G0716: Preparing Clinical Notes
CMS level: Element Minor. 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 2026-10-20; CMS agency list file dated 2026-05-27. CMS source file. What the labels mean
Where it was cited
- Indiana118
- California85
- Florida75
- Michigan60
- North Carolina56
- New York53
- Oklahoma44
- Alabama31
- Texas29
- Colorado21
- Ohio18
- Massachusetts16
- Pennsylvania15
- Missouri13
- Nevada10
- Illinois8
- Louisiana7
- Minnesota7
- Idaho6
- South Carolina5
- Utah3
- Alaska2
- Puerto Rico2
- Connecticut1
- Georgia1
- Kansas1
- Maryland1
- Montana1
- Oregon1
- Tennessee1
- Wisconsin1
- Wyoming1
Most recent citations
The 20 most recent of 693 citations. Newest inspection first.
Keyes 2 Life Health Services LLC
No longer in CMS listThe agency failed to ensure the nursing documents were specific of the wound care performed for the patient for 2 of 2 active clinical records reviewed with wound care performed (Patients #1 and #2) and included an overall look of a patient's chest port for 1 of 1 active clinical records reviewed…
A Better Tomorrow Health and Wellness LLC
No longer in CMS listThe nurse failed to prepare clinical notes appropriately regarding treatment ordered and delayed for 1 of 8 active patients’ records reviewed.
Mission Home Health of Irvine, LLC
The agency failed to ensure the skilled professionals prepared accurate clinical notes for two of five sampled patients (Patients 4 and 5).
Heritage Home Health Services
The agency failed to ensure the RNs completed wound measurements assessment timely for 2 of 3 active clinical records reviewed of patients receiving wound care.
North Woods Home Nursing
The agency failed to ensure skilled professionals prepared clinical notes per agency expectation for 1 (P-8) of 13 records reviewed, resulting in the potential for unmet care needs.
Faith Home Health
The agency failed to ensure the completion of clinical notes were being completed in a timely manner for five (Pt #1, 2, 3, 4, and 5) of seven patients.
Providence Home Care
The agency failed to ensure SN visit notes were completed for two (Patients #6 and #7) of 17 patients.
Health Care Solutions Services, Inc
The agency failed to ensure the skilled professionals consistently completed the clinical records for three of eight sampled patients (Patients 1, 4, and 5).
Pinnacle Home Health of Baton Rouge
The agency failed to ensure skilled professionals accurately prepared clinical notes.
Home of My Own Home Health LLC
No longer in CMS listThe agency failed to ensure the skilled professional completed accurate clinical notes for 4 of 6 active clinical records reviewed with patients receiving SN (Patient #1, 4, 5, and 7).
Gfk Home Health Care
The agency failed to ensure the clinical notes for three of seven sampled patients (Patients 1, 2, and 5) were accurate.
Caretenders
The RN failed to ensure all documentation was accurate for 1 of 1 home visit observation with an RN (Patient #2) Findings include: 1.During a home visit observation with Patient #2 on 06/18/2026 beginning at 7:37 AM, RN 1 failed to conduct a complete skin assessment to check for wounds or skin…
Choice Health at Home
The agency failed to ensure skilled professionals maintained responsibility to prepare clinical notes in that the agency did not enforce a written policy for implementation of care for required documentation on missed visits or services for 1 of 7 patients when PTA 1 missed the scheduled visit on…
Green Meadows Home Health Care, Inc
The agency failed to ensure the clinical notes were accurate and complete for one of five sampled patients (Patient 1).
Majestic Home Health LLC
The home health agency failed to ensure all SN visit note documentation was completed the day of service for 1 of 1 discharge record reviewed with wounds (Patient #4).
Benevolent Care Home Health Services LLC
No longer in CMS listThe agency failed to ensure the nursing notes included a complete assessment and description in 1 of 1 active clinical records reviewed with a patient with a wound.
Neogen Care Corp
Rather than in a traditional healthcare facility setting) failed to ensure that the skilled nurses submit completed skilled visit notes for one of 20 sampled patients (Patient 12).
St Luke's Home Health Services, Inc
The agency failed to ensure the agency’s skilled professionals prepared accurate clinical notes for two of eight sampled patients (Patient 2 and 7).
Modern Home Health, Inc
The agency failed to have completed clinical documentation of skilled nursing services provided according to the Plan of Care (POC) for 1 (#9) of 17 patient records reviewed.
Aplus Health Care LLC
The agency failed to ensure clinical notes were prepared for 2 of 3 patients (P3, P1) reviewed who received skilled services.