Health inspection·May 1, 2023

F 0573 Level of Harm - Minimal harm or potential for actual harm 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, clinical record and policy review, the facility failed to ensure that; Residents Affected - Few 1. Two of two sampled resident's (Resident 1 and 2) received a copy of their medical records within two-working days of the request, in accordance with federal regulations; and 2. The facility's medical records policy was in accordance with federal regulations. This failure violated Resident 1 and 2's right to allow them to have a copy of their medical records within 2 business days from their requests. Findings: 1. On 5/1/23 at 12:23 pm, an interview was conducted with Resident 1's family member (FM). The FM indicated that Resident 1 had signed a record release form on 2/21/23, and had not received Resident 1's records timely and in a manner that he could access. FM indicated that he received a flash drive (a memory device of data that plugs into a computer) in the mail on 4/18/23, two months after the records were requested. FM indicated he could not see the medical record information because the flash drive required a password that he was not given. The FM stated that on 4/18/23, he called the facility and notified the Health Information Manager (HIM) about this issue, but never heard back from the facility and the issue remains unresolved. On 5/1/23, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE] with the diagnoses of a lung disease, altered mental status and Post-Traumatic Stress Disorder. Resident 1 was capable of making his own healthcare decisions. He was discharged from the facility on 2/21/23. A review of the facility's form titled, Request and Authorization for Release Of Health Information reflected that Resident 1 had signed and requested a copy of his entire medical record on 2/21/23. On 5/1/23 at 2:20 pm, an interview and concurrent record review was conducted with the HIM concerning Resident 1's record requests. Resident 1's medical records request form was reviewed, and the HIM confirmed that the record was requested on 2/21/23. She stated that there was confusion with what format the Resident wanted his records in (paper or electronic). When it was confirmed to be electronic, she attempted to download the files on a flash drive but was unsuccessful. The HIM emailed their IT (Information Technology, the management of storing data using computers) Manager (ITM) on 3/31/23, for help. HIM indicated that she did not hear back from ITM until 4/5/23 (5 days later). The ITM Page 1 of 2 555151 555151 05/01/2023 Willows Post Acute 320 North Crawford Street Willows, CA 95988

F 0573 Level of Harm - Minimal harm or potential for actual harm proceeded to download the files himself and send the flash drive to Resident 1. HIM did not know exactly when this had happened and stated that she had not followed up on it. She was unaware that Resident 1 was still unable to access his medical records files. The HIM indicated she had not documented any information concerning this incident. She confirmed that Resident 1 had not received a copy of his medical record within 2 business days. Residents Affected - Few On 5/1/23, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE] with the diagnoses of multiple fractures, lung disease, and an anxiety disorder. She was her own responsible party. A review of a record requests faxed to the facility on 3/20/23 at 9:28 am, from ChartSquad (a company that assists residents with requesting their medical records) revealed a record request signed on 3/1/23 by Resident 2. A Follow-up reminder for Patient Access Summary was reviewed and indicated, One of our members previously sent you a patient access request letter that is still pending. We wanted to send you a reminder to help promote Patient Access! Package sent on March 10th, 2023. On 5/1/23 at 3:07 pm, an interview was conducted with the Assistant Health Information Manager (AHIM). She indicated that she uploaded the documents onto a flash drive and sent it to ChartSquad on 3/24/23 at 11:00 am, four days after the request had been made. She indicated that she did not follow up to see if Resident 2 had received her medical records or if she was able to access the information on the flash drive. 2. On 5/1/23 at 3:07 pm, a concurrent interview and facility policy review was conducted with the HIM and AHIM. The facility's policy titled, Protected Health Information (PHI), Residents' Rights Relative to dated March 2014, indicated, Our facility will act upon a resident's request for access to his/her medical records or other information no later than thirty days after receipt of such request The HIM and AHIM indicated that they thought they had 30 days to get residents a copy of their medical records. The HIM and AHIM indicated that they were both not aware that the federal regulations specified that the facility had 2 days or 48 hours, to copy and provide a resident with their medical record, once requested. HIM and AHIM confirmed that Resident 1 and Resident 2 had not received a copy of their medical records within 2 days. On 5/1/23 at 3:37 pm, a concurrent interview and record review was conducted with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON). The Policy titled, Protected Health Information (PHI), Residents' Rights Relative to dated March 2014, was reviewed. The DON and ADON confirmed that the facility's policy incorrectly indicated that they had 30 days to provide a resident with a copy of their medical record, instead of 2 days. 555151 Page 2 of 2