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)
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.