G0654: Track Adverse Patient Events
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
- Michigan36
- Indiana19
- Nevada10
- Missouri9
- Oklahoma9
- Idaho7
- New York7
- Alabama6
- California6
- Connecticut5
- Iowa5
- North Carolina5
- New Jersey5
- Pennsylvania5
- Wisconsin5
- Massachusetts4
- Illinois3
- Louisiana3
- Montana3
- Virginia3
- Florida2
- Minnesota2
- New Hampshire2
- New Mexico2
- Ohio2
- West Virginia2
- Arizona1
- Nebraska1
- Oregon1
- Rhode Island1
- South Carolina1
- Texas1
- Vermont1
Most recent citations
The 20 most recent of 174 citations. Newest inspection first.
American Nursing Home Health Care, Inc
The agency failed to develop any performance improvement activities with its Quality Assessment Performance Improvement (QAPI) program to track and trend adverse patient events, analyze potential cause(s) and implement preventive actions, resulting in the potential for substandard care and unmet…
Absolute Home Health LLC
The Home Health Agency failed to track all adverse patient events, to determine through subsequent analysis whether they were the result of errors that should have been preventable, to reduce the likelihood of such events in the future.
Tlc Home Care of the Twin Cities
The facility failed to establish a system to track adverse patient events, analyze their causes, and implement preventive actions.
St Peter's Health Home Health and Hospice
The agency failed to track patient adverse events and perform a root cause analysis for identification and implementation of interventions.
Extracare Home Health Services
The agency failed to develop performance improvement activities, as part of the Agency's Quality Assessment Performance Improvement (QAPI) program, to track and trend adverse patient events, analyzing the cause and implementing preventive interventions, resulting in the potential for the rendering…
Well Care Home Health
The agency failed to document an incident report for 1 of 1 patient with falls (patient #1).
Horizon Home Health Magic Valley
The HHA failed to follow its own established policy for investigating and responding to a serious adverse event for 1 of 1 sampled patient who experienced an unexpected death (Patient #1).
Homestead Health LLC
The agency failed to track adverse patient events, analyze their causes, and implement corrective and preventive actions.
Salmon Valley Home Health LLC
The agency failed to track all adverse patient events for 1 of 2 patients (Patient #1) whose records were reviewed and were no longer on service.
Bayada Home Health Care, Inc.
The agency failed to track and analyze a patient fall with an injury for 1 of 1 patient experiencing a fall with an injury (patient #3).
Caregivers, Inc
The agency failed to ensure the agency tracked and analyzed adverse patient events and implemented actions to prevent adverse events for 1 of 1 agency.
West Carroll Memorial Hospital Home Health
The Home Health Agency failed to have documentation of performance improvement activities that track adverse patient events, analyze their causes, and implement preventive actions in their QA.
H&M Care Inc
The Home Health Agency (HHA) failed to show evidence of tracking adverse patient events, analyzing their causes, and implementing preventive actions.
Dependable Healthcare Services LLC
This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to track unexpected and/or adverse events that have, or potentially could impact a patient’s plan of care, and have the potential to cause a decline in a patient’s condition.
Good Samaritan Society Home Health
The agency failed to conduct a root cause analysis to identify the underlying cause preventing the agency from obtaining regulatory compliance, and failed to develop and implement an action plan to obtain and sustain regulatory compliance for deficiencies cited at G536, G572, and G808 on 1/30/25.…
Atlantic Home Health Care, Inc
The agency failed to track adverse patient events, analyze their causes, and implement actions.
Proficient Home Health Services, LLC
The agency failed to develop performance improvement activities, as part of the agency's Quality Assessment Performance Improvement (QAPI) program, that tracked and trended adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering…
Care in Action Home Healthcare Agency LLC
The home health agency (HHA) failed to select the indicators that it would utilize in its QAPI program based upon identified adverse or negative patient outcomes or agency processes that the HHA wished to monitor and measure.
Accelerated Homecare Services, Inc
The agency failed to develop performance improvement activities, as part of the agency's Quality Assessment Performance Improvement (QAPI) program, to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of…
Liberty Home Care, LLC
The agency failed to track and analyze an adverse event for 1 of 1 patient that had a fall with injury (patient #7).