cms_SC: 10232
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10232 | UNIHEALTH POST ACUTE CARE - AIKEN, LLC | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2010-11-22 | 153 | G | 6LCC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on record review and interviews, the facility failed to provide access to all medical records for 1 of 4 residents sampled for the request of medical records (Resident #1). A written request made by the wife (personal representative) of Resident #1 made initially to the facility on [DATE] and then again on [DATE] was denied. The Regional Ombudsman, after numerous attempts to assist the resident's wife in obtaining the medical records of Resident #1, filed a complaint with the State Survey Agency on [DATE]. Nurses' Notes documented that the facility notified Resident #1's wife with any change in condition and acknowledged her as his personal representative. The facility failed to acknowledge the Health Care Consent Act (SC Code [DATE] et. esq.) and failed to recognize Resident #1's wife as his personal representative when she requested copies of his medical record. The findings included: On [DATE] the facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Resident #1 required extensive to total assistance for all activities of daily living on the Admission and Quarterly MDS. Review of the current medical record revealed a Do Not Resuscitate (DNR) Authorization for Patient/Resident Without Decision-Making Capacity for Resident #1 signed [DATE] by two physicians and by the resident's wife ([DATE]). During an onsite visit to the facility on [DATE], Resident #1 was sampled as a result of a complaint received by the State Agency on [DATE]/2010, which alleged that the resident's wife failed to receive requested medical records. The allegation stated that the Ombudsman had worked since [DATE] to resolve a complaint filed against the facility related to the denial of requested copies of the medical record. Review of the current medical record indicated that on [DATE] the resident's wife signed a facility provided Authorization for Use & Disclosure of Information form requesting records for her husband (Resident #1) from "[DATE] - Present for personal purposes". On [DATE] Resident #1's wife received a letter from a representative of the facility, which stated, "...regarding your request for the above mentioned patients' medical records. As you are aware, the Health Insurance Portability and Accountability Act and the privacy regulations promulgated there under (collectively, "HIPPAA") has imposed strict requirements on health care providers regarding the release of protected health information ("PHI"). Under HIPPAA, a provider may disclose an individual's PHI to a personal representative who under state law has authority to act on behalf of the individual. See 45 CFR 164.502(g)(1), 164.514(h)(1)(i). Further, HIPPAA requires that the provider verify the identity of the personal representative and that person's authority to access PHI as a personal representative. See 45 CFR... 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 state if the individual is deceased . The Advance Directive provided to the facility does not provide the proper authority. The center will not be able to release these records until it receives verification of the applicable representation..." Information provided by the Ombudsman revealed a letter to Resident #1's wife dated [DATE] in which she was advised of her rights under the Health Care Consent Act (SC Code [DATE] et. esq.). A letter to the facility dated [DATE] from the Ombudsman was also provided, which included the following statement, "...I will meet with Resident #1's wife in the morning to visually inspect the medical record and from there will assist as needed in identifying the records she wants copied for her personal use." On [DATE] Resident #1's wife signed another Authorization for Use & Disclosure of Information form requesting records "from date of admission to present: nurses notes, skin asst. (assessments)/body audits, Soc (social) Services notes, all physical therapy, speech therapy, care plans" for personal use. Review of the Health Care Consent Act (SC Code [DATE] et. esq.) Section [DATE] states, "Persons who may make health care decisions for patient who is unable to consent; order of priority; exceptions. (A) Where a patient is unable to consent, decisions concerning his health care may be made by the following persons in the following order of priority: (1) a guardian appointed by the court pursuant to Article 5, Part 3 of the South Carolina Probate Code, it the decision is within the scope of the guardianship; (2) an attorney-in-fact appointed by the patient in a durable power of attorney executed pursuant to Section [DATE], if the decision is within the scope of his authority; (3) a person given priority to make health care decisions for the patient by another statutory provision; (4) a spouse of the patient..." Resident #1's spouse is his personal representative and per the Health Care Consent Act is the person who makes health care decisions for him. In a telephone interview with the facility on [DATE] the facility stated that this was a HIPPA concern and they would not release information to Resident #1's wife for "personal use" and that the wife would have to complete the request to list specific information and the purpose of the use of the information. In an interview with the surveyor on [DATE] the Ombudsman stated that she met with Resident #1's wife at the facility on [DATE] in order to review Resident #1's medical record during a care plan meeting. A verbal review was conducted of the medical record with the Administrator, Social Worker, Director of Health Services, Senior Care Partner and Speech Therapist present along with Resident #1's wife and the Ombudsman. Following the verbal review Resident #1's wife and the Ombudsman looked at the record page by page to determine what she wanted copied. When asked if the resident's wife filled out the authorization form, the Ombudsman stated that the facility staff completed the Authorization for Use & Disclosure of Information form and the resident's wife initialed and signed where needed. At no time did the facility staff give any instructions to the resident's wife regarding how to fill out the form. At the time of the survey Resident #1's wife had not received the requested copies of her husband's medical record. | 2014-03-01 |