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 757737 (X3) Date Survey Completed 03/19/2026
Name of Provider or Supplier Alaunus Home Health, Inc Street Address, City, State 110 S Rosemead Blvd. Suite R4, 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)
G0716 Preparing clinical notes
CFR(s): 484.75(b)(6)

Preparing clinical notes;


This ELEMENT is not met as evidenced by:
Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure clinical visit notes were completed for two of seven sampled patients (Patient 2 and Patient 3).

 

This failure had the potential to result in delayed or inappropriate treatment and lack of coordination between the interdisciplinary team for Patient 2 and Patient 3. 


a. During a review of Patient 2’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period from 1/15/2026 to 3/15/2026, the POC indicated Patient 2 was admitted to the HHA on 1/15/2026 with a primary diagnosis of pressure ulcer of the right heel (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness on the right heel).

 

During an interview on 3/18/2026 at 12:08 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated the Nursing Progress Notes for Patient 2 dated 1/19/2026, 1/23/2026, 2/2/2026, and 2/9/2026 were blank. LVN 3 stated she has not yet completed charting her visits for Patient 2. LVN 3 stated it was important to document visit notes in the patient’s electronic health record timely so the interdisciplinary group can see how the patient is progressing.

 

During a concurrent interview and record review on 3/18/2026 at 2:34 p.m. with the Director of Patient Care Services (DPCS), Patient 2’s “Nursing Progress Notes,” dated 1/19/2026, 1/23/2026, 2/2/2026, and 2/9/2026, authored by LVN 3, were reviewed. The Nursing Progress Notes were blank. The DPCS stated the visit notes were blank. The DPCS stated nurses are expected to document their visits in the patient’s electronic health record within seven days. The DPCS stated missing and late documentation could jeopardize the patients’ care and result in a lack of communication with their physician.

 

b. During a review of Patient 3’s POC for the certification period from 1/16/2026 to 3/16/2026, the POC indicated Patient 3 was admitted to the HHA on 1/6/2026 with a primary diagnosis of stage 1 pressure ulcer of the sacral region (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness on the tailbone).

 

During an interview on 3/18/2026 at 12:10 p.m. with LVN 3, LVN 3 stated the Nursing Progress Notes for Patient 3 dated 1/20/2026, 1/27/2026, 2/3/2026, 2/10/2026, 2/25/2026, 3/4/2026, and 3/10/2026 were blank. LVN 3 stated she has not yet completed charting her visits for Patient 3. LVN 3 stated it was important to document visit notes in the patient’s electronic health record timely so the interdisciplinary group can see how the patient is progressing.

 

During a concurrent interview and record review on 3/18/2026 at 2:36 p.m. with the DPCS, Patient 3’s “Nursing Progress Notes,” dated 1/20/2026, 1/27/2026, 2/3/2026, 2/10/2026, 2/25/2026, 3/4/2026, and 3/10/2026, authored by LVN 3, were reviewed. The Nursing Progress Notes were blank. The DPCS stated the visit notes were blank. The DPCS stated nurses are expected to document their visits in the patient’s electronic health record within seven days. The DPCS stated missing and late documentation could jeopardize the patients’ care and result in a lack of communication with their physician.

 

During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection”, revised 11/2017, the P&P indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.”