| 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) |
| G0572 | Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that three of five sampled patients (Patient 9, Patient 10, and Patient 11) received home health services that are written in an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients. This failure resulted in Patient 9, Patient 10, and Patient 11 receiving home health services without an individualized, written plan of care that included management of their medical conditions. On 5/16/2025, at 12:12 p.m., the State Survey Agency (SSA) 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 called in the presence of the agency’s Owner (OW) related to the agency’s failure to provide home health services that are written in an individualized plan of care (a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients for three of five sampled patients (Patient 9, Patient 10, and Patient 11). On 5/26/2025 at 4:00 p.m., 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 a telephone interview with the Director of Patient Care Services (DPCS) on 5/13/2025, at 1:42 p.m., the DPCS stated that she did not go to the interdisciplinary meetings in person due to distance. The DPCS stated she lived far away from the HHA’s office. The DPCS stated she participated in the meetings through group texts and phone calls. When the DPCS was asked if she had access to the electronic health record system used by the HHA, the DPCS stated that she did not have access yet. The DPCS stated she was not sure if she could join the revisit survey because she had to attend to her own businesses, and she did not have time. During an interview on 5/15/2025 at 10:44 a.m., Registered Nurse 1 (RN 1) stated he tried to do the plan of care (POC). The POC was based on what the doctor ordered. If after the assessment, additional interventions were needed, the doctor was notified, and the additional interventions were added to the POC. RN 1 stated he wrote the orders received from the doctor and gave it to the OW, for the purpose of amendments of the documentation. RN 1 stated he did not create the POC in the electronic medical record (EMR) and did not know who created the POC. During an interview on 5/15/2025, at 11:00 a.m., the OW stated that the doctor’s orders for Patients 9,10, 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. On 5/15/2025, at 11:10 a.m., the OW stated the plan of care for all patients had been completed and the survey team should be able to view it on the EMR. During an interview with the OW on 5/15/2025, at 2:55 p.m., the OW stated she created the plan of care for Patient 9, Patient 10, and Patient 11 and uploaded them to the EMR on the evening of 5/14/2025 with the help of a consultant. The OW stated the consultant gave her the information for the POC by e-mail, which she then transcribed to the EMR of Patient 9, Patient 10, and Patient 11. The OW stated she also received help from her other friends for the POC. The OW stated the consultant was not a Registered Nurse. The OW also stated the consultant had never seen the patients. The OW stated that it was the responsibility of a clinician, such as the DPCS, to complete the POC, but she completed the plan of care because she wanted to “take care of her business.” a. During a review of Patient 9’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 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). On 5/13/2025, during a review of Patient 9’s Home Health Certification and Plan of Care, for the certification episode of 4/7/2025 to 6/5/2025, the Home Health Certification and Plan of Care was not completed. The sections for the patient’s diagnosis, medications, DME (Durable Medical Equipment, any medical equipment used in the home to aid in a better quality of living) and supplies, safety measures, nutritional requirements, allergies, mental status, prognosis, orders for disciplines and treatments including amount/frequency/duration, and goals/rehabilitation potential/discharge plans were blank. There was no nurse’s signature and no physician’s signature to indicate that a Registered Nurse received the physician’s orders, and a physician reviewed the Home Health Certification and Plan of Care. On 5/14/2025, during a review of Patient 9’s Home Health Certification and Plan of Care, for the certification episode of 4/7/2025 to 6/5/2025, the Home Health Certification and Plan of Care was not completed. During a concurrent record review and interview with the Owner (OW) on 5/15/2025, at 11:55 a.m., the OW reviewed Patient 9’s Home Health Certification and Plan of Care on the electronic health record system. The OW confirmed the Home Health Certification and Plan of Care for Patient 9 was not completed. The OW stated, “Sometimes you can see it, sometimes you cannot see it.” b. 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 of Patient 10’s medical records on 5/13/2025, did not indicate the presence of a POC. A POC template was present, but there was no clinical information. 