Every finding on record at Titan Health Services LLC

Purpose of Visit: Recertification and Relicensure Survey An entrance conference was conducted on 7/25/23 at 1:00 p.m., with the Administrator and the Alternate Administrator/Supervising Nurse. Agency Census: Licensed and Certified Home Health Services – 0 Licensed Home Health Services – 0 Personal Assistance Services – 0 An exit conference was conducted on 8/2/23 at 5:37 p.m., with the Administrator and the Alternate Administrator/Supervising Nurse. The agency staff was informed of the preliminary findings. The Administrator and the Alternate Administrator/Supervising Nurse were afforded the opportunity to provide additional information throughout the survey. The agency was in compliance with federal and state requirements. No deficiencies/violations are cited.

Purpose of Visit: Recertification and Relicensure Survey An entrance conference was conducted on 7/25/23 at 1:00 p.m., with the Administrator and the Alternate Administrator/Supervising Nurse. Agency Census: Licensed and Certified Home Health Services – 0 Licensed Home Health Services – 0 Personal Assistance Services – 0 An exit conference was conducted on 8/2/23 at 5:37 p.m., with the Administrator and the Alternate Administrator/Supervising Nurse. The agency staff was informed of the preliminary findings. The Administrator and the Alternate Administrator/Supervising Nurse were afforded the opportunity to provide additional information throughout the survey. Written instructions were provided for submitting a plan of correction within 10 calendar days of receipt of the statement of deficiencies/ licensing violations. The Administrator and the Alternate Administrator/Supervising Nurse were informed that the agency was out of compliance with the Medicare Conditions of Participation. The agency was out of compliance with the following Medicare Conditions of Participation: 42 CFR Part 484.110 Clinical Records

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to establish and maintain a client record system to ensure that the care and services provided to each client are completely and accurately documented, readily accessible and systematically organized to facilitate the compilation and retrieval of information, in that: the Administrator/Owner did not provide access to the surveyor until 6 days after the request for access to the electronic records to conduct record reviews for seven of seven discharged clients (#1, #2, #3, #4, #5, #6, and #7) who the agency had provided care and services to. Failure to provide the surveyor access to records for review placed the agency out of compliance for current clinical standards of practice, caused a delay in the survey process and prevented the surveyor from reviewing records to validate and confirm that care/services was provided in accordance with the plan of care. This failure could also affect the agency’s future clients. [Refer to G-1026] Based on record review and interview, the agency failed to establish and maintain a client record system to ensure that the care and services provided to each client are completely and accurately documented, readily accessible and systematically organized to facilitate the compilation and retrieval of information, in that: the Administrator/Owner did not provide access to the surveyor until 6 days after the request for access to the electronic records to conduct record reviews for seven of seven discharged clients (#1, #2, #3, #4, #5, #6, and #7) who the agency had provided care and services to. Failure to provide the surveyor access to records for review placed the agency out of compliance for current clinical standards of practice, caused a delay in the survey process and prevented the surveyor from reviewing records to validate and confirm that care/services was provided in accordance with the plan of care. This failure could also affect the agency’s future clients. [Refer to G-1030] The findings included: During the entrance conference on 07/25/23 at 1:00 p.m., the Administrator/Owner stated that the clinical records were electronic. He further stated that he had zero patient census and could only access discharged client records as needed upon request by Social Security, for legal litigations, and for state surveys. The Administrator/Owner stated that the contracted software company was usually pretty good about cooperating and providing access to the clinical records would contact the contracted software company to inform that the State Surveyor was here to conduct a recertification survey and needed a password to access and review the clinical records. During an interview on 7/26/23 at 11:20 a.m., the Administrator/Owner stated that he contacted the support staff from the contracted software company and was told that it would take 24-48 hours for access to the clinical records, but due to the circumstances [State Survey] would escalate the process to provide access to the clinical records as a “read-only.” The Administrator/Owner stated that the Support Staff from the contracted software company stated only one person per agency could have access to review the electronic clinical records. The Administrator/Owner stated that this often occurred, and that he [Administrator/Owner] would give that access to this Surveyor. The Surveyor asked if documents such as the plan of care (POC), physician’s orders and medication profiles could be printed since these were “read only” and further stated that these were required as part of the patient clinical record review. The Administrator/Owner stated that he was not sure if he would be able to print documents. On 7/26/23 at 12:00 noon, the surveyor asked the Administrator/Owner if he had heard anything from the contracted software company regarding access to the electronic clinical records. The Administrator/Owner stated that he had not heard from the company and their response was still pending. On 07/26/23 at 1:55 p.m., the Administrator/Owner stated that he went to a local printing company to print documents and to send request to the contracted software company regarding the status of access for the State Surveyor to review the electronic clinical records, because he was having issues with the internet at the agency. He further stated that the request for surveyor “read only” access was still pending and would see tomorrow. On 7/26/23 at 3:45 p.m., the Surveyor requested a copy of the agency’s contract with the electronic medical records software company. The Administrator/Owner stated that the contracts were not at the agency and would have to go to his storage to retrieve those documents. On 07/27/23 at 10:43 a.m., the Surveyor made follow-up call to the Administrator/Owner regarding the status of access for record review of the electronic medical records with the contracted software company. There was no answer to the call, the Surveyor left a message on voicemail with Surveyor’s contact information and purpose of the call. On 07/27/23 at 11:30 a.m., the Surveyor made another follow-up call to inquire about status of access to review electronic medical records. The Alternate Administrator/Supervising Nurse answered and stated that the Administrator/Owner had just stepped out and should return between one to two hours. She further stated that she was not sure about the status of the access to the electronic clinical records, and that the Surveyor would have to call back within one to two hours to speak with the Administrator/Owner. On 07/27/23 at 1:40 p.m., the Surveyor made another follow-up call to inquire about status of access to review electronic medical records. The Alternate Administrator/Supervising Nurse answered and stated that Administrator/Owner had not returned, and she still had not heard anything regarding status of access to review the electronic medical records. During an interview on 07/27/23 at 2:21 p.m., the Administrator/Owner stated that he still did not have access to the electronic medical records and that he still had not heard from the contracted company. He stated that he had gone up the chain and was told by the support staff that he was placed on a wait list for access to review the electronic medical records. He stated that he explained that he was currently be surveyed by the State for recertification survey, that he needed to speak to a manager who could escalate the process. He stated that he would call back this Surveyor as soon as he heard back from the contracted electronic medical records company. 