G1012: Required Items In Clinical Record
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 2026-10-21; CMS agency list file dated 2026-09-21. CMS source file. What the labels mean
Where it was cited
- Michigan119
- California118
- Illinois99
- Indiana70
- Florida65
- North Carolina40
- Colorado33
- Iowa30
- Texas30
- Oklahoma22
- Nevada15
- Pennsylvania15
- New York10
- Arkansas9
- Louisiana9
- Virginia9
- Missouri8
- Massachusetts6
- Ohio6
- Minnesota4
- Nebraska4
- Rhode Island4
- Connecticut3
- Idaho3
- New Jersey3
- Utah3
- West Virginia3
- Alabama2
- Kansas2
- New Mexico2
- Puerto Rico2
- South Carolina2
- Wisconsin2
- District of Columbia1
- Delaware1
- Kentucky1
- Maryland1
- Oregon1
- South Dakota1
- Tennessee1
Most recent citations
The 20 most recent of 759 citations. Newest inspection first.
Gundersen Palmer Lutheran Hosp & Clin-Home Health
The agency failed to ensure the clinical record included a complete clinical record for 1 of 7 sampled patients (Patient #2).
USA Home Health, Inc
Failed to ensure the patient’s clinical records included complete and accurate assessment, including assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders, for three of 7 sampled patients (Patient 2, Patient 4, and…
Cedar County Public Health Nursing Services
The agency failed to ensure the clinical record included a complete clinical record for 3 of 7 sampled patients (Patients #3, #4 and #6).
Palo Alto Community Health
The agency failed to provide a complete wound assessment on a weekly basis per agency policy for 1 of 3 sampled patients with a wound (Patient #6).
Blue Horizon Pk, Inc.
The Home Health Agency (HHA- an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure that three of seven sampled patients (Patients 1, 3 and 5) had complete and accurate clinical records.
Cns Homecare, Inc
The agency failed to ensure clinical notes were complete, accurate, and maintained for 2 (P-5, P-8) of 10 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.
Hegg Home Health Care
The agency failed to provide a complete wound assessment on a weekly basis per agency policy for 1 of 3 sampled patients with a wound (Patient #7).
Better Health Home Care
Or age) failed to ensure the physician’s medication orders for vitamin C and multivitamins were updated on the medication profile (up-to-date comprehensive record of all the medications taken by the patient, including the strengths, dosages, routes, and frequency of each medication) based on the…
Gmm Home Health Care, Inc
The Home Health Agency (HHA) failed to ensure the clinical record contained completed nursing notes, visit notes, current plan of care, and updated certification/recertification assessments for six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6 and Patient 7).
Verdugo Hills Home Care, Inc
The Home Health Agency (HHA) failed to ensure one of ten sampled patients (Patient 6) clinical record included an accurate assessment of the patient's integumentary (skin) status related to the location of the patient's wound.
St Anthony Regional Hospital and Nursing Home
The agency failed to provide a complete wound assessment on a weekly basis per agency policy for 1 of 1 sampled patient with a wound (Patient #1).
North Woods Home Nursing
The agency failed to ensure the clinical record was complete and contained accurate documentation for 3 (P-2, P-4, P-13) of 3 patients, resulting in the potential for unidentified, untreated health concerns, lack of continuity of care and unmet patient care needs.
Faith Home Health
The agency failed to ensure all aide clinical notes were completed for two (Pt #2 and 5) of seven patients.
Happy Visit Home Health
A public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the initial comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and…
Prime Home Health Services, Inc
The Agency failed to ensure that information in the clinical records was complete and accurate.
Vana Home Health Inc
The agency failed to include all the clinical notes in the patients clinical record in 3 of 5 patients (Pt 1, Pt 2, Pt 3) whose records were reviewed.
Elite Health Care Services, LLC
The home health agency (HHA) failed to ensure the pressure wounds (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of 7 sampled patients (Patient 5) was documented accurately.
Magnolia Home Health
The agency failed to ensure that physical therapy clinical notes were included timely in the patients clinical records, in that, 11 (Patients # 1 through # 10 and # 12) of 13 patient records reviewed the agency did not ensure that PT A included clinical notes according to the timeline of the…
American Nursing Home Health Care, Inc
The agency failed to ensure clinical notes were complete, accurate, and maintained for 2(P-1, P-3) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.
1ST State Home Healthcare, Inc
The agency failed to ensure a detailed discharge summary was included in the record for 1 of 2 discharge patient (P-2) records reviewed, resulting in a lack of information to the receiving facility or the patient's physician to ensure continuity of care.