1. NORTH AMERICAN – Medical Records – 2011 Status to Quality Documentation RHONDA ANDERSON, RHIA, President, AHIS In coordination with Marivic Perez, R.N.

2. Presented By RHONDA ANDERSON, RHIA Anderson Health Information Systems, Inc. 940 W. 17 th St., Santa Ana, California, 92706 Phone 714-558-3887 Email: rhonda@ahis.net, trisha@ahis.net, lizeth@ahis.netrhonda@ahis.nettrisha@ahis.net lizeth@ahis.net IN COORDINATION WITH NORTH AMERICAN HEALTH CARE 2

3. Objectives PARTICIPANTS WILL: Follow-up on prior requirements for Quality Documentation Identify the schedule for audits and related findings in coordination with other audit Identify all the audits and if there is duplication how to manage that toward accurate quality documentation. Identify training and other needs Identify new approaches and also what is 100% audit 3

4. Objectives -2 PARTICIPANTS WILL (cont.) Peer Review – what is it? Clinical Documentation Improvement – defined and how can we use to reduce ‘ole fashion’ audits Findings and action plans from workshop reviews. Quality Assurance – what is you role and how are you carrying it out? MDS Filing – identify questions and solutions Solutions to your workshop “best practices” 4

5. Audit Schedule Identify the required audits Identify the period audits What is your coverage and cross-training like? What is your follow up system Is it effective. 5

6. 6 Healthcare (CDI) Consumer & Agency is Unique In their services Staff skill set Combination of medical conditions Services

7. 7 North American Facilities Number of admissions Complexity of the healthcare conditions Proactive clinical review process

8. 8 Focus of Most CDI Programs Improving the quality of clinical documentation regardless of its impact on revenue or care Facilitating an accurate representation of healthcare inservices Through complete & accurate reporting/documentation of care Diagnoses to support that care & clinical procedures Facilities communication

9. 9 CDI Processes Proactive Review of Documentation Documentation is reviewed near when it happens There is a facilitated process to clarify the services and documentation Need to capture quality documentation near the point of care to support those services. Challenge is obtaining that quality documentation Collecting some standardized data to compare the quality documentation Taking action on those findings

10. 10 Record Review Historically Data collection occurred after the resident discharged Retroactive audit processes Monitoring proactive Clinical Documentation Improvement

11. 11 CDI Process Proactively (not post or after the fact audit the next day or an “auditor” coming in Real time activity close enough to the situation that clarification/completion of documentation

12. 12 Examples of Suggestions for Most High-Risk Areas Self actualization Self checking Cross review by the caregivers Medical Records involvement more proactive or near the activity, i.e., change of condition review more often during the day, not wait until the next morning

13. 13 CDI Downside to this proactive involvement by nursing and cross-checking themselves is “we do not have time”

14. 14 Medical Records Utilize monitoring tools How and when these monitoring tools are used is the challenge

15. 15 Methods of Implementing a CDI Process Changing the method of when the monitoring would be carried out From post audit to near real time Add some admission clinical criteria for review, i.e. for Medicare coverage by diagnosis/covered type Change of condition review to be carried out more frequently each day not during that day, i.e., a.m., p.m. before end of shift and late in the evening

16. 16 Methods -2 Qualitative Treatment audit carried out Immediately following Treatment rounds each week By the RN Supervisor and/or HIM/Record staff immediately For example, review the ‘qualitative treatment criteria’ Discharge, if resident discharge to home Post discharge plan of care completed Reviewed by another nurse Complete and meets requirements

17. 17 Methods -3 Discharge, if resident discharge to home (cont.) Notification to HIM/Records Department to review record before discharge Send information to physician along with discharge telephone order or sign while in-house All discharges

18. 18 Method -4 Current NAHC processes that changed into a CDI, i.e., change of condition, admission, discharge, qualitative treatment medication/treatment documentation, behavior drugs, Medicare coverage review, weekly licensed nursing notes. Tracking certs/recerts and follow-up physician, physician’s visits 100% audit – Review examples

19. 19 Re-Evaluate the QA/I Committee Activities Utilize the systems that are already in the AHIS HIM/Record Manual Review the ‘standup’ process

