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)
G0574 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 interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to develop an individualized plan of care (POC) that included problems, goals and interventions for two of seven sampled patients (Patient 1 and Patient 5).

 

For Patient 1, who had a diagnosis of acute appendicitis with perforation (a medical emergency where the appendix, a small worm-shaped organ attached to the large intestine, ruptures and releases bacteria into the abdominal cavity).  

This failure had the potential to result in Patient 1 not receiving the identified needs and services, which could lead to a decline in his health status and/or injury.

 

For Patient 5, the HHA failed to ensure that each patient's plan of care (POC) included all disciplines involved and clearly stated the frequency and duration of visits.

This deficient practice resulted in patient's needs and services not coordinated among the staff providing the care. 

 

 

 


During a concurrent home visit on 10/30/2025, at 11:30 a.m., with the DPCS preset, an interview with patient 5 (Spanish-speaking only) and Family Member 1(FM1) in the den of Patient 5’s residence. FM 1 stated that Patient 5 had a rash on his back that had been there and itching real bad for over a month. FM 1 stated that the LVN comes twice a week and that the CNA, who visits twice weekly , asked the family what for then rashes redness and itching of his back.

Observation of Patient 5’s back indicated a large multiple bumpy red rash on his entire back with redness around patients 5’s cocci and buttocks area. During the home visit, the DPCS stated that she was not aware of the rash and would have to review the records and talk to the Skilled Nurse who was providing care.

During a concurrent record review of patient 5’s EMR and interview with the DPCS in the HHA’s office on 11/3/2025, at 12pm., The DPCS stated the CNA providing care to patient 5 was employed through a registry due to the agency not having an in-house CNA. The DPCS confirmed there were no CNA visit notes in patient 5’s electronic medical record.

The DPCS Stated CNA  documentations were stored “ in a portal” and that she eeded to download and put them in the chart. The DPCS further stated she had not reviewed the CNA notes or the complete chart.

During a review of Patient 5’s Home Health Certification and Plan of Care for the certification period of  9/29/2025 to 11/27/2025, with the Adm/DPCS in the HHA, it  did not indicate the disciplines providing services or the frequency of visit.

During an interview with the ADM/DPCA on 11/3/2025, at 11:30, in the office, she stated se did not know the POC was to have the information and that the HHA has a standard visit which is at least once a week routine.  The ADM/DPCS stated she would have to ask the Skilled Nuse (SN) for the information. The ADM/DPCS was asked how does she ensure the disciplines are visiting the patient in which the ADM/DPCS stated, “they call me”. The ADM/DPCS was unable to provide the CNA/PT visit notes or any documentation the isit were being done by the various disciplines.

The ADM/DPCS was unable to provide the documents and  policy and procedures requested.

 

 

 

 

Review of the home health certification and plan of care for patient 5 indicated a start of care date (SOC) of  2/1/2025 ,for the certification period of 9/29/2025 to 11/27/2025, With diagnosis that include hypertensive heart failure with heart failure( refers to heart problems that occur because of high blood pressure that is present for a long time), acute kidney failure( Sudden loss of kidney function when the kidneys  can't filter waste which affects fluid and electrolyte balance it can happen quickly and is often reversible with treatment  Alzheimer's disease( memory loss and other cognitive abilities that interfere with daily life), and cachexia( extreme loss of weight and muscle mass), and bed confinement status,

During a review of Patient 1’s  GACH 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 led 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 are a lot of patients needing help.  

 

 During a review of Patient 1’s electronic medical record (EMR) indicated that HHA did not develop a plan of care for intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into the vein) infusion management to treat Patient 1’s intra-abdominal abscess ( a collection of puss located within the abdominal cavity).

  

During an interview, on 11/2/2025, at 12 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the HHA failed to develop a care plan for IV infusion management.

 

During a review of the agency’s policy and procedure (P&P) titled, Home Health Certification and Plan of Care, dated 7/9/2018, the P&P indicated the Home Health Certification and Plan of Care (485) is the ordering practitioner’s order for home care services. The Plan of Care will be individualized to include, but not limited to, all treatments, procedures, medications, and services authorized to be provided by direct care staff(s). The Plan of Care shall include, but not limited to identified patient problems to include diagnoses and surgical procedures.