Failure to Provide Timely Access to Medical Records
Summary
The facility failed to provide timely access to medical records for a resident, identified as Resident #10, who was cognitively intact and had multiple diagnoses including chronic osteomyelitis, metabolic encephalopathy, paraplegia, a pressure ulcer, depression, and diabetes mellitus type II. Resident #10 reported during a resident council meeting that he had requested to see his medical record concerning x-ray results and wound assessments but was denied access. Despite the resident's report, the facility's Administrator was initially unaware of any such request. The resident could not recall who he had spoken to about the request, but he permitted his name to be shared with the Administrator. Following the initial report on 01/09/25, Resident #10 stated on 01/13/25 that he still had not been granted access to his medical record. The facility's policy, last updated in May 2023, stipulates that a resident's record should be accessible within 24 hours of a request, excluding weekends and holidays. However, the Administrator admitted to not knowing if anyone had provided the requested access and was unable to identify who was responsible for ensuring compliance with the request. This lack of action and communication within the facility led to the deficiency in providing the resident with timely access to his medical records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
A resident with Type 2 DM and dementia and the resident’s responsible party requested access to the resident’s medical records during an IDT care plan meeting attended by the SSA, RN, rehab staff, and AD. The SSA verbally agreed to obtain the records but did not document the request, did not complete the process, and did not inform the MRD. In the following weeks, the responsible party repeatedly called the facility, but the receptionist reported the SSA was unavailable and did not connect the caller with other staff. When eventually reached, the MRD stated she had not been informed of the earlier request and explained that a request form was required. The facility’s policy allowed resident access to records within 24 hours of a written or oral request, but this was not followed or explained.
The facility failed to provide a resident and the resident’s representative with timely and reasonably priced access to the resident’s medical records. Despite a written HIPAA-compliant authorization and a policy requiring records to be available within 48 hours, the facility issued a high-cost invoice for over 1,400 pages and conditioned release of the records on payment. A later request for a complete electronic copy resulted instead in an incomplete paper set missing key portions of the chart, including MDS and CNA flow sheets, and the records were still being compiled weeks later. The Director of Medical Records reported difficulty providing electronic records, while the NHA confirmed that records could be sent electronically and that the resident’s records were not released as requested in a timely manner or at a reasonable cost.
A former resident who had been hospitalized after a hip fracture and later died had her medical records requested by her family’s attorney, who supplied all required authorizations and identifying documents. The facility initially sent only partial records and, despite repeated written, faxed, and telephone follow-up requests for specific missing items such as MDS, assessments, nursing notes, MD progress notes, therapy notes, MARs, TARs, and ADL logs, did not provide evidence that a complete record was released within the timeframe outlined in its own policy. The medical records staff stated that all requests are routed through the Administrator to corporate and are not released without corporate approval, and the Administrator acknowledged receiving multiple requests and forwarding them to corporate but could not provide a corporate contact, resulting in delayed and incomplete access to the former resident’s records.
The facility failed to provide timely access to medical records to a resident's legal representative after the resident, who had severe cognitive impairment and multiple behavioral and fall-related diagnoses, had been discharged home on hospice and subsequently died. The family submitted a completed authorization form and death certificate, but the Director of Medical Records did not forward the request to the third-party compliance vendor until more than two working days later, due in part to multiple competing duties and a misunderstanding of the required timeframe. As a result, the legal representative did not receive access to the requested records within the required two working days of the written request.
A resident’s written request for a copy of clinical records was received by MRP but not fulfilled until about two weeks later, despite facility policy requiring that residents or their legal representatives receive copies of their records within 2 working days of a request. During interview and record review, facility leadership confirmed that the “Release of Medical Records” policy was not followed, resulting in a delay and violation of the resident’s right to timely access to their medical information.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Failure to Provide and Explain Access to Medical Records Upon Request
Penalty
Summary
The facility failed to provide and explain the process for obtaining a copy of a resident’s medical records upon request, in accordance with its policy on Protected Health Information. A resident with Type 2 DM and dementia was admitted in early February, and an IDT care plan review was conducted later that month, authored by the Social Service Assistant (SSA) and attended by an RN, rehabilitation staff, the Activity Director (AD), the resident, and the resident’s responsible party (RP). The IDT documentation did not include the topics discussed during the meeting and was not signed and dated by the SSA. During this IDT meeting, the RP requested the resident’s medical records, and the SSA verbally stated she would obtain the records, but no documentation of this request or follow-through was made. Following the meeting, the RP waited several weeks without receiving the records and repeatedly called the facility to follow up. The receptionist reported the SSA was unavailable and did not connect the RP with another staff member who could assist. After multiple attempts, the RP was eventually transferred to the Medical Records Director (MRD), who stated she had not been informed of the earlier request and told the RP that a request form needed to be completed. The MRD reported that the SSA, who no longer worked at the facility, had not communicated the RP’s request from the IDT meeting. The AD confirmed being present at the IDT meeting and recalled the RP asking for the records and the SSA stating she would get them. The facility’s policy stated that a resident may have access to records within 24 hours of a written or oral request, excluding weekends and holidays, but this process was not followed or explained to the RP.
