2. Health Information and Administrative Policy Updates Presented by Rhonda Anderson, RHIA, President Ligia Rios, RHIT, HI Consultant Anderson Health Info. Systems, Inc. 940 W. 17 th Street, Suite B Santa Ana, CA 92706 714/558-3887Fax 714/558-1302

3. Presented To NORTH AMERICAN HEALTH CARE, INC. DIRECTOR OF STAFF DEVELOPMENT SEMINAR February 17, 2010

4. 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

5. POLICY UPDATES Committees – SB 158 Inclusion of Safety Committee requirements Must meet at least yearly Can be part of QA/CQI Committee Must have separate minutes

6. SB 158 -2 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

7. 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

8. 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

9. 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.

10. PRINCIPLES OF DOCUMENTATION Willful Omission and Willful Falsification of Records…. How to Avoid the Risks

11. PRINCIPLES OF DOCUMENTATION -2 Why is this important with AUDITS and WHAT CAN YOU DO TO KEEP A LEGAL RECORD WITHOUT COMPRIMISING LEGAL REVIEWS/$$ REVIEWS, and reflect that the quality of care and services were provided and when there is a way to clarify documentation.

12. 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

13. ENTRIES 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

14. ENTRIES -2 In black or dark blue ink or typewritten (automated, printed documents clear, not too dark/light!!) Must be capable of being copied Must be legible 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!!!

15. 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

16. CORRECTIONS Records may be corrected by drawing one line through the error, designate error, initial the error and chart the correct information with date and time if applicable.

17. CORRECTIONS -2 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

18. 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 $$…personally can be assigned to the employee

19. BE ALERT TO ACCURATE CHARTING 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 $$…personally can be assigned to the employee

20. ADMINISTRATIVE MANUAL UPDATES More Administrative Policy and Procedural Updates will be coming: this is how; – Via No American email or via a CD sent to the Administrator!! – Also, ASK YOUR HIM CONSULTANT!!!

21. OTHER ITEMS YOU SHOULD KNOW!!

22. OTHER ITEMS YOU SHOULD KNOW!! -2

23. OTHER ITEMS YOU SHOULD KNOW!! -3

24. OTHER ITEMS YOU SHOULD KNOW!! -4

25. OTHER ITEMS YOU SHOULD KNOW!! -5

26. OTHER ITEMS YOU SHOULD KNOW!! -6

27. OTHER ITEMS YOU SHOULD KNOW!! -7

28. INFORMED CONSENT

29. INFORMED CONSENT -2

30. INFORMED CONSENT -3

31. INFORMED CONSENT -4

32. INFORMED CONSENT -5

33. INFORMED CONSENT -6

34. INFORMED CONSENT -7

35. 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.

36. 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!!!

37. MY LIST OF ITEMS TO DO

40. ITEMS LOCATION IN FACILITY POLICY AND PROCEDURE IDENTIFY FOR FOLLOW UP

41. PREVENTION PROGRAMS  Identified as part of the Infection Control Committee  Infection Control training is documented. DSD special attention to the care areas that relate to your facility, i.e., patients with infections, pressure ulcers, IVs, ventilators, humidifier

42. SURVEILLANCE PROGRAMS  Identify the specific for your facility -- i.e., TB, MRSA, Culture and Sensitivity follow up on change of condition, how infections are evaluated and monitoring of prevention strategies. Specify where these are located.  DSD involved in and uses the Surveillance Program for their training of the CNAs’ and other training and surveillance they may be assigned.  Do you assist to report any of the infections, other hazards for patients?  What are they?  What is done with them?

43. PREVENTIVE MEASURES  Implement measures relating to disease surveillance and the prevention of health- care-associated infections. Infection control policies and procedures are current.  DSD know where the Infection Control Policies and Procedures are located.  Utilization of a checklist or another tool to ensure compliance and carry out the information in your own assignments for training and monitoring.

