G0236: Clinical Records
CMS level: Standard Moderate. On this site, a condition-level citation is labeled Serious, a standard-level citation Moderate, and an element-level citation Minor. What the labels mean · How to choose an agency
Data from CMS inspection reports (Form 2567), 2018-01-02 to 2026-10-15, downloaded 2026-10-21; CMS agency list file dated 2026-09-21. CMS source file. What the labels mean
Where it was cited
- California7
- Illinois3
- Texas3
- Georgia2
- Indiana2
- Arkansas1
- Colorado1
- Florida1
- Iowa1
- Kentucky1
- Michigan1
- Nevada1
- New York1
- Pennsylvania1
- Utah1
- Wisconsin1
Most recent citations
The 20 most recent of 28 citations. Newest inspection first.
Prohealth Home Care, Inc
The agency failed to maintain comprehensive and timely clinical records for 2 of 10 sampled patients (Patient 4 and Patient 1) when: 1. Patient 4's physician orders for an additional 7 weeks of nursing visits were not updated until after Patient 4 was discharged; and, 2. Patient 1's record did not…
Healthwise Home Care Solutions Inc
The Home Health Agency (HHA) failed to maintain current clinical records for four of five sampled patients (Patients 1, 2, 4, and 5).
River Valley Home Health
The Home Health Agency (HHA) failed to maintain complete clinical records for two (2) of seven (7) sampled patients when: 1. For Patient 3, the "Home Health Certification and Plan of Care " (Form 485) authenticated by the physician, was not maintained in patient health record.
Successful Aging Inc
The agency did not follow its policy regarding the placement of discharge summaries in the clinical record, for two (2) of five (5) clinical records reviewed (Clinical records #2 and #3) . Findings include: 1. A review of the Agency policy entitled "Medical Records" was conducted on 1-19-18, at…
Amazing Care Home Health Services LLC
The home health agency did not maintain clinical records which contained pertinent past and current findings in accordance with accepted professional standards.
Agape Home Care
The agency failed to ensure clinical notes and assessments where incorporated into the patients' clinical records according to the time frame indicated in the agency's policy and procedure for two (2) of 10 samples patients (Patients 3 and 4).
All Your Home Health, Incorporated
The agency failed to ensure that entries to the clinical record were current, complete and accurate for three of ten active patients (Patients #4, #7, and #8) whose clinical records were reviewed, in that: 1. The Alternate Supervising Nurse did not document that she called the physician to notify…
Centerwell Home Health
The agency failed to ensure in four out of twenty records (Patient # 2, 3, 4, 5) professional staff maintain an accurate, current and clearly documented record related to the provision of the patient's care.
Home Nursing and Therapy Services
The agency failed to maintain an accurate and complete clinical record for two of 13 patients (Patients #7 and #12) whose clinical records were reviewed, in that: 1. The SN (skilled nurse) did not document wound measurements on three visit notes for Patient #7.
In Home Care Group, LLC
The home health agency (HHA) failed to ensure clinical records were maintained in accordance with accepted professional standards when: 1. nurse's notes were not signed and dated for four out of 10 sampled patients (1, 2, 8, and 9) 2. physician's orders were not signed and dated for five out of 10…
Atlas Healthcare Inc.
The agency failed to ensure staff utilized appropriate forms when conducting SN (skilled nurse) and wound care visits in 2 of 12 records reviewed (patients #8 and #10).
First Quality Home Care Inc
The provider failed to maintain clinical records that includes pertinent past and current findings in accordance with accepted professional standards for patients receiving home health services for 2 out of 10 Sampled Patients (SP).
Golden Angels Home Health Care
The agency failed to provide accurate and current clinical record for five sampled patients (Patients 1, 4, 6, 9, and 10) and three of five randomly sampled (Patients 11, 12 and 13) when the clinical records were missing several home visit notes and clinical notes were not completed in a timely…
Helping Angels, Inc
No longer in CMS listThe agency failed to ensure that an initial assessment visit was documented for 11 of 11 records reviewed (#1,2,3,4,5,6,7,8,9,10,11).
Interim Healthcare of Fort Collins Inc
The agency failed to ensure clinical records contained accurate and complete documentation of pertinent past and current findings in accordance with accepted professional standards for 2 of 12 patient records reviewed (Patients #3 and #6).
Visiting Nurse Health System, Inc
The agency failed to ensure the clinical records contained clear, complete, and accurate documentation for 7 of 20 ( #6, #10, #11, #13, #14, #16, and #20) sampled patients.
Elder Homecare Inc
No longer in CMS listThe agency failed to ensure that the clinical records were current, complete and accurate for four of five discharged patients (Patients #2, #3, #4 and #5) whose clinical records were reviewed, in that: 1. Patient #2's clinical record did not include a "Consent for Service." 2. The section titled…
Visiting Nurse Association
No longer in CMS listThe agency failed to ensure the agency staff completed and incorporated accurate documentation into patient clinical records in a timely manner and/or corrected errors in documentation according to agency policy for 11 of 12 sampled patients (Patients #1, #3, #4, #5, #6, #7, #8, #9, #10, #12 and…