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)
G0580 Only as ordered by a physician
CFR(s): 484.60(b)(1)

Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner.


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 therapeutic services to a patient’s personal residence) failed to ensure that Registered Nurse (RN 1) administered Ertapenem (medication used to treat bacterial infections) Intravenous (IV- refers to a way of giving drug or other substances through a needle or tube inserted into a vein) medication as ordered by the physician for one of seven (7) sampled patients (Patient 1) 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, 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 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 11/11/2025 the HHA was able to submit an IJ removal plan for G580 and G1012. The IJ removal plan was reviewed and accepted on 11/12/2025.

 

 

On 11/12/2025 at 3:10 P.M., the survey team verified the implementation of the IJ removal while onsite and the IJ was removed in the presence of the DPCS.




Findings: 



 

 



During a review of Patient 1’s General Acute Care Hospital (GACH) discharge order dated 8/2/2025, the discharge order indicated to infuse Ertapenem 1 gram (unit of measurement) in Normal Saline (a mixture of water and salt) 100 milliliters (ml, unit of measurement) over 30 minutes via IV access every 24 hours via rate-flow/mini-bag (a small IV bag of medication that is administered at a controlled rate using a flow rate controller) 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) on 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 were a lot of patients needing help. 



  

 



During an interview with RN 1 on 10/29/2025, at 1 p.m., she stated she had a scheduled visit on 8/5/2025, to infuse the IV Ertapenem medication but she was unable to do the visit because she had to go to a court hearing on that day. RN 1 stated she tried looking for a replacement nurse, but they refused to do the visit because the patient lives far. 



  

 



During a review of Patient 1’s electronic medical record (EMR) (from 8/3/2025 to 8/10/2025), Patient 1’s EM indicated that HHA did not complete the initial evaluation using the Outcome and Assessment Information Set (OASIS) for evaluation conducted on 8/3/2025, there was no plan of care developed, no physician’s order for all patient’s medications being administered to the patient, no nursing notes completed for nursing visit scheduled dates of 8/3/2025 and 8/4/2025. 



 



  



A review of the HHA's policy dated 11/2023 entitled" Administration and Documentation of Medications", indicated that the license nurse will administer medications as ordered by the physician that can be safely administered and monitored during a home visit.  License nursing personnel will administer and document medications which have been ordered as part of the plan of care and have been approved for safe administration and monitoring during a home visit.