44. RESOURCES  DPH list is included in the facility policies and procedures to spell out the diseases and conditions which health care providers and local health officers are required to report to the local public health department. (See 17 CCR §2500 et seq.)  List the type of activities that you currently carry out that relate to the Safety Plan.  See Health & Safety Code § 1279.1 [AFL 09-05]

45. COMMITTEES AND POLICIES & PROCEDURES  The policies/procedures and committees include the information about the “development, implementation – the pol/proc will comply with a patient safety plan for the purpose of improving the health and safety of patients and reducing preventable patient safety events”. (Health & Safety Code § 1279.6)  DSD identify all those patient safety items.

46. INFECTION CONTROL COMMITTEE  The DSD needs to know the Infection Control Policies and Procedures and participation in the follow/up as noted above.  The Administrative Manual is up to date. (AHIS provided updates.) Key is --- the facility doing what it says in the Manual.

47. SAFETY COMMITTEE  Provide information to and from the Committee – part of QA?

48. QUALITY ASSURANCE  The QA Plan, our reference here is used to report the Patient Safety reports- follow up – all a part of QA, but should have separate minutes or activities under QA, part is included in Infection Control, training and follow up

49. NURSING PROCEDURE MANUAL  Reference your own manual

50. OTHER – LIST

51. SB 138 SAFETY PLAN (See H.O. #1)

52.  PSC or equivalent shall be composed of the facility's various health care professionals, including who is your Committee (Note: The composition required is similar to that of the patient care policy and infection control committees required under 22 CCR § 72525) Physicians Nurses Pharmacies Administrators

53.  Policies and Procedures include the following to meet the requirements of  Review and approve the patient safety plan  Receive and review reports of defined patient safety. The reports that you as a facility are defining for patient safety should be clearly identified

54.  Policies and Procedures (cont.)  Monitor implementation of corrective actions for patient safety events. Example, if DSD has training assigned for CNAs and/or Nursing Staff then this would be part of the Safety Committee if it came from that process. Also, important to report for Patient Safety those areas where you have conducted training, carried out observations, etc. to PREVENT patient accidents, incidents, handle difficult patient and high risk patients, infections, reduce potential for infections, etc.

55.  Policies and Procedures (cont.)  Make recommendations to eliminate future patient safety events.  Review and revise the patient safety plan, at least once a year, and as necessary, to evaluate and update the plan and incorporate advancements in patient safety practices.

56.  The minimum safety plan requires the development and implementation of a reporting system for patient safety events that allows anyone involved, including, but not limited to, health care practitioners, facility employees, patients, and visitors, to make a report of a patient safety event to the health facility.  Patient incidents and more – all the reports for unexpected outcomes for patients that might be related to poor handling techniques, results of incidents and accidents, facility acquired infections, i.e., hydration training, nutrition training for staff to prevent dehydration and adequate nutrition.

57.  Requires a process for a team of facility staff to conduct analyses, including, but not limited to, root cause analyses of patient safety events a reporting process that supports and encourages a culture of safety and reporting patient safety events.

58.  Spelled out in the Resident Safety Plan to include the following definitions and broken into 6 categories  Surgical (NA to SNF)  Product or device (Generally would be NA)  Patient protection  Case management  Environmental  Criminal

59.  Surgical events (NA to SNF)

60.  Death or serious disability associated with the use of a contaminated drug, device, or biologic provided by the health facility when the contamination is the result of generally detectable contaminants in the drug, device, or biologic, regardless of the source of the contamination or the product.  Generally would be NA

61.  Death or serious disability associated with the use of a function of a device (including catheter, drain, or other specialized tube, infusion pump, or ventilator) in patient care in which the device is used or functions other than as intended.  Documented training on use of these devices.  Death or serious disability associated with intravascular air embolism that occurs while being cared for in a facility, excluding deaths associated with neurosurgical procedures known to present a high risk of intravascular air embolism.

