Complaint Investigation Report

Allegation: Staff did not make resident's records available to their designated representative upon written consent

On 07/01/2025, Licensing Program Analyst (LPA) L. Alexander interviewed Witness (W1). W1 stated that on 06/04/2025, they submitted a request for R1’s file via fax. After allowing one week for acknowledgment, W1 followed up with the facility on 06/11/2025 by emailing the authorization and status request to Staff (S2) and leaving a voicemail message. W1 reported no response was received. W1 confirmed that R1 was a former resident of the facility.

On 07/02/2025, LPA interviewed Staff (S1). S1 confirmed a faxed request was received but stated they were unsure which document W1 was referring to due to the volume of faxes. S1 stated that per facility policy, once a resident leaves the facility, S2 is responsible for reviewing and releasing records.

LPA reviewed the following documents: Authorization to Handle Claim (05/29/2025), Authorization to Release Medical Documents (06/04/2025), Durable Power of Attorney for Financial Management (05/20/2023), Advance Health Care Directive (05/20/2023), Subpoena Request for Medical Records (06/04/2025), and the facility’s Policy for Release of Resident Records. Documentation verified that R1’s legally authorized representative was acting on R1’s behalf.

On 09/14/2025, S1 confirmed the requested records had been sent. On 09/15/2025, LPA followed up with W1, who confirmed the records were received on 08/19/2025—approximately two months after the initial request. The preponderance of evidence demonstrates that the facility did not release records within a reasonable or timely manner. Therefore, the allegation is substantiated .