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 757375 (X3) Date Survey Completed 07/07/2025
Name of Provider or Supplier Intense Home Health Inc Street Address, City, State 3786 La Crescenta Ave. Suite 104, Glendale, 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 interviews and record review the Home Health Agency (HHA) failed to ensure clinical records included clinical nursing notes needed to accurately reflect the care for one of seven sampled patients (Patient 6). 

 

This failure resulted in an incomplete clinical record. 


On 7/2/2025 at 12:45 p.m., Patient 6’s current plan of care, medication list, and recertification nursing assessment were requested and provided by the Director of Patient Care Services (DPCS).  



During a record review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” dated from 4/18/2025 to 6/16/2025, indicated a start of care date of 2/17/2025 with a primary diagnosis of diabetes type II (high blood sugar).  



During a record review of Patient 6’s medical record form titled “Drug Regimen Review” dated 4/14/2025, indicated list was documented on 4/14/2025. 



During a record review of Patient 6’s medical record form titled “Recertification/Follow-Up Assessment” dated 4/14/2025, indicated Patient 6 was assessed and deemed eligible for home health services on 4/14/2025. 



During a concurrent observation and interview on 7/7/2025 at 12:15 p.m., with Office Manager (OM1) of Patient 6’s medical records, OM1 was requested to provide Patient 6’s current plan of care, medication list, and recertification nursing assessment. OM1 was observed taking Patient 6’s recertification nursing assessment and medication list out of a black cardboard box. OM1 stated that visiting nurses document their visit notes on their computers. Then when they go to the agency the nurses print and turn in their visit notes. The notes are placed inside the black cardboard box waiting to be transcribed. OM1 stated she then transcribes the nurses’ notes into their computer system, prints them out, then files the notes into the patient’s medical record. OW1 stated that Patient 6’s recertification nursing assessment, medication list, and plan of care should have been placed in Patient 6’s medical record seven days after it was completed, by 6/21/2205. 



 



During a concurrent interview and record review on 7/7/2025 at 2 p.m., with the Director of Patient Care Services (DPCS) of Patient 6’s medical record, the DPCS stated Patient 6’s medical record did not have her (Patient 6) plan of care or recertification nursing assessment. The DPCS stated Patient 6’s plan of care or recertification nursing assessment should have been placed in her (Patient 6) medical record within 7 days of the assessment, by 6/21/2025. The DPCS stated that it was important to have patients’ medical records complete and current because the medical record holds the most current physician orders, and the nurses need to follow the physician orders. The DPCS also stated that the medical record, particularly the recertification nursing assessment, will indicate what the patient needs are. 



 



During a record review of the HHA’s undated document titled “Clinical/Services Data Collection”, indicated “A clinical record… will include at a minimum: C. physician orders… D. Changes in the plan of care. F. Patient response to care and services… I. Current patient status and progress toward goals.” The Clinical/Services Data Collection form also indicated “Entries into the clinical/services record will be made on the day are/services is provided to the patient. All documentation will be turned into the office at the end of the workday.”