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)
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.