F0573

D

Failure to Ensure Reasonable Access and Fees for Resident Medical Records

Wintersville, Ohio Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The facility failed to ensure ease of access for a resident and the resident’s family to obtain copies of the resident’s medical records, specifically therapy records. The resident, who had diagnoses including peripheral vascular disease, hypertensive heart disease without heart failure, encephalopathy, difficulty walking, dysphagia, atherosclerotic heart disease, kidney disease, alcohol abuse, and chronic peripheral disease, was severely impaired for daily decision making and used a wheelchair and front-wheeled walker for mobility. After discharge, the resident’s daughter requested physical and occupational therapy reports so home health could review what therapy had been provided. She was told the resident would need to come in person to sign a release form because the facility would not accept a verbal request, and the facility required a resident signature unless a power of attorney or other legal representative was in place. Due to the resident’s limited mobility and cold weather, the daughter did not bring him in to sign until a later date.

The daughter reported being told by therapy staff that obtaining copies of the therapy records would cost approximately $60 to $80, and due to this reported cost, the family did not obtain the records. The facility’s fee schedule, based on the Ohio Revised Code and Consumer Price Index, allowed charges up to $3.88 per page for requests by a resident or resident representative, and for other requesters included an initial search fee of $23.94 plus up to $1.58 per page. The Administrator stated that therapy was provided by a contracted company using a different computer system and that this company set its own prices for records, which the Administrator did not know or verify for compliance, and that the facility used state fee requirements rather than federal. The Administrator also confirmed that the facility’s fee structure included additional fees for locating records and that verbal requests were not accepted. Medical Records staff indicated that requests required a signed release form, were routed through Quality Assurance and legal, and that the business office had a price sheet, but staff did not inform requesters of the cost. Corporate Business Office staff stated that charges were sometimes waived depending on page count and that the facility business office could not give residents or representatives a price, with therapy records handled separately by the third-party therapy agency.