HEALTH INFORMATION / RECORD SYSTEMS “Non-Negotiable” Monitoring Systems Process for CQI – Phase I

Presenters Diane Settle, RHIT Director of Health Information Khaleelah Wagner, RHIA Director of Operations, AHIS Rhonda Anderson, RHIA President, AHIS 2

Date & Time Date:February 17, 2015 Time – Attend one session – Refer to from Rockport Offices AM PM 3

Objectives Participants will identify: Admission Monitor and instructions Change of Condition Monitor content and instructions The Monitor follow-up process for Change of Condition Medical Nutritional Therapy monitor & follow up Medication and Treatment Monitoring Physician visit & H & P Monitoring and follow up The calendar – Phase I of the CQI monitoring process 4

Objectives (cont.-2) Participants will identify: The stand up reporting & follow up system The weekly & monthly trends and report to CQI 5

Schedule I 6

Schedule (cont.-2) Monitor Phase I With priorities identified by _____”*”____________ for CQI monitoring Example – You can schedule day of week per facility practice 7

Schedule (cont.-3) Grey out areas – May be part of current schedule Will be focus of future webinars Choose a day a week for example to review physician visits & H & Ps’ due Schedule available made available for review by management, DON, others; CQI reporting 8

Admission 9

Admission (cont.-2) Admission and readmit daily, as applicable – 24,72, 7, 14, 21 days Take Admit Monitor to stand-up and identity follow up until 100% or resident compliance “MORE” Pay attention to high risks!!! i.e. neuro, new infection; psychotherapeutic drugs on admission and “MORE” 10

Admission (cont.-3) Re-admission resident out greater than 24 hours – same process >> for record content – timeliness - accuracy Monitor form – see Example I. If added notes needed to explain, utilize the comments page – sample in the packet Note the next slide – instructions on the back of the monitor – will find most monitors include instructions for quick reference 11

Admission (cont.-4) 12

Discharge Chart Monitor New procedure for prior process New procedure for prior process Medicare documentation Focus on record completion timely and support accuracy of Medicare documentation Content is also directed for Rockport Medicare Reviewers access internal = ‘monitoring’ New process – on retaining the monitor re: completion/filing/retention Review the instructions re: completion/filing/retention 13

Discharge (cont.-2) 14

Discharge (cont.-3) 15

Discharge (cont.-4) 16

Discharge (cont.-5) When to complete: Discharge from Medicare Discharge from Medicare and facility Discharge from Medicare and staying in facility (keep the Discharge from the Medicare Monitor until resident is discharged from facility and use the same monitor) 17

Discharge (cont.-6) Keep Discharge Medicare and Final Discharge Monitor for ease of location for the facility staff at the time of discharge from Medicare or from the facility, for Rockport UR/Medicare Reviewers and for outside reviewers 18

Discharge (cont.-7) KEEPING THE DISCHARGE MONITOR: Keep in the overflow folder or notebook – alpha order and pull the Medicare Discharge Audit and complete remainder of the monitor at discharge Comments POLST – Needs to go with resident to hospital and home – ensure it is copied after completed on admission – after Dr. sees resident & completes the POLST – include in active chart 19

Discharge (cont.-8) 20

Discharge (cont.-9) 21

Change of Condition 22

Change of Condition (cont.-2) 23

Change of Condition (cont.-3) Allow 24 hours – for Review: Any change for the resident: increase in meds or new medication, i.e., elevated temperature, resident found on floor; Skin condition changes – increase in Psychotherapeutic Drug, Pain, not previously identified “ACTION” -- Follow up 24/48/72 hours, until complete, as applicable 24

Change Of Condition (cont.-4) System to identify C of C >> 24 hour log & telephone orders Allow 24 hours – for Review: Other internal systems Take C of C report to standup Discussion at standup re: action and follow up Report follow up next day until documentation ??? Resolved Review the Standup flow chart – from this session 25

Certs & Recerts 26

Certs & Recerts (cont.-2) Complete for each Cert/Recert due Track for timeliness and completion Statement of continued need for the reason for skilled care (not just restated on an order) All portions of the Cert/Recert must be complete, dates accurate based on required due dates Delayed certs should be used rarely – but an option. (Use that procedure – check compliance requirements ) 27

Certs & Recerts (cont.-3) Signature must be legible, dated – match Signature Sheet Signature Signature Sheet – if you use one, use current process, assume legible signatures Without legible signatures – claims may be denied 28

Medical Nutritional 29

Medical Nutritional Therapy (cont.-2) Dietician provides a copy of RD recommendations for follow up to DON & HIM/Records Dept. for Review of the recommendations from the Dietary Consultant – to determine action needed HIM/Records - Follow up on documentation recommendations to determine if they were addressed by Nursing with physician and follow up (as applicable) Report status at stand up and CQI 30

Medical Nutritional Therapy (cont.-3) 31

Medication Monitoring Quantitative MAR/TAR narratives MAR/TAR – Monitor – Daily for last 24 hours – One (1) sheet per each day Daily with immediate follow up Include name of Nurse CQI – The monitor is intended for continuous CQI process evaluation of the treatment management system CQI – The monitor is intended for continuous CQI process evaluation of the treatment management system 32

Medication (cont.-2) 33

Medication (cont.-3) 34

TAR & MAR 35

TAR & MAR (cont.-2) Identify date monitor is conducted “what that means to the MRD” Narcotic Book monitoring Monitor of PRNs for MAR/TAR Identification of Medication Who receives copies (cc:) of Monitor Legalities & Risks CQI focuses 36

Physician Visit & H&P Use the Physician Visit and H&P log. (If you already use such or a General Update Log / Clinical Record Monitor – continue to use it – must contain visit dates and H&P due dates, monitoring and follow up = compliance Identify trends and physicians who are not timely Work with the Medical Director & CQI to reduce untimely H&P/Visits as applicable 37

Physician Visit & H&P (cont.-2) 38

Physician Visit & H&P (cont.-3) 39

Stand Up Flow Process – Monitor Focus 40

Stand Up Flow Process – Monitor Focus (cont.-2) Monitor Calendar used Identify Change of Condition – utilize the resources for COC – 24 hr. report, new admits, new antibiotics, falls, incidents, hospitalization, Dischg. Resident/family concerns 41

Stand Up Flow Process – Monitor Focus (cont.-3) Identify items from Monitor needing follow up Identify items not completed from prior Monitors Stand up “staff” indicate who is to follow up following Monitor and response Focus on monitors, timely, completion of documentation w/in legal record requirements 42

Monitor Follow Process Binder at Nursing station Follow up process and managing the follow through to completion within the legal limitations (depending on the situation and risks, incident reports may be required) Avoid copying individual nurse Monitor and lots of paper – HIPAA concern 43

Monitor Follow Process (cont.-2) Concerns re: late entry! Remember this is a legal medical record whether electronic or paper. What is in the computer is can also be recovered, even if you are allowed to delete; change, update – the prior record is not gone!! 44

Questions and Answers!! When do I start or revise the process I currently have, if needed? By March 1, 2015 By March 1, 2015 Who will be my resource? Diane Settle; her at ROCKPORT HealthCare Services; –cell Anderson Health Info. Systems at and w/reference to Khaleelah Wagner or Rhonda Anderson 45

THANK YOU Thanks for your great work; your work for tomorrow and the support of our clinical team. 46