H EALTH I NFORMATION AND A DMINISTRATIVE P OLICY U PDATES Presented by Staci LePage, RHIT Anderson...

HEALTH INFORMATION AND ADMINISTRATIVE POLICY UPDATES

Presented by Staci LePage, RHIT Anderson Health Information Systems Inc. 714-558-3887 Fax [email protected], [email protected]

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OBJECTIVES The participants will:

Review the latest requirements for Safety and the focused policies and procedures & Quality Assurance process

Identify those areas in the revised Policies and Procedures updates

Identify some of the latest HIPAA changes and how these will affect the future electronic record and electronic transmission of Protected Health Information

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OBJECTIVES -2

Participant will… Review of Discharge Procedures – safety and

security of the medical record – revisit Change of Condition – What It Means to You New Laws update Falsification of Records and Correction of audits

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POLICY UPDATES Committees – SB 158

Inclusion of Safety Committee requirements Must meet at least yearly Can be part of QA/CQI Committee (see H.O. #1) Must have separate minutes

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SB 158 SAFETY Administrative update includes a checklist

to assist in identification of related safety requirements to ensure compliance (see H.O. #2).

Injuries / Illness prevention program – Hand washing program included with policy update – this is a focus related to SB 158.

Training of staff has been a key focus.

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Responsible for the overall direction of the facility’s quality improvement functions through a quality assessment/improvement program/plan.

QUALITY ASSESSMENT

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TOP DEFICIENCIES & FOCUSED AUDITS

1. Quality of Care – identify those audits that would measure documentation, i.e., behavior drugs, falls, restraints, pain, CHANGE OF CONDITION, etc.

2. Care Plans – Identify where the most deficiency is applicable to your facility; at C of Condition, after IT Team Quarterly Reviews with the MDS, resulting in update of CP.

3. Measure against Unnecessary Drugs – Pharmacy QI include in QA process Complete Records. 7

In order to ensure that the documentation of the quality of care and services provided to all residents meets the needs of the residents and reflects high quality outcome of services and care process.

Documentation supports those services and we can document the quality of services.

Part of your Safety Plan.

WHY PLAN FOR AUDITS AS PART OF QA

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SYSTEM BENEFITS

Reduces duplication of efforts Follow up tasks identified and assigned

to staff on specified due dates

Focus on: Timely identification of

deficiencies/problems Prevention of repeat

deficiencies/problems Continued review of follow through until

resolution so that nothing “falls through the cracks

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Used to identify problems, concerns and conditions where additional follow up, review or referral are needed or desired

A method of continuous quality care outcome review

Action/results oriented Part of your safety plan

DAILY QUALITY ASSURANCE REVIEW SYSTEM – CHANGE OF CONDITION

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Utilizes time spent in daily stand up meeting to maximize results – quality outcomes

Promotes ID team involvement in problem identification and problem solving – Daily Safety!!!

SYSTEM BENEFITS

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Another important link in the audit trail

Provides detailed information that must be carefully documented, reviewed and trended

Must be integrated into the QA process ongoing

Daily review of reports to ensure quality outcomes and timely follow up

INCIDENT REPORTS

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Biggest change to HIPAA requirements to date

Defines unsecured electronic PHI Outlines reporting requirements for breaches

of unsecured PHI Outlines reporting requirements for business

associates

HITECH ACT

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Administrative #2030 has been updated to comply with the business associate requirements for reporting of breaches.

All BA agreements need to be updated. The facilities should have received a CD from

North American Corporate Office – via mail to Administrator!!

Has your B.A. agreement been updated?

BUSINESS ASSOCIATES

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SB 541 requires notification of the department within 5 days of discovery of an unauthorized disclosure of PHI.

SB 337 modifies this requirement to mean 5 “business days”.

Both Administrative (see H.O. #3) and HIM (see H.O. #4) policies have been updated.

SB 541 AND SB 337

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A new policy for those facilities / areas using POLST (Admin #6007).

Policy includes physician order part and the requirements.

