Health Information and Administrative Policy Updates Presented by Rhonda Anderson, RHIA Anderson Health Information Systems, Inc

Presented to UNIFIED CARE SERVICES, LLC 2368 Torrance Blvd., Suite 200 Torrance, CA March 22, 2010

OBJECTIVES The participants will: – Review the latest requirements for Safety and the focused policies and procedures – Identify those areas in the revised Policies and Procedures that will change any of their current processes in the facility – Identify some of the latest HIPAA changes and how these will affect the future electronic record and electronic transmission of Protected Health Info. – Review POLST policies and procedures

POLICY UPDATES Committees – SB 158 Inclusion of Safety Committee requirements Can be part of QA/CQI Committee Must have separate minutes

SB 158 – continued… Administrative update includes a checklist to assist in identification of related safety requirements to ensure compliance 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

HITECH ACT 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

BUSINESS ASSOCIATE!! Policy 2030 has been updated to comply with the business associate requirements for reporting of breaches. All BA agreements need to be updated. *** Identify your BA and take action

SB541 and SB337 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 and HIM policies have been updated

POLST A new policy for those facilities / areas using POLST Policy includes physician order part and the requirements Flow chart of steps required from the facility included

RED FLAGS Policy developed for Red flags/ Identity theft prevention program due now in April, 2010 Facility must have a program in place to detect possible medical identity theft Program must be reviewed and approved by Administrator.

ADMINISTRATIVE MANUAL UPDATES More Administrative Policy and Procedural Updates will be coming: this is how; – Via or via a CD sent to the Administrator!! – Also, ASK YOUR HIM CONSULTANT!!!

OTHER ITEMS YOU SHOULD KNOW!!

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POSTING OF CITATIONS

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INFORMED CONSENT

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PSYCHOTHERAPEUTIC DRUG AUDIT Lets review those requirements – key items. Should be part of your QA!!

EMERGENCY DRUG SUPPLY ASK YOUR PHARMACISTS – NEW REQUIREMENTS POLICIES AND PROCEDURES HAVE TO BE UPDATED.

MORE AND MORE Dual Enforcement – state deficiencies reports to CMS for some areas. State Survey focus HIV Screening in Medical Setting

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.

TO DO WHEN I GO HOME Each of the Manuals, Administrative and the HIM/Records has a checklist. Please see your consultant if you need assistance. MY LIST OF ITEMS TO DO!!!

MEDICARE

CERTS / RE-CERTS

PHYSICIAN CERTIFICATION A physician, must certify and re-certify every thirty days the need for extended care services in the SNF. Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable. Re-certifications must be completed every 30 days The routine admission order established by a physician is not a certification of the necessity for post-hospital extended care services for purposes of the program There must be a separate, signed statement indicating that the patient will require on a daily basis SNF covered care

WHO CAN SIGN THE CERTIFICATIONS? A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a nurse practitioner (NP) or Clinical Nurse Specialist (CNS) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician.

IS THERE AN OFFICIAL FORM? The SNF must obtain and retain the physician’s NP’s, or CNS’s certification and recertification statements. The intermediary may request them to assist in determining medical necessity when necessary. The SNF will determine how to obtain the required certification and recertification statements. There is no requirement for a specific procedure or form as long as the approach adopted by the facility permits verification that the certification and recertification requirement is met.

CERTIFICATIONS TIMELINESS The initial certification is completed on or prior to admission for Medicare coverage. Within 72 hours of admission; On the day the physician visits the resident and writes the first progress note; On the Interfacility Transfer form as an alternative to completing the initial certification. The facility is responsible for obtaining timely and complete certification/re-certifications. Re-certifications are due on or before the 14th day of admission, and every 30 days after that until coverage ends.

ATTESTATION – DELAYED CERT If the Cert is delayed, wrong, there really is no absolute way to make it correct but you must try in good faith and then be sure you do not keep repeating the same issue; no trend or there will be a question re: falsification or what we call FALSE CLAIMS and the FALSE CLAIM ACT APPLIES.

DETERMINING THE PRINCIPAL DIAGNOSIS FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admissions to, continued residence in the nursing facility and the diagnosis that support the reimbursement and should be sequenced first.”

LOCATING DIAGNOSIS Transfer Records History & Physical Progress Notes Admission Orders

LOCATING PRINCIPAL DIAGNOSIS

NOT A CODING WORKSHOP DIAGNOSIS AND SPECIAL ATTENTION TO DOCUMENTATION AND TRIPLE CHECK IS A MUST TO RECOVER $$$$ DOCUMENTATION TO SUPPORT THE $$$$

AUDITS – HOW DO YOU TEST??? RAC audits – look to the past but also there are future audits…you wan to keep your $$$. Have the Consultants pay special attention to this area for your facility!!

WHAT IS YOUR MONITORING PROCESS CALENDAR Sample Calendar Change of Condition Audit

SAMPLE CALENDAR Sample Calendar Change of Condition Audit

CHANGE OF CONDITION AUDIT Sample Calendar Change of Condition Audit

MY LIST OF ITEMS TO DO

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

THANKS FOR ATTENDING