§483.10(g)(2) The resident has the right to access personal and medical records pertaining to him or herself.
(i) The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays); and
(ii) The facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility. The facility may impose a reasonable, cost-based fee on the provision of copies, provided that the fee includes only the cost of:
(A) Labor for copying the records requested by the individual, whether in paper or electronic form;
(B) Supplies for creating the paper copy or electronic media if the individual requests that the electronic copy be provided on portable media; and
(C)Postage, when the individual has requested the copy be mailed.
§483.10(g)(3) With the exception of information described in paragraphs (g)(2) and (g)(11) of this section, the facility must ensure that information is provided to each resident in a form and manner the resident can access and understand, including in an alternative format or in a language that the resident can understand. Summaries that translate information described in paragraph (g)(2) of this section may be made available to the patient at their request and expense in accordance with applicable law.
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Observations:
Based on staff interviews, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that medical records requested by/and or on behalf of residents were provided in a timely manner for 3 out of 3 records reviewed. (Resident R1, Resident R2, and R3)
Review of the facility policy, " Release of Information, " with a revision date of November 2009 indicated that the resident may initiate a request to release information to anyone he/she wishes and that such request will be honored only upon the receipt of written, signed, and dated request from the resident or representative. The policy also stated that a resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written request. Continued review of the policy indicated that a resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight hour (excluding weekends and holidays) advanced notice of such request, and that a fee may be charged for copying services.
Review of a medical records request documentation from the facility's Medical Records Department indicated that the facility received a signed request for the release of medical records for Resident R1 on July 3, 2025. Continued review of the documentation from the facility's Medical Records Department indicated that the medical records were not sent to the requestor until July 21, 2025.
Review of medical records request documentation from the facility's Medical Records Department indicated that the facility received a signed request for the release of medical records for Resident R2 on August 8, 2025. Continued review of the documentation from the facility's Medical Records Department indicated that the medical records were not sent to the requestor until September 5, 2025.
Review of a medical records request documentation from the facility's Medical Records Department indicated that the facility received a signed request for the release of medical records for Resident R3 on July 16, 2025. Continued review of the documentation from the facility's Medical Records Department indicated that the medical records were not sent to the requestor until August 4, 2025.
During an interview with Employee E3 (Medical Records Director) on October 30, 2025, at 2:00 p.m. the above referenced medical records request documentation for Resident R1, R2 and R3 was reviewed with Employee E3. During the above reference interview with Employee E3, it was discussed that the medical records request made by the resident and/or on behalf of the resident were not released to the requestor in a timely manner.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a)(b) Resident rights
| | Plan of Correction - To be completed: 12/22/2025
The facility has reviewed the documentation for Resident R1, R2, and R3 and confirmed that the requested medical records were eventually sent to the requestors.
Resident R1: Records sent on July 21, 2025 (18 days after the July 3, 2025 request).
Resident R2: Records sent on September 5, 2025 (28 days after the August 8, 2025 request).
Resident R3: Records sent on August 4, 2025 (19 days after the July 16, 2025 request).
The Medical Records Director (Employee E3) has been educated regarding the facility's policy on the timely release of medical records and the required timeframes (48 hours for photocopies, excluding weekends/holidays, per policy; or within the legally required timeframe for initial access).
The Medical Records Director will immediately review all medical record release requests processed within the last 30 days to identify any other instances where records were not provided within the policy-stipulated timeframe (48 hours for copies, or 24 hours for access, excluding weekends/holidays).
For any identified delayed requests, the Medical Records Director will contact the resident or requestor to apologize for the delay and confirm that the records were received and that the resident's needs were met.
This review will be documented, including the resident's initials, request date, release date, and whether the policy timeframe was met.
Policy Review and Revision: The facility's policy, "Release of Information," will be reviewed and updated by December 15, 2025, to ensure it clearly reflects all current Federal and State regulatory requirements for the release of medical records, including access and copying timeframes.
Medical Records Director will be educated by December 16, 2025 on the revised policy, focusing specifically on timely compliance (24 hours for access, 48 hours for copies, excluding weekends/holidays) and the correct workflow and documentation procedures.
A new Medical Records Request Tracking Log will be implemented by December 1, 2025. This log will be utilized for every request and will include:
Date and Time Request Received
Resident Name
Type of Request (Access/Copy)
Required Release Date (based on policy/regulation)
Actual Date Records Released
Reason for Delay (if any)
NHA/Designee will audit the Medical Records Request Tracking Log weekly x4 then monthly x2
All findings will be presented at QAPI committee x3 months.
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