G0438: Have A Confidential Clinical Record
CMS level: Element Minor. On this site, a condition-level citation is labeled Serious, a standard-level citation Moderate, and an element-level citation Minor. What the labels mean · How to choose an agency
Data from CMS inspection reports (Form 2567), 2018-01-02 to 2026-10-15, downloaded 2026-10-21; CMS agency list file dated 2026-09-21. CMS source file. What the labels mean
Where it was cited
- Indiana25
- California17
- Colorado5
- Florida4
- Idaho4
- Kansas4
- Illinois3
- Michigan3
- Pennsylvania3
- Virginia3
- Iowa2
- Missouri2
- New Mexico2
- Nevada2
- New York2
- Texas2
- Alaska1
- Alabama1
- Louisiana1
- Maryland1
- Ohio1
- Oklahoma1
- Oregon1
- Puerto Rico1
- Wyoming1
Most recent citations
The 20 most recent of 92 citations. Newest inspection first.
Genus Home Care, Inc
The agency failed to ensure personal health information was kept confidential for one of three sampled patients (Patient 1) when Licensed Vocational Nurse (LVN 1) received and sent Patient 3’s clinical records using her personal cell phone.
Genus Home Care of San Bernardino
The facility failed to ensure personal health information was kept confidential for one of three sampled patients (Patient 1) when Licensed Vocational Nurse (LVN 1) received and sent Patient 1’s clinical records using her personal cell phone.
Comfort Care Home Health
The Home Health Agency (HHA - an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure that patient clinical records were safeguarded through a secured platform for six of seven sample patients (Patient 3, Patient 7, Patient 8, Patient 9…
All Americans Choice Home Health Inc
The facility failed to ensure personal health information were kept confidential for one (1) of 3 (three) sampled Patients (Patient 1) for home visits when one Registered Nurse (RN 1) received and sent Patient 1’s clinical records using her personal cell phone.
Bay Nation Home Health Services Inc
HHA 1 discharged Patient 1 on 2/6/2026. During a review of Patient 1’s document titled “Patient Care Coordinator (PCC) Final Discharge Planning Note” dated 1/24/2026, the PCC indicated Patient 1 had elected to receive home health care services from another Home Health Agency (HHA 2) and not HHA 1.…
Tjf Investment Group Inc
No longer in CMS listThe agency failed to maintain patient information in accordance with the Health Insurance Portability and Privacy Act (HIPPA) for 1 of 1 active patients' medical and insurance information (Patient: #14), found in an agency binder in another patient’s home.
Dr Home Health
The agency (Agency A) failed to ensure the confidentiality of 2 of 15 discharged patients (Patients #14 and #15) identifiable information contained in the clinical record, including OASIS data, and did not prevent the release patient identifiable OASIS information to anyone other than an agency…
Island Home Care
The agency failed to ensure transmission of confidential medical information was secured for 1(Patient #3) of 1 patient observed having confidential information transmitted. using an employee’s private cell phone.
Legacy Home Health, Inc
The facility failed to ensure personal health information were kept confidential when Certified Home Health Aide (CHHA) received and sent Patient 1’s clinical records using her personal cell phone.
Central Home Health Services of Texas LLC
The home health agency failed to ensure the confidentiality and protection of 11 of 17 active and discharged patients’ (#7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17) Protected health information in that an unauthorized individual had documents containing confidential medical and identifying…
Sweetgrace Home Health Services, LLC
The facility failed to ensure for one of seven sampled patients (Patient 2) personal health information was kept confidential when the Home Health Licensed Vocational Nurse (HHLVN 1) took a photograph of Patient 2’s abdomen and upper body using HHLVN 1’s personal cell phone.
247 Allstaff West LLC
No longer in CMS listThe agency failed to ensure the patient or their representative received written notice of the patient’s rights and responsibilities which included the right to have a confidential clinical record and access to or release of patient information and clinical records for three of seven sampled…
Caring Angels Home Health Services, Inc
The Agency failed to ensure clinical record information is maintained in a private and confident manner.
Las Vegas Home Health Care, Inc
The agency failed to maintain patient privacy and protect patient information obtained electronically for 1 of 7 patients (Patient #6).
Happy Life Home Health Care, Inc
No longer in CMS listThe Home Health Agency (HHA) failed to ensure seven (7) of 17 sampled patients (Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 9, and Patient 16) clinical records were kept confidential and accessed only by authorized and qualified personnel of the HHA.
Hospital Home Care Services
" " on the premises " or the like " and did not provide appropriate safeguards to protect the privacy of protected health information (PHI), for two (2) of nine (9) CR of Patients who received Home Health Physical Therapy (CR1 & CR2).
All Care Home Health
The agency failed to ensure confidentiality of a patient record for one unsampled patient.
Aveanna Healthcare
The agency failed to honor patient rights to have a confidential record for 1 of 3 sampled patients who had intakes with no admission to home health care.
Faithful Friends Home Healthcare Inc
No longer in CMS listThe home health agency failed to protect the confidentiality for 1 of 4 clinical records reviewed (Patient #4).