1/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up.

 

During a concurrent interview and record review, on 11/2/2025, at 11:30 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed  Patient 3’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 8/3/2025 to 10/1/2025, Patient 3’s vital signs were within normal range, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 3 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 3 should have been discharged because his goals have been met and there was no need for skilled nursing services.  

 

During a review of the agency’s policy and procedure (P&P) titled, Discharge Criteria and Process, dated April 2020, the P&P indicated the purpose of the policy is to outline the process for discharging a patient from service. Services will be terminated when the patient meets one of the following discharge criteria: if appropriate, the physician and the organization agree that the goals of home care have been attained or are no longer attainable.