| 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) |
| 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. |