20. Quality Assessment Established a Quality Assessment/Assurance Committee that: Is a standing committee of the facility; Identifies and addresses quality issues; Provides points of accountability for ensuring quality of care and quality of life; Coordinates the qualitative evaluations of facility systems; Establishes assessment and improvement priorities for resident care and services; 20

21. Quality Assessment -2 The facility has an established Quality Assessment/Assurance Committee that: Sets expected outcomes for resident care, services, safety, including applicable informed consents for psychotherapeutic drugs, restraints and prolonged use of devices that may lead to he inability to gain use of a normal body function and related administrative services; 21

22. Quality Assessment -3 Established a Quality Assessment/Assurance Committee that: Monitors and evaluates quality practices, safety and outcomes utilizing the facility roster/matrix, investigative protocols and the facility Quality Indicator/Quality Measure Reports MDS 3.0 and other clinical statistical reports available in the computer system/, and results from customer satisfaction surveys; Collects and analyzes data, practices that cause negative outcomes, enhances quality of care, life and service; 22

23. Quality Assessment -4 Established a Quality Assessment/Assurance Committee that: Communicates the results of quality assessment/ improvement Develops and implements plans of action to correct identified quality deficiencies and care processes Keeps systems functioning, including maintenance of correct practice standards; Establishes a method of reporting to the Governing Body; 23

24. Quality Assessment -5 Established a Quality Assessment/Assurance Committee that: Is responsible for those functions previously designated to the [ ] pharmacy infection control and the [ ] utilization review committee. 24

25. Quality Assessment -2 Evaluation, communications and implementation re: CMS State Operations Manual and other CMS updates and California Department of Public Health – All Facility Letters (AFL) as applicable Include informed consent for psychoactive/antipsychotic/psychotherapeutic drugs, restraints and prolonged use of devices. 25

26. Quality Assessment -2 Review shall include but not be limited to assessment: Of effectiveness of the monitoring and evaluation process; Of performed quality assurance activities versus the quality assessment/assurance plan; Of communication of quality assessment information; To determine if resident care has improved. 26

27. Quality Improvement Plan – By Month 27

28. 28 Admission – 7/14/21/30 Day Monitor Key Issues Consents to Tx / Rights signed/dated by resident/legal representative H&P completed or updated / Informed consent / Rehab. Potential within 72 hours Behaviors Drugs Include diagnosis, specific behavior manifestation Behavior count initiated Notification of interested family member of antipsychotic medication orders if resident consents

29. 29 Admission – 7/14/21/30 Day Monitor -2 Restraints Informed consent obtained for restraint orders (physical) Informed consent Devices Informed consent

30. SBAR Documentation Forms Refer to H.O. #4 30

31. 31 SBAR Change of Condition (COC) Review the communication book to determine Change in condition is identified Follow up that is carried out Use COC Monitor daily to review SBAR (C of C) documentation Take to standup q day Quantitative and qualitative review Take notes re condition, observations, nursing action, pain scale if applicable

32. 32 SBAR COC -2 Review SBAR = complete, date, time, description of condition, observations (also check the nurses’ notes for consistency in documentation) Check for: Follow up note Timely notification to MD, resident, family Informed consent, if chemical/physical restraint is applicable Timely notification to Pharmacy Pharmacy order book for new/change

33. 33 SBAR COC -3 Check for: See if the medication was ordered from the Pharmacy or a new label requirement New order carried out – on PO form, order completed; Dx added New order, PO = Med/Tx sheet, laboratory/x-ray Condition on Care Plan Date, shift nurse who documented Identify if a remonitor is due

34. 34 Informed Consent – Psychotherapeutic Meds & Devices The resident has a right to Make decisions with regards to his/her medical condition Accept/refuse the proposed treatment Free from any physical/chemical restraint imposed Receive information and consent to the use of physical/chemical restraints and prolonged use of devices

35. 35 Informed Consent -2 Attending physician shall be responsible for: Obtaining informed consent Prior to the first use of a physical/chemical restraint ON ADMISSION if had a restraint or chemical restraint/psychotherapeutic drug prior to admission When a chemical restraint / psychotherapeutic drug dosage is increased, informed consent is needed only if the increase falls outside of the dosage range covered by the previous consent. (Informed consent may be obtained for a specific dosage range. Refer to the specifics within the Pharmacy manual also). Verification of informed consent Determine the resident’s decision making capacity