63.  Death or serious disability associated with the use of a contaminated drug, device, or biologic provided by the health facility when the contamination is the result of generally detectable contaminants in the drug, device, or biologic, regardless of the source of the contamination or the product.  Generally would be NA

64.  Death or serious disability associated with the use of a function of a device (including catheter, drain, or other specialized tube, infusion pump, or ventilator) in patient care in which the device is used or functions other than as intended.  Documented training on use of these devices.  Death or serious disability associated with intravascular air embolism that occurs while being cared for in a facility, excluding deaths associated with neurosurgical procedures known to present a high risk of intravascular air embolism.

66.  A patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug, the wrong dose, the wrong patient, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration, excluding reasonable differences in clinical judgment on drug selection and dose.

67.  Patient death or serious disability directly related to hypoglycemia, the onset of which occurs while the patient is being cared for in a health facility.  A Stage 3 or 4 ulcer, acquired after admission to a health facility, excluding progression from Stage 2 to Stage 3 if Stage 2 was recognized upon admission.  Assessment, monitoring, training, follow up, specific documented training for all staff who treat residents in general with high risk, ways of identifying high risks, also, once pressure ulcer identified, assure the C.N.A is trained specifically to the patient/s to re-enforce techniques, goes a log way if there are issues later.

68.  Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by a toxic substance  A patient death or serious disability associated with a burn incurred from any source while being cared for in a health facility.  A patient death associated with a fall while being cared for in a health facility. Fall management training, follow up, risk assessment, analysis, initial assessment, PT involvement when indicated.

69.  A patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health facility  Again the documentation of the restraint program, the documented training, special training for staff if there are residents that are at specific risks, has fallen, fall prevention specifically designed for the patient, the staff all know.

70.  Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.  The abduction of a patient of any age

71.  Facility-wide “Hand Hygiene Program.” (Health & Safety Code § 1279.7)  Well documented, observed hand washing program

72.  Beginning January 1, 2011, a health facility will be prohibited from using an intravenous connection, epidural connection, or enteral feeding connection that would fit into a connection port other than the type it was intended for, unless an emergency or urgent situation exists and the prohibition impairs the ability to provide health care. (Health & Safety Code § 1279.7)

74. HITECH & HIPAA ACCESS HITECH HIPAA SB 541 BREACHES Privacy and Security

75. Breaches 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 SB 541 HITECH ACT

76. 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

77. Breaches 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.

78. No 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

79. 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.

80. HIPAA Civil Penalties Under New HITECH Provisions Effective November 30, 2009 Violation CategoryEach Violation All such violations of an identical provision in a calendar year Did not know$100-50,000$1,500,000 Reasonable Cause$1,000-50,0001,500,000 Willful neglect corrected within 30 days $10,000-50,0001,500,000 Willful neglect - not corrected $50,0001,500,000

81. 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

82. AHIS as Your Partner Implementation Plan Risk Analysis Policy and Procedure Current system review Action as needed

83. Utilizing the QI Process/Format to monitor the facility’s procedures

84.  Review of personnel files

85.  Review of ongoing education  DSD role in assuring training for only C.N.A. staff and/or all staff. Each facility has their own assignments.  Do you know where your policies and procedures are located? Have you checked the Administrative Manual?

86.  Facility procedures for review of incidents/accidents  Trending  Response  Are you as DSD involved in any of the Q A process? The facility procedures are known to you so you can focus on key areas for training???

87.  Review vs. new regulation/survey protocol  Policy includes protection of residents  Policy clear on  How to report  To whom to report

88.  What constitutes abuse/neglect  How and to whom to report

89.  Process in place to respond to investigative findings  Part of QA/QI Process

90. 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

91. EVALUATION AND FEEDBACK LIST THE ITEMS YOU WOULD LIKE COVER AT THE NEXT WORKSHOP FOR DIRECTORS. For HIM/Record Staff

92. THANKS FOR ATTENDING