2. H EALTH I NFORMATION AND A DMINISTRATIVE P OLICY U PDATES Presented by Staci LePage, RHIT Anderson Health Information Systems Inc. 714-558-3887Fax 714-558-1302 rhonda@ahis.netrhonda@ahis.net, stacilepage@comcast.net 1

3. O BJECTIVES 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 2

4. O BJECTIVES -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 3

5. P OLICY U PDATES 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 4

6. S B 158 S AFETY 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. 5

7. Responsible for the overall direction of the facility’s quality improvement functions through a quality assessment/improvement program/plan. Q UALITY A SSESSMENT 6

8. T OP D EFICIENCIES & F OCUSED A UDITS 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

9. 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. W HY P LAN F OR A UDITS A S P ART O F Q A 8

10. S YSTEM B ENEFITS 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 9

11. 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 D AILY Q UALITY A SSURANCE R EVIEW S YSTEM – C HANGE O F C ONDITION 10

12. 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!!! S YSTEM B ENEFITS 11

13. 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 I NCIDENT R EPORTS 12

14. 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 A CT 13

15. 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? B USINESS A SSOCIATES 14

16. 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 15

17. 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 16

18. 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. R ED F LAGS 17

19. Willful Omission and Willful Falsification of Records…. How to Avoid the Risks P RINCIPLES OF DOCUMENTATION 18

20. 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? P RINCIPLES 19

21. 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 20

22. accurate!! Complete, concise, 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)!! E NTRIES 21

23. E NTRIES -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!!! 22

24. 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 23

25. C ORRECTIONS 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. 24

26. F ACTUAL, A CCURATE 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 25

27. W ILLFUL F ALSIFICATION 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! 26

28. N EW I SSUE 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. 27

29. P ROTECTING THE I NTEGRITY OF THE R ECORD How are you protecting your discharge records? 28

30. D ISCHARGE R ECORDS 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. 29

31. R ESIDENT T RANSFERRED O UT / D ISCHARGED 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 30

32. T RANSFERS TO ER/A CUTE B. Residents transferred to ER/Acute the ? will: 1)Secure the record 2)Obtain all loose papers 3)Place the record in a secure location in the medication room 31

33. D ISCHARGE R ECORDS A FTER H OURS C.Discharge records after hours and on weekends 1)Nurse in Charge a)Place these discharges in the Medication Room b)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 32

34. T RANSFER R ECORDS A FTER H OURS 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 33

35. C OLLECT A LL D ISCHARGE R ECORDS 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 34

36. R EVIEW O F P AST A GREEMENTS 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. 35

37. P ROTECTING THE R ECORDS 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! 36

38. P AST A GREEMENTS Current items. List follow up needed at your facility: 1. 2. 3. 37

39. A DMINISTRATIVE M ANUAL U PDATES 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!!! 38

40. O THER ITEMS YOU SHOULD KNOW !! 39

41. O THER ITEMS YOU SHOULD KNOW !! -2 40

42. O THER ITEMS YOU SHOULD KNOW !! -3 41

43. O THER ITEMS YOU SHOULD KNOW !! -4 42

44. O THER ITEMS YOU SHOULD KNOW !! -5 43

45. O THER ITEMS YOU SHOULD KNOW !! -6 44

46. O THER ITEMS YOU SHOULD KNOW !! -7 45

47. P OSTING C ITATIONS 46

48. P OSTING C ITATIONS -2 47

49. P OSTING C ITATIONS -3 48

50. P OSTING C ITATIONS -4 49

51. P OSTING C ITATIONS -5 50

52. I NFORMED C ONSENT 51

53. I NFORMED C ONSENT -2 52

54. I NFORMED C ONSENT -3 53

55. I NFORMED C ONSENT -4 54

56. I NFORMED C ONSENT -5 55

57. I NFORMED C ONSENT -6 56

58. I NFORMED C ONSENT -7 57

59. P SYCHOTHERAPEUTIC D RUG A UDIT 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). 58

60. K EY H IM /R ECORD M ANUAL U PDATES 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. 59

61. P SYCHOACTIVE D RUGS MONITOR UPDATE (see H.O. #7) 60

62. E MERGENCY D RUG S UPPLY ASK YOUR PHARMACISTS – NEW REQUIREMENTS POLICIES AND PROCEDURES HAVE TO BE UPDATED. 61

63. M ORE A ND M ORE Dual Enforcement – state deficiencies reports to CMS for some areas. State Survey focus 62

64. T O 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!!! 63

65. M Y L IST O F I TEMS T O D O 64

66. M Y L IST O F I TEMS T O D O 65

67. Y OUR AHIS C ONSULTANT 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 66

68. E VALUATION A ND F EEDBACK List the items you would like covered in the next seminar for directors For HIM/Record Staff 67

69. T HANKS FOR A TTENDING ! Staci LePage, RHIT stacilepage@comcast.net AHIS, Inc. 940 W. 17 th Street, Suite B Santa Ana, CA 92706 714/558-3887 Fax 714/558-1302 68