Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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 provide a reasonable cost-based fee for the provision of
medical records for 1 of 2 residents (Resident #1) who were reviewed for access to medical records.
The facility failed to charge the RP, for Resident #1, reasonable prices for medical records cost determined
in the Texas Health and Safety Code, Title 4. Health Facilities; Subtitle B. Licensing of Health Facilities;
Chapter 241. Hospitals; Subchapter A. General Provisions; Section 241.154 (THSC 241.154.)
This failure placed residents, or their RP, at risk for complications with continuity of care and financial
hardship.
Findings included:
Record review of Resident #1's Discharge MDS, dated [DATE], reflected the Resident was a [AGE] year-old
female who admitted to the facility on [DATE]. She was diagnosed with peripheral vascular disease (which
was slow and progressive circulation disorder caused by narrowing of the blood vessels.) Section C.,
Cognitive Patterns: Indicated Resident #1's short-term memory was appropriate; independent decisions
were consistent and reasonable. Staff assessed BIMS.
Record review of a release of information request, dated 2/12/2024, reflected RP #2's request for Resident
#1's medical records from the facility.
Record review of an invoice, dated 3/8/2024, reflected a cost breakdown for the medical records requested
on 2/12/2024. The total cost was $274.28 for 216 pages. The invoice was sent by MRC A to RP #2. The
cost breakdown reflected:
1. Pages 1-10 = $52.12 (search fee); 10 pages; Cost equaled $52.12
2. Pages 11-60 = $1.76 (per page); 50 pages; Cost equaled $88.00
3. Pages 61-400 = .86 (per page); 156 pages; Cost equaled $134.16
Invoice to RP #2, dated 3/8/2024, reflected $52.12 + $88.00 + $134.16= $274.28
Record review on 7/17/2024 of Texas Health and Safety Code, Title 4. Health Facilities; Subtitle B. Licensing
of THSC 241.154, effective date 5/27/2023, reflected: (1) a basic retrieval or processing
(continued on next page)
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
675924
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675924
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Woodway Rehabilitation and Healthcare Center
7801 Woodway Dr
Waco, TX 76712
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
fee, which must include the fee for providing the first 10 pages of the copies and which may not exceed
$30; and (A) a charge for each page of: (i) $1 for the 11th through the 60th page of the provided copies; (ii)
.50 cents for the 61st through the 400th page of the provided copies.
Having used a calculator on a state issued iPhone on 7/17/2024: Calculations for the 216 pages of
Resident #1's medical record copies, based on THSC 241.154 reflected:
1. Pages 1-10 = $30.00 (basic retrieval and processing fee); 10 pages; Cost equaled $30.00
2. Pages 11-60 = $1.00 (per Page); 50 pages; Cost equaled $50.00
3. Pages 61-400 = .50 (per page; 156 pages; Cost equaled $78.00
Calculations with THSC 241.154 reflected $30.00 + $50.00 + $78.00= $158.00
Having used a calculator on a state issued iPhone on 7/17/2024: $274.28 - $158.00 = $116.28 of an
inflated cost.
Interview on 7/17/2024 at 9:45 AM with MRC B revealed the invoice for Resident #1's medical record
copies was created on 3/8/2024, and sent to RP #2, by MRC A, who no longer worked at the facility. MRC
B stated the CCO, from the corporate offices was the person who calculated the prices for medical records
and calculated the amount of $274.28 for Resident #1's medical record copies.
Interview on 7/17/2024 at 10:15 AM with RP #2 revealed the facility was unjust in asking for $274.28 for
copies of Resident #1's medical records. Upon his own research with RP #3, he stated the cost was
supposed to had been much lower. He had hoped the matter could be resolved so he could have attained
the medical records at a reasonable cost.
Interview on 7/17/2024 at 10:25 AM with RP #3 revealed the facility had charged inflated rates for Resident
#1's medical record copies. RP #3 stated she researched Texas law and determined the rates for medical
records were supposed to be a basic retrieval or processing fee, which must include the fee for providing
the first 10 pages of the copies and which may not exceed $30; and a charge of $1.00 for the 11th through
the 60th page; and .50 cents for the 61st through the 400th page. RP #3 wanted the discrepancy addressed
and the facility to follow the guidance she discovered through her own research of Texas law.
