032539 Mesa Dialysis Center (Fmc)

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 52534 Based on document review, and interview, it was determined that the facility failed to ensure the nephrologist completed and signed discharge summaries for 2 of 4 patients (Patients #6 and 7) within 30 days of a patient ’ s discharge as required by state law, which poses the potential risk of a disruption of a continuity of care. Findings include: The Arizona Administrative Code (A.A.C.) requires “...R9-10-1018. Dialysis Services ...L. For a patient who received dialysis services, an administrator shall ensure that after the patient ’ s discharge from an outpatient treatment center that is authorized to provide dialysis services, the nephrologist responsible for the dialysis services provided to the patient documents the patient ’ s discharge in the patient ’ s medical record within 30 calendar days after the patient ’ s discharge and includes: 1. A description of the patient ’ s medical condition and the dialysis services provided to the patient, and 2. The signature of the nephrologist ....” The facility policy titled “Documenting Progress Notes, Transfers, Transplants, Discharges and Order Review” requires “...The nurse or designee will complete the FMS Discharge Assessment in eCC for each discharged patient (permanent and transient) as soon as reasonably possible and within 30 days of a patient being discharged from the facility. The nurse will provide the necessary information to complete the FMS Discharge Assessment. Additional discharge notes will be documented by other disciplines if required by state regulations (ex. AZ)....” The facility policy did not explicitly require the nephrologist to document the patient’s medical condition, dialysis services provided, and the nephrologist’s signature as required by Arizona law. Patient #6 Patient #6 ’ s medical record review on 08/04/2025 revealed a discharge date of 06/18/2025. Patient #6 ’ s discharge summary was signed by the patient ’ s nephrologist but did not have the date the nephrologist signed the document. Patient #7 Patient #7 ’ s medical record review on 08/04/2025 revealed a discharge date of 05/25/2025. Patient #7 ’ s discharge summary was not signed by a nephrologist. Employees #1, 2, and 25 confirmed on 08/05/2025 that Patients #6 and 7 did not have their discharge summaries signed by their nephrologist within 30 days from their discharge, as required by state law.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure common supply carts and shelving units used to store clean dialysis supplies and equipment were placed sufficient distance from patients receiving dialysis treatment to prevent contamination which has the potential risk of increased infection for patients from cross contamination. Findings include: The facility policy titled “Storage of Supplies” requires: “ ...All supplies must be stored in a clean ...environment ...Sterile supplies must be stored above clean supplies ....” The facility policy titled “Acid Concentrate Storage and Handling” requires: “ ...store in a covered container labeled: ‘Clean Wand’ ....” The facility policy titled “General Cleanliness and Infection Control Guidelines” requires: “ ...Walkways must be kept clear of debris and free of clutter ...Fans or air purifiers may not be used in treatment areas. (ex floor fans, box fans, individual portable fans) ....” Observation on 08/05/2025 revealed two (2) portable glove box poles that contained three boxes of clean gloves each in the middle of the treatment floor placed immediately adjacent to an open biohazard waste bin, three (3) glove box poles that contained three boxes of clean gloves each placed between the dialysis machines at stations #5/6, 9/10, and 11/12. The three-box dispenser between the dialysis machines at #5/6 were inches from the dialyzer on station #5 and the dirty sharps container on station #6. The three-box dispenser and boxes of gloves were touching the dialyzer of the patient at station #11. The boxes of gloves were 3 inches from the dialyzer at station #9, and touching the side of the sharp’s container at station #10. Observation on 08/05/2025, revealed metal wire shelving in the middle of the treatment area between stations #1-4 and #5-8. The wire shelving bottom shelf contained an open bin with sterile saline flushes; an open bin with a box of open transducer protectors, sterile fistula needles, emesis basins, oxygen tubing, pH test strips, a single sterile syringe