Country Hills Post Acute

Let each resident or the resident's legal representative access or purchase copies of all the resident's records. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to make medical records available for Family Member (FM) 1 to review within 24 hours of the request, for one of two sampled residents (1). As a result, Resident 1 was not aware of the details of his medical record and the facility violated his right to access his medical records.Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include heart failure, deaf (inability to hear) nonspeaking, and parkinsonism (a group of symptoms that include difficulty moving).

Per the facility's Authorization Form for the Release of Health Information, dated 11/22/24, Resident 1 authorized the facility to release his medical records to FM 1.

Per the facility's Authorization Form for the Release of Health Information, dated 3/18/25, Resident 1 authorized the facility to release his medical records to FM 1. On 7/3/25 at 11:27 A.M., an interview and record review was conducted with the Medical Records Director (MRD).

The MRD stated, FM 1 requested copies of Resident 1's medical records but FM 1 did not want to pay for the copies.

The MRD further stated, FM 1 then requested to review Resident 1's medical records if he could not obtain copies for free, but the facility told FM1 that they would still charge FM1 to review Resident 1's records.

The MRD stated that the facility discussed FM 1's record request with him by email.

Per an email thread on 12/5/24, FM 1 notified the facility that he wanted to inspect Resident 1's records in person.

The facility Administrator responded to FM1's email stating that FM 1 would still have to pay the facility to review Resident 1's records in person.

The MRD stated that FM 1 never reviewed Resident 1's medical records at the facility.Per the facility's policy, titled Release of Information, revised November 2009, 8.

The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes.9. A resident may have access to his or her records within ____ hours (excluding weekends or holidays) of the resident's written or oral request.

The policy did not specify how many hours the facility had to make the records available for review.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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