36. 36 Informed Consent -3 Attending Physician responsible (cont.) Seek consent of capable residents Notify interested family member Use of a device is anticipated to be prolonged which might result in the loss of bodily function. Most common devices include: urinary catheters, nasogastric tube, gastrostomy tube Facility’s responsibilities: Documenting verification of informed consent Assessment of appropriateness of medication or device and determination of risks/benefits

37. 37 Informed Consent -4 Treatment may be initiated without informed consent if: Documentation in the record of an emergency “New” physicians will be advised of the requirements

38. 38 Resident’s Capacity Determination Guidelines Physician shall make a determination of resident’s capacity & document his/her ability for decision-making Not capable of his/her own decision-making Surrogate decision-maker shall receive the same information and have the same rights as the resident When a conservator provides informed consent, conservatorship papers must be on file When no conservator, designated representative

39. 39 Informed Consent Facility staffs Verify that the resident’s record contains documentation that the resident has given informed consent Physical/chemical restraints / psychotherapeutic drugs Prolonged use of a device

40. 40 Pressure Sore / Ulcer / Skin Conditions Monitor Physician’s orders for each site Review the skin report for the following items Date, Location site Stage Size Depth Exudate/drainage Odor Comments/progress or lack of progress Nurse

41. 41 Pressure Sore / Ulcer / Skin Conditions Monitor -2 Lab If there is draining, check to see if a lab was ordered If so, was there follow up? Comments? Family/Doctor Notified – Check for the notifications by nursing to the physician & family. Usually in the nurses’ notes or weekly skin report Dietary progress note that describes the skin condition intake and addresses recommendations or none depending on their clinical decision-making

42. 42 Pressure Sore / Ulcer / Skin Conditions Monitor -3 CP current – review the CP to see if the condition on the Pressure Sore/Ulcer/Skin Conditions monitor. Discontinued when healed. Care Plan – check: To be sure there is a separate condition on the care plan for each skin treatment The intervention for preventive equipment, observation of related conditions Check the Skin Report, Tx Sheets, CP and Weekly licensed nursing notes

43. Sample Review – Data Collection - Discuss 43

44. Sample Review – Data Collection – Discuss -2 44

45. 45 Purpose – MDS 3.0 15 Months Retention of the MDS Federal regulatory requirement at 42 CFR 483.20(d) requires nursing homes to maintain all resident assessments completed within the previous 15 months in the resident’s active clinical record.

46. 46 Policy – MDS 3.0 15 Months Retention of the MDS Maintain 15 months of MDS Be available to the Interdisciplinary team, Other key staffs, Surveyors, CMS and other agencies, Administrative uses Store all MDS assessments within the previous 15 months Separate binders at each station / centralized location Available to all staff who need the MDS

47. 47 Procedure – MDS 3.0 15 Months Retention of the MDS Resident is discharged return anticipated Returns to the facility within 30 days Copy the previous RAI and transfer that copy to the new record Does not return after 30 days, do not copy the previous RAI to the new record Resident returns to the facility after a long break in care (e.g., 15 months or longer) Review the older record to familiarize themselves with the resident history and care – Do not need to copy previous RAI

48. 48 Procedure – MDS 3.0 15 Months Retention of the MDS -2 Printed MDS to be filed is marked as “COPY” Most current MDS Assessment (OBRA or PPS) will be in the active charge Previous MDS assessment will be filed in binder at the nurse’s station up to 15 months of MDS Slip sheet will be placed in the active record indicating the location of the forms (e.g., “MDS Documents can be found in the alphabetically or numerically arrange MDS binders at the nursing station

49. 49 Use of Electronic Signatures for MDS Purpose – Ensure proper security measures are implemented to maintain the integrity & privacy of the record per RAI Policy Utilize electronic signatures for MDS (Minimum Data Set) Ensure proper security measures

50. 50 Use of Electronic Signatures for MDS -2 Procedure Employees should complete the form certifying the use of own computer security Signature is a result of individual’s unique password Electronic signature must only be used by the person whose signature it represents

51. Best Practices! Let’s discuss… 51

52. Thank You for Attending! 52 Hope You Had A Happy