MarinerMariner Health Care Health Care

QUALITY QUALITY ASSURANCE AND ASSURANCE AND MONITORING forMONITORING for

The HEALTH The HEALTH Information Information Management/Record Management/Record DepartmentDepartment

PRESENTED TO

February 15, 2010 (Northern Cal.)

February 16, 2010 (Southern Cal.)

Rhonda Anderson, RHIAPresident

Anderson Health Information Systems, Inc.940 W. 17th Street, Suite B

Santa Ana, CA 92706Tel. 714/558-3887 Fax 714/558-1302

office@ahis.net

OBJECTIVES

Participants will identify the key management principles for:– Managing the HIM/Record Department– Assuring a HIM/Record Department Evaluation is

followed up– Identifying those QA processes that are used as a

guiding principal for managing the facility.– Specifically reviewing the QA process as it relates

to managing audits

OBJECTIVES -2

Participants will…– Developing a plan for your own audit process and

follow up action plan – Identifying the ADM, MRD and HIM/Record

Consultant action/follow up.– Will review the HIPAA requirements – more

specific-- related to California Breaches regulations (SB541-SB337)

QI GOAL

Identify systems breakdown in audit process and develop and monitor interventions.

Identify those Health Information/Record Department requirements and how do you meet those.

Review of Consultant’s evaluation and what facility should do with the identified areas and recommendations.

QA PROCESS

Review of the QA Process Identify areas of concern/continuous quality

improvement processes, set out the goals, identify the criteria, collect data, identify measurement, evaluate and assess the information, analyze the causative factors, develop action plans and follow up – recycle!!

QA

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

We will spend more time on this in the future workshops.

HIM/RECORD DEPARTMENT ORGANIZATION

Review of the HIM/Record Department organization and expectations.

HIM/Record Department Evaluation 1. Location of Items in the HIM/Record Dept

(H.O. #1)

2. The Basics of organization – what are some of the key areas to maintain organization? How? What to do? Discuss.

HIM/RECORD DEPARTMENT ORGANIZATION -2

HIM/Record Department Evaluation 3. Auditing and monitoring

policy/schedule/organization/follow – up – QA reports

4. What about HIPAA. Do you know the requirements. We will review later.

HIM/RECORD DEPARTMENT ORGANIZATION -3

Identify those Health Information Department items for improvement and documentation items from the HIM/Record Consultant.

WORKSHOP EXERCISE: – Determine for your facility those areas that need

improvement, then list them.– Reconcile for all the facilities.– Facility and Corporate action plan

TOP DEFICIENCIES & FOCUSED AUDITS

1. Quality of Care – identify those audits that would measure documentation, i.e., behavior drugs, falls, restraints, pain, 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 >> resultingin update of CP.

TOP 20 DEFICIENCIES & FOCUSED AUDITS -2

3. Pharmacy Procedures – results from the new pharmacy survey, RECAPS, med/tx Documentation, etc.

4. Measure against Unnecessary Drugs – Pharmacy QI include in QA process

5. Complete Records

H.O. #2 Top 20 Deficiencies

WHY PLAN FOR AUDITS AS WHY PLAN FOR AUDITS AS PART OF QAPART OF QA

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.

QA PROCESS

Identifies and addresses quality issues; including documentation items.

Provides a tool to coordinates the qualitative documentation activities of all departments.

Establishes assessment and improvement priorities for audits and follow up.

Sets expected outcomes for documentation of resident care, services and related administrative services;

RE-ADMISSION POLICY AND PROCEDURE

What is your procedure? Do you have a clear policy and procedure? Have you and the Consultant made sure it

meets requirements?

CALENDAR

Let us review the Calendar (H.O. #3) Identify items to ??? Yourself.

– Do you have all the required audits on the calendar?

– How do you schedule the monthly audits?– How do you schedule the treatment monitoring,

what days, what input from Nursing, etc.– Admission Audits

CALENDAR -2

Other required audits and timelines. – Have they changed?– Is the monitoring process in place.

What is the follow up process? What are your biggest challenges? How will you solve them? Who will you ask

to work with you?

QA AUDITS AND MONITORING

REVIEW of the Audit Compliance Grid– This is the ‘standard” (H.O. #4)

Let’s agree on a standard!– Get input from the facilities…

QA - PLANNING

Identify those standard audits that need to be carried out.

Identify the priorities for Mariner!– The rating of where Mariner stands against

those CMS identified areas where improvement is needed.

– Determine which audits will apply to your facility.

COLLECT INFORMATION

Establish the Medical Record Director’s schedule for auditing.

Standard Audits – those are the required audits as set by Mariner.

