cms_SC: 10164
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10164 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 153 | G | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint survey,and Extended Survey, based on record reviews, review of facility documents, and interviews, the facility failed to ensure that the resident's legal representative was provided with the opportunity to purchase copies of the medical record for 2 of 7 resident representative requests reviewed (Residents #23 and #39) and failed to provide copies of requested records in two working days for 3 of 7 resident representative requests approved to received them (Residents C, D, E). The findings included: During the Entrance Conference, the facility was asked to provide a list of requests made since [DATE] for copies of resident medical records. A list of nineteen names was provided. The facility was then asked to provide dated request forms and evidence the copies were provided as requested. Documents for eighteen residents were provided which included Authorization For Use & Disclosure Of Information, PHI (protected health information) Request Cover Sheet, written requests, Power of Attorney documentation, Certificates of Appointment, Fiduciary Letters, letters of denial, e-mail correspondence with the facility medical records person, "Goin Postal" receipts for certified letters, Medical Record Billing Invoices, and Certified Mail receipts. None of the resident information packets contained copies of all the above listed forms, usually two or three forms were provided for each resident. All of the resident representatives who requested copies of the medical record were identified by the facility as the resident's Responsible Party and were the individuals notified concerning changes in the resident's condition or treatment (protected health information). The denials all stated in part: "... As you may be aware, the Health Insurance Portability and accountability Act and the privacy regulations promulgated thereunder (collectively, "HIPAA") has imposed strict requirements on health care providers regarding the release of protected health information ("PHI") Under HIPAA, a provider may release PHI of an individual to a personal representative authorized under state law to act on behalf of the individual. See 45 CFR 164.502(g). Further, HIPAA requires that the provider verify the identity of the personal representative and that person's authority to access PHI as a personal representative. 164.514(h)(1)(i). Such a personal representative may be a durable power of attorney for health care or guardian of the person if the individual is living or the permanent administrator or executor of the estate if the individual is deceased . The center will not be able to release these records until it receives verification of the applicable representation. ..." Resident #23 arrived at the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident assessments of [DATE] and [DATE] showed no memory, decision making, or communication problems. On admission, the resident's brother was listed as the Responsible Party but this was changed to his son on an unknown date. The resident's son did start receiving the resident's Statement of Account by [DATE]. Resident #23's son began requesting copies of the medical record on [DATE]. The resident was transferred to the hospital on [DATE] and expired later that day. His son continued to make multiple requests for copies of the medical record and enlisted the aide of The Regional Ombudsman. His requests were repeatedly denied by the corporation legal staff. The Power of Attorney document provided by the son was deemed unacceptable. The probate court's certification of the son as the resident's personal representative was also deemed insufficient. Resident #23's son was directed to produce a fiduciary letter. During an interview with the Administrator on [DATE] at 8:35 AM, a representative from the corporate legal department was called and confirmed that copies of the resident's medical record had not been provided because the son failed to produce fiduciary letters. Resident #39 entered the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's daughter was listed as her Responsible Party. Review of the resident assessment of [DATE] revealed the facility was unable to assess the resident's memory and decision making ability due to her medical status. Communication was impaired. Resident #39 was found unresponsive on [DATE]. Cardiopulmonary resuscitation was initiated and the resident was sent to the hospital where she expired. The daughter was notified of all the events leading to discharge. On [DATE], the resident's daughter requested copies of her mother's medical record and was denied that same day. The corporate representative stated during the interview on [DATE] that it was because she did not have the resident's Healthcare Power of Attorney. Information provided by the facility revealed the following information concerning lack of timeliness in addressing requests for copies of the medical record made by resident representatives: The resident representative for Resident C requested copies of the medical record on [DATE] and was initially denied on [DATE] but documents provided by the facility showed this decision was reversed at a later date. The second request, made on [DATE], showed corporate approval on [DATE] and a posting bill dated [DATE]. Resident D's representative made a request for copies on [DATE] and did not receive approval for the copies until [DATE]. Resident E's representative requested copies of the record on [DATE] but did not receive approval for the copies until [DATE]. | 2014-04-01 |