Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 757188 (X3) Date Survey Completed 02/13/2025
Name of Provider or Supplier Simple Touch Home Health Care, Inc Street Address, City, State 5250 Santa Monica Blvd Suite 211, Los Angeles, CA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G0000 The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey, conducted from 2/11/2025 to 2/13/2025.


Complaint Number: 112075





Active Patients- 5


Unduplicated admissions: 7


Sample Size - 7


Home visits – 3





The following Condition of Participation not met:


484.55 Comprehensive assessment of patients


484.110 Clinical records
G0510 Comprehensive Assessment of Patients
CFR(s): 484.55

Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment.


This CONDITION is not met as evidenced by:
Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows:







a. The Home Health Agency (HHA) failed to assess the patient's continuing need for home care services for two of 7 sampled patients (Patient 1 and Patient 2). This deficient practice resulted in the continued certification of the patients to receive the skilled nursing (SN) services. (Refer to G532)






b. The HHA failed to update the comprehensive assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) for two of seven sampled patients, (Patient 1 and Patient 2) after a certification for another 60 days of continuous skilled nurse services. (Refer to G544).



































The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Comprehensive Assessment of Patients to ensure all certified patients for home health services receive the highest quality of patient care.
















1. The HHA failed to ensure a registered nurse completed the initial patient assessment within 48 hours of the physician’s referral and/or the start of care for one of 7 sampled patients (Patient 4). This deficient practice can result in the patient’s needs not being identified and assessed thoroughly and had the potential in the provision of poor-quality nursing care necessary to maintain the highest practicable physical, mental and psychosocial well-being of the patients under the agency’s care. (Refer to G514)


2. The HHA failed to ensure a comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 4). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor-quality nursing care needed to maintain the patient’s quality of life and well-being. (Refer to G520)


3. The HHA failed to assess the patient's continuing need for home care services for four of 7 sampled patients (Patient 1, Patient 2, Patient 5 and Patient 6). This deficient practice resulted in the provision of an unnecessary home health services to the patient who do not need skilled nursing services. (Refer to G532)


4. The HHA failed to maintain an accurate, current medication profile for one of 7 sampled patients (Patient 5). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. (Refer to G536)


5. The HHA failed to update the comprehensive assessment for two of seven sampled patients, (Patient 1 and Patient 2) after a certification for another 60 days of continuous skilled nurse services. This deficient practice had the potential to result in Patient 1 and Patient 2’s identified needs not being met. (Refer to G544)





The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Comprehensive Assessment of Patients to ensure all patients certified for home health services receive the highest quality of patient care in a safe environment.

1. The HHA failed to ensure the registered nurse completed the initial comprehensive assessment within 48 hours of the physician’s referral and/or the start of care for one of 7 sampled patients (Patient 4). This deficient practice has the potential to result in the patient’s immediate care needs will not be identified and assessed to formulate the individualized plan of care (POC) needed for the patient's certification to receive the Medicare home health services. (Refer to G514)





2. The HHA failed to ensure a comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 4). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor-quality nursing care needed to maintain the patient’s quality of life and well-being. (Refer to G520)





3. The HHA failed to assess the patient's continuing need for home care services for four of 7 sampled patients (Patient 1, Patient 2, Patient 5 and Patient 6). This deficient practice resulted in the continued provision of the skilled nurse services to these patients lacking the comprehensive assessments to clearly demonstrate the continuing provision of the home health benefits. (Refer to G532)





4. The HHA failed to maintain an accurate, current medication profile for one of 7 sampled patients (Patient 5). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. (Refer to G536)





5. The HHA failed to update the comprehensive assessment for two of 7 sampled patients, (Patient 1 and Patient 2) after a certification for another 60 days of continuous skilled nurse services. This deficient practice had resulted in the recertification of these patients for home health services lacking the documented evidence of an updated comprehensive assessments that clearly demonstrate the continuing provision of the Medicare home health benefits. (Refer to G544)





The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Comprehensive Assessment of Patients to ensure all patients certified for home health services receive the highest quality of patient care in a safe environment.
G0514 RN performs assessment
CFR(s): 484.55(a)(1)

A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date.


