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 05/16/2025
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)
G0374 Accuracy of encoded OASIS data
CFR(s): 484.45(b)

Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment.


This STANDARD is not met as evidenced by:
Based on interview and record review, the Home Health Agency (HHA) failed to ensure the OASIS accurately reflected the patients status for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12):

 

 1. Patient 8 had a start of care (SOC) on 3/27/2025, with diagnosis of radiculopathy lumbar region.  The OASIS-start of care assessment, dated 3/27/2025, indicated the Owner (OW), who is not a licensed nurse, completed the assessment.

 2. Patient 9 had SOC on 4/7/2025, with Type 2 DM with hyperglycemia. The OASIS-start of care assessment, dated 4/7/2025, indicated the OW, who is not a licensed nurse, completed the assessment.

 3. Patient 10 had a SOC on 3/28/2025 with diagnoses of Type 2 DM with hyperglycemia. The OASIS-start of care assessment, dated 3/28/2025 and OASIS-transfer, dated 5/10/2025 indicated the OW, who is not a licensed nurse, completed the assessment.

4. Patient 11 had a SOC on 4/7/2025, with diagnoses of Type 2 DM with hyperglycemia. The OASIS-start of care assessment, dated 4/7/2025 and OASIS-transfer, dated 5/8/2025 indicated the OW, who is not a licensed nurse, completed the assessment.

 

5. Patient 12 had a SOC on 4/9/2025, with diagnoses of chronic pain syndrome. The OASIS-start of care assessment, dated 4/9/2025, indicated the OW, who is not a licensed nurse, completed the assessment.

 

The cumulative effect of these systemic practices resulted in Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12, not having an accurate OASIS,  placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians; and affect the patients’ care and services that could lead to hospitalization and death.

 

On 5/16/2025, at 11:51 a.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the HHA’s Owner (OW) for failing to ensure the OASIS accurately reflected the patients status for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12).

On 5/26/2025 at 4:00 pm, the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely).


During an interview on 5/13/2025, at 1:34 p.m., the owner (OW) stated she was not a licensed nurse.

During an interview on 5/15/25 at 10:41 a.m. Registered Nurse 1 (RN 1) stated the start of care (SOC) assessment was on paper. RN 1 stated he brings the SOC assessment to the office within 2 days at the latest and gives the documents to the OW. RN 1 stated “someone” (stated doesn’t know who) puts it in in the electronic medical record (EMR) and he reviews it, makes sure it is okay.

During an interview on 5/15/2025, at 11:00 a.m., the OW stated that the doctor’s orders for Patients 8,9,10,11, and 12 should have been in the EMR. The OW reviewed the EMR and stated the doctor’s orders were not in the patient records and did not understand why they were not there. The OW stated she had uploaded the orders on 5/14/2025 and stated the EMR “sometimes doesn’t work.” The OW stated she would email the doctor’s orders to the survey team.

During an interview on 5/15/2025, at 11:12 a.m., RN 1 stated he did not document the SOC assessments (OASIS) because he did not have access to the EMR. RN 1 then stated he reviewed the OASIS for accuracy and signed the documents.

On 5/15/2025, at 1:35 p.m., the OW stated she did all of the OASIS for all the patients. The OW stated she used information from RN 1, the consultant, and doctors orders. The OW stated she signed the OASIS assessment so it can be complete because if it is not complete, visits cannot be added, and the plan of care cannot be done. The OW stated she documented all of the information on the OASIS assessment for all the patients.

A record review of Patient’s 8,9,10,11, and 12, did not indicate RN 1 had signed the OASIS.

On 5/13/2025, 5/14/2025, and 5/15/2025, there was no evidence of a doctor’s order indicating the treatments and services needed for Patients 8,9,10,11, and 12.

1.

During a review of Patient 8’s SOC Worksheet (Start of Care Worksheet, a document used by the HHA that contains patient’s personal information such as name, date of birth, insurance, primary physician, diagnosis, and the date the patient was admitted to the HHA), the SOC Worksheet indicated that Patient 8 was a fifty five-year-old female, who was admitted to the HHA on 3/27/2025, with diagnosis that included radiculopathy (occurs when a nerve root in the spine is compressed or irritated, which can lead to symptoms like pain, weakness, numbness, or tingling in the area served by the affected nerve), lumbar (the area of the spine between the thoracic [chest] area and the sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) region and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time).

During a review of Patient 8’s OASIS Start of Care Assessment, dated 3/27/2025, the OASIS Start of Care Assessment was signed by the OW and by Consultant 1.

