G1010: Contents Of Clinical Record
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
- Florida29
- California22
- New York21
- Kansas13
- Texas12
- Pennsylvania11
- Michigan8
- Puerto Rico8
- Colorado6
- Illinois5
- Indiana4
- North Carolina4
- New Mexico3
- Nevada3
- Utah3
- Alabama2
- Massachusetts2
- New Jersey2
- Ohio2
- Oklahoma2
- Connecticut1
- District of Columbia1
- Louisiana1
- Maryland1
- New Hampshire1
- Virginia1
Most recent citations
The 20 most recent of 168 citations. Newest inspection first.
Golden Plus Home Health Care
The agency failed to define abbreviations documented in the clinical record in 1 (P-1) of 7 records reviewed and failed to maintain required elements of the clinical record in 1 (P-7) of 7 records out of a total sample of 7 records reviewed, resulting in documentation that is missing and may be…
Elevate Home Health Group
The provider failed to maintain complete and accurate records according to accepted professional standards and practices regarding clear/concise wound care orders for 1of 1 patient reviewed for wound care of a total sample of 7 patients, (#2).
Safe Hands Home Health Care
The agency failed to ensure the clinical record was accurate and individualized to the patient during the time(s) when health care was provided in 1 (P-1) out of a total sample of 10 records reviewed, resulting in unrecognized increased medical needs of the patient at the time of discharge from…
Comforcare Home Care - York
The agency failed to ensure medical records contained adequate and complete documentation.
Sympathy Home Health Care, Inc
No longer in CMS listThe agency failed to ensure the patient's medical records included a skilled nursing note that reflected the care and services provided every visit and was documented, for three out of seven sampled patients (Patien1, 4 and Patient 5), and failed to ensure the address on patient 1's current address…
Centerwell Home Health
The agency failed to ensure in three out of seventeen records (Patient # 8, 9 and 10) professional staff maintain an accurate, current and clearly documented record related to the provision of the patient's care.
Angeles San Cristobal
The agency failed to ensure that medical records contain and reflect past and current information of patient's status for 4 out of 17 records reviewed (R.R-H.V #1, #3, R.R #11, and #12).
Southwestern Home Health
The agency failed to ensure accuracy of wound documentation for one (Patient #2) of seven patients.
Concierge Home Care
The facility failed to ensure an accurate electronic record was maintained for one patient (Patient #1) of three patients surveyed by failing to ensure a Physical Therapy evaluation signed and dated by the physical therapist was a part of the patient’s electronic record.
Americare Homehealth Services
The facility failed to ensure that the clinical record comprehensive assessment documents the wound measurements once a week according to the policy/procedure and filed to monitoring glucose level accordance to patient plan of care (485) for five (5) out of seven (7) records reviewed.
Gateway Home Health Corp.
The home health agency did not maintain complete medical records.
Amedisys Home Health
The Home Health Agency (HHA) failed to keep complete and accurate medical records by omission of documentation when there was a delay of a Start of Care (SOC) and that the physician, referring agency, and patient were notified of this delay for 3 of 17 patient charts reviewed (Patient Identifiers…
Sovereign Home Health Care Agency, Inc
The Home Health Agency (HHA) failed to document and communicate the current status and discharge of one of six patients (PT1).
Firstat Nursing Services-West Palm Beach
The HHA failed to ensure an accurate and complete record for 2 of 16 sampled patients as evidenced by the failure to ensure an accurate diagnosis was recorded in Patient #3’s Plan of Care (POC) and include "Missed Visit" Notes as part of Patient #7's record (Patient #3 and #7).
Aveanna Healthcare
The agency failed to ensure medical records contained adequate and complete documentation.
St Mary's Home Care
The Agency failed to ensure that a comprehensive nursing assessment is completed and maintained for each patient.
Golden Care of Northeast PA, Inc
The agency failed to ensure clinical record entries were completed as per agency policy and procedure for two (2) of five (5) PDN (pediatric shift care) clients (patients).
Americare in Home Nursing
The agency's staff's failure to document visit notes timely placed patients at risk for negative health outcomes.
Concordia Visiting Nurses
The agency failed to maintain accurate clinical record information for one (1) of three (3) clinical records (CR3).
Golden Home Health Care
The agency failed to ensure medical records contained adequate and complete documentation.