This ELEMENT is not met as evidenced by:
Based on interview and record review, the Home Health Agency (HHA) failed to ensure a registered nurse (RN) completed the initial comprehensive assessment within 48 hours of the physician’s referral and/or the start of care for one of 7 sampled patients (Patient 4).





This deficient practice has the potential to result in the patient’s immediate care needs will not be identified and assessed to formulate the individualized plan of care (POC) needed for the patient's certification to receive the Medicare home health services.








Findings:


During a review of Patient 4's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 2/5/2025.


During a review of the Physician’s (MD 1) referral form, the referral form indicated Patient 4's diagnoses included stroke (loss of blood flow to a part of the brain), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).


Patient 4 was wheelchair dependent and was referred for home health services to assist with medication management and daily activities to ensure safety and prevent falls. The Physician’s referral form was dated 2/3/2025.


During an interview with the HHA’s Owner/CEO on 2/12/2025 at 2:15 p.m., the Owner/CEO stated the registered nurse (RN) conducted Patient 4's initial assessment 4 in the morning of 2/12/2025, or 1 week after the SOC.


During a concurrent interview and record review on 2/13/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s clinical records. The DPCS was unable to provide documented evidence of Patient 4’s RN initial assessment visit and stated it was not available for review. The DPCS stated the initial RN assessment should be conducted within 48 hours of the physician’s referral to determine and assess the needs of the patient.





During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2020, the P&P indicated an initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist, or speech therapist. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician (or other authorized licensed independent practitioner), or at the patient/family request with the approval of the physician (or another authorized licensed practitioner).







G0520 5 calendar days after start of care
CFR(s): 484.55(b)(1)

The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care.


This ELEMENT is not met as evidenced by:
Based on interview and record review, the Home Health Agency (HHA) failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 4).





This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being.


Findings:


During a review of Patient 4's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) of 2/5/2025.


During a review of the Physician’s (MD 1) referral form, the referral form indicated Patient 4 had a diagnosis including stroke (loss of blood flow to a part of the brain), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). Patient 4 had dependence on wheelchair and was referred for home health services for the nurse to assist with medication management and daily activities to ensure safety and prevent falls. The Physician’s referral form was dated 2/3/2025.





During an interview with the HHA’s Owner/CEO on 2/12/2025 at 2:15 p.m., the Owner/CEO stated the registered nurse (RN) conducted the initial assessment of Patient 4 in the morning of 2/12/2025, or 1 week after the SOC.


During a concurrent interview and record review on 2/13/2025 at 12:45 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s clinical records. The DPCS was unable to provide documented evidence Patient 4’s RN comprehensive assessment was completed and stated it was not available for review. The DPCS stated the patient’s comprehensive assessment should be conducted, completed and available for review within 5 days from the start of care.





During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2020, the P&P indicated a comprehensive patient assessment will be completed within five (5) calendar days of the patient start of care. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs.




G0532 Continuing need for home care
CFR(s): 484.55(c)(3)

The patient's continuing need for home care;


This ELEMENT is not met as evidenced by:
Based on observation, interview and record review, the Home Health Agency (HHA) failed to assess the patients' continuing need for home care services for four of 7 sampled patients (Patient 1, Patient 2, Patient 5 and Patient 6).





This deficient practice resulted in the continued skilled nurse services to these patients lacking the comprehensive assessments to clearly demonstrate the continuing provision of the home health benefits.


c. During a review of Patient 5's Face Sheet, the Face Sheet indicated a SOC date of 11/1/2024.





During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period from 11/1/2024 to 12/30/2024, the POC indicated Patient 5’s diagnosis which included hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), essential hypertension (HTN-high blood pressure), and constipation (infrequent or difficult bowel movements). The POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and patient’s response and compliance to medication and diet regimen, home safety and psychosocial adjustment. The goals and outcomes included patient’s blood pressure will be maintained within established parameters without signs and symptoms (s/sx) of hypotension (low blood pressure) or hypertension (high blood pressure) with compliance to prescribed medication, will demonstrate knowledge of medication and diet, and will remain safe at home, free from fall/injury/hospitalization throughout the certification period. Discharge planning indicated to discharge patient under self/caregiver’s assistance with regular MD (physician) follow-up when all goals were met, when medical condition was stable and patient no longer in need of skilled services.





