Every finding on record at Eprimetec Inc

A re-certification survey was conducted on 07/14/2025 at 1:12PM. The agency’s L&C census was 1. No deficiencies were cited.

A re-certification survey was conducted on 07/14/2025 at 1:12PM. The agency’s L&C census was 1. Abbreviations ADM (Administrator) Alt ADM (Alternate Administrator) ADON (Alternate Director of Nursing) CLIA (Clinical Laboratory Improvement Amendments) CR (Clinical record) DON (Director Nursing) EMR (Electronic Medical Record) EPRP (Emergency Preparedness Response Plan) FM (Family Member) HHA (Home Health Agency) HCSSA (Home and Community Support Services Agency) HHSC (Health and Human Services Commission) IQIES (Internet Quality Improvement and Evaluation System) L&C (Licensed and Certified Home Health Services) MDS (Minimum Data Set) N/T- Alt ADM/ADON (New/Training- Alternate Administrator/ Alternate Director of Nursing) OASIS (Outcome and Assessment Information Set) OBQI (Outcome-Based Quality Improvement) OBQM (Outcome-Based Quality Monitoring) OtS (Other Staff) POC (Plan of Care) RN (Registered Nurse) SN (Skilled Nursing and/or Skilled Nurse) SOC (Start of Care) SR (Surveyor) UL (Unlisted)

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to protect the clinical records - its contents and the patient information contained therein- for 1 of 1 discharged patients (patient #1), from loss or unauthorized use in the office setting in that the agency provided the clinical records of 1 of 1 discharged patients to a potential buyer who did not require the records for the purchase of the agency. This failure resulted in the health and other demographic information of the 1of 1 discharged patients being available to non-agency personnel without the patient's knowledge or consent. Findings Record review of a document entitled, “Letter of Intent to Sell” revealed that the N/T- Alt ADM/ADON mentioned in the letter was not officially associated with the agency. The letter also revealed Agency 2 was located at Address B and that the ADM of Agency 2 was the potential buyer of the agency. During an interview with the ADM/DON on 07/14/2025 at 1:08PM, SR asked for the Bill of Sale and/or Transfer of Stocks (to show the agency had been sold). ADM/DON stated, “I don’t have either, I just have a Letter for Intent to Sell.” During an interview with the ADM/DON on 07/14/2025 at 1:10PM. SR asked the ADM/DON what "the books are not here right now" meant. ADM/DON stated, “All of the agency’s clinical records, and all of the agency’s books like QAPI are not here right now.” SR asked where the patient's records were if not at the agency. The ADM/DON stated, “They are located at [Address B]. It is my mistake, they currently have all the records, so they can review them. I don’t have anything for you to review. The only thing that is here is the license and the CLIA Waiver. Is it possible, if you can come back tomorrow? I will have everything by then.” Surveyor observed a white colored minivan arrive at the agency on 07/14/2025 at 2:30PM. A person was observed bringing all the agency’s discharged clinical records and the agency’s manuals / logs (QAPI, EPRP, Infection Control, Complaints, In-services, etc) into the agency. The ADM/DON stated that all the agency’s clinical and operational records were to be dropped off by [Unlisted Nurse] from Agency 2. Record review of agency’s administrative policy titled, “Medical Record Information Confidentiality” revised date on 08/11/2012, pages 1 to 6, read in part, “Purpose: To ensure the confidentiality, security and integrity of information in accordance with applicable regulations, federal, and state laws. Policy: Agency will ensure that all patient identifiable information in the clinical record, including OASIS data, will remain confidential and will be secured and controlled, whether in hard copy, electronic format or a combination of both in compliance with the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPPA)… Procedure… L. Medical records will be located in areas to avoid unofficial use, access to another unauthorized individuals, or visible to public areas…”