07/27/23 at 3:09 p.m., the Surveyor made another follow-up call to the agency regarding the status of access for record review of the electronic medical records with the contracted software company. The Surveyor spoke with the Alternate Administrator/Supervising Nurse, who informed the Surveyor that they still had not heard back from the contracted electronic medical record company and there was still no access for the Surveyor to review the clinical records. During this same interview, the Surveyor provided the Alternate Administrator/Supervising Nurse with the PM of Region 8’s contact information just in case it was needed to help escalate Surveyor access to the electronic medical records. On 07/28/23 at 9:45 a.m., the Surveyor made another follow-up call to the agency regarding the status of access to review electronic medical records. The Alternate Administrator/Supervising Nurse answered and stated that they still have not heard anything from the contracted electronic medical record company and that the Administrator/Owner had sent an email at 8:00 a.m., to them [contracted EMR]. The Surveyor informed the Alternate Administrator/Supervising Nurse that she would arrive at the agency about 12:00 noon. During an interview on 07/28/23 at 12:15 p.m., the Administrator/Owner stated that he still had not heard from the EMR company. That he had paid up to July 2022 (exact date unknown) when his last patient was discharged. He stated that he had spoken to a representative from the support staff of the contracted EMR company and was told that there’s a wait list for “read only” access to review records. The Administrator/Owner stated that he should not be held accountable and be cited for something not within his control due to a third-party contract agency. The Surveyor noted that the Administrator/Owner was upset that his tone of voice escalated and became hostile. The Surveyor stated that the Region 8 PM would be contacted to discuss the issues of being placed on wait list for “read only” access. During a telephonic conference on 7/28/23 at approximately 2:00 p.m., with the Region 8 PM (R8PM), the Administrator/Owner, the Alternate Administrator/Supervising Nurse, the Administrator/Owner stated that he had been back/fourth with the EMR company regarding getting the Surveyor access to the EMR, still not sure when “read only” access will be available. He stated that he expressed the urgency of the matter, that a State Surveyor was at the agency. He stated that his case had been escalated but that there is no specific time given when access would be granted to the Surveyor for “read only” access for record review. The R8PM informed the Administrator/Owner that the Surveyor will return to continue the survey on Monday 07/31/23. The Surveyor also requested a copy of the agency's contract with the electronic medical record company. On 7/31/23 at 12:52 p.m., another follow-up call was made, the Alternate Administrator/Supervising Nurse stated the Administrator/Owner had still not heard from the Contracted EMR company and had sent an e-mail to the company with no response. The Surveyor requested a copy of the e-mail and requested copies of the agencies policies and procedures regarding clinical records, responsibilities of the administrator and a copy of the contract with the EMR company. On 08/01/23 at 12:37 p.m., the Surveyor informed the Administrator/Owner and the Alternate Administrator/Supervising Nurse that the agency was now in an extended survey, due to not having access to review records to verify visits. The Administrator/Owner became very upset and turned to the Alternate Administrator and asked, “Did the Surveyor tell you that we were going into an extended survey?” The Surveyor then stated, “I just now called the extended survey and informed both of you.” The Administrator/Owner responded, “I am speaking to my Alternate Administrator, why are you getting so defensive?” The Surveyor noted that the demeanor of the Administrator/Owner was becoming more hostile/agitated. On 08/01/23 at 1:07 p.m., during the telephonic conference, the Administrator/Owner stated that he would not allow the Surveyor to do an extended survey, that the Surveyor was very unprofessional and disrespectful, and that this was not his fault, and he should not be held responsible for a third-party company. The R8PM stated that we could not keep a survey open indefinitely…that there’s a process…that generally surveys were conducted between three-four days. The R8PM stated that we requested access to review the electronic medical records on the day of entrance and according to the regulations once the request had been made for access to clinical records, the agency had eight hours to provide access. The Administrator/Owner became agitated to the point of belligerence i.e., banging his fingers on the table which was tilted and supported by textbooks. At which point the Surveyor had to pick up the phone and slide it back up on the table so that it did not slide off the glass table. The Administrator/Owner stated asked if she [R8PM] had heard from the agency’s EMR company and/or if she tried to contact the EMR company. The R8PM responded, “We do not contact any company contracted by the agencies…That is a contract made between the agency and that company.” The R8PM then asked the Administrator/Owner, “what exactly do you want us to do?” The Administrator/Owner further stated, “give me another day, I will go up to Austin and get access to the electronic medical records.” The R8PM stated, that she would give the Administrator/Owner another day, but the Surveyor would return on Tuesday 08/02/23 to do the exit conference.” The Administrator/Owner got up from the table and left the agency. On 08/01/23 at 5:01 p.m., this Surveyor received an email from the Health and Human Services Administrative Assistant II with the user id/password for access to the agency's electronic clinical records. However, the Administrator wasn’t sure if one of the characters in the password was an O or a zero and advised the surveyor to try both. On 08/02/23 at 8:32 a.m., the R8PM was notified that the user id/password provided by the Administrator/Owner did not work and provided a snip image of the message which read as follows: “You have entered an invalid username or password…If you are unable to login, please contact your administrator.” On 08/02/23 at 9:51 a.m., the R8PM forwarded an email from the Administrator/Owner that read, “please allow them to reset. After the first log in it states that you need to change your password. The temporary password expires after your first attempt. I will send it to you as I get it. Please sign in and change the password.” On 08/02/23 at 9:55 a.m., the R8PM forwarded an email from the Administrator/Owner that was forwarded from the EMR company with a password reset and instructions on how to change temporary password once logged in. However, this did not work, and the surveyor received the same message of invalid user id/password. On 08/02/23 at 10:51 a.m., the R8PM sent an email to the Administrator/Owner to inform that the Surveyor was still not able to access the electronic clinical records and that the Surveyors (#1 and #2) would meet the Administrator/Owner at the agency at between 12:00 noon and 12:30 p.m., so he could assist in getting access into the electronic medical records. On 08/02/23 at 12:30 p.m., the Surveyors (#1 and #2) arrived at the agency. Surveyor #2 was introduced to the Administrator/Owner and the Alternate Administrator/Supervising Nurse and gave the Administrator/Owner her business card. During an interview on 12:30 p.m., at 08/02/23 Surveyor #2 discussed the accessibility to clinical records with the Administrator/Owner and the difficulty/confusion with the ability to log-in into the system for review of clinical records. The Administrator/owner stated, “only one person can log in at the same time because, he was no longer contracted with EMR company.” Surveyor #2 asked the Administrator about their back-up system and if there was one in place for readily accessible records. The Administrator stated, “that was his backup system.” The Administrator/owner was asked if he would like to provide the Lead Surveyor (#1) with his access into the EMR using his [Administrator/Owner] log in ID so she may review the records or would he like to print all seven clinical records for the surveyors to review? The Administrator/Owner stated, he "would like to print all the charts, grabbed several reams of paper and said he would be back.” The Administrator/Owner stated, “I’m happy to print everything out…Yes, I’m okay with that…I have to go to a place to print…be right back”. The Lead Surveyor (#1) stated, “that’s fine” and the Administrator/Owner left the agency. On 08/02/23 at 2:13 p.m., 2:30 p.m., and 3:00 p.m., Surveyor #2 asked the Alternate Administrator/Supervising Nurse if she heard from the Administrator/Owner and/or if she knew when he would be back. The Alternate Administrator stated that she still had not heard anything from him, that she had no idea where he went and added that he could have gone to the local supermarket. She stated she did not have access to the clinical records and that the agency no longer has a contract with that electronic clinical record company. She stated that the Administrator, probably called the EMR company to request access. She stated she does not know how