needle, and a blood pressure cuff; and a third bin with chux pads, 10 mL syringes, and recirculation connectors. The middle shelf contained an open bin with torn open packages of 2x2 gauze exposed without protection from contamination and exposed rolls of paper tape; another bin with loose tourniquets; and two bins of catheter supplies. The top shelf contained packages of bloodlines and dialyzers. Sterile and non-sterile supplies were mixed on the shelves without regard for placing sterile items above non-sterile supplies along with the blood pressure cuff and test strips. The dialysis chair at station #3 was less than 2 feet from the metal shelving and open, unprotected patient supplies. The patient’s feet were hanging over the end of the foot rest on the chair and were within 18 inches of touching the patient supplies. Observation on 08/05/2025, revealed two (2) three shelf utility carts on the treatment floor. One cart contained bleach solution containers (1:10 and 1:100 concentration) on the top shelf of cart #1; the second shelf contained open, unlidded basins with exposed hemostat clamps and fistula clamps, a bottle of blood leak test strips, a 100 ml specimen cup, two dry erase markers, and soiled under pads; the bottom shelf contained two jugs bleach concentrate, a urine collection container, a dry “magic eraser” cleaning pad, and soiled wet under pads. The cart also contained vinegar solution in a spray bottle on the top shelf with the bleach solution. Cart #2 contained open bins of hemostat and fistula clamps on the middle shelf between a bottom shelf with a gallon of bleach concentrate and urine specimen jug, and the top shelf containing 1:10 and 1:100 bleach solution. Observation on 08/05/2025, revealed acid concentrate wands on a utility cart in an uncovered bin. Observation on 08/05/2025, revealed two (2) personal size (approximately 4-6-inch diameter) portable fans on the treatment floor. One fan was clipped to the metal patient supply shelving unit and the other attached to the PCT workstation next to the patient supply shelf unit. Employees #2 and 25 confirmed on 08/05/2025 that disposable and clean reusable supplies and equipment used for patient treatment were not placed at a sufficient distance to prevent contamination from patients receiving dialysis treatment at the facility. Additionally, they confirmed that clean equipment was not stored in a manner off the dirty bleach cart to prevent contamination, and that fans in use in the treatment area had the potential to contaminate items stored in the same area.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff discarded biohazardous medical waste appropriately which has the potential for spread of infection through poor infection control practices. Findings include: The facility policy titled “General Cleanliness and Infection Control Guidelines” requires: “ ...Regulated waste shall be placed in containers which are: Closable ....” Observation on 08/05/2025, revealed a large, square biohazard waste bin on a wheeled trolly in the middle of the treatment floor. The waste bin had a detachable lid which did not cover the opening of the bin. The cover was placed sideways and at an angle which provided physical and visual access to the exposed contents of the bin. Bloody discarded bloodlines were hanging over the side of the bin and touching the floor. Additionally, the open bin with bloody waste hanging over the side of the bin was stored immediately adjacent to two portable glove box poles that contained three boxes of clean gloves each. Employee #2 confirmed on 08/05/2025, that staff did not ensure bloody used bloodlines were not placed inside the biohazard bin and the lid closed to prevent access or accidents involving biohazardous medical waste as required. Additionally, that boxes of clean, disposable exam gloves were stored immediately adjacent to the open bin.