Spectrum Dialysis

“CFC-MEDICAL RECORDS CFR(s): 494.170 This Condition is not met as evidenced by: 51860 Based on observation, interview, and record review, the facility failed to ensure Patient 1’s beneficiary received requested medical records in a timely manner. The failure resulted in Patient 1’s beneficiary’s not being able to move forward in matters related to Patient 1’s death. Findings: During an interview on 7/15/25 at 2:40 p.m. with complainant Legal Assistant (LA) 1, LA 1 stated there had been a total of eight requests between 6/03/25 and 7/11/25 on Patient 1’s beneficiary’s behalf to obtain the medical records for the deceased Patient 1. During a record review of ‘State of California Certification of Vital Records, Conty of Los Angeles, Department of Public Health, Certificate of Death’, the Certificate of Death indicated Patient 1 expired on 11/26/24. Certificate of Death provided by LA 1. During a record review of Declaration of [Patient 1’s brother’s name] (As Successor in Interest to Patient 1), the Declaration indicates Patient 1’s brother states he is the Decedent’s Successor in Interest. Declaration provided by LA 1. During a record review of the letter an electronic mail (e-mail) thread for the dates of 6/05/25 to 7/11/25, the e-mail history indicates eight communications were sent to facility, six e-mails to Admissions Coordinator for Spectrum (ACS) and two letters sent to facility. During a review of Patient 1’s History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 4/17/24, the H&P indicates Patient was has a past medical history of the following but not limited to: hypertension (high blood pressure), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy coronary artery disease (a condition that negatively impacts the heart and blood vessels) with a heart angioplasty (a medical procedure that involves widening narrowed or blocked blood vessels) and a stent (a small, expandable tube made of metal or plastic mesh that is inserted into an artery to keep it open) placement, ESRD (End Stage Renal Disease - irreversible kidney damage) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). The H&P indicates Patient 1 receives home hemodialysis three times a week. During a review of Patient 1’s Home Hemodialysis (HHD) Treatment Flowsheet from his last hemodialysis treatment dated 11/26/24, the HHD Treatment Flowsheet indicates there were no complications noted during the hemodialysis treatment. During an interview on 7/17/24 at 1:30 p.m. with the Interim Facility Administrator (IFA), IFA stated the following: - Requests for copies of the medical record would be received by staff members and then forwarded the Vice President of Operations (VPO). - IFA stated Patient 1 would need to have signed release of information with the beneficiary’s name for the release of records process to begin. - IFA stated the release with beneficiary’s name would need to be signed while the patient was alive. - IFA stated a release of records would need to be signed and the request would be given to the VPO. - IFA states if after a patient expires and it turns out they (patient) has a Power of Attorney (POA) that is not mentioned on the admission forms, they (POA designee) are not given medical records. - IFA states the facility would need to see a POA before patient expires to release records after patient expires. - IFA states it would be the attending physician or the VPO who would decide to release records or not after patient expires and a POA is presented. During an interview on 7/17/24 at 1:40 p.m. with IFA, the IFA was provided with complainant’s documented request for medical records dated: 6/03/25, 6/05/25, 6/06/25, 6/10/25, 6/20/25, 6/27/25, 7/02/25, 7/07/25, and 7/11/25, along with a death certificate and a Successor in Interest document. IFA was shown the facility’s phone number which is to a call center. IFA was shown name of person who received mail and e-mail correspondence and stated ACS is the Admissions Coordinator. IFA stated there were too many requests for records and it was unfortunate situation was not resolved promptly. IFA stated would attempt to facilitate release of medical records promptly. During a review of the facility’s Privacy Notice, Uses and Disclosures of Health Information dated 7/10/24 and signed by Patient 1 7/10/24, the Privacy Notice indicates the following: - Your Rights: The health record is the physical property of the unit that compiled it. The information belongs to you. YOU HAVE THE RIGHT TO: “ Inspect and copy your health record as provided for in 45 CFR 164.528. “ The facility is responsible to: - Maintain the privacy of your health information, to use and disclose information only with your consent or authorization, unless there are exceptions described in this notice or otherwise allowed by related laws, rule, and regulations. “ Notify you if we are unable to agree to requested restrictions/s. - Report a problem - or if you have a question, or desire additional information, you may contact the Clinical Nurse Manager at: (818) 341 -XXXX or if you are not satisfied, contact: Security Officer - ACS 1. During a concurrent interview and record review on 7/17/25 at 1:45 p.m. with Interim Facility Administrator (IFA), the facility’s policy and procedure (P&P) titled, Patient Medical Records, adopted 7/31/24 was reviewed. The P&P indicated: - The facility maintains complete medical records on all patients in accordance with accepted professional standards, practices and state regulations. - Facility Administrator will serve as supervisor of medical records services and will ensure that all records are properly documented, completed, protected, and preserved. - Requests by patients to review their record will be referred to the attending physician. If the patient/responsible party wished to obtain a copy of their medical records, the VPO will be notified for guidance and approval. - Written consent of the patient, or of an authorized representative acting on behalf of the patient is required for the release of information.”