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)
G1024 Authentication
CFR(s): 484.110(b)

Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry.


This STANDARD is not met as evidenced by:
Based on observation, interview and record review, the Home Health Agency failed to ensure that all clinical record entries were clear, complete, and appropriately authenticated, signed, dated, and timed for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12).

This failure had the potential for the patients’ clinical records to be lacking validity.


a.

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.

During a review of Patient 8’s Home Health Certification and Plan of Care, for the certification episode of 3/27/2025 to 5/25/2025, the Home Health Certification and Plan of Care had 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 8’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 3/27/2025 to 5/25/2025. The Nurses Notes section indicated “empty category.”

 

b.

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.

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 telephone interview with Licensed Vocational Nurse 1 (LVN 1) on 5/15/2025, at 2:04 p.m., LVN 1 stated she was the visiting nurse for Patient 8 and Patient 9. According to LVN 1, she visited both patients once a week. LVN 1 stated that she documented her visit notes on paper, and she would later upload them to the electronic health record, depending on how busy she was. LVN 1 stated she had access to the electronic health record.

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 9’s start of care assessment with her, as it was paper based. RN 2 was not listed in the staff list provided to the survey team.

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.

 

c.

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 5/15/2025 of Patient 10’s records indicated the presence of an 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.

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.

A record review of Patient 10’s 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. None of these visit notes were signed by the author of the note.

 

During an interview on 5/15/2025, at 1:56 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she had all of Patient 10’s nursing notes at her home. LVN 1 stated she wrote her visit notes on paper, then put them in the EMR. LVN 1 stated she tried to put the notes in the EMR the same day or the next day the latest. LVN 1 stated she thought she had entered Patient 10’s notes into the EMR,  but would have to double check.

 

d.

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 5/15/2025 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.

A record review of Patient 11’s  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. None of these visit notes were signed by the author of the note.

 

e.

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  nursing visit notes indicated visits were made on 4/12/2025, 4/15/2025, 4/18/2025, 4/25/2025, 5/2/2025, and 5/9/2025. None of these visit notes were signed by the author of the note.

 

A record review of the HHA’s undated document titled, Contents of Medical records, indicated, “2. Documentation Standards: Entries must be legible, dated, times, and signed with credentials...Documentation should be completed within 24-48 hours of the visit or service, depending on urgency.”

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.