The OASIS Start of Care Assessment indicated that Patient 8 had impaired hearing (speaker has to increase volume and speak distinctly), impaired vision (limited vision; not able to see newspaper headlines but can identify objects), and constant delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings). The OASIS Start of Care Assessment indicated that Patient 8 was dependent on a walker (a mobility aid, specifically a frame with four legs, designed to assist individuals who have difficulty walking due to age-related mobility issues, injury, or other medical conditions) and lived with other people in the home around the clock.

During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 5/1/4/2025, at 11 a.m., Patient 8 was observed alert and oriented to person, place, time, and situation (fully aware of who they are, where they are, what day it is, and what is happening around them). Patient 8 was also observed walking independently without any assistive device. Patient 8 stated she did not need a walker. Patient 8 stated she lived on her own. There was no other person observed at Patient 8’s home during the visit. Patient 8 was able to read the home visit consent on her own, verbalize understanding, and sign the consent on the designated space. No delirium was observed. Patient 8 was able to hear the surveyor and LVN 2 within normal distance and without the speaker having to increase the volume.

During an interview with Patient 8 on 5/14/2025 at 11:25 a.m., Patient 8 stated she was a published author. Patient 8 showed the surveyor and LVN 2 one of her books that was recently published.  

2.

During a review of Patient 9’s SOC Worksheet, the SOC Worksheet indicated that Patient 9 was an eighty one-year-old female, who was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose), essential hypertension (high blood pressure where the cause is not definitively known), and Alzheimer’s disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior).

During a review of Patient 9’s OASIS Start of Care Assessment, dated 4/7/2025, the OASIS Start of Care Assessment was not signed. 

During a concurrent interview and record review with the OW on 5/15/2025, at 2:05 p.m., the OW reviewed the OASIS Start of Care Assessment for Patient 8 and Patient 9. The OW stated that she was the one who documented the OASIS Start of Care for Patient 8 and Patient 9 with the help of Consultant 1.  The OW stated that neither she nor Consultant 1 had seen Patient 8 and Patient 9. The OW stated that she based the information that she put in the OASIS Start of Care Assessment on the Registered Nurse (RN) who admitted the patients and conducted the comprehensive assessment. The OW stated that she and Consultant 1 were not RNs. The OW was not able to provide the full name, contact information, or contract/agreement she had for Consultant 1. The OW stated that Consultant 1 “only worked for a week.” The OW stated she did not know Consultant 1’s full name.

When the OW was requested to provide the surveyor with the comprehensive assessment done by the RN for Patient 8 and Patient 9, the OW was not able to provide the RN assessment for Patient 9. The OW stated that RN 2, who conducted the start of care assessment for Patient 9, was currently on vacation and was unavailable. The OW stated that RN 2 had Patient 8’s start of care assessment with her, as it was paper based. 

During a review of an untitled document, with Patient 8’s name on it, who the OW stated was the start of care assessment done by RN 1, the document indicated the completion date was 4/3/2025. The document was not signed to indicate it was completed by RN 1. The document indicated that Patient 8 was alert, oriented, disoriented, and forgetful (all boxes were checked). The document did not indicate that Patient 8 had impaired vision or impaired hearing. There was no other assessment of Patient 8’s body system.

On 5/15/2025, at 11:25 a.m., RN 1 stated he had to leave the HHA’s office because he had to see patients and therefore, he was not able to review Patient 8’s Start of Care Assessment. The survey  requested RN 1 to rejoin the survey the following day. The OW stated that RN 1 was not available the following day since he had to visit patients.

3a.

During a review of Patient 10’s SOC Worksheet, the SOC Worksheet indicated that Patient 10 was admitted to the HHA on 3/28/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose).

A record review on 5/13/2025 of Patient 10’s OASIS start of care assessment, dated 3/28/2025, indicated the assessment was completed by a Registered Nurse (RN, also known as a licensed nurse). Further review of the record indicated the OW signed the document. On 5/13/2025, there was only 1 OASIS assessment (start of care assessment). No other OASIS assessment was in Patient 10’s records. 

During an interview on 5/13/2025 at 2:55 p.m., the OW added Patient 10 to the census. The OW stated she had just added Patient 10 to the census because she was discharged from the hospital on 5/11/2025.

During an interview on 5/12/2025, at 3:21 p.m., the OW stated Patient 10 had agreed for a home visit on 5/14/2025.