Determine the required without exception – identify those audits/monitoring

ADMISSION MONITORING

Most common admission audit findings:– Incomplete admission assessment– Incomplete or lack of documentation on the CP

that represents key problems for which the resident was admitted.

– Other key areas.– Review and discuss

ADMSSION MONITORING -2

Set an action plan for your facility List:

HOW TO CALCULATE COMPLIANCE

Counting the number of items that met compliance (denoted as “+”).

Dividing the number of “+”s (Met Compliance) by the total number of records reviewed in that category.

Multiplying by the result by 100 to obtain the percentage.

– Example: 5 records reviewed – 3 items met

3 divided by 5 = .6 x 100 = 60%

LET’S PRACTICE!

1. Count the number of items in compliance (1st column)

2. Count the total number of records reviewed

3. Divide the number of “Met” (answer to #1) into the total # of records (answer to #2)

4. Multiply the result (answer to #3) by 100

NEW ADMISSION AUDIT

What has changed???

24-HOUR AUDIT

CompleteFace SheetWith Dx

AllergySticker

Nursing Adm.Asmn'tcomplete

Tx Ordersmatch BodyAsmn't

VS/Ht/WT

MD andalternate MDon facesheet

MatchesHospitaland adm.Records

Body Asmn'tcomplete

Admission Ordersverified

I&OInitiated

***

24-HOUR AUDIT -2

PCPStarted=Reasonadmit

Inv done w2 sig

Physical &Chem Rest

PhysicalRestraint

MatchesDevice Riskand BenefitsForm

Consent toTx

MedicareCert *

Informedconsent

RestraintAsmn't

All formscompleted

72-HOUR AUDIT

H&P Informed &Rehab potential

Admissionagreement TB Screen

PASSARResidentCapacity PIC Form

HydrationAsmn't

7-DAY AUDIT

Dietary & Followup Social Svc.

5 day MDS

Multi-DisciplineAsmn'ts (check ifcomplete)

P○ Pain

E○ Educ

R○ RestActivitiesDischplanning

SpiritualAsmn't(JCAHO)

14-DAY AUDIT

14 Day MDSRAPS/

CP Proceed

B&B Eval *Recert

21-DAY AUDIT

Care plan complete

Care Plan matches RAPs

STANDARD AUDITS

Weight audit – (may be done by others) Admission Audit Discharge Audits Psychotherapeutic drugs Specialized monitoring, i.e., review the

– H.O. #5 (Change of Condition)– H.O. #6 (Pressure Sore/Ulcer / Skin Conditions)

STANDARD AUDITS

Change of Condition – daily. Weekly skin report (done by the treatment

nurse and audited by the MRD for qualitative documentation) (HIM/Record Consultant may need to assist with the quality training).

Quantitative Reviews – is it or is it not there?

DISCHARGE AUDIT

A discharge form is not required on this record for one of the following reasons. Medical record staff is to check one reason and file this form on the front of the closed record.

Diagnoses are included in admission/discharge (face sheet) record, history and physical. In some cases a certification and re-certification form has the current diagnoses, progress notes includes condition on evaluation (if the resident was seen by the physician during the stay), physician’s orders include diagnoses to support medications/treatment.

DISCHARGE AUDIT -2

[ ] Resident was not discharged. He/she was transferred and is expected to return. See transfer form for current diagnoses, for the reason for transfer. Notations re: additional documents sent with resident.

[ ] Resident was released/discharged to home with an interdisciplinary discharge summary and post-discharge plan of care.

DISCHARGE AUDIT -3

[ ] Resident was transferred to another skilled or health care facility or assisted living. An interfacility transfer report was sent with the resident, including other identified record information, see notations of information sent.

[ ] Resident was not discharged. He/she expired. See death certificate.

[ ] Resident was not discharged. Resident left the facility { } ama-against medical advise { } left without discharge orders

{ } AWOL

AWAY WITHOUT LEAVE

Diagnoses are required by the California administrative code, Medicare/medical to identify the medical necessity for admission, specify the conditions supporting the stay and the condition at

discharge/death.

Provided based on information from Delores Galias, R.N., RHIT

AUDITS AND THE FOLLOW UP

Audit schedule with required audits and QA reporting and schedule.

Audit/Monitor Schedule (H.O. #3) on the Administrator’s and DNS desk. Follow up to assure MRD audits carried out as planned.

HIM/Record Consultants assist with above and provide training and monitoring to assist with the quality of the process.

OBJECTIVES

Participants will identify: The basic reason for physician’s orders The legal requirements for physician’s

orders The link between adequate/complete

orders and the medication and treatment records.