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff label three (3) open 1-gallon jugs of Naturalyte acid concentrate solution or discard unlabeled and open jugs which has the potential risk of patients receiving contaminated supplies during treatment. Findings include: The facility policy titled “Acid Concentrate Storage and Handling” requires: “...Concentrating Container Labeling....will occur when...1-gallon: ...if unused acid will be stored for further use, record the date and time it was opened and the initials of the staff member that opened the container...Post treatment...If concentrate will be stored for future use...Open, labeled concentrate must be stored separately on a properly labeled location...Do not return the opened acid to the same shelf as the unopened acid concentrate...If not able to meet requirements, acid concentrate must be discarded after treatment....” Observation on 08/04/2025, revealed a utility cart on the treatment floor that contained seven (7) unopened 1-gallon jugs of 2.0 K, 3.0 Ca acid concentrate, one (1) open, uncapped 1-gallon jug 2.0 K, 3.0 Ca acid concentrate, one (1) used, mostly empty 1-gallon jug 3.0 K, 3.0 Ca acid concentrate with red wand attached on the top shelf of the utility cart. The bottom shelf contained one (1) unopened 1-gallon jug 3. K, 3.0 Ca acid concentrate and one (1) used, mostly empty 1-gallon jug 2.0 K, 2.0 Ca acid concentrate with red wand attached. Employees #2 and 8 confirmed on 08/04/2025, that three (3) open, used 1-gallon acid concentrate jugs had been returned to a clean acid concentrate cart after use without being labeled upon opening the jugs. Additionally, they confirmed that different concentrates were mixed together on the two shelves of the cart in regards to prescription composition in addition to open unlabeled and unused containers.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 37489 Based on document review, observation, and an interview, it was determined that the facility failed to ensure staff separated chemicals with the potential to be harmful if combined which poses a potential risk of caustic vapors to harm patients in the event of accidental mixing of the chemicals. Findings include The policy titled “Storage of Supplies” requires: “ ...Bleach and vinegar should not be stored next to each other to minimize the potential for reaction leading to harmful vapors in the case of accidental breakage or spills ....” Observation on 08/05/2025 revealed a 1-quart spray bottle containing vinegar stored on a shelf with two (2) containers of bleach solution and a 1-gallon container of bleach concentrate on a utility cart on the treatment floor. Employee #13 confirmed on 08/05/2025, that vinegar, bleach solution, and bleach concentrate were stored together on a utility cart on the treatment floor.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 52534 Based on document review and interview, it was determined that the facility failed to ensure (4) of (5) patients (Patients #1, 2, 3, and 5) received hemodialysis treatment as prescribed by their nephrologist. This deficient practice poses the potential risk of inadequate dialysis, decreased clearances, and increased hospitalizations if hemodialysis treatments are not given as prescribed. Findings include: The facility policy titled “Patient Assessment and Monitoring” requires “...Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered ....Document any findings and interventions in the medical record ....” Patient #1 Patient #1 ’ s medical record review on 08/05/2025 revealed a prescribed Blood Flow Rate (BFR) of 400 mL/min and a prescribed Dialysate Flow Rate (DFR) of 800 mL/min. The following dialysis treatments were not delivered as prescribed: 07/28/2025 - the BFR was set to 400 mL/min at 16:41, changed to 320 mL/min at 17:08, and changed to 300 mL/min at 19:02 for the remainder of the treatment 07/25/2025 - the BFR was set to 400 mL/min at 16:05 and changed to 300 mL/min at 16:22 for the remainder of the treatment 07/23/2025 - the DFR was set to 500 mL/min for the entirety of the treatment, the BFR was set to 400 mL/min at 16:02 and changed to 350 mL/min at 16:22 for the remainder of the treatment 07/21/2025 - the BFR was set to 350 mL/min from 16:02 to 16:40 No documentation or rationale for the changes in the BFR or DFR were found in the treatment records. Patient #2 Patient #2 ’ s medical record review on 08/05/2025 revealed a prescribed BFR of 400 mL/min. The following treatments were not delivered as prescribed: 07/24/2025 - the BFR was set to 400 mL/min at 11:25 and changed to 350 mL/min at 11:44 for the remainder of the treatment 07/22/2025 - the BFR was set to 400 mL/min at 11:19 and changed to 350 mL/min at 11:23 for the remainder of the treatment No documentation or rationale for the changes in the BFR were found in the treatment records. Patient #3 Patient #3 ’ s medical record review on 08/05/2025 revealed a prescribed BFR of 450 mL/min. The following treatments were not delivered as prescribed: 07/26/2025 - the BFR was changed from 400 mL/min to 450 mL/min at 06:11 07/24/2025 – the BFR was changed from 450 mL/min to 400 mL/min at 07:05 for the remainder of the treatment No documentation or rationale for the changes in the BFR were found in the treatment records. Patient #5 Patient #5 ’ s medical record review on 08/05/2025 revealed a prescribed BFR of 350 mL/min and a prescribed DFR of 700 mL/min. The following treatments were not delivered as prescribed: 08/02/2025 - the BFR was set at 300 mL/min at 11:56 and was changed to 350 mL/min at 13:21. the DFR was set to 800 mL/min for the entirety of the treatment 07/31/2025 - the DFR was set to 800 mL/min for the entirety of the treatment 07/28/2025 - the DFR was set to 800 mL/min for the entirety of the treatment No documentation or rationale for the changes in the BFR or DFR were found in the treatment records. Employees #2 confirmed on 08/05/2025 that Patients #1, 2, 3 and 5 did not receive their hemodialysis treatments as prescribed by their nephrologist.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 37489 Based on document review and interview, it was determined that the facility failed to ensure the registered nurse (RN) assessed Patient #4 with abnormal blood pressure and heart rate and reported findings to the patient’s provider prior to dialysis treatment which poses a potential risk of adverse outcomes including increased risk of mortality. Findings include: The facility policy titled “Assessment and Monitoring” requires: “ ...The Registered Nurse will assess/reassess any findings addressed pre or during treatment as needed ...Pre-Treatment ...Record blood pressure. Verify: ...Systolic blood pressures less than or equal to 100 mm/hg systolic during treatment. Record pulse. Verify pulses manually if automated readings display below 60 or greater than 100 beats per minute ... ...During treatment ...Document any findings and interventions in the medical record ....” Patient #4’s medical record contained the following document titled “CMAB Recommended Acute Kidney Injury Requiring Dialysis (AKI-D) Management Algorithm Version 1.0” requires: “ ...This algorithm is only for patients with Acute Kidney Injury (AKI-D) ...At various steps in the Algorithm consultation may be required with the Physician/NP/PA. All consultations must be documented in the patient record ...5. Volume Management ...The RN will notify physician of systolic blood pressure (SBP) per the AKI Order Set: Patient Management ...If the patient present with a pre-treatment sitting SBP less than 110 mmHg ...Then Assess patient for any of the following: Decrease in interdialytic wight gain, Increase in self-reported urine output, Acute/transient fluid loss, e.g. diarrhea and vomiting, New or change in dose of current medications including: diuretics and blood pressure medications ...Review above assessment with physician/NP/PA and obtain orders for any change in dialysis treatment prescription or follow up laboratory testing ...Patient experiences intradialytic SBP < (less than) 100 mmHg or symptoms of intolerance of UFR ...Review patient fluid assessment with physician/NP/PA and obtain orders for any changes in the dialysis prescription as indicated ....” Patient #4 The treatment sheet dated 07/19/2025 revealed the following. 1427 Pre-Treatment blood pressure (BP) 76/46 1427 Pre-Treatment pulse (HR) 144 1453 RN Pre-Treatment nursing assessment revealed: “ ...Cardiovascular-History of Tachycardia ...Cardiovascular-Physical Exam ...Heart Rate ...Regular ....” 1501 Nursing Evaluation: “ ...Pt verified at 1435. Bath and dialyzer verified. CVC site with no s/s of infection. Pt denied any GI symptoms ...A&Ox4 ...Pt stable for tx initiation ...Pulse Rhythm - regular ....” 1607 BP 83/39 HR 104 1625 BP 94/44 1747 BP 99/50 1857 BP 99/51 1905 BP 93/51 1914 Post-Treatment BP 103/51 HR 100 2037 RN Post-treatment nursing assessment: “ ...pulse - Rhythm ...Regular ...Tx tolerated ....” The treatment sheet revealed that the Registered Nurse did not follow the AKI algorithm for volume management as ordered by the nephrologist; nor did the RN recognize, assess, address, or consult with the medical practitioner for the patient’s pre-treatment tachycardia and hypotension, intradialytic hypotension, or post-treatment tachycardia. The Medical Director confirmed on 08/05/2025 that the Registered Nurse failed to recognize and assess hypotension and tachycardia in Patient #4 and therefore, ultimately failed to report the findings to the medical practitioner for consultation and appropriate intervention.”

