Statement of Deficiencies

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)

G0942

Governing body
CFR(s): 484.105(a)

Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program.

This STANDARD is not met as evidenced by:
Based on interview and record review, the Home Health Agency (HHA) failed to ensure a governing body assume responsibility for the operations of the HHA by failing to:

a.     Ensure the agency’s Director of Patient Care Services provided oversight to ensure the clinical records were completed for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12).

b.    Ensure the agency has a qualified Administrator who assumed responsibility for the day-to-day operations of the agency.

c.     Ensure the agency’s Administrator ensured a clinical manager was available during all operating hours.

This failure resulted in Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 did not have clinical notes to validate the services being received were according to a doctor’s orders and based on the needs of the patients. The lack of oversight placed all patients at risk of injury, hospitalization, and/or death by not ensuring patients were receiving quality care.

On 5/16/2025, at 12:17 p.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 a governing body assume responsibility for the operations of the HHA.

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).

Patient 8 had a start of care (SOC) on 3/27/2025, with diagnosis of radiculopathy lumbar region.

Patient 9 had SOC on 4/7/2025, with Type 2 DM with hyperglycemia.

Patient 10 had a SOC on 3/28/2025 with diagnoses of Type 2 DM with hyperglycemia.

Patient 11 had a SOC on 4/7/2025, with diagnoses of Type 2 DM with hyperglycemia.

Patient 12 had a SOC on 4/9/2025, with diagnoses of chronic pain syndrome.

a.

A record review of the HHA’s organizational chart indicated the Director of Patient Care Services (DPCS) was also the Administrator (ADM). DON-Director of Nurses. An administrator designee (DPCS D) was also listed. The record indicated the owner’s (OW) role was Governing body/board of directors. CO/CFO/Secretary 100% ownership.

During an interview on 5/13/2025, at 12:22 p.m., the OW stated the DPCS and DPCSD were responsible for patient care.

During an interview on 5/13/2025, at 1:34 p.m., the OW stated she was responsible for the day-to-day operation of the HHA because this was a small home health agency, and she just needed a Registered Nurse to see the patients. The OW stated the last time the DPCS was in the agency was two weeks ago. The OW stated the ADM designee and DPCS designee as listed on the organizational chart, was a “designee on paper”, and had not worked at the HHA. The OW stated the DPCS was also the designee. The OW stated Registered Nurse 1 could cover the DPCS role as ADM, but RN 1 could not cover the DPCS role because he did not have at least 3 years experience.

On 5/13/2025, at 1:42 p.m., the DPCS stated she oversaw the nursing staff along with the OW. The DPCS stated the nurses consult with her through the phone and email. The DPCS stated she lived far away. The DPCS stated she did not do home visits. The DPCS supervised the nursing staff through calls, text messages, and “stuff like that”. The DPCS stated RN 1 did management duties. The DPCS stated she was not the administrator. The DPCS stated the last time she came to the office was in April 2025. The DPCS was asked if she was available to participate in the revisit survey: the DPCS stated, “I’m not sure if I am available with all of that.” The DPCS stated she preferred not to participate in the survey. The DPCS stated she had all of her businesses that she needed to attend to and did not have a lot of time. The DPCS stated her designee was RN 1. The DPCS stated she was not the administrator, and was under the impression that the OW was the ADM. The DPCS stated she did not have access to the electronic medical record (EMR).

During an interview on 5/15/2025 at 10:12 a.m., the OW stated that the DPCS was the ADM. The OW stated the DPCS doesn’t know that she is the ADM because the DPCS thinks the ADM is an office person who answers calls and does paperwork.

During an interview on 5/15/2025, at 10:33 a.m., RN 1 stated he was not hired to any management role including DPCS, supervisory, ADM, and administrator designee duties. RN 1 stated he had not supervised any Licensed Vocational Nurses for this HHA.

On 5/13/2025, 5/14/2025, 5/15/2025, and 5/16/2025, the DPCS was not available.

The effect of the DPCS not being in the agency with the patient care and the clinical operations was no oversight to ensure plan of care was done, visit notes entered in the medical record, doctor notes present, and OASIS done accurately.

b.

During a review of clinical records on 5/13/2025, there was no plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) available for Patient 9, Patient 10, and Patient 11 on the electronic health record.

During a review of clinical records on 5/14/2025, there was no POC available for Patient 9, Patient 10, and Patient 11 on the electronic health record.

During a review of clinical records on 5/15/2025, Patient 9, Patient 10, and Patient 11 had completed POC on the electronic health record.

During an interview with the Owner (OW) on 5/15/2025 at 11 a.m., the OW stated she generated the POC for the three patients the night before (5/14/2025).

During an interview with the OW on 5/15/2025, at 2:55 p.m., the OW stated she created the POC for Patient 9, Patient 10, and Patient 11 and uploaded them to the electronic health record on the evening of 5/14/2025 with the help of a consultant. The OW stated the consultant gave her the information for the plan of care by e-mail, which she then transcribed to the electronic health record 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.”

During a review of clinical records on 5/13/2025, 5/14/2025, and 5/15/2025, there were no physician orders available for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12.

During an interview with the OW on 5/15/2025, at 1:13 p.m., the OW stated the only order the physician wrote was the home health referral.

During a review of the physician order, the document did not indicate the type of home health services, interventions, medications, treatments, and goals for the patients. The referral document indicated “Home Health.”

During a review of clinical records on 5/13/2025, there were no nursing visit notes available for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 on the electronic health record.

During an interview with the OW on 5/15/2025 at 3:05 p.m., the OW that Licensed Vocational Nurse 1 (LVN 1) endorsed to her (OW) the patient’s information over the phone, which the OW then transcribed into the nursing visit note. The OW stated that has always been the practice of the HHA. Per OW, she entered the nursing visit notes for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12. The OW acknowledged she was not a clinician.

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 that she had been visited by a nurse (LVN 1) and by a physical therapist from the HHA once a week. 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).

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.

During a review of Patient 9’s clinical records on 5/13/2025, the Nurses Notes section in the electronic health record indicated there were 0 (zero) notes entered for the certification episode of 4/7/2025 to 6/5/2025. The Nurses Notes section indicated “empty category.”

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.

3.

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. 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.

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.

During a record review, 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 Governing Body indicated, “Simple Touch Home Health shall maintain an active Governing Body with full legal authority and responsibility for the management, oversight, and operation of the agency. The Governing Body shall define the organization’s mission, ensure the provision of quality care, approve policies, and oversee fiscal and administrative operations. Composition: The Governing Body may include the agency’s owners, executives, Administrator, Director of Patient Care Services (DPCS), and other appointed members as appropriate.”

A record review of the HHA’s undated document titled, Job Description Summary for the Executive Director/Administrator, indicated the job responsibilities included ensuring organizational compliance with legal, regulatory, and accreditation standards; ensuring program personnel have current clinical information and current practices; assuring appropriate personnel supervision during all operating hours; is responsible for all day-to-day operation of the HHA; ensures that a clinical manager is available during all operating hours; the administrator or a pre-designated person is available during all operating hours.

A record review of the HHA’s undated document titled, Job Description Summary for the Clinical Director/Director of Patient Care Services, indicated the job responsibilities included: oversees the maintenance of patient clinical records, statistics, reports and records for purposes of evaluation and reporting of organization activities; assures proper maintenance of clinical records in compliance with local, state and federal laws; if the DPCS is also acting as the clinical manager: the clinical manager’s oversight must include the following:...coordinating patient care...assuring that patient needs are continually assessed, assuring the development, implementation, and updates of the individualized plan of care.