PHYSICIAN ORDERS

Purpose Gives clear direction in care of resident

PHYSICIAN

Orders given by physician Must be accepted by licensed nurse Must be documented on P.O. sheet Must be cosigned and dated by MD Must be maintained in chronological order Can be written by Licensed HC

professional Must be counter-initialed and dated by LN

PHYSICIAN -2

Orders received and signed via fax May be accepted Both physician office and facility to

maintain Part of Medical Record Must be clearly identified

With resident name and medical record number Every 30 days or as required reviewed and

signed by MD

RECEIVING A WRITTEN/FAXED ORDER

MD or state health care professional must write on PO or RX pad

Licensed Nurse receiving order must verify Date Time Physician signature Accurate dosage Accurate frequency Duration, as applicable Accurate route and/or site, if applicable Other info as may be necessary to carry out

order

TRANSCRIBING WRITTEN ORDER Licensed nurse (L.N.) verifies order Documents the word “noted” With his/her signature, title and date Transcribes to TAR, MAR or other document

Order not required to be documented on MAR/TAR must be followed up per facility policy*

Draw an error to box signifying the day and time

Order for limited time –Indicate the stop date Mark STOP DATE on Medication or Treatment

Record

RECEIVING A T.O./VERBAL ORDER

Repeat the order to physician/person giving order, clarify the order to be sure it is accurate

Information received should be Dosage Route of administration Time and/or frequency of administration Number of days or doses Diagnosis for medication

Write on T.O.

RECEIVING A T.O./VERBAL ORDER -2

LN records time, dates, and signs Notify pharmacy of new order, if

indicated Notify ancillary service if the order if for

a laboratory test, or other diagnostic test, consultation, etc.

MONTHLY PHYSICIAN ORDERS

Renewed every month, or as directed by law (California usually 30 days, or if facility has a 45 day stop order policy

Medical Record will conduct monthly audit To ensure signed by MD

AUDIT MONTHLY POs

MRD Care in entry of orders Follow up Review by Licensed Nursing Personnel Good time to review when you are

doing C of C for all new orders at least.

AUDIT PHYSICIAN ORDERS

Specific to drug strength and frequency “PRN” state reason and time frame TX order include site (1 per site) and

condition Diet order includes type of diet Admission activity order Orders verified with MD Orders not listed on transfer sheet – T.O. Recap of order is correct Review of orders indicated by

signature/initials

AUDIT P.O. ORDERS -2

MD signed and dated Foley order includes size Irrigation order includes type, amount of

solution and frequency (if used, not used much anymore)

NGT/GT order includes cc fluids, time period for intake

Enema order indicates type and frequency Laxative order include sequence criteria for

use

AUDIT P.O. ORDERS -3

Physical restraint order, includes medical reason and when to use

Behavior drug orders include specific behavior

Behavior control have behavior count set-up

Informed consent prior to usage (unless in effect prior to admit)

DISCONTINUATION OF ORDER

MD order required prior to discontinuation Any change in P.O. must be transcribed as

new order LN must transcribe order

Makes notation DC’d His/her initials Date

DAILY QUALITY ASSURANCE REVIEW SYSTEM

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

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”

SYSTEM BENEFITS -2

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

Promotes ID team involvement in problem identification and problem solving

SYSTEM COMPONENTS

24 hour report/shift report Incident reports Change of condition monitor Reports of

resident/family/concerns/complaints Daily quality assurance review form (log) Daily standup meeting

24-HOUR REPORT

Centralizes nursing communications on a shift by shift basis

Helps to ensure timely follow up from shift to shift or day to day

Usually the first documented indication of a new or impending problem or change of condition

An important link in the audit trail Important source of information for the IDT as well

as nursing

INCIDENT REPORTS

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

CHANGE OF CONDITION MONITOR

Complete daily prior to the standup meeting Reviews information given in the 24 hour

report, incident reports and telephone orders Identifies changes and problems requiring

follow up in the last 24 hours (or 72 hrs. over the weekend)

Centralizes and identifies changes and any deficiencies or “loose ends” in documentation

RESIDENT/FAMILY CONCERNS AND COMPLAINTS

Frequently not picked up and processed in a methodical manner

An important source of information about the resident, impending or actual problems and changes of condition

Need to be identified and addressed by the IDT in a timely manner

IDT involvement and reporting is critical

WHAT MAY INDICATE A CHANGE OF CONDITION?