Flow chart of steps required from the facility included (see H.O. #5).

POLST

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Policy developed for Red flags/ Identity theft prevention program NOT DUE YET..NEW DATES…??? There is a date but will wait and see!!

Facility must have a program in place to detect possible medical identity theft – check insurance, Medicare, Medi-Cal cards, other identification … prevent fraudulent use of identification.

Program must be reviewed and approved by Administrator.

RED FLAGS

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Willful Omission and Willful Falsification of Records….How to Avoid the Risks

PRINCIPLES OF DOCUMENTATION

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Why is this important with AUDITS and WHAT CAN YOU DO TO KEEP A LEGAL RECORD WITHOUT COMPROMISING LEGAL REVIEWS / $$ REVIEWS, and reflect that the quality of care and services were provided and when there is a way to clarify documentation?

PRINCIPLES

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Every entry is recorded promptly after the care/tx is given, i.e., for medications/treatments the documentation is done at the time of the med/tx. Food intake, at the end of the meal Intake and output – at the time of measure of the

intake and the output

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Complete, concise, accurate!!accurate!! Made by the person carrying out the care/tx

(not by another person for someone else) MDS signatures must be by the assessor for instance.

Chronological Used abbreviations only if approved by the

facility and in the manuals In black or dark blue ink or typewritten

(automated, printed documents clear, not too dark/light)!!

ENTRIES

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ENTRIES -2

Must be capable of being copied Must be legible PRINTER INK --- A NEW ISSUE!! Must be dark

enough to copy!! Highlighters may cause obliteration when

copied – recommend against use. Include date, month, year and time if

appropriate. Signed by appropriate person with

professional title, i.e., C.N.A., R.N., L.V.N. (electronic signatures are tracked whether you know or not and timed)!! In the electronic system!!!

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Do Not Use White out, write over an entry, black out an entry Sign for another person Copy records or completing any portion of a

record without your personal knowledge the care was given, the data is accurate. Otherwise this could be construed as “falsification of records”

Do not leave blank spaces Do not document before an entry occurs

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CORRECTIONS

Records may be corrected by: Drawing one line through the

error; Designate error; Initial the error; Chart the correct information

with date and time if applicable.

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FACTUAL, ACCURATE Entries in the record shall be factual Accurately reflect the services provided to

the resident Accurately reflect the condition

of the resident Accurately reflect the resident’s response to

treatment and services

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WILLFUL FALSIFICATION

All staff shall be aware that an entry in the record that is made with the knowledge that the record falsely reflected the condition or situation is “willful material falsification”.

Subject to civil penalty and $$ may be the employee’s personal responsibility!

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NEW ISSUE ELECTRONIC RECORDS – method for

correction, amendment. What do you know? Is there is an audit trail and any changes can be

tracked? More information later on the electronic

record modules, i.e., CareTracker. What has been done??? Need to check with

Rhonda re: legalities and pol/procedures.

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PROTECTING THE INTEGRITY OF THE RECORD How are you protecting your discharge

records?

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DISCHARGE RECORDS RECORDS OF RESIDENTS SENT TO ACUTE,

DISCHARGED. Legalities of the medical record intact; Discharge records completed within required

times frames; Maintained and secured.

This includes records of residents sent to the acute hospital, ER and admitted residents.

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RESIDENT TRANSFERRED OUT / DISCHARGED

A. Records for residents sent out during the day. The ______________ will: 1) Secure the record obtain all loose

papers for filing, medication, treatment/therapy records immediately following discharge

2) Take the record to the Record Department

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TRANSFERS TO ER/ACUTE

B. Residents transferred to ER/Acute the ? will: 1) Secure the record 2) Obtain all loose papers3) Place the record in a secure location in the

medication room

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DISCHARGE RECORDS AFTER HOURS