he printing...and that he must have access…” At 3:07 p.m., the Administrator/Owner was contacted by Surveyor #2. He stated he was still printing and almost done. He stated about 20 minutes and would return to the agency with the seven clinical records for the Surveyors (#1 and #2) to review. At 3:19 p.m., Surveyor (#2) received a text message from the Administrator/Owner indicating the following: FYI, [Surveyor #2’s first name] the print que has several charts to print so it might be longer than 30 mins. In case, you guys want to eat something for lunch I will keep you posted.” I [Surveyor #2] responded, “We will wait for you to return…Thank you.” The Administrator/Owner sent a 2nd text message…” You may also have access that I obtained for you. I will not have enough paper I’ve used 4 trams (reams). Go to the [EMR company name].com…User ID: Surveyor. [agency name] …Password: Password1$...please try getting in…let me know I will have to go buy more paper at [name of local office supplier]…Please call me for instructions on getting in…” On 08/02/23 at 3:26 p.m., Surveyor #2 notified the R8PM that the Administrator/Owner had given the Surveyors access to the electronic clinical records and that Surveyor #1 now able to log in and review the clinical records. Surveyor #2 contacted the Administrator/Owner and informed that the Surveyors were able to access the electronic clinical records and the exit conference would be at 4:30 p.m. The Administrator/Owner responded, "Okay, I'll be there." During an interview on 08/02/23 at 4:15 p.m., Surveyor #2 asked the Administrator/Owner, "do part of your duties as an Administrator include effective management of the day-to-day operations of the agency? The Administrator/Owner stated, “yes…Access to records has always been available to me. I have my own access, on Tuesday, I requested access for surveyor #1, sent in email asking for user ID. I gave her [Surveyor #1] the status of pending access. I kept calling them, and they have several other customers. They told me only one user ID may be given. Stopped contract with them [Electronic medical record company name] August 2022. I made the mistake of telling [Surveyor #1] about the amount of money I owe to [Electronic medical record company name]. Plan was to call [Electronic company] and reset password. Everything she was asking for; I gave her the information…Not getting into [electronic medical record company] is beyond my control.” During the same interview, Surveyor #2 asked the Administrator, why he didn’t provide the Lead Surveyor (#1) access to his user ID and password since there had been multiple unsuccessful attempts. The Administrator/Owner stated - “She never asked me for it…Again, like I told you…[name of electronic medical company] provides only one user id and its confidential…Like I told you, I’ve always had access to the clinical records…by me providing her [Surveyor #1] user id’s for [name of electronic medical record company] shows proof I have provided her [Surveyor #1] access to the records…now, her [Surveyor #1] not getting in was not my fault….” The Administrator continued to raise his voice to the surveyors, banging his fingers on the desk, and saying, “She’s unprofessional” while pointing the Lead Surveyor. The Administrator continued to make rude comments to the Lead Surveyor about her work ethic and indicated that she was only out to shut his agency down. The Administrator continued to threaten with hostile behavior towards the Surveyors (#1 and #2). During the same interview, Surveyor #2 asked the Administrator, “tell me how you ensured that you effectively managed the day-to-day operations of the agency. Did you maintain a budget plan to maintain access to the electronic records. The Administrator responded, “the surveyor has the responsibility of asking for anything…she did not ask me for access for my records…Like I told you, I made the mistake of telling her I stopped paying [name of electronic medical record company] last year…” During the same interview, Surveyor #2 stated, "since entrance on 7/25, the lead surveyor was not able get access to the client records…Records must be readily accessible for surveyor to review." The Administrator/Owner, responded and stated, “that’s beyond my control…I’m only human…she never asked me to use my user id…” During the same interview, Surveyor #2 asked the Administrator, “Why doesn’t your Alternate Administrator/Supervising RN have access to the records?" The Administrator responded, “We are no longer contracted with [name of the Electronic medical record company]. We only get one password…I’m in the process of obtaining another company for electronic records…I did everything possible to give her [Surveyor #1] access.” During the same interview, Surveyor #2 asked the Administrator, “Tell me how your agency will have patient records readily accessible in the future and what is the impact for not having access to client records." The Administrator responded, “I asked [name of electronic medical record company] for a CD of the records. They wouldn’t do that… My back up plan is to have everything in paper so, I can print from my CD’s. I’m in the process of obtaining another company for electronic records.” During the same interview, Surveyor #2 informed the Administrator that the pre-exit process was done and that the official exit conference was about to begin. At that time the R8PM was called. On 08/02/23 at 5:33 p.m., the PM notified the Administrator and the Alternate Administrator/Supervising RN of exit, discussed preliminary findings and conditions. During the entrance conference, the R8PM stated "This is our official exit conference at 5:37 pm, understand they are preliminary." The Administrator responded, “Okay… The first is clinical records? What’s the difference? The R8PM stated to the Administrator, “Your responsibilities, access to clinical records, day-to-day operations.” During the exit conference, the Administrator was informed that he would receive the 2567 and 3724 within ten business days and upon receipt of the statement of violations, the agency had ten calendar days to submit the plan of correction to HHSC. The Administrator responded, “the plan of correction will be submitted and an IROD will be completed.” The R8PM informed the Administrator/owner that this would be a condition. On 08/02/23 at 5:50 p.m., the surveyors provided the Administrator/Owner with the preliminary findings and notified the Administrator/Owner that the surveyors were exiting the agency building. Record review of the agency's policy titled, "Personnel Policies" Policy Number: V, revised date, 07/01/2012 read in part, An administrator must be responsible for implementing and supervising the administrative policies and operations of the agency...1. a. manage the daily operations of the agency..." Record review of the agency's policy titled, "Clinical Record Documentation" Policy Number: II.E, revised date 11/01/2020, read in part, "...11. Back-ups of computerized clinical records shall be made every day. These back-ups shall be stored in the [agency name] office in a fire proof box..." Record review of the agency's policy titled, "Standards for Licensed HHS" Policy Number: X.A., effective date 04/15/2003, read in part, "The administrator...will administratively supervise the provision of all health services, organize and direct the agency's ongoing functions...4. Records shall be retained for five (5) years by [agency name] and safeguarded against loss and unofficial use." Record review of the agency's policy titled, "Handling of Policy Clinical Records" Policy Number: II.D, revised date, 09/19/2011, read in part, "4. Retention of Records: a) All Medical records and all other records considered by [Agency's name]...will be retained in their original or legally reproduced form...and may be stored at the parent location, branch office or administrative support site or record storage facility for five years after the date of the patient's discharge...c) [Agency name] has made arrangements for preservation of inactive records to ensure compliance with the minimum standards...7. Computerized Patient Records may be part of [Agency Name]...The [agency name]has adopted and enforced policies and procedures to ensure that: EHR can be readily accessed and systematically organized to facilitate the compilation and retrieval of information. Record review of the agency's policy titled, "Survey Procedures" Policy Number: I.B1 effective date, 07/01/2012, read in part, "(b) the [agency name] will provide the surveyor access to all agency records required by a DADS [HHSC] to be maintained by or on behalf of the agency...(c) if the Surveyor requests an agency record that is stored at a location other than the survey site, the [agency name] will provide the record to the surveyor within eight working hours after request...(d) [Agency name], will provide the surveyor with copies of agency records upon request."

