CMS SOM App. PP, Tag F573

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.

DEFINITIONS §483.10(g)(2)-(3)

“Records,” includes all records, in addition to clinical records, pertaining to the resident, such as

trust fund ledgers pertinent to the resident and contracts between the resident and the facility.

GUIDANCE §483.10(g)(2)-(3)

An oral request is sufficient to produce the resident’s personal and medical record for review.

The facility may charge a reasonable, cost-based fee for providing a copy of the requested

records, whether in paper or electronic form. This may only include the cost of labor for copying

the records, supplies for creating the paper copy or electronic media, and postage, if applicable.

Additional fees for locating the records or typing forms/envelopes may not be assessed.

KEY ELEMENTS OF NONCOMPLIANCE §483.10(g)(2)-(3)

To cite deficient practice at F573, the surveyor’s investigation will generally show that the

facility failed to do one or more of the following:

• Support the resident’s right to access his or her own personal and medical records; or

• Provide the resident access to his or her personal and medical records within 24 hours

(excluding weekends and holidays) of a written request; or

• Allow the resident to purchase a copy of his or her personal and medical records upon

request and with 2 working days advanced notice; or

• Charge a reasonable, cost-based fee, including only the cost of labor, supplies, and

postage involved in providing or sending the personal and medical records requested; or

• Ensure the information is provided:

o In a form the resident can access and understand ;or

o In a form and format agreed upon by the facility and the resident.