During an interview on 5/13/2025, at 9:24 p.m., the OW stated the home visit for 5/14/2025 was cancelled because Patient 10 was in a rehabilitation unit since 5/11/2025.

During an interview on 5/15/2025 at 11:12 a.m. RN 1 reviewed the paper documents for Patient 10. RN 1 stated none of those documents were a start of care assessment because there was no information about mobility and DME (durable medical equipment). RN 1 stated he did an assessment for Patient 10 on 4/3/2025. 

During a concurrent interview and record review, on 5/15/2025, at 11:15 a.m., RN 1 reviewed the SOC paper documents and OASIS-start of care assessment, dated 3/28/2025. The OASIS indicated the assessment was done on 3/28/2025.  RN 1 stated the OASIS had components that were incorrect such as vital signs and immunizations. Further record reviews of the documents indicated discrepancies with the paper document and the OASIS. This included insulin. The paper document mentioned the dose of 13 units, but there was no name of the medication. The OASIS indicated the name of the medication Novolog, but no additional information was documented. The paper document indicated Patient 10 needed SN (skilled nurse) services twice a week for 2 weeks (2w2), followed by 5 times a week for 1 week (5w1), PT (physical therapy) services, and Medical Social Work (MSW) services. The OASIS did not reflect the need for MSW. The OASIS indicated SN and PT services, but no frequency was mentioned. The OASIS indicated all interventions were to be based on doctor’s orders.

During an interview on 5/15/2025, at 1:35 p.m., the OW stated Patient 10’s start of care OASIS assessment was done on 3/28/2025, not 4/3/2025. The OW stated RN 1’s assessment date was wrong.

3b. A record review on 5/15/2025 of Patient 10’s records indicated the presence of another OASIS assessment. The OASIS E1 transfer document indicated Patient 10 was hospitalized for the reason of dehydration, and an RN had completed the assessment on 5/10/2025. Further review of the record did not indicate a signature to indicate who had completed the document.

During an interview on 5/15/2025, at 1:43 p.m., the OW stated she had documented the information on the OASIS E1 transfer assessment. The OW stated she obtained all of the information documented from the consultant and Patient 10’s husband. The OW stated she did not have medical knowledge. The OW stated the consultant was not an RN.

4a.

During a review of Patient 11’s SOC Worksheet, the SOC Worksheet indicated that Patient 11 was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). 

A record review on 5/13/2025 of Patient 11’s OASIS start of care assessment, dated 4/7/2025, indicated the assessment was completed by an RN. There was no signature on the document to specify the RN who did the assessment. On 5/13/2025, there was only 1 OASIS assessment (start of care assessment). No other OASIS assessment was in Patient 11’s records.

During an interview on 5/15/2025, at 3:15 p.m., the OW stated she did not have paper documents that the nurse did for the start of care assessment for Patient 11, to indicate the accuracy of the OASIS assessments. The OW stated she documented the information on the OASIS based on doctor’s orders and the information sent by the doctor.

During an interview on 5/13/25 at 3:20 p.m., the OW stated Patient 11 was hospitalized, and unable to do home visit.

4b.

A record review of Patient 11’s medical records on 5/15/25 indicated the presence of an additional OASIS assessment. This document was an OASIS transfer without discharge assessment, dated 5/8/2025. The document indicated the visit date was on 5/8/2025, but the assessment was completed on 5/7/2025. Further review of the document indicated the RN completed the assessment. The document was signed by the OW. The document indicated the reason Patient 11 was hospitalized was due to pneumonia (a condition that makes breathing difficult). 

During an interview on 5/15/2025 at 1:56 p.m., the OW stated she had documented on the OASIS transfer assessment based on what the nurse and consultant told her.

5.

During a review of Patient 12’s SOC Worksheet, the SOC Worksheet indicated that Patient 12 was admitted to the HHA on 4/9/2025, with diagnosis of chronic pain syndrome.  

A record review of Patient 12’s, OASIS-start of care assessment, dated 4/9/2025, indicated the OW, who is not a licensed nurse, completed the assessment.

During an interview on 5/15/2025, at 3:15 p.m., the OW stated she did not have paper documents that the nurse did for the start of care assessment for Patient 11, to indicate the accuracy of the OASIS assessments.

 A record review of the HHA’s undated document titled, Who Can Complete the OASIS, indicated, the Registered Nurse, primary clinician for most OASIS assessments, especially the start of care and recertification was responsible in completing the assess