During a joint home visit, on 2/12/2025 at 3:05 p.m., at Patient 5’s residence with the licensed vocational nurse (LVN 1), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During an interview, Patient 5 she goes visit her physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and can managed her medication and diet regimen independently. Patient 5 stated she does not have a caregiver or needed one.





During a concurrent interview and record review, on 2/13/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 5’s clinical records. The DPCS stated Patient 5’s blood pressure and vital signs were within normal parameters, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 5 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 5 should have been discharged because her goals have been met and there was no need for skilled nursing services.





d. During a review of Patient 6's Face Sheet, the Face Sheet indicated a SOC date of 9/30/2024.





During a review of Patient 6’s Home Health Certification and POC for the certification period from 9/30/2024 to 11/28/2024, the POC indicated Patient 6’s diagnosis which included spondylosis (age-related wear and tear of the spinal disks), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). The POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and patient’s response and compliance to medication and diet regimen, home safety and psychosocial adjustment. The goals included patient will demonstrate fair to moderate improvement on functional abilities, will maintain vital signs within normal parameters, skin integrity will remain intact, will demonstrate compliance with medication and diet, and will be free from falls/injuries/hospitalizations. Discharge planning indicated to discharge patient under self/caregiver’s assistance with regular MD (physician) follow-up when all goals were met, when medical condition was stable and patient no longer in need of skilled services.





During a phone interview, on 2/13/2025 at 9:15 a.m., Patient 6 stated she was doing fine.





During a concurrent interview and record review, on 2/13/2025 at 12:45 p.m. with the DPCS, the DPCS reviewed Patient 6’s clinical records. The DPCS stated Patient 6’s vital signs were within normal parameters, that she had no recent admissions to the hospital, no episodes of falls, no documented evidence of wound care treatment, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 6 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 6 should have been discharged at the end of the first benefit period because her goals have been met and there was no need for skilled nursing services.





During a review of the agency’s policy and procedure (P&P) titled, Discharge Criteria and Process, dated April 2020, the P&P indicated the purpose of the policy is to outline the process for discharging a patient from service. Services will be terminated when the patient meets one of the following discharge criteria: if appropriate, the physician and the organization agree that the goals of home care have been attained or are no longer attainable.






















a. During a review of Patient 1's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 9/29/2024, with a diagnosis of unspecified hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone).





During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the re-certification period from 11/28/2024 to 1/26/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up.





During a phone interview, on 2/12/2025 at 2:30 p.m., with family member (FM 1), FM 1 stated Patient 1 was able to ambulate using a walker, goes to visit his physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and manages his own medications.





During a concurrent interview and record review, on 2/13/2025 at 12:50 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 11/28/2024 to 1/26/2025, Patient 1’s vital signs were within normal range, that he had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 1 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 1 should have been discharged because his goals have been met and there was no need for skilled nursing services.








b. During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 11/20/2024, with a diagnosis of unspecified epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptom).





During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the certification period from 11/20/2024 to 1/18/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up.





During a phone interview, on 2/12/2025 at 2:30 p.m., with family member (FM 1), FM 1 stated Patient 2 was able to ambulate without using any assistive device and drives a car to do errands, goes to visit her physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and manages her own medications.





During a concurrent interview and record review, on 2/13/2025 at 1:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 2’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 11/20/2024 to 1/18/2025, Patient 2’s vital signs were within normal range, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 2 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 2 should have been discharged because his goals have been met and there was no need for skilled nursing services.





During a review of the agency’s undated policy and procedure (P&P) titled, Patient Discharge Process, the P&P indicated discharge planning is initiated for every home care patient at the time of the patient’s admission for home care. Planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes. Criteria for discharge may include but are not limited to the following: the patient has reached defined goals and is no longer in need of home care.
G0536 A review of all current medications
CFR(s): 484.55(c)(5)

A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.


This ELEMENT is not met as evidenced by:
Based on observation, interview and record review, the home health agency (HHA) failed to maintain an accurate current medication profile for one of 7 sampled patients (Patient 5).