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to enforce it's written policy for the retention of records and to inform the State agency where clinical records would be maintained, in that, the agency did not provide access to the surveyor until 6 days after the request for access to the electronic records to conduct record reviews for seven of seven discharged patients (#1, #2, #3, #4, #5, #6, and #7) who the agency had provided care and services to. This failure placed the agency out of compliance for current clinical standards of practice, caused a delay in the survey process, and prevented the Surveyor from reviewing records to confirm that care/services were provided in accordance with the plan of care. The findings included: During the entrance conference on 07/25/23 at 1:00 p.m., the Administrator/Owner stated that the clinical records were electronic. He further stated that he had zero patient census and could only access discharged client records as needed upon request by Social Security, for legal litigations, and for state surveys. The Administrator/Owner stated that the contracted software company was usually pretty good about cooperating and providing access to the clinical records would contact the contracted software company to inform that the State Surveyor was here to conduct a recertification survey and needed a password to access and review the clinical records. During an interview on 7/26/23 at 11:20 a.m., the Administrator/Owner stated that he contacted the support staff from the contracted software company and was told that it would take 24-48 hours for access to the clinical records, but due to the circumstances [State Survey] would escalate the process to provide access to the clinical records as a “read-only.” The Administrator/Owner stated that the Support Staff from the contracted software company stated only one person per agency could have access to review the electronic clinical records. The Administrator/Owner stated that this often occurred, and that he [Administrator/Owner] would give that access to this Surveyor. The Surveyor asked if documents such as the plan of care (POC), physician’s orders and medication profiles could be printed since these were “read only” and further stated that these were required as part of the patient clinical record review. The Administrator/Owner stated that he was not sure if he would be able to print documents. On 7/26/23 at 12:00 noon, the surveyor asked the Administrator/Owner if he had heard anything from the contracted software company regarding access to the electronic clinical records. The Administrator/Owner stated that he had not heard from the company and their response was still pending. On 07/26/23 at 1:55 p.m., the Administrator/Owner stated that he went to a local printing company to print documents and to send request to the contracted software company regarding the status of access for the State Surveyor to review the electronic clinical records, because he was having issues with the internet at the agency. He further stated that the request for surveyor “read only” access was still pending and would see tomorrow. On 7/26/23 at 3:45 p.m., the Surveyor requested a copy of the agency’s contract with the electronic medical records software company. The Administrator/Owner stated that the contracts were not at the agency and would have to go to his storage to retrieve those documents. On 07/27/23 at 10:43 a.m., the Surveyor made follow-up call to the Administrator/Owner regarding the status of access for record review of the electronic medical records with the contracted software company. There was no answer to the call, the Surveyor left a message on voicemail with Surveyor’s contact information and purpose of the call. On 07/27/23 at 11:30 a.m., the Surveyor made another follow-up call to inquire about status of access to review electronic medical records. The Alternate Administrator/Supervising Nurse answered and stated that the Administrator/Owner had just stepped out and should return between one to two hours. She further stated that she was not sure about the status of the access to the electronic clinical records, and that the Surveyor would have to call back within one to two hours to speak with the Administrator/Owner. On 07/27/23 at 1:40 p.m., the Surveyor made another follow-up call to inquire about status of access to review electronic medical records. The Alternate Administrator/Supervising Nurse answered and stated that Administrator/Owner had not returned, and she still had not heard anything regarding status of access to review the electronic medical records. During an interview on 07/27/23 at 2:21 p.m., the Administrator/Owner stated that he still did not have access to the electronic medical records and that he still had not heard from the contracted company. He stated that he had gone up the chain and was told by the support staff that he was placed on a wait list for access to review the electronic medical records. He stated that he explained that he was currently be surveyed by the State for recertification survey, that he needed to speak to a manager who could escalate the process. He stated that he would call back this Surveyor as soon as he heard back from the contracted electronic medical records company. 07/27/23 at 3:09 p.m., the Surveyor made another follow-up call to the agency regarding the status of access for record review of the electronic medical records with the contracted software company. The Surveyor spoke with the Alternate Administrator/Supervising Nurse, who informed the Surveyor that they still had not heard back from the contracted electronic medical record company and there was still no access for the Surveyor to review the clinical records. During this same interview, the Surveyor provided the Alternate Administrator/Supervising Nurse with the PM of Region 8’s contact information just in case it was needed to help escalate Surveyor access to the electronic medical records. On 07/28/23 at 9:45 a.m., the Surveyor made another follow-up call to the agency regarding the status of access to review electronic medical records. The Alternate Administrator/Supervising Nurse answered and stated that they still have not heard anything from the contracted electronic medical record company and that the Administrator/Owner had sent an email at 8:00 a.m., to them [contracted EMR]. The Surveyor informed the Alternate Administrator/Supervising Nurse that she would arrive at the agency about 12:00 noon. During an interview on 07/28/23 at 12:15 p.m., the Administrator/Owner stated that he still had not heard from the EMR company. That he had paid up to July 2022 (exact date unknown) when his last patient was discharged. He stated that he had spoken to a representative from the support staff of the contracted EMR company and was told that there’s a wait list for “read only” access to review records. The Administrator/Owner stated that he should not be held accountable and be cited for something not within his control due to a third-party contract agency. The Surveyor noted that the Administrator/Owner was upset that his tone of voice escalated and became hostile. The Surveyor stated that the Region 8 PM would be contacted to discuss the issues of being placed on wait list for “read only” access. During a telephonic conference on 7/28/23 at approximately 2:00 p.m., with the Region 8 PM (R8PM), the Administrator/Owner, the Alternate Administrator/Supervising Nurse, the Administrator/Owner stated that he had been back/fourth with the EMR company regarding getting the Surveyor access to the EMR, still not sure when “read only” access will be available. He stated that he expressed the urgency of the matter, that a State Surveyor was at the agency. He stated that his case had been escalated but that there is no specific time given when access would be granted to the Surveyor for “read only” access for record review. The R8PM informed the Administrator/Owner that the Surveyor will return to continue the survey on Monday 07/31/23. The Surveyor also requested a copy of the agency's contract with the electronic medical record company. On 7/31/23 at 12:52 p.m., another follow-up call was made, the Alternate Administrator/Supervising Nurse stated the Administrator/Owner had still not heard from the Contracted EMR company and had sent an e-mail to the company with no response. The Surveyor requested a copy of the e-mail and requested copies of the agencies policies and procedures regarding clinical records, responsibilities of the administrator and a copy of the contract with the EMR company. On 08/01/23 at 12:37 p.m., the Surveyor informed the Administrator/Owner and the Alternate Administrator/Supervising Nurse that the agency was now in an extended survey, due to not having access to review records to verify visits. The Administrator/Owner became very upset and turned to the Alternate Administrator and asked, “Did the Surveyor tell you that we were going into an extended survey?” The Surveyor then stated, “I just now called the extended survey and informed both of you.” The Administrator/Owner responded, “I am speaking to my Alternate Administrator, why are you getting so defensive?” The Surveyor noted that the demeanor of the Administrator/Owner was becoming more hostile/agitated. On 08/01/23 at 1:07 p.m., during the telephonic conference, the Administrator/Owner stated that he would not allow the Surveyor to do an extended survey, that the Surveyor was very unprofessional and