Interview on 7/17/2024 at 11:13 AM with the CCO revealed she was the Chief Compliance Officer for the
facility's corporate offices. She stated the corporate offices followed the guidelines in THSC 241.154 when
having determined reasonable cost for medical record copies; however, the invoice of cost provided to RP
#2, dated 3/8/2024, for Resident #1's medical record copies was not correct. The CCO stated THSC
241.154 was utilized for the reasonable cost of medical records in the facility's Release of Medical Records
Policy, dated January 2023. The THSC 241.154 was updated, on 5/27/2023, to reflect a reduction of
reasonable cost, but the facility's Release of Medical Records Policy, dated January 2023, was not updated
to reflect the new reasonable cost. Resident #1's medical record copies invoice, dated 3/8/2024, utilized
calculations with the outdated version of THSC 241.154. The CCO stated the cost for Resident #1's medical
record copies, calculated on the invoice on 3/8/2024, was based on an outdated THSC 241.154, prior to the
5/27/2023 update, and on the facility's Release of Medical Records Policy dated January 2023, which she
should have reflected the update. She stated she discovered the discrepancy in April 2024 and updated the
facility's Release of Medical Records Policy
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675924
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675924
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Woodway Rehabilitation and Healthcare Center
7801 Woodway Dr
Waco, TX 76712
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
on 4/29/2024 to reflect the new THSC 241.154 guidelines for reasonable cost for medical records, effective
5/27/2023. The CCO stated the corporate offices did not reach out to RPs, who had requested copies of
medical records between 05/27/2023 and 4/29/2024, to inform them they had been charged inflated prices.
Interview on 7/17/2024 at 1:25 PM with MRC B revealed she took the position over as medical records
coordinator about a month ago with a Release of Medical Records Policy, dated 4/29/2024. MRC B stated
RP #2 or RP #3 had not contacted the facility to address the cost provided in the invoice, dated 3/8/2024,
for Resident #1's medical record copies. MRC B stated she had no knowledge that the prices in the invoice,
dated 3/8/2024, were calculated with prices from an outdated version of THSC 241.154, prior to 5/27/2023,
or a non-updated facility policy, dated January 2023. MRC B stated the failure to have updated prices and
an updated policy, at the time the medical records were requested on 2/12/2024, fell upon communication,
not checking the policy, or verifying the prices. MRC B stated access to medical record was important for
residents who needed to continue care elsewhere. As well, the inflated cost $116.28 was a lot of money
and could have gone elsewhere for better use.
Interview on 7/17/2024 at 1:37 PM with the CCO stated the costs associated with copies of medical records
came from the corporate offices. The failure for the facility to have the correct information fell at the
corporate level. There was a leadership change, and the failure was human error on behave of corporate.
Safeguards in place to avoid this type of this failure were policy reviews and meetings with the compliance
teams. The CCO stated the addition expenses for the medical records copies placed the requestor at risk
for financial hardship.
Interview on 7/17/2024 at 2:20 PM with the ADM revealed medical record release, and reasonable medical
record release cost, were important for continued care. She expressed dissatisfaction the facility was being
held responsible for a failure at the corporate level.
Record review of the facility's Release of Medical Records Policy, dated January 2023, reflected basic
retrieval and processing fee not to exceed $52.12 for the first 10 pages. $1.76 per page for pages 11-60.86
cents per page for pages 61-400.47 cents per page for any remaining.
Record review of the facility's Release of Medical Records Policy, dated April 29, 2024, reflected basic
retrieval and processing fee not to exceed $30.00 for the first 10 pages. $1.00 per page for pages 11-60.50
cents per page for pages 61-400.25 cents per page for any remaining.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675924
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F573 - The resident has the right to access personal and medical records pertaining
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
FAQ · About this visit
Common questions about this visit
What happened during the July 17, 2024 survey of WOODWAY REHABILITATION AND HEALTHCARE CENTER?
This was a inspection survey of WOODWAY REHABILITATION AND HEALTHCARE CENTER on July 17, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WOODWAY REHABILITATION AND HEALTHCARE CENTER on July 17, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Let each resident or the resident's legal representative access or purchase copies of all the resident's records."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.