Failure to Provide Timely, Reasonably Priced Access to Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s medical records in a timely manner and at a reasonable cost, as required by regulation and the facility’s own policy. The facility policy on Release of Information, revised November 2009, states that residents may obtain photocopies of their records with at least 48 hours’ notice (excluding weekends and holidays), and that a fee may be charged for copying services. For one resident, a written, HIPAA-compliant authorization signed by the resident’s Power of Attorney was submitted on October 13, 2025. The facility generated an invoice on October 23, 2025, billing $732.08 for 1,424 pages of records. The Director of Medical Records (Employee E12) stated that the resident’s son was told he would have to pay this amount to receive the records, in accordance with facility policy, and that he declined to pay. A subsequent written request for “any and all records” with a HIPAA-compliant authorization, dated January 3, 2026, was submitted through a third party on behalf of the resident. On February 9, 2026, that party emailed Employee E12, warning that regulatory agencies would be notified if the records were not provided without further delay. E12 responded on February 10, 2026, that the records would be prepared that week, and later reported that the resident’s son picked up a paper copy on February 17, 2026. On February 22, 2026, the requesting party reported that the resident had requested an electronic version via an electronic form but instead received an incomplete paper copy missing multiple important parts of the chart, and requested a PDF copy of the PCC chart. E12 replied on February 25, 2026, that the missing records would be provided as soon as possible, and on March 3, 2026, stated that MDS documents and nine more months of CNA flow sheets were still being compiled and would be scanned by the end of the week. By March 10, 2026, the requester was still following up, and on March 19, 2026, E12 stated she had been printing and scanning as fast as she could and did not know how to send the chart electronically. The Nursing Home Administrator confirmed that records can be sent electronically via a link and confirmed that the resident’s records were not released upon request in a timely manner or at a reasonable cost.
Failure to Timely Provide Complete Medical Records to Former Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to timely release a complete medical record for a former resident to the resident’s family and their legal representative, despite multiple written and faxed requests. The former resident was admitted on 01/11/24 and later discharged to the hospital after a fall with hip fracture, and subsequently died. On 10/30/25, the family’s attorney submitted an initial request for a certified copy of the resident’s medical record for a specified date range, providing the resident’s identifying information, a notarized affidavit of next of kin, a signed authorization for release of medical records, the death certificate, and contact information. The facility’s policy stated that residents or their representatives may obtain photocopies of records by providing at least 48 hours’ notice (excluding weekends and holidays). The facility’s medical records staff member reported that record requests are forwarded to the Administrator, who then sends them to corporate, and that records are not released until corporate approves what can be released. The attorney reported receiving only partial records on 12/11/25, including a consent to treat form for psychiatric therapy, the facility discharge form, a hospital history and physical, diagnosis and allergy audit reports, immunization audit report, order summary report, weight and vital summary, and the care plan report. On 12/15/25, the attorney notified the facility via fax and mail that the record was incomplete and specifically requested additional documents such as the MDS, all assessments, nursing notes, physician progress notes, therapy notes, MARs, TARs, caregiver notes, consultations, and ADL logs. Additional requests were sent on multiple later dates, with fax confirmations and documented phone calls and voicemails to the Administrator, but there was no response indicating that the missing portions were provided. The Administrator confirmed receiving all of the dated requests and stated that they were forwarded to corporate and that, to her knowledge, the complete record had been sent, but she did not provide a corporate contact number when asked. This sequence of events shows that the facility did not provide timely and complete access to the former resident’s medical record as required by its own policy and regulatory expectations.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records to a resident's legal representative as required by regulation and facility policy. The facility's policy dated 12/02/2025 stated that residents could request access to their medical information orally or in writing, and that such requests would be submitted in a timely manner to the corporate compliance vendor for approval and tracking. Resident #3, who had diagnoses including anxiety, bipolar disorder, repeated falls, and severe cognitive impairment per a 06/05/2023 MDS, was discharged home on hospice on 07/27/2023. After the resident's death, the family requested medical records. On 03/25/2025, the Director of Medical Records sent the family an authorization form, and on 04/07/2025 the family returned the completed authorization form and death certificate. Despite receipt of the completed request on 04/07/2025, the Director of Medical Records did not submit the request and supporting documents to the third-party corporate compliance company until 04/24/2025. The Director of Medical Records acknowledged that the request may have been missed or not handled timely due to competing responsibilities, which included scheduling appointments, referrals, transportation, managing provider dictations, scanning and uploading external records, and other medical records duties. The Director also believed records requests needed to be completed within 30 days, rather than the regulatory requirement of two working days for access. The Administrator stated that the Director of Medical Records was responsible for medical records requests and that staff would forward any such requests to that individual. The delay from 04/07/2025 to 04/24/2025 in submitting the request to the third-party company resulted in the resident's legal representative not receiving access to the medical records within two working days of the written request, in violation of 10 NYCRR 415.3(c)(1)(iv).
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its own policy and procedure for release of medical records when a written request for a resident’s clinical record was not fulfilled within the required timeframe. On 2/17/26, Medical Records Personnel (MRP) received a written request for Resident 1’s clinical record, but the record was not released until 3/9/26, resulting in approximately a 14‑day delay from the request date. During a concurrent interview and record review with the Administrator and MRP, MRP confirmed the dates of the request and release, and the Administrator confirmed that the facility’s policy titled “Release of Medical Records” was not followed. Review of the facility’s 2025 policy “Release of Medical Records” showed that residents or their legal representatives are to receive a copy of the medical record within 2 working days after the request is made. The failure to provide Resident 1’s clinical records within this 2‑working‑day timeframe constituted a violation of the resident’s right to access their records as specified in the facility’s own policy.
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