disrespectful, and that this was not his fault, and he should not be held responsible for a third-party company. The R8PM stated that we could not keep a survey open indefinitely…that there’s a process…that generally surveys were conducted between three-four days. The R8PM stated that we requested access to review the electronic medical records on the day of entrance and according to the regulations once the request had been made for access to clinical records, the agency had eight hours to provide access. The Administrator/Owner became agitated to the point of belligerence i.e., banging his fingers on the table which was tilted and supported by textbooks. At which point the Surveyor had to pick up the phone and slide it back up on the table so that it did not slide off the glass table. The Administrator/Owner stated asked if she [R8PM] had heard from the agency’s EMR company and/or if she tried to contact the EMR company. The R8PM responded, “We do not contact any company contracted by the agencies…That is a contract made between the agency and that company.” The R8PM then asked the Administrator/Owner, “what exactly do you want us to do?” The Administrator/Owner further stated, “give me another day, I will go up to Austin and get access to the electronic medical records.” The R8PM stated, that she would give the Administrator/Owner another day, but the Surveyor would return on Tuesday 08/02/23 to do the exit conference.” The Administrator/Owner got up from the table and left the agency. On 08/01/23 at 5:01 p.m., this Surveyor received an email from the Health and Human Services Administrative Assistant II with the user id/password for access to the agency's electronic clinical records. However, the Administrator wasn’t sure if one of the characters in the password was an O or a zero and advised the surveyor to try both. On 08/02/23 at 8:32 a.m., the R8PM was notified that the user id/password provided by the Administrator/Owner did not work and provided a snip image of the message which read as follows: “You have entered an invalid username or password…If you are unable to login, please contact your administrator.” On 08/02/23 at 9:51 a.m., the R8PM forwarded an email from the Administrator/Owner that read, “please allow them to reset. After the first log in it states that you need to change your password. The temporary password expires after your first attempt. I will send it to you as I get it. Please sign in and change the password.” On 08/02/23 at 9:55 a.m., the R8PM forwarded an email from the Administrator/Owner that was forwarded from the EMR company with a password reset and instructions on how to change temporary password once logged in. However, this did not work, and the surveyor received the same message of invalid user id/password. On 08/02/23 at 10:51 a.m., the R8PM sent an email to the Administrator/Owner to inform that the Surveyor was still not able to access the electronic clinical records and that the Surveyors (#1 and #2) would meet the Administrator/Owner at the agency at between 12:00 noon and 12:30 p.m., so he could assist in getting access into the electronic medical records. On 08/02/23 at 12:30 p.m., the Surveyors (#1 and #2) arrived at the agency. Surveyor #2 was introduced to the Administrator/Owner and the Alternate Administrator/Supervising Nurse and gave the Administrator/Owner her business card. During an interview on 12:30 p.m., at 08/02/23 Surveyor #2 discussed the accessibility to clinical records with the Administrator/Owner and the difficulty/confusion with the ability to log-in into the system for review of clinical records. The Administrator/owner stated, “only one person can log in at the same time because, he was no longer contracted with EMR company.” Surveyor #2 asked the Administrator about their back-up system and if there was one in place for readily accessible records. The Administrator stated, “that was his backup system.” The Administrator/owner was asked if he would like to provide the Lead Surveyor (#1) with his access into the EMR using his [Administrator/Owner] log in ID so she may review the records or would he like to print all seven clinical records for the surveyors to review? The Administrator/Owner stated, he "would like to print all the charts, grabbed several reams of paper and said he would be back.” The Administrator/Owner stated, “I’m happy to print everything out…Yes, I’m okay with that…I have to go to a place to print…be right back”. The Lead Surveyor (#1) stated, “that’s fine” and the Administrator/Owner left the agency. On 08/02/23 at 2:13 p.m., 2:30 p.m., and 3:00 p.m., Surveyor #2 asked the Alternate Administrator/Supervising Nurse if she heard from the Administrator/Owner and/or if she knew when he would be back. The Alternate Administrator stated that she still had not heard anything from him, that she had no idea where he went and added that he could have gone to the local supermarket. She stated she did not have access to the clinical records and that the agency no longer has a contract with that electronic clinical record company. She stated that the Administrator, probably called the EMR company to request access. She stated she does not know how he printing...and that he must have access…” At 3:07 p.m., the Administrator/Owner was contacted by Surveyor #2. He stated he was still printing and almost done. He stated about 20 minutes and would return to the agency with the seven clinical records for the Surveyors (#1 and #2) to review. At 3:19 p.m., Surveyor (#2) received a text message from the Administrator/Owner indicating the following: FYI, [Surveyor #2’s first name] the print que has several charts to print so it might be longer than 30 mins. In case, you guys want to eat something for lunch I will keep you posted.” I [Surveyor #2] responded, “We will wait for you to return…Thank you.” The Administrator/Owner sent a 2nd text message…” You may also have access that I obtained for you. I will not have enough paper I’ve used 4 trams (reams). Go to the [EMR company name].com…User ID: Surveyor. [agency name] …Password: Password1$...please try getting in…let me know I will have to go buy more paper at [name of local office supplier]…Please call me for instructions on getting in…” On 08/02/23 at 3:26 p.m., Surveyor #2 notified the R8PM that the Administrator/Owner had given the Surveyors access to the electronic clinical records and that Surveyor #1 now able to log in and review the clinical records. Surveyor #2 contacted the Administrator/Owner and informed that the Surveyors were able to access the electronic clinical records and the exit conference would be at 4:30 p.m. The Administrator/Owner responded, "Okay, I'll be there." During an interview on 08/02/23 at 4:15 p.m., Surveyor #2 asked the Administrator/Owner, "do part of your duties as an Administrator include effective management of the day-to-day operations of the agency? The Administrator/Owner stated, “yes…Access to records has always been available to me. I have my own access, on Tuesday, I requested access for surveyor #1, sent in email asking for user ID. I gave her [Surveyor #1] the status of pending access. I kept calling them, and they have several other customers. They told me only one user ID may be given. Stopped contract with them [Electronic medical record company name] August 2022. I made the mistake of telling [Surveyor #1] about the amount of money I owe to [Electronic medical record company name]. Plan was to call [Electronic company] and reset password. Everything she was asking for; I gave her the information…Not getting into [electronic medical record company] is beyond my control.” During the same interview, Surveyor #2 asked the Administrator, why he didn’t provide the Lead Surveyor (#1) access to his user ID and password since there had been multiple unsuccessful attempts. The Administrator/Owner stated - “She never asked me for it…Again, like I told you…[name of electronic medical company] provides only one user id and its confidential…Like I told you, I’ve always had access to the clinical records…by me providing her [Surveyor #1] user id’s for [name of electronic medical record company] shows proof I have provided her [Surveyor #1] access to the records…now, her [Surveyor #1] not getting in was not my fault….” The Administrator continued to raise his voice to the surveyors, banging his fingers on the desk, and saying, “She’s unprofessional” while pointing the Lead Surveyor. The Administrator continued to make rude comments to the Lead Surveyor about her work ethic and indicated that she was only out to shut his agency down. The Administrator continued to threaten with hostile behavior towards the Surveyors (#1 and #2). During the same interview, Surveyor #2 asked the Administrator, “tell me how you ensured that you effectively managed the day-to-day operations of the agency. Did you maintain a budget plan to maintain access to the electronic records. The Administrator responded, “the surveyor has the responsibility of asking for anything…she did not ask me for access for my records…Like I told you, I made the mistake of telling her I stopped paying [name of electronic medical record company] last year…” During the same interview, Surveyor #2 stated, "since entrance on 7/25, the lead surveyor was not able get access to the client records…Records must be readily accessible for surveyor to review." The Administrator/Owner, responded and stated, “that’s beyond my control…I’m only human…she never asked me to use my user id…” During