This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions.


Findings:


During a review of Patient 5's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) of 11/1/2024.


During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period from 12/31/2024 to 2/28/2025, the POC indicated Patient 5’s diagnosis which included hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), essential hypertension (HTN-high blood pressure), and constipation (infrequent or difficult bowel movements).


The POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and patient’s response and compliance to medication and diet regimen, home safety and psychosocial adjustment.


During a joint home visit, on 2/12/2025 at 3:05 p.m., at Patient 5’s residence with the licensed vocational nurse (LVN 1), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device.


During a review of Patient 5’s current medication, on 2/12/2025 at 3:32 p.m., with LVN 1, it was noted the bottle of lorazepam (used to treat anxiety disorders) 1 milligram (mg, a unit of measurement) 1 tablet orally daily could not be found. Patient 5’s current medication list provided by the HHA indicated Patient 5 was still taking this medication. During a concurrent interview with Patient 5 stated she was not taking lorazepam daily for several months.


During an interview, on 2/13/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated nursing staff need to review the patient’s current medication every nurse visit and update the medication profile in the patient’s clinical record.





During a review of the agency’s policy and procedure (P&P) titled, Medication Profile, dated April 2020, the P&P indicated patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.




G0544 Update of the comprehensive assessment
CFR(s): 484.55(d)

Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than-


This STANDARD is not met as evidenced by:
Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to update the comprehensive assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) for two of seven sampled patients, (Patient 1 and Patient 2) for the continuing need for skilled nurse services.





This deficient practice had resulted in the recertification of these patients for home health services lacking the documented evidence of an updated comprehensive assessment that clearly demonstrate the continuing provision of the Medicare home health benefits.























a. During a review of Patient 1's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 9/29/2024, with a diagnosis of unspecified hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone).


During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the re-certification period from 1/27/2024 to 3/27/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up.


During a concurrent interview and record review, on 2/13/2025, at 11 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted and completed for Patient 1 to be recertified for another 60 days for continuous skilled nursing services for the period of 1/27/2025 to 3/27/2025. The DPCS further stated the comprehensive assessment should be done within the last 5 days of every 60 days of re-certification, but it was not done.





b. During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 11/20/2024, with a diagnosis of unspecified epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptom).


During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the re-certification period of 1/19/2025 to 3/19/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up.





During a concurrent interview and record review, on 2/13/2025 at 1:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 2’s clinical nursing notes, nursing assessment and the POC. The DPCS stated that for the month of 11/20/2024 to 1/18/2025, Patient 2’s vital signs were within normal range, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. DPCS stated Patient 2 was re-certified for another 60 days for continuous skilled nursing services. DPCS further stated Patient 2 should have been discharged because his goals have been met and there was no need for skilled nursing services.





During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, the P&P indicated a comprehensive patient assessment will be completed within five calendar days of the patient’s start of care. This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter:


1. The last five days of every 60-day episode beginning with the start of care date (recertification)


2. Upon transfer


3. Significant change in condition resulting in a new case mix


4. Within 48 hours of the patient’s return home or of this Organization’s knowledge of the patient’s return from a 24-hour hospital admission for other than diagnostic testing, or on the physician-ordered resumption date


5. At discharge













G1008 Clinical records
CFR(s): 484.110

Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically.


This CONDITION is not met as evidenced by:



Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure the Condition of Participation for Clinical Records was met as follows:


a. The Home Health Agency (HHA) staff failed to submit nursing clinical notes within the timeframe as indicated in the agency's policy and procedure for two of seven sampled patients (Patient 1 and Patient 2). (Refer to G1012).





b. The HHA failed to ensure the patient’s discharge summary (a written document by a health facility that includes the reason for discharge, the patient discharge condition, and patient and family instructions) was completed and filed in the clinical record for one of seven sampled patients (Patient 3). (Refer to G1022).








The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure all certified patients for home health services receive the highest quality of patient care.