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 45999 Based on document review, observation, and staff interview, the Department determined that the facility failed to ensure staff appropriately disinfected (1) of (2) patient’s (Patient #8) vascular access prior to cannulation with fistula needles; prior to initiation of treatment. Failure to perform vascular access cannulation, and adherence to established infection control practices for hand hygiene pose a potential risk for increased infections, sepsis, and adverse outcomes for dialysis patients. Findings include: 1. The facility policy titled “Access Assessment and Cannulation” requires: “...Skin Disinfection...Disinfect the cannulation site as follows using any of the disinfectants below: 70% isopropyl alcohol pad...clean the access site...for 30 seconds and allow it to dry before cannulation...Perform skin antisepsis on one site at a time, allow to dry and them (sic) cannulate. Do not touch cannulation sites after skin disinfection. Note: This method minimizes the risk of contaminating the second site while cannulating the first site....” Observation on September 3, 2024 revealed Employee #16 performing the cannulation procedure for Patient #8’s arteriovenous graft. Employee #16 used an isopropyl alcohol pad to apply the disinfectant for 21 seconds to the arterial cannulation site then immediately used a second disinfectant pad to apply disinfectant to the venous cannulation site for 23 seconds. Employee #1 confirmed during an interview on August 29, 2024, that Employee #16 did not follow facility policy and procedure for access cannulation.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 45999 Based on a review of facility policy and procedures, observation, and staff interview, the Department determined that the facility failed to ensure that supplies and medications had not expired, which poses the potential risk of loss of efficacy of medication, decreased sterility of supplies and delayed care if not immediately available. Findings include: Facility policy, “Storage of Supplies” revealed: “...Appropriately dispose of items that have reached the expiration date....”. During an observation on September 3, 2024, the following expired items were discovered: 11- Wingeater 15g needle set, expired 5-15-2024 1-Master guard plus 17g needle set expired, 6-30-2024 12-0.9 Sodium Chloride 1000ml expired, August 2024 Employee #1 confirmed during an interview on August 12, 2024, that supplies were not disposed of, and/or stored as required per facility policy and regulation.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 37489 Based on document review and interview, it was determined that the facility failed to provide a complete copy of Patient #1’s medical record upon request which has the potential risk of violating patient rights and impeding the continuity of care. Findings include: Patient #1’s medical record revealed that the patient was admitted to the facility on [11/08/2022] and admission paperwork and consent to treat was signed by the patient’s court appointed guardian on the same date. Additionally, the medical record contained copies of “SUPERIOR COURT OF ARIZONA, MARICOPA COUNTY, Letters of Appointment as Permanent Guardian of and Adult and Acceptance of Letters” dated [08/03/2021]. The letters revealed that Guardian #1 was appointed until further order of the court as the guardian of the incapacitated adult, Patient #1 without any restrictions to the appointment. The medical record also contained two “AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION” (Release of Information, ROI) forms filled out and signed by Guardian #1 on [05/12/2023 and 05/25/2023]. The guardian requested the facility provide the entire medical record for personal reasons. The facility policy titled “Employee, Medical Professional and Patient Access to patient Medical Records, 05/01/2023” requires: “...Patient Access to Medical Record...The patient or authorized legal representative also, generally, has the right to access (view the physical record and/or obtain a copy of) the patient’s medical record upon request. Exceptions include: 1. A licensed health care professional has determined that providing the access is reasonably likely to endanger the life or physical safety of the patient or another person. 2. FMCNA obtained the requested information from someone other that a health care provider under a promise of confidentiality and the access would be reasonably likely to reveal the source of the information. 3. An inmate of a correctional institution makes a request, FMCNA is action under the direction of a correctional institution, and the inmate’s request would jeopardize the health, safety, security, custody, or rehabilitation of the Inmates or the safety of any officer, employee or other person at the institution. 4. FMCNA obtained the information in the course of research that is in progress; the individual has agreed to the denial of as part of the informed consent process; and FMCNA has informed the individual that the right of access will be reinstated upon completion of the research. Any potential denial of records to a patient or personal representative must be reviewed by the Privacy Office....” The facility document titled “Fresenius Medical Care, Guide to Responding to Requests for Medical & Billing Records, COR-ISO-044” requires: “...FMCNA facilities may produce medial or billing records in response to the following without review or approval from a Corporate Function: ...Signed by the Personal Representative of an Incapacitated Patient...If the patient has been deemed incapacitated by a physician, verify that the Health Care Power of Attorney, Health Care Proxy or court-appointed Guardianship empowers the requestor to access medical information and is filed in the medical records. The legally authorized personal representative stands in the shoes of the incapacitated patient and may sign the HIPAA authorization or Request for Access form. Provide the records to the designated recipient as soon as possible or in no more than 30 days of receiving the written request....” Employee #1 and 4 confirmed on 01/10/2024 that Patient #1’s complete medical records were not provided to the patient’s guardian. Additionally, Employees #1 and 3 confirmed on 01/10/2024 that the medical record did not contain documentation to support why the complete medical record was not provided to Patient #1’s guardian upon two requests for the release of medical records and determined that there was no reason to potentially deny the request.”