the same interview, Surveyor #2 asked the Administrator, “Why doesn’t your Alternate Administrator/Supervising RN have access to the records?" The Administrator responded, “We are no longer contracted with [name of the Electronic medical record company]. We only get one password…I’m in the process of obtaining another company for electronic records…I did everything possible to give her [Surveyor #1] access.” During the same interview, Surveyor #2 asked the Administrator, “Tell me how your agency will have patient records readily accessible in the future and what is the impact for not having access to client records." The Administrator responded, “I asked [name of electronic medical record company] for a CD of the records. They wouldn’t do that… My back up plan is to have everything in paper so, I can print from my CD’s. I’m in the process of obtaining another company for electronic records.” During the same interview, Surveyor #2 informed the Administrator that the pre-exit process was done and that the official exit conference was about to begin. At that time the R8PM was called. On 08/02/23 at 5:33 p.m., the PM notified the Administrator and the Alternate Administrator/Supervising RN of exit, discussed preliminary findings and conditions. During the entrance conference, the R8PM stated "This is our official exit conference at 5:37 pm, understand they are preliminary." The Administrator responded, “Okay… The first is clinical records? What’s the difference? The R8PM stated to the Administrator, “Your responsibilities, access to clinical records, day-to-day operations.” During the exit conference, the Administrator was informed that he would receive the 2567 and 3724 within ten business days and upon receipt of the statement of violations, the agency had ten calendar days to submit the plan of correction to HHSC. The Administrator responded, “the plan of correction will be submitted and an IROD will be completed.” The R8PM informed the Administrator/Owner that, this would be a condition. On 08/02/23 at 5:50 p.m., the surveyors provided the Administrator/Owner with the preliminary findings and notified the Administrator/Owner that the surveyors were exiting the agency building. Record review of the agency's policy titled, "Personnel Policies" Policy Number: V, revised date, 07/01/2012 read in part, An administrator must be responsible for implementing and supervising the administrative policies and operations of the agency...1. a. manage the daily operations of the agency..." Record review of the agency's policy titled, "Clinical Record Documentation" Policy Number: II.E, revised date 11/01/2020, read in part, "...11. Back-ups of computerized clinical records shall be made every day. These back-ups shall be stored in the [agency name] office in a fire proof box..." Record review of the agency's policy titled, "Standards for Licensed HHS" Policy Number: X.A., effective date 04/15/2003, read in part, "The administrator...will administratively supervise the provision of all health services, organize and direct the agency's ongoing functions...4. Records shall be retained for five (5) years by [agency name] and safeguarded against loss and unofficial use." Record review of the agency's policy titled, "Handling of Policy Clinical Records" Policy Number: II.D, revised date, 09/19/2011, read in part, "4. Retention of Records: a) All Medical records and all other records considered by [Agency's name]...will be retained in their original or legally reproduced form...and may be stored at the parent location, branch office or administrative support site or record storage facility for five years after the date of the patient's discharge...c) [Agency name] has made arrangements for preservation of inactive records to ensure compliance with the minimum standards...7. Computerized Patient Records may be part of [Agency Name]...The [agency name]has adopted and enforced policies and procedures to ensure that: EHR can be readily accessed and systematically organized to facilitate the compilation and retrieval of information. Record review of the agency's policy titled, "Survey Procedures" Policy Number: I.B1 effective date, 07/01/2012, read in part, "(b) the [agency name] will provide the surveyor access to all agency records required by a DADS [HHSC] to be maintained by or on behalf of the agency...(c) if the Surveyor requests an agency record that is stored at a location other than the survey site, the [agency name] will provide the record to the surveyor within eight working hours after request...(d) [Agency name], will provide the surveyor with copies of agency records upon request."

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to establish and maintain a client record system to ensure that the care and services provided to each client are completely and accurately documented, readily accessible and systematically organized to facilitate the compilation and retrieval of information, in that: the Administrator/Owner did not provide access to the surveyor until 6 days after the request for access to the electronic records to conduct record reviews for seven of seven discharged clients (#1, #2, #3, #4, #5, #6, and #7) who the agency had provided care and services to. Failure to provide the surveyor access to records for review placed the agency out of compliance for current clinical standards of practice, caused a delay in the survey process and prevented the surveyor from reviewing records to validate and confirm that care/services was provided in accordance with the plan of care. This failure could also affect the agency’s future clients. The findings included: During the entrance conference on 07/25/23 at 1:00 p.m., the Administrator/Owner stated that the clinical records were electronic. He further stated that he had zero patient census and could only access discharged client records as needed upon request by Social Security, for legal litigations, and for state surveys. The Administrator/Owner stated that the contracted software company was usually pretty good about cooperating and providing access to the clinical records would contact the contracted software company to inform that the State Surveyor was here to conduct a recertification survey and needed a password to access and review the clinical records. During an interview on 7/26/23 at 11:20 a.m., the Administrator/Owner stated that he contacted the support staff from the contracted software company and was told that it would take 24-48 hours for access to the clinical records, but due to the circumstances [State Survey] would escalate the process to provide access to the clinical records as a “read-only.” The Administrator/Owner stated that the Support Staff from the contracted software company stated only one person per agency could have access to review the electronic clinical records. The Administrator/Owner stated that this often occurred, and that he [Administrator/Owner] would give that access to this Surveyor. The Surveyor asked if documents such as the plan of care (POC), physician’s orders and medication profiles could be printed since these were “read only” and further stated that these were required as part of the patient clinical record review. The Administrator/Owner stated that he was not sure if he would be able to print documents. On 7/26/23 at 12:00 noon, the surveyor asked the Administrator/Owner if he had heard anything from the contracted software company regarding access to the electronic clinical records. The Administrator/Owner stated that he had not heard from the company and their response was still pending. On 07/26/23 at 1:55 p.m., the Administrator/Owner stated that he went to a local printing company to print documents and to send request to the contracted software company regarding the status of access for the State Surveyor to review the electronic clinical records, because he was having issues with the internet at the agency. He further stated that the request for surveyor “read only” access was still pending and would see tomorrow. On 7/26/23 at 3:45 p.m., the Surveyor requested a copy of the agency’s contract with the electronic medical records software company. The Administrator/Owner stated that the contracts were not at the agency and would have to go to his storage to retrieve those documents. On 07/27/23 at 10:43 a.m., the Surveyor made follow-up call to the Administrator/Owner regarding the status of access for record review of the electronic medical records with the contracted software company. There was no answer to the call, the Surveyor left a message on voicemail with Surveyor’s contact information and purpose of the call. On 07/27/23 at 11:30 a.m., the Surveyor made another follow-up call to inquire about status of access to review electronic medical records. The Alternate Administrator/Supervising Nurse answered and stated that the Administrator/Owner had just stepped out and should return between one to two hours. She further stated that she was not sure about the status of the access to the electronic clinical records, and that the Surveyor would have to call back within one to two hours to speak with the Administrator/Owner. On 07/27/23 at 1:40 p.m., the Surveyor made another follow-up call to inquire about status of access to review electronic medical records. The Alternate Administrator/Supervising Nurse answered and stated that Administrator/Owner had not returned, and she still had not heard anything regarding status of access to review the electronic medical records. During an interview on 07/27/23 at 2:21 p.m., the Administrator/Owner stated that he still did not have access to the electronic medical records and that he still had not heard from the contracted company. He stated that he had gone up the chain and was told by the support staff that he was placed on a wait list for access to review the electronic medical records. He stated that he explained that he was currently be surveyed by the State for recertification survey, that he needed to speak to a manager who could escalate the process. He stated that he would call back this Surveyor as soon as he heard back from the contracted electronic medical records company. 