§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(i) Medical records.
§483.70(i)(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(i)(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(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(i)(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(i)(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 observations, review of resident records, and interviews with staff it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of nine residents reviewed. (Resident R1)
Findings Include:
Review of resident Minimum Data Set (MDS) revealed an admission date of August 18, 2022. The resident was admitted with a diagnosis of pulmonary embolism, seizures, tachycardia, chronic viral hepatitis, respiratory failure, hypocalcemia, depression, anxiety, hypertension, alcohol dependence with withdrawal, insomnia, bilateral primary osteoarthritis, adjustment disorder, and basal cell carcinoma of the skin.
Review of Resident R1's record revealed the resident had a Level of Care determination on April 18, 2024 after an assessment was completed at the facility on March 25, 2024 and the determination was that the resident was "Nursing Facility Ineligible".
Review of Resident R1's all progress notes revealed at no time was this determination discussed with Resident R1.
Interview with social services director Employee E3 on June 13, 2023 at 1:15 p.m. confirmed there was no documentation to prove that the social worker discussed the resident's ineligibility with him.
Review of Resident R1's record revealed the resident was given a discharge notice on May 8, 2024. Review of the discharge notice revealed there was no reason checked off as to why the transfer or discharge was appropriate for the resident.
Review of the resident's discharge summary revealed the discharge summary was incomplete. The discharge instruction sheet revealed the facility listed the housing as arrangement for the resident as "refused to provide".
28 Pa. Code:211.5(b) Clinical records.
| | Plan of Correction - To be completed: 07/01/2024
Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1. Director of social services or designee will re-educate social services on the importance of proper documentation.
2. Director of social services or designee will do random audits of 30-day discharges to ensure proper documentation. Weekly x4 monthly x3
3. Results will be reviewed at the quarterly QAPI meeting.
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