Health inspection·September 20, 2023

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1's representative was allowed to obtain a copy of the medical records within the required time frame. This failure had the potential to result in Resident 1's representative undue concern and anxiety on behalf of Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. During a review of the letter requesting medical records dated 8/23/23, the letter, addressed to the facility's Custodian of Records, indicated a request for Resident 1's medical records be sent through the following methods: -Contacting the requesting office at their phone number when medical records are located to schedule a copy appointment. -Emailing the records to the requesting office's email address. -Furnishing a copy via facsimile to the requesting office's fax number. -Mailing a copy of the records to the requesting office's mailing address. During a concurrent interview and review with Operations Manager & Director of Medical Records (OMDMR) on 9/20/23 at 11:38 a.m., the letter requesting for medical records was reviewed. OMDMR stated receiving the letter with the following documents: -Authorization to Handle Claim dated 8/21/23. -Authorization For The Release Of Patient Information. -Declaration of Resident 1's Representative as successor in interest to Resident 1. -Resident 1's Certificate of Death. Page 1 of 2 055239 055239 09/20/2023 East Bay Post-Acute 20259 Lake Chabot Road Castro Valley, CA 94546

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few OMDMR stated receiving the records request letter on her desk on 8/25/23, which was then sent to the facility's legal team on 8/26/23 for clearance. The request letter included a Notice to Subpoenaed Party that indicated the facility must comply with the request on or before 8/28/23. OMDMR stated receiving clearance from facility's legal team on 8/26/23 but did not begin to process the request until 8/28/23. OMDMR also stated the request was processed and access to Resident 1's medical records was available on 8/29/23 but did not send the medical records until 9/1/23. OMDMR could not show a fax confirmation for the medical records sent to the requesting office on 9/1/23. OMDMR stated Requesting Staff (RS) had called on 9/7/23 about the medical records that were not sent to their office. OMDMR stated Resident 1's medical records were sent again via email on 9/7/23. OMDMR stated, for residents who currently stay at the facility, medical records were provided within 48 hours of request, but for residents that were already discharged /were no longer at the facility, medical records could take some time because requests would have to be reviewed and cleared with the facility's legal team. During a telephone interview with RS on 9/20/23 at 9:47 a.m., RS stated making several follow-up calls to the facility several times after the request and subpoena (legal document compelling one to produce documents or records at a specified time) were sent. RS also stated, after many attempts to reach the facility's Custodian of Records, the requesting office received the medical records on 9/19/23, three weeks after the request and subpoena were sent. During a review of the facility's policy and procedure (P&P), undated, titled Medical Records Request Process Procedure, the P&P indicated to notify the Administrator and Director of Nursing (DON) of the request. The facility's P&P did not indicate a time frame in releasing medical records. During an interview with DON on 9/20/23 at 12:36 p.m., DON stated she was not aware of the medical records request. 055239 Page 2 of 2