Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 757375 (X3) Date Survey Completed 07/07/2025
Name of Provider or Supplier Intense Home Health Inc Street Address, City, State 3786 La Crescenta Ave. Suite 104, Glendale, CA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G1028 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 interview and record review the Home Health Agency (HHA) failed to ensure patient health records were safeguarded for seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). 

 

This failure resulted in an unqualified and unknown person had access to patients' confidential clinical records.

 


During a general observation of nursing visit notes on 7/2/2025, at 12 p.m., it was observed that the notes were typed and manually signed by a nurse with a date and time.  



 During an interview on 7/2/2025, at 12 p.m., the Office Manager 1 (OM 1) stated the HHA did not have an electronic medical record (EMR). The OM 1 stated all the nursing visit notes were written and placed in the patient’s chart. 



 During an interview on 7/7/2025, at 12:05 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she used a template using Word (a type of computer software) on her personal computer for nursing visit notes. LVN 1 stated she typed her notes using a keyboard on her computer, which she would print, manually sign and turn into the office.  



 During an interview on 7/7/2025, at 12:28 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she used a template, obtained from the HHA, on her personal computer for nursing visit notes. LVN 3 stated she printed and signed the notes and turned them in to the HHA. 



 During an interview on 7/7/2025, at 1:42 p.m., the Director of Patient Care Services (DPCS) stated she agreed that personal computers may not be safeguarded against hacking or unauthorized use. However, other health care organizations have had their EMR hacked, so it can happen with any computer system. 



 During a concurrent interview and record review on 7/7/2025, at 1:58 p.m., the OM 1 reviewed the agencies document titled, “Electronic Clinical Documentation Submission”, dated 1/5/2025. The record indicated, “All patient visit notes, and other required clinical documentation must be completed and submitted electronically in the agency’s EMR Synergy…This includes but is not limited to: Skilled Nursing Visit Notes…All documentation must be submitted through the agency’s designated Synergy platform. Paper or handwritten notes are not accepted unless under pre-approved emergency circumstances.” OM 1 stated the policy did not apply because the HHA never went EMR. The policy was in place in case the agency adopts an EMR system. OW 1 stated, “we are in a grey area right now”.  



During an observation on 7/2/2025 at 10 a.m. at the HHA, three females and one male were noted in the agency. The females introduced themselves as the Office Manager (OM1), the Director of Patient Care Services (DPCS), and the office worker 2 (OW2). 



 During a concurrent observation, interview, and record review, on 7/2/2025 at 12:45 p.m. in the HHA with the DPCS and OW2 of Patient 5 and Patient 6’s medical records, the DPCS was requested to provide copies of Patient 5 and Patient 6’s plan of care, medication list, and most current comprehensive nursing assessment. The DPCS handed Patient 5 and Patient 6’s medical records to OW2. The OW2 opened and started looking in Patient 5 and Patient 6’s medical records for the requested documents. OW2 was asked her position/title in the HHA. OW2 stated she did not work at the HHA and that she (OW2) was there to help out only.  



During an interview on 7/2/2025 at 12:50 p.m., with OM1 stated that OW2 was hired on 7/2/2025. OM1 stated that the HHA hired OW2 on 7/2/2025 because OW2 was familiar with their computer system. OW2’s employee file was requested. The DPCS and the OM1 stated that OW2 did not have an employee file because she (OW2) was just hired. OW2’s employment application was requested. The DPCS and the OM1 stated OW2 did not fill out an employment application. 



During an interview on 7/2/2025 at 1:34 p.m., with OW2 stated she did not fill out an HHA employment application or discussed her pay thus far with the DPCS or OM1. OW2 stated OM1 called her to ask for her help with the survey. OW2 stated she logged into the HHA computer system with the log in information provided by OM1. OW2 stated she (OW2) did not know whose log in information she was using.  



 



During a record review of the HHA’s undated document titled “Safeguarding/Retrieval of Clinical/Service Record” undated indicated “only authorized personnel will have access.” 



During a record review of the HHA’s undated document titled “Clinical/Services Data Collection”, indicated “Entries to the clinical/service record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization.”