1. The HHA staff failed to submit nursing clinical notes and nursing assessment within the timeframe as indicated in the agency's policy and procedure for four of 7 sampled patients (Patient 1, Patient 2, Patient 4 and Patient 5). For Patient 1, Patient 2 and Patient 5, there was no documented evidence in the patient’s electronic health records that the skilled nurse (SN) submitted their visit notes in a timely manner. For Patient 4, the HHA failed to ensure a comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care. This failure resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. (Refer to G1012)


2. The HHA failed to follow their discharge policy by not completing the discharge summary (a written document by a health facility that includes the reason for discharge, the patient discharge condition, and patient and family instructions) within 72 hours of discharge from home health service for two of 7 sampled patients (Patient 3 and Patient 7). This deficient practice had the potential to result in miscommunication and poor hand-off, and can affect the care and services needed in the continuation of care for the affected patient. (Refer to G1022)





The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure all certified patients for home health services receive the highest quality of patient care.
G1012 Required items in clinical record
CFR(s): 484.110(a)(1)

The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders;


This ELEMENT is not met as evidenced by:
Based on observation, interview and record review, the Home Health Agency (HHA) staffs failed to submit nursing clinical notes within five (5) calendar days of the patient start of care as indicated in their policy and procedure for four of 7 sampled patients (Patient 1, Patient 2, Patient 4 and Patient 5).


For Patient 1, Patient 2, and Patient 5 indicated no documented evidence in their electronic health records the skilled nurses (SN) submitted their visit notes within 5 days from the start of care.


For Patient 4, the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was not completed within 5 days from the start of care.


This failure resulted in patients' incomplete clinical records that could lead to misinformation and lack of care and services provided to the patient.


Findings:


c. During a review of Patient 4's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 2/5/2025.





During a review of the Physician’s (MD 1) referral form, the referral form indicated Patient 4 had a diagnosis including stroke (loss of blood flow to a part of the brain), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and dependence on wheelchair, and was referred to a home health nurse to assist with medication management and daily activities to ensure safety and prevent falls. The Physician’s referral form was dated 2/3/2025.





During an interview with the HHA’s Owner/CEO on 2/12/2025 at 2:15 p.m., the Owner/CEO stated the registered nurse conducted the initial assessment of Patient 4 in the morning of 2/12/2025, or 1 week after the SOC.





During a concurrent interview and record review on 2/13/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s clinical records. The DPCS was unable to provide documented evidence Patient 4’s comprehensive assessment was completed and stated it was not available for review. The DPCS stated the patient’s comprehensive assessment should be conducted, completed and available for review within 5 days from the start of care.





d. During a review of Patient 5's Face Sheet, the Face Sheet indicated a SOC date of 11/1/2024.





During a review of Patient 5’s Home Health Certification and POC for the certification period from 12/31/2024 to 2/28/2025, the POC indicated Patient 5’s diagnosis which included hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), essential hypertension (HTN-high blood pressure), and constipation (infrequent or difficult bowel movements). The POC included an order for the skilled nurse to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and patient’s response and compliance to medication and diet regimen, home safety and psychosocial adjustment.





During a joint home visit, on 2/12/2025 at 3:05 p.m., at Patient 5’s residence with the licensed vocational nurse (LVN 1), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During an interview, Patient 5 stated she was being visited by the agency’s SN at least once a week since the SOC.





During a concurrent interview and record review on 2/13/2025 at 12:45 p.m. with the DPCS, the DPCS reviewed Patient 5’s SN Clinical Visit Notes for the month of January 2025 to February 2025. The DPCS stated and confirmed the visiting nurse have not submitted their visit notes on the electronic health records from January 2025 to February 2025. The DPCS stated field nurses ideally should submit their visit notes on the day the visit was conducted, dated and timed, and signed by them, but have 5-7 days to submit in accordance with the agency’s policy. The DPCS further stated it was important to document visit notes in a timely manner to keep the patient’s status up to date so that all staff involve can see the progress of the patient.





During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2020, the P&P indicated a comprehensive patient assessment will be completed within five (5) calendar days of the patient start of care. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs.





During a review of the agency’s P&P titled, Contents of the Clinical Record, dated April 2020, the P&P indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel. The following information will be available in the clinical record for patients receiving skilled care…. Signed and dated progress notes for each discipline rendering service. Clinical notes shall be signed and incorporated into the patient’s health record at least every seven working days.












a. During a review of Patient 1's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 9/29/2024, with a diagnosis of unspecified hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone).