C. Discharge records after hours and on weekends1) Nurse in Charge

a) Place these discharges in the Medication Roomb) Secure the medical record in a location specified in

the Medication Room

2) The DNS and HIM/Record Designee will: a) Check the discharge/transfer record for completion

to determine if the documentation that led up to discharge/transfer reflects the care and treatment given/clinically appropriate and complete the record as legally allowed

b) Check the summary of care for completion/ determine if the post-discharge plan of care was complete and provided to the resident as indicated

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TRANSFER RECORDS AFTER HOURS Transfer to ER/Acute transfers to another

skilled nursing or assisted living facility: Check the inter-facility transfer form and notes

for completeness Amend or make late entries only using

appropriate legal procedures

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COLLECT ALL DISCHARGE RECORDS Collect all flow sheets immediately following

discharge to avoid erroneous entries Secure the record Any late entries made to the record must be

discussed with DON Any staff requiring access to the discharge

records must check out the record from the HIM department or DON’s office

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REVIEW OF PAST AGREEMENTS Review of H.O. and the past agreements. Review of the key items and what is the

current status in the facility. The prevention of survey and legal issues,

follow the rules for transfers/discharges.

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PROTECTING THE RECORDS

Make sure all records removed from the nurse’s station are signed out!

Always know the location of the records and who is accessing the information!

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PAST AGREEMENTS

Current items.List follow up needed at your facility:1.2.3.

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ADMINISTRATIVE MANUAL UPDATES More Administrative Policy and

Procedure Updates will be coming via: Email to Administrators (& MRDs if

provided) A CD sent to the Administrator from

corporate Also, ASK YOUR HIM CONSULTANT!!!

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OTHER ITEMS YOU SHOULD KNOW!!

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OTHER ITEMS YOU SHOULD KNOW!! -2

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POSTING CITATIONS

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POSTING CITATIONS -2

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INFORMED CONSENT

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INFORMED CONSENT -2

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INFORMED CONSENT -3

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INFORMED CONSENT -4

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INFORMED CONSENT -5

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INFORMED CONSENT -6

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INFORMED CONSENT -7

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PSYCHOTHERAPEUTIC DRUG AUDIT Let’s review those requirements – key items. Should be part of your QA!! H.O. re: Flow Chart for Psychoactive Drug

Consents (see H.O. #6).

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KEY HIM/RECORD MANUAL UPDATES These were provided to the facilities,

included audit updates, Admission, Adv. Directive, Behavior – Psychotherapeutic Monitor, HIPAA Amendment, 7002 & 7003 regarding the Misuse and unlawful or unauthorized disclosure, Leaving Against Medical Advise, etc.

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PSYCHOACTIVE DRUGS MONITOR UPDATE (see H.O. #7)

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EMERGENCY DRUG SUPPLY ASK YOUR PHARMACISTS – NEW

REQUIREMENTS POLICIES AND PROCEDURES HAVE TO BE

UPDATED.

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MORE AND MORE Dual Enforcement – state deficiencies reports

to CMS for some areas. State Survey focus

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TO DO WHEN I GO HOME Each of the Manuals, Administrative (H.O.

#3) and the HIM/Records (H.O. #4) has a checklist. Please see your consultant if you need assistance.

MY LIST OF ITEMS TO DO!!!

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MY LIST OF ITEMS TO DO

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MY LIST OF ITEMS TO DO

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YOUR AHIS CONSULTANT

Will assist you with manual / policy updates Can assist with focused studies as part of QA Can assist with trending and analysis of audit

findings Can assist with staff training and in-services

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EVALUATION AND FEEDBACK List the items you would like covered in the

next seminar for directors

For HIM/Record Staff

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THANKS FOR ATTENDING!

Staci LePage, [email protected]

AHIS, Inc.940 W. 17th Street, Suite B

Santa Ana, CA 92706714/558-3887

Fax 714/558-1302

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H EALTH I NFORMATION AND A DMINISTRATIVE P OLICY U PDATES Presented by Staci LePage, RHIT Anderson...

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Transcript of H EALTH I NFORMATION AND A DMINISTRATIVE P OLICY U PDATES Presented by Staci LePage, RHIT Anderson...