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)
G1028 Protection of records
CFR(s): 484.110(d)

Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164.


This STANDARD is not met as evidenced by:
Based on interview and record review, the Home Health Agency failed to ensure the safeguarding of clinical records against unauthorized access or loss for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12).

This failure had the potential to result in the patients’ protected health information (PHI, any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) being accessed or used by unauthorized personnels, and loss of clinical records.


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 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.

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.

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).

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 and 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.

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).

On 5/13/2025, 5/14/2025, and 5/15/2025, there was no evidence of paper documents used by the nurse for the start of care of Patient 11.  There was no paper consents present at the HHA.

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.

 

On 5/13/2025, 5/14/2025, and 5/15/2025, there was no evidence of paper documents used by the nurse for the start of care for Patient 12. There was no paper consents present at the HHA.

During an interview with the Owner (OW) on 5/13/2025, at 12:53 p.m., when the OW was asked how the HHA maintained the patients’ clinical records, the OW stated there were no paper documents in the HHA’s office for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12. The OW stated that all records were either uploaded into the electronic health records (EMR) or in her e-mail.

During an observation on 5/13/2025 at 12:54 p.m., the OW called Registered Nurse 1 (RN 1) on the cell phone and placed the call on speaker. The OW inquired about the patients’ consent forms. RN 1 told the OW that he had all the consents with him and would bring to the HHA today, 5/13/2025.

During an interview on 5/15/2025, at 10:41 a.m., RN 1 stated he brought the admission paperwork and patients consents to the office within 2 days of the start of care. RN 1 stated he gave the documents to the OW, then someone puts in in the EMR. RN 1 stated he did not know who documents into the patients’ EMR.

During an interview with the OW on 5/15/2025, at 2:55 p.m., the OW stated the plan of care (POC) for Patient 9, Patient 10, and Patient 11 was uploaded 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.

A record review of the HHA’s undated document titled, Safeguarding of Medical Records, indicated that the HHA shall maintain all patient medical records in a secure, confidential, and retrievable manner. Medical records shall be protected against loss, unauthorized access, alteration, or destruction and retained in accordance with state and federal laws...Physical Safeguards: Medical records in paper form are stored in locked file cabinets or secured rooms with restricted access...Access is limited to authorized personnel only...Electronic Safeguards: Electronic Health Records (EHRs) are maintained in a secure, encrypted system with role-based access. User IDs and passwords are required for all access to electronic records.