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)
G1012 Required items in clinical record
CFR(s): 484.110(a)(1)

The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders;


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 maintain a clinical record containing past and current information of patient receiving home health services for one of seven sampled patients (Patient 1) by failing to: 



 



 

 



 1. Ensure Patient 1 (General Acute Care Hospital) GACH Discharge order dated 8/2/2025 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, 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 11/11/2025 the HHA was able to submit an IJ removal plan. 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.




Review of Patient 5’s Home Health Certification and Plan Of Care form, indicated Patient 5 was admitted to the HHA, with a start of care date of 2/1/2025, with diagnosis of Hypertensive heart disease  with heart failure, acute kidney failure, Cachexia ,Alzheimer’s for the certification period of 9/29/2025 to 11/27/2025.

There were no CNA visit notes in patients EMR for the certification period

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.

Findings: 



 

 

 



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 complete the initial evaluation using the Outcome and Assessment Information Set (OASIS) dated 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, and no discharge OASIS done. 



  

 

 



During an interview with RN 1 on 10/29/2025, at 1:30 p.m., she stated she did not complete the OASIS assessment, her nursing notes, the discharge OASIS and discharge summary and she did not transfer the hospital’s discharge physician’s order to their agency’s physician’s order form 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.  



  

 

 



A review of the HHA's policy and procedure dated 11/2023, entitled "Contents Of The Clinical Records", indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient's problem and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contact personnel. The following information will be available in the clinical record for patients receiving skilled care as follows: a. Plan of treatment, plan of care b. signed and dated progress notes for each discipline rendering service  c. Record and Findings of initial and ongoing assessments  d. Procedures and treatments rendered  e. Care planning activity based on the patient's problem, needs, and expected outcomes   f. Transfer/discharge summaries  and other summary reports sent to the physician as required by law and regulation and organization policy.