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. A record review on 5/15/2025 of Patient 10’s records indicated the presence of The OASIS E1 transfer assessment, dated 5/10/2025. This document was not present on 5/13/2025, the day the revisit survey began. The document indicated Patient 10 was hospitalized for the reason of dehydration. A record review on 5/15/2025 of Patient 10’s records indicated the presence of an unsigned plan of care titled, Home Health Certification and Plan of Care, for certification period 3/28/2025 to 5/26/2025. The record included nursing interventions as follows: -Skilled nurse (SN) frequency as per MD ordered. -SN to note blood pressure (BP) trends and report to doctor if BP less than 90/60, greater than 200/100, heart rate less than 60 beats per minute (bpm) or greater than 100 bpm. SN to report to MD in a timely manner of any significant findings or negative outcome. During an interview on 5/15/2025, at 1:56 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she found out Patient 10 was hospitalized due to “drastically low blood pressure”. LVN 1 stated Patient 10 was on dialysis (a mechanical process of removing waste from the body, when the kidneys do not work). LVN 1 stated she called Patient 10 on 5/5/2025 to confirm her home visit for 5/7/2025. At this time, she was already hospitalized and could not visit Patient 10 on 5/7/2025. LVN 1 stated prior to hospitalization, LVN 1 visited Patient 10 on 4/30/2025. LVN 1 stated Patient 10 had returned from the doctor’s office and new medications were prescribed. LVN 1 stated she had checked Patient 10’s blood pressure and it was “101 over 50 something, and the blood sugar was fine.” LVN 1 stated she had all her nursing note visit documents at home and wrote her visit notes in the EMR. LVN 1 stated no one wrote her notes. LVN 1 stated she entered the notes for Patient 10, but would have to double check. A record review of Patient 10’s unsigned nursing visit notes indicated visits were made on 4/2/2025, 4/9/2025, 4/16/2025, 4/23/2025, 4/30/2025, and 5/7/2025. A record review of Patient 10’s nursing visit note on 4/30/2025, indicated Patient 10’s blood pressure was 138/83. The blood pressure document did not support LVN 1’s interview of Patient 10’s blood pressure being “101 over 50 something” on 4/30/2025. A record review of Patient 10’s nursing visit notes indicated a visit was documented on 5/7/2025, the day LVN 1 could not do a home visit due to Patient 10 being hospitalized. A record review of Patient 10’s EMR, did not indicate any notes to indicate LVN 1 called the doctor to report Patient 10’s blood pressure of “101 over 50 something”. c. 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 of Patient 11’s medical records on 5/13/2025, did not indicate the presence of a POC. A POC template was present, but there was no clinical information. 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. A record review on 5/15/2025 of Patient 11’s records indicated the presence of an unsigned plan of care titled, Home Health Certification and Plan of Care, for certification period 4/7/2025 to 6/5/2025. The primary diagnosis was listed as acute and chronic respiratory failure. Further review of the POC, did not indicate Patient 11 had Type 2 diabetes. The record included nursing interventions as follows: -Skilled nurse (SN) frequency as per MD ordered. -SN to monitor oxygen saturations every SN visit. During an interview on 5/15/2025, at 2:02 p.m., LVN 1 stated Patient 11 had a scheduled home visit on 5/7/2025. LVN 1 stated she texted Patient 11’s daughter on 5/6/2025 to confirm the visit. LVN 1 stated Patient 11’s daughter texted LVN 1 back on 5/7/2025, to let her know he was back in the hospital but did not mention the reason. LVN 1 could not get more information about his hospitalization. A record review of Patient 11’s unsigned nursing visit notes indicated visits were made on 4/10/2025, 4/14/2025, 4/17/2025, 4/22/2025, 4/19/2025, and 5/6/2025. A record review of Patient 11’s SN visit note for 4/17/2025, did not indicate the SN monitored Patient 11’s oxygen saturation. A record review of Patient 11’s nursing visit notes indicated a visit was documented on 5/6/2025, the day LVN 1 texted Patient 11’s daughter to confirm the scheduled HV on 5/7/2025. During a review of the HHA’s undated policy and procedure, titled “Plan of Care,” the policy and procedure indicated the HHA will develop and maintain a Plan of Care for each patient that is individualized, based on a comprehensive assessment, and established under the direction of the patient’s physician. The plan shall guide the home health team in delivering medically necessary services and will be reviewed and updated as the patient’s condition changes. The policy and procedure indicated the plan of care must include but is not limited to: • Diagnoses and medical history • Functional limitations • Medications and treatments • Services and disciplines required (e.g., nursing, PT, OT, ST, MSW, HHA) • Visit frequency and duration • Nutritional needs • Safety measures • Discharge planning • Patient-specific goals and outcomes • Physician's signature and date |