During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the re-certification period from 1/27/2025 to 3/27/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up.



























On 2/13/2025, at 10 a.m., during a review of Patient 1's License Vocational Nurse (LVN) Visit Calendar, it indicated the last submitted LVN note was dated 2/2/2025.























b. During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 11/20/2024, with a diagnosis of unspecified epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptom).





During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the certification period from 1/19/2025 to 3/25/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up.





On 2/13/2025, at 10:30 a.m., during a review of Patient 2's License Vocational Nurse (LVN) Visit Calendar, it indicated the last submitted LVN note was dated 1/26/2025.





During an interview on 2/13/2025 at 11:30 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated the visit notes from LVN 1 for Patient 1 and Patient 2 were late. The DPCS further stated LVN 1 supposed to submit her visit notes within 5-7 days after each visit but has not been able to because of her workload.









During a review of the agency’s undated policy and procedure (P&P) titled, Clinical Documentation, the P&P indicated agency will document each direct contact with the client. This documentation will be completed by the direct caregivers and monitored by the skilled professional responsible for managing the client’s care. Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into the clinical record within seven (7) days after the care has been provided.
G1022 Discharge and transfer summaries
CFR(s): 484.110(a)(6)(i-iii)

(i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer.


This ELEMENT is not met as evidenced by:



Based on interview and record review, the home health agency (HHA) failed to follow their discharge policy by not completing the discharge summary (a written document by a health facility that includes the reason for discharge, the patient discharge condition, and patient and family instructions) within 72 hours of discharge from home health service for two of 7 sampled patients (Patient 3 and Patient 7).





This deficient practice had the potential to result in miscommunication that can affect the care and services needed in the continuation of care for the affected patients.


































b. During a review of Patient 7's Face Sheet, the Face Sheet indicated a start of care date (SOC) date of 4/25/2024.





During a review of Patient 7’s Home Health Certification and POC for the certification period from 10/22/2024 to 12/20/2024, the POC indicated Patient 7’s diagnosis which included spondylosis (age-related wear and tear of the spinal disks), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and to perform medication reconciliation once a week and inform the agency of any changes in medication regimen.





During a concurrent interview and record review, on 2/13/2025 at 12:45 p.m. with the DPCS, the DPCS reviewed Patient 7’s clinical records. The DPCS stated Patient 7 was discharged on 12/20/2024 due to goals have been met. The DPCS stated there was no documented evidence in Patient’ 7s electronic health record a discharge summary was completed and signed by a registered nurse. The DPCS further stated a discharge summary should have been completed on the day the patient was discharged from service and will be provided to the patient’s physician.





During a review of the agency’s policy and procedure (P&P) titled, Discharge Summary, dated April 2020, the P&P indicated each patient discharged from a service and/or from the organization will have a written discharge summary completed and filed in the clinical record. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service.





During a review of the agency’s P&P titled, Contents of Clinical Record, dated April 2020, the P&P indicated a clinical record will be maintained for each patient receiving care. The following information will be available in the clinical record for patients receiving skilled care…. Transfer/discharge summaries and other summary reports sent to the physician, as required by law and regulation and organization policy. The discharge statement shall include the date of discharge, reason for termination of services, and condition upon discharge.


























During a record review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 7/15/2024, with a primary diagnosis of alzheimer's disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking and other cognitive functions, eventually leading to dementia).





During a record review of Patients 3’s Home Health Certification and Plan of Care (POC) for the certification period starting from 9/13/2024 to 11/24/2024, with Skilled Nurse (SN) frequency visits of once a week for nine weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness.





During a concurrent interview and record review, on 2/13/2025, at 12:30 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated and acknowledged there was no documented evidence a discharge summary was completed for Patient 3 when Patient 3 was discharged on 11 11/2024. The DPCS further stated a discharge summary was not done for Patient 3.





During a record review of the HHA’s (undated) policy and procedure titled, “Discharge Summary,” the policy indicated that the discharge summary and other relevant clinical record documents will be completed within 72 hours of discharge from service.