Changes can be physical, mental or psychosocial

Change can be– Slow to develop and show subtle signs or– Developed rapidly with more obvious signs

and symptoms

WHAT MAY INDICATE A CHANGE OF CONDITION? -2

When reviewing the 24 hr. Report look for:– Reports to nursing by family, C.N.A.’S, R.N.A.’S, ancillary

services that something has occurred or is changing in the resident’s condition

– Don’t overlook resident/family complaints– New orders for

An antibiotic, Treatment, Physical or chemical restraint, New support or assistive device, Weight loss or gain, X-rays and labs

WHAT MAY INDICATE A CHANGE OF CONDITION? -3

Changes in orders can also indicate a change of condition. For example:– Increase in dose of psychotropic medication– A change from one type of physical restraint to

another type– A change in type of assistive device used to treat

a condition or maintain mobility– Change in treatment order because the site is not

responding

WHAT MAY INDICATE A CHANGE OF CONDITION? -4

When reviewing incident reports look for– Falls– Medication errors– Injuries/death resulting from defective equipment– Resident to resident or resident to staff

altercations

COMPLETING THE COC MONITOR

Work Session – Review of the last 5 change of condition monitors from each facility (work as a group).

Summarize issues Plan for facility and Corporate-wide

COMPLETING THE COC MONITOR -2

Look at the audit form (H.O. #5) Review the Legend at the bottom of the form

– These are the codes used to complete the form

Review the Incidents and Accidents box– These are some general related guidelines

COMPLETING THE COC MONITOR -3

Reviews information given in the 24 hour report, incident reports and telephone orders

Identifies changes and problems requiring follow up in the last 24 hours (or 72 hrs. over the weekend)

Centralizes and identifies changes and any deficiencies or “loose ends” in documentation

HITECH and HIPAA

SB541 – SB337 BREACHES

HITECH and HIPAA

SB541 – SB337 BREACHES

HITECH & HIPAA HITECH & HIPAA

ACCESS

HITECH HIPAA

SB 541

BREACHES

Privacy and Security

Privacy and Security

BreachesBreaches

Part of the American Recovery and

Reinvestment Act of 2009

Applies the HIPAA privacy and security rules and

their penalties to HIPAA business associates

Creates a new breach reporting requirement for

HIPPA CEs and BAs

Effective Date February 2009

Part of the American Recovery and

Reinvestment Act of 2009

Applies the HIPAA privacy and security rules and

their penalties to HIPAA business associates

Creates a new breach reporting requirement for

HIPPA CEs and BAs

Effective Date February 2009

California legislature that enforces reporting

requirements for unlawful or

unauthorized access, use or disclosure of a

patient’s medical information

Reporting requirement within 5 days of

discovery

Effective Date 2009

California legislature that enforces reporting

requirements for unlawful or

unauthorized access, use or disclosure of a

patient’s medical information

Reporting requirement within 5 days of

discovery

Effective Date 2009

Health Insurance Portability and

Accountability Act

Guidance for Privacy and Security of protected health

information

45CFR 160 -164

Effective Date 2003

Health Insurance Portability and

Accountability Act

Guidance for Privacy and Security of protected health

information

45CFR 160 -164

Effective Date 2003

HIPAA HIPAA

SB 541SB 541HITECH ACT HITECH ACT

HITECH STATE LAW Vocabulary HITECH STATE LAW Vocabulary

• Breach – the unauthorized acquisition, access, use or disclosure of protected health information which compromises the security or privacy of such information

Breaches ElectronicBreaches Electronic

• The notice to individuals must contain a description of what happened and the PHI involved, efforts to investigate, mitigate and prevent further breaches and contact information.

No Safe HarborNo Safe Harbor

• California covered entities are still required to report unlawful or unauthorized access, use or disclosure of a patient’s medical information within 5 days to comply with SB 541 – which has been in effect since January 2009

Penalties Penalties

• SB-541 – failure to report within 5 days

$100 per day for each day that the unlawful or unauthorized access, use or disclosure is not reported up to a maximum of $250,000.

HIPPA Civil Penalties Under New HITECH Provisions

Effective November 30, 2009

HIPPA Civil Penalties Under New HITECH Provisions

Effective November 30, 2009

Violation Category Each Violation

All such violations of an identical provision in a calendar year

Did not know $100-50,000 $1,500,000

Reasonable Cause $1,000-50,000 1,500,000

Willful neglect corrected within 30

days $10,000-50,000 1,500,000

Willful neglect - not corrected

$50,000 1,500,000

Risk Analysis and Implementation Risk Analysis and Implementation

• AHIS will help you analyze possible areas of risk

• Provide you with guidance on documentation of investigation and notification of breaches

AHIS As Your Partner AHIS As Your Partner

Implementation Plan

Risk Analysis

Policy and Procedure

Current system review

Action as needed

RECORD DEPARTMENT NEEDS

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RECORD DEPARTMENT NEEDS -2

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FORMS

Who orders and sign up. One sign in sheet for forms, include name,

facility, address, phone and email address.

OFFSITE STORAGE

When? What is required – reference to the

HIM/Record Manual? YOUR ACTION PLAN!

Follow up

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THANK YOU FOR ATTENDING!

Please Complete and Leave the Evaluation with the Instructor