§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.
§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.
§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
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Observations:
Based on a review of clinical records and interviews with staff, it was determined that the facility failed to maintain complete and accurate medical records for one of eight residents reviewed (Resident 1).
Findings include:
Review of Resident 1's progress note of January 30, 2025, revealed resident returned to facility via transport van from pain management facility. Review of progress note of January 31, 2025, at 6:53 a.m. revealed resident is 2/9 (two of nine shifts) s/p (status post - condition or status after a specific event) fall.
Further review of the clinical record revealed no documentation indicating that the resident had a fall.
Review of facility documentation dated January 30, 2025, revealed that "resident was being transported to pain management this am 0820 [8:20 a.m.], he slid from his wheelchair to the floor of the van, the driver stopped (COTA-L [certified occupational therapist - licensed] and repositioned back into the wheelchair, fastened the seat belts, and continued on to his appointment, after determining that there was not injury sustained during the fall".
Interview with the Nursing Home Adminstrator on February 27, 2025, at 3:35 p.m confirmed that there was no documentation in the clinical record that the resident had sustained a fall.
28 Pa. Code 211.5(f) Clinical records
Previously 10/25/24
28 Pa. Code: 211.12(d)(1) Nursing services
| | Plan of Correction - To be completed: 03/16/2025
The facilities will adopt robust standardized documentation practices to enhance the quality and reliability of resident records. This includes providing comprehensive training for all staff on proper documentation techniques, ensuring that every pertinent detail is accurately captured in each resident's record. The DON will create detailed guidelines for staff on how to document patient information. The DON will also conduct regular audits of medical records to identify any inconsistencies or errors in documentation.
2. The DON will provide comprehensive training to all staff on proper documentation practices, including the importance of accuracy, completeness, and confidentiality. This will be ongoing education and training to keep staff updated on the best practices and any changes in documentation standards.
3. The DON will ensure that all staff are aware of and comply with HIPAA guidelines regarding the privacy and security of resident's information.
4. To improve our transportation process and enhance the overall experience for our residents, we are implementing a new procedure for documenting transport activities. The transport driver will be required to prepare a comprehensive report immediately upon the residents' return to the facility. This report will include detailed progress notes that capture several key components of the trip.
The report will document departure and arrival times to provide a clear timeline for the transport. It will also note the residents' condition throughout the journey, highlighting any changes or observations made by the driver. This report will be reviewed daily by the Director of Nursing (DON) alongside a member of the Interdisciplinary Team (IDT).
5. NHA or designee will complete an audit of staff competencies daily before appointments x 4 weeks. The audit will then transition to once weekly x 4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
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