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)
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).