| 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) |
| 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 |