The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

WESTCHESTER MEDICAL CENTER 100 WOODS RD VALHALLA, NY 10595 Feb. 9, 2016
VIOLATION: PATIENT RIGHTS: ACCESS TO MEDICAL RECORD Tag No: A0148
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and staff interview, in 1 (one) of 5 (five)medical records reviewed, it was determined that the facility did not provide the patient's authorized relative, a copy of the medical record within ten (10) working days, as per facility policy (Patient #1).

Findings include:
Review of the facility document (untitled) of patients who expired from July to September 2015, revealed: patient #1 died on [DATE]. The patient's husband requested an autopsy immediately. The facility document titled "Expirations with request for records," stated the 1st request for the medical record was received on 10/23/15 by the facility.

The facility contractor notified the husband in a letter dated 11/19/15 stating; "Unfortunately we will not be able to comply with your request due to the following:
The Authorization to release the records is not valid in accordance with State or Federal Law. Clarify in section 5 of the HIPPA Authorization what it is that is needed. Only check one box."
The "Authorization to Use or Disclose Protected Health Information" form states in #5; "The information to be used or disclosed is as follows: (check the appropriate boxes and INCLUDE THE APPROXIMATE DATES OF SERVICE)."

There were 4 boxes of options given. The Husband, who is the requestor of the records selected 2 options which states:
" Entire record 9/9/2015-9/14/15.
" Other- (please describe) Provisional Autopsy plus full Autopsy upon completion."

The husband sent the following document with the request:
1. Affidavit- which was notarized and dated 10/24/15.
2. Certificate of Death- certified copy.
3. Authorization to Use or Disclose Protected Health Information- signed by the requestor on 10/15/15.

The Provisional autopsy report was completed on 9/21/15 and the full autopsy report was completed on 11/27/15.


The facility documented in the recording system (marked Prism Web), that the request was received on 10/23/15

During interview on 2/4/16 at 11:50 AM, the Director of Health Information Management Staff #Q, verified that there were unusual delays in processing the Request of Information (ROI) because the staff did not know the policy and procedure and should have released the record based on the 1st valid request sent in by the husband.


A review of the facility policy and procedure titled: "Request for Release of PHI," revised 1/2014, states on page 7 of 21, Section "D"; "A copy of the requested information will be provided within ten (10) working days, provided a valid written authorization is presented."

The facility received a valid written authorization, presented by the husband on 10/23/15, requesting release of the patient's medical record and the autopsy report.

The facility released the medical record to the husband 4 months later on 1/5/16 after several follow-up calls and 3 written requests.