07/27/23 at 3:09 p.m., the Surveyor made another follow-up call to the agency regarding the status of access for record review of the electronic medical records with the contracted software company. The Surveyor spoke with the Alternate Administrator/Supervising Nurse, who informed the Surveyor that they still had not heard back from the contracted electronic medical record company and there was still no access for the Surveyor to review the clinical records. During this same interview, the Surveyor provided the Alternate Administrator/Supervising Nurse with the PM of Region 8’s contact information just in case it was needed to help escalate Surveyor access to the electronic medical records. On 07/28/23 at 9:45 a.m., the Surveyor made another follow-up call to the agency regarding the status of access to review electronic medical records. The Alternate Administrator/Supervising Nurse answered and stated that they still have not heard anything from the contracted electronic medical record company and that the Administrator/Owner had sent an email at 8:00 a.m., to them [contracted EMR]. The Surveyor informed the Alternate Administrator/Supervising Nurse that she would arrive at the agency about 12:00 noon. During an interview on 07/28/23 at 12:15 p.m., the Administrator/Owner stated that he still had not heard from the EMR company. That he had paid up to July 2022 (exact date unknown) when his last patient was discharged. He stated that he had spoken to a representative from the support staff of the contracted EMR company and was told that there’s a wait list for “read only” access to review records. The Administrator/Owner stated that he should not be held accountable and be cited for something not within his control due to a third-party contract agency. The Surveyor noted that the Administrator/Owner was upset that his tone of voice escalated and became hostile. The Surveyor stated that the Region 8 PM would be contacted to discuss the issues of being placed on wait list for “read only” access. During a telephonic conference on 7/28/23 at approximately 2:00 p.m., with the Region 8 PM (R8PM), the Administrator/Owner, the Alternate Administrator/Supervising Nurse, the Administrator/Owner stated that he had been back/fourth with the EMR company regarding getting the Surveyor access to the EMR, still not sure when “read only” access will be available. He stated that he expressed the urgency of the matter, that a State Surveyor was at the agency. He stated that his case had been escalated but that there is no specific time given when access would be granted to the Surveyor for “read only” access for record review. The R8PM informed the Administrator/Owner that the Surveyor will return to continue the survey on Monday 07/31/23. The Surveyor also requested a copy of the agency's contract with the electronic medical record company. On 7/31/23 at 12:52 p.m., another follow-up call was made, the Alternate Administrator/Supervising Nurse stated the Administrator/Owner had still not heard from the Contracted EMR company and had sent an e-mail to the company with no response. The Surveyor requested a copy of the e-mail and requested copies of the agencies policies and procedures regarding clinical records, responsibilities of the administrator and a copy of the contract with the EMR company. On 08/01/23 at 12:37 p.m., the Surveyor informed the Administrator/Owner and the Alternate Administrator/Supervising Nurse that the agency was now in an extended survey, due to not having access to review records to verify visits. The Administrator/Owner became very upset and turned to the Alternate Administrator and asked, “Did the Surveyor tell you that we were going into an extended survey?” The Surveyor then stated, “I just now called the extended survey and informed both of you.” The Administrator/Owner responded, “I am speaking to my Alternate Administrator, why are you getting so defensive?” The Surveyor noted that the demeanor of the Administrator/Owner was becoming more hostile/agitated. On 08/01/23 at 1:07 p.m., during the telephonic conference, the Administrator/Owner stated that he would not allow the Surveyor to do an extended survey, that the Surveyor was very unprofessional and disrespectful, and that this was not his fault, and he should not be held responsible for a third-party company. The R8PM stated that we could not keep a survey open indefinitely…that there’s a process…that generally surveys were conducted between three-four days. The R8PM stated that we requested access to review the electronic medical records on the day of entrance and according to the regulations once the request had been made for access to clinical records, the agency had eight hours to provide access. The Administrator/Owner became agitated to the point of belligerence i.e., banging his fingers on the table which was tilted and supported by textbooks. At which point the Surveyor had to pick up the phone and slide it back up on the table so that it did not slide off the glass table. The Administrator/Owner stated asked if she [R8PM] had heard from the agency’s EMR company and/or if she tried to contact the EMR company. The R8PM responded, “We do not contact any company contracted by the agencies…That is a contract made between the agency and that company.” The R8PM then asked the Administrator/Owner, “what exactly do you want us to do?” The Administrator/Owner further stated, “give me another day, I will go up to Austin and get access to the electronic medical records.” The R8PM stated, that she would give the Administrator/Owner another day, but the Surveyor would return on Tuesday 08/02/23 to do the exit conference.” The Administrator/Owner got up from the table and left the agency. On 08/01/23 at 5:01 p.m., this Surveyor received an email from the Health and Human Services Administrative Assistant II with the user id/password for access to the agency's electronic clinical records. However, the Administrator wasn’t sure if one of the characters in the password was an O or a zero and advised the surveyor to try both. On 08/02/23 at 8:32 a.m., the R8PM was notified that the user id/password provided by the Administrator/Owner did not work and provided a snip image of the message which read as follows: “You have entered an invalid username or password…If you are unable to login, please contact your administrator.” On 08/02/23 at 9:51 a.m., the R8PM forwarded an email from the Administrator/Owner that read, “please allow them to reset. After the first log in it states that you need to change your password. The temporary password expires after your first attempt. I will send it to you as I get it. Please sign in and change the password.” On 08/02/23 at 9:55 a.m., the R8PM forwarded an email from the Administrator/Owner that was forwarded from the EMR company with a password reset and instructions on how to change temporary password once logged in. However, this did not work, and the surveyor received the same message of invalid user id/password. On 08/02/23 at 10:51 a.m., the R8PM sent an email to the Administrator/Owner to inform that the Surveyor was still not able to access the electronic clinical records and that the Surveyors (#1 and #2) would meet the Administrator/Owner at the agency at between 12:00 noon and 12:30 p.m., so he could assist in getting access into the electronic medical records. On 08/02/23 at 12:30 p.m., the Surveyors (#1 and #2) arrived at the agency. Surveyor #2 was introduced to the Administrator/Owner and the Alternate Administrator/Supervising Nurse and gave the Administrator/Owner her business card. During an interview on 12:30 p.m., at 08/02/23 Surveyor #2 discussed the accessibility to clinical records with the Administrator/Owner and the difficulty/confusion with the ability to log-in into the system for review of clinical records. The Administrator/owner stated, “only one person can log in at the same time because, he was no longer contracted with EMR company.” Surveyor #2 asked the Administrator about their back-up system and if there was one in place for readily accessible records. The Administrator stated, “that was his backup system.” The Administrator/owner was asked if he would like to provide the Lead Surveyor (#1) with his access into the EMR using his [Administrator/Owner] log in ID so she may review the records or would he like to print all seven clinical records for the surveyors to review? The Administrator/Owner stated, he "would like to print all the charts, grabbed several reams of paper and said he would be back.” The Administrator/Owner stated, “I’m happy to print everything out…Yes, I’m okay with that…I have to go to a place to print…be right back”. The Lead Surveyor (#1) stated, “that’s fine” and the Administrator/Owner left the agency. On 08/02/23 at 2:13 p.m., 2:30 p.m., and 3:00 p.m., Surveyor #2 asked the Alternate Administrator/Supervising Nurse if she heard from the Administrator/Owner and/or if she knew when he would be back. The Alternate Administrator stated that she still had not heard anything from him, that she had no idea where he went and added that he could have gone to the local supermarket. She stated she did not have access to the clinical records and that the agency no longer has a contract with that electronic clinical record company. She stated that the Administrator, probably called the EMR company to request access. She stated she does not know how he printing...and that he must have access…” At 3:07 p.m., the Administrator/Owner was contacted by Surveyor #2. He stated he was still printing and almost done. He stated about 20 minutes and would return to the agency with the seven clinical records for the Surveyors (#1 and #2) to review. At 3:19 p.m., Surveyor (#2) received a text message from the Administrator/Owner indicating the following: FYI, [Surveyor #2’s first name] the print que has several charts to print so it might be longer than 30 mins. In case, you guys want to eat something for lunch I will keep you posted.” I [Surveyor #2] responded, “We will wait for you to return…Thank you.” The Administrator/Owner sent a 2nd text message…” You may also have access that I obtained for you. I will not have enough paper I’ve used 4 trams (reams). Go to the [EMR company name].com…User ID: Surveyor. [agency name] …Password: Password1$...please try getting in…let me know I will have to go buy more paper at [name of local office supplier]…Please call me for instructions on getting in…” On 08/02/23 at 3:26 p.m., Surveyor #2 notified the R8PM that the Administrator/Owner had given the Surveyors access to the electronic clinical records and that Surveyor #1 now able to log in and review the clinical records. Surveyor #2 contacted the Administrator/Owner and informed that the Surveyors were able to access the electronic clinical records and the exit conference would be at 4:30 p.m. The Administrator/Owner responded, "Okay, I'll be there." During an interview on 08/02/23 at 4:15 p.m., Surveyor #2 asked the Administrator/Owner, "do part of your duties as an Administrator include effective management of the day-to-day operations of the agency? The Administrator/Owner stated, “yes…Access to records has always been available to me. I have my own access, on Tuesday, I requested access for surveyor #1, sent in email asking for user ID. I gave her [Surveyor #1] the status of pending access. I kept calling them, and they have several other customers. They told me only one user ID may be given. Stopped contract with them [Electronic medical record company name] August 2022. I made the mistake of telling [Surveyor #1] about the amount of money I owe to [Electronic medical record company name]. Plan was to call [Electronic company] and reset password. Everything she was asking for; I gave her the information…Not getting into [electronic medical record company] is beyond my control.” During the same interview, Surveyor #2 asked the Administrator, why he didn’t provide the Lead Surveyor (#1) access to his user ID and password since there had been multiple unsuccessful attempts. The Administrator/Owner stated - “She never asked me for it…Again, like I told you…[name of electronic medical company] provides only one user id and its confidential…Like I told you, I’ve always had access to the clinical records…by me providing her [Surveyor #1] user id’s for [name of electronic medical record company] shows proof I have provided her [Surveyor #1] access to the records…now, her [Surveyor #1] not getting in was not my fault….” The Administrator continued to raise his voice to the surveyors, banging his fingers on the desk, and saying, “She’s unprofessional” while pointing the Lead Surveyor. The Administrator continued to make rude comments to the Lead Surveyor about her work ethic and indicated that she was only out to shut his agency down. The Administrator continued to threaten with hostile behavior towards the Surveyors (#1 and #2). During the same interview, Surveyor #2 asked the Administrator, “tell me how you ensured that you effectively managed the day-to-day operations of the agency. Did you maintain a budget plan to maintain access to the electronic records. The Administrator responded, “the surveyor has the responsibility of asking for anything…she did not ask me for access for my records…Like I told you, I made the mistake of telling her I stopped paying [name of electronic medical record company] last year…” During the same interview, Surveyor #2 stated, "since entrance on 7/25, the lead surveyor was not able get access to the client records…Records must be readily accessible for surveyor to review." The Administrator/Owner, responded and stated, “that’s beyond my control…I’m only human…she never asked me to use my user id…” During the same interview, Surveyor #2 asked the Administrator, “Why doesn’t your Alternate Administrator/Supervising RN have access to the records?" The Administrator responded, “We are no longer contracted with [name of the Electronic medical record company]. We only get one password…I’m in the process of obtaining another company for electronic records…I did everything possible to give her [Surveyor #1] access.” During the same interview, Surveyor #2 asked the Administrator, “Tell me how your agency will have patient records readily accessible in the future and what is the impact for not having access to client records." The Administrator responded, “I asked [name of electronic medical record company] for a CD of the records. They wouldn’t do that… My back up plan is to have everything in paper so, I can print from my CD’s. I’m in the process of obtaining another company for electronic records.” During the same interview, Surveyor #2 informed the Administrator that the pre-exit process was done and that the official exit conference was about to begin. At that time the R8PM was called. On 08/02/23 at 5:33 p.m., the PM notified the Administrator and the Alternate Administrator/Supervising RN of exit, discussed preliminary findings and conditions. During the entrance conference, the R8PM stated "This is our official exit conference at 5:37 pm, understand they are preliminary." The Administrator responded, “Okay… The first is clinical records? What’s the difference? The R8PM stated to the Administrator, “Your responsibilities, access to clinical records, day-to-day operations.” During the exit conference, the Administrator was informed that he would receive the 2567 and 3724 within ten business days and upon receipt of the statement of violations, the agency had ten calendar days to submit the plan of correction to HHSC. The Administrator responded, “the plan of correction will be submitted and an IROD will be completed.” The R8PM informed the Administrator/Owner that this would be a condition. On 08/02/23 at 5:50 p.m., the surveyors provided the Administrator/Owner with the preliminary findings and notified the Administrator/Owner that the surveyors were exiting the agency building. Record review of the agency's policy titled, "Personnel Policies" Policy Number: V, revised date, 07/01/2012 read in part, An administrator must be responsible for implementing and supervising the administrative policies and operations of the agency...1. a. manage the daily operations of the agency..." Record review of the agency's policy titled, "Clinical Record Documentation" Policy Number: II.E, revised date 11/01/2020, read in part, "...11. Back-ups of computerized clinical records shall be made every day. These back-ups shall be stored in the [agency name] office in a fire proof box..." Record review of the agency's policy titled, "Standards for Licensed HHS" Policy Number: X.A., effective date 04/15/2003, read in part, "The administrator...will administratively supervise the provision of all health services, organize and direct the agency's ongoing functions...4. Records shall be retained for five (5) years by [agency name] and safeguarded against loss and unofficial use." Record review of the agency's policy titled, "Handling of Policy Clinical Records" Policy Number: II.D, revised date, 09/19/2011, read in part, "4. Retention of Records: a) All Medical records and all other records considered by [Agency's name]...will be retained in their original or legally reproduced form...and may be stored at the parent location, branch office or administrative support site or record storage facility for five years after the date of the patient's discharge...c) [Agency name] has made arrangements for preservation of inactive records to ensure compliance with the minimum standards...7. Computerized Patient Records may be part of [Agency Name]...The [agency name]has adopted and enforced policies and procedures to ensure that: EHR can be readily accessed and systematically organized to facilitate the compilation and retrieval of information. Record review of the agency's policy titled, "Survey Procedures" Policy Number: I.B1 effective date, 07/01/2012, read in part, "(b) the [agency name] will provide the surveyor access to all agency records required by a DADS [HHSC] to be maintained by or on behalf of the agency...(c) if the Surveyor requests an agency record that is stored at a location other than the survey site, the [agency name] will provide the record to the surveyor within eight working hours after request...(d) [Agency name], will provide the surveyor with copies of agency records upon request."