north american health care, inc. documentation–documentation– documentation documentation

NORTH AMERICAN HEALTH CARE, INC.

DOCUMENTATIONDOCUMENTATION––

DOCUMENTATIONDOCUMENTATION––

DOCUMENTATIONDOCUMENTATION

PRESENTED BY

Rhonda L. Anderson, RHIAPresident, AHIS

940 W. 17th Street, Ste. BSanta Ana, California 91706

Email: Office@ahis.net, Rhonda@ahis.netTrisha@ahis.net

714-558-3887 Fax: 714-558-1302

DATE & LOCATION July 17, 2008

Northern California

August 20, 2008Southern California

OBJECTIVES Participants will review the following:

Care Tool – CMS Admission Monitoring and review of

findings and issues Admission Documentation and risk

reduction Review of Admission Audit content

OBJECTIVES -2

Participants will review the following (continued) Legal Records – IN REVIEW– IN REVIEW - The record

location and guidance when resident is out of the facility. “Review of the MRD MRD and the Unit Coordinator’s and the Unit Coordinator’s responsibilities responsibilities

CQI – Quality Assurance Processes CQI – Quality Assurance Processes and best practicesand best practices

WHY MONITORING & QA CMS TO RATE NURSING HOME

QUALITY NEW FIVE-STAR SYSTEM TO BE ADDED TO NURSING HOME COMPARE SITE

CMS – CARE TOOL What is new? Prepare for the future

Handouts #1a & #1b (Care Tool Information)

CMS – STAR RATING The Facility is a “STAR”

CMS – STAR RATING -2

The Centers for Medicare & Medicaid Services today announced it will soon launch a ground-breaking ranking system of America’s nursing homes, giving each a “star” rating.    Handout #2 (Announcement) Handout #3 (OPD Five Star Rating

System)

CMS – STAR RATING -3

Provide a nursing home quality of care rating of 1 to 5 stars derived from 3 data sources Survey & Certification Data or Health

Survey Inspections Quality Measures (QMs) Staffing Data

CMS – STAR RATING -4

CMS is requesting comments on the system designed to provide patients and their families an easy to understand assessment of nursing home quality, making meaningful distinctions between high performing and low performing homes.  

CMS – STAR RATING -5

The ratings will be posted on the agency’s Nursing Home Compare Web site by the end of this year. A sample screen shot of the proposed star ratings is available at www.cms.hhs.gov/PressContacts/10_PR_f

ivestar.asp Medicare Compare can be found at

www.medicare.gov

CMS – STAR RATING -6

The new “five-star” rating system will provide a composite view of the quality and safety information currently on Nursing Home Compare

December 2008 and input being collected now. Handout #4 (Press Contact) Handout #5 (Screen Shot 5 Star Rating

System )

ADMISSION, 7, 14 DAY AUDIT Admission, 7 and 14 day audit

shall be carried out as required by the HIM/Record Manual.

Qualitative reviews-monitors shall be carried out by the MRD and/or the HIM/Record Consultant.

Refer to MRD and Unit Coordinators Schedules - to discuss later.

Handout #6 (Admission Audit)

NAME:ROOM NO.:PHYSICIAN:

ADMIT DATE: MONITOR DATE:RETURN TO: BY:

REMONITOR DATE:

I. ADMISSION REVIEW A. Interfacility transfer report, if applicable A B. Admission Record/ Face Sheet completed/ allergies/ B mortuary listed.

C. Consents/ Rights signed/ dated by res./ legal rep. CD. *Admission Agreement incl. signed Acknowledgment re: D

MDS Transmission. E. Privacy Notice Acknowledgment signed. E F. Advance Dir./ IHCI Ack. signed/ dated. (copy on chart) F G. H&P completed or updated/ Informed consent/ G

Rehab. Potential H. Capacity for decision-making complete/ reason/ surrogate H indicated (if applicable)

Legend: + = Met 0 = Not Met N/ A = Not Applicable I = Incomplete NS = Need Signature ND = Need Date NT = Need Time D = Dietary A = Activity S = Social Services P = Discharge Planning X = See other side for additional comments Special Instructions: *MDS form by 5th - 8th day for Medicare *MDS Transmission Ack. may be on separate form.

CommentsDATE: Met/ Not Met

I. ADMISSION REVIEW I. *Resident Care Plan initiated (*by Nursing/ includes all I signature problems). J. Physician Orders: J 1. Admission activity order. 1 2. Diet orders. 2

3. Tx orders incl. site & condition. (1 site per order) 34. Beh. control drugs incl. diagnosis, specific behavior 4

manifestation.5. Behavior count initiated. 56. Restraint order incl. med. symptom(s)/ reason/ type/ 6

when to use.7. Informed consent obtained for restraint orders 7

(physical/ chemical).8. Orders match *PIC (If applicable). 8

K. Orders signed/ dated. K L. Restraint Assessment if applicable. L M. Possessions List - completed/ signed/ witnessed. M N. Daily Shift Charting - licensed personnel, if applicable. N

CommentsDATE: Met/ Not Met

I. ADMISSION REVIEW O. TB Screening initiated. O P. Medicare charting every shift/ everyday. P Q. Medicare cert signed/ date. Q R. Nursing (Clinical Assessment) R

1. Admission assessment 1a. Body diagram-Skin Assessment ab. Admission Note completed-include pain b

2. Height/ weight/ vital signs recorded. 23. Allergies - Chart labeled, if applicable. 3

II. SEVEN DAY REVIEW DATE: A. Admission Assessment Completed/ updated: A

1. Nursing 1a. Braden/ Norton Assessment ab. Fall risk assessment bc. Pain Assessment updated, if applicable c

2. Social Services/ Discharge Plan 23. Activity 34. Dietary 4

B. Care Plan Updated B

CommentsDATE: Met/ Not Met

III. FOURTEEN DAY REVIEW DATE:A. B & B evaluation completed, if applicable. A

B. T.B. Screening results. B C. 14 day recert completed/ signed/ dated. C D. *MDS Face Sheet completed/ signed/ dated by D

RN Coordinator E. *Basic Tracking form completed/ signed/ dated. E F. Discharge/ Re-entry Tracking forms (if applicable). F G. *MDS completed/ signed/ dated. G

H. *RAP Summary completed/ signed/ dated (if 14 day MDS HA8a).

IV. TWENTY-ONE DAY REVIEW DATE: A. Care plan completed/ updated/ matches MDS. AV. THIRTY DAY REVIEW DATE: A. I/ O Evaluation (if applicable). A

Met/ Not Met Comments

CONSENTS AND WHAT THAT MEANS TO YOU! Admission assessment – cognitive MDS Section – cognitive Signing of Admission papers obtained

by the office staff. Update ?? When??

Resident Care Planning Conferences, Family input

Social Service involvement

NORTH AMERICAN HEALTH CARE INC.

FACILITY: Record Number for each resident

TOPIC: Resident Capacity to Understand, Make Decision and Sign Admission Papers 1. 6.

Review Date: Location: 2. 7.

Population/Sample Size: 3. 8.

Report Prepared By: F Tag: 323, 324 4. 9.

5. 10.LEGEND: + = Met; 0 = Not Met

N/A = Not Applicable

*Key Items RESIDENT1 2 3 4 5 6 7 8 9 10

1. Resident signed admission papers.

2. Resident representative signed admission papers.

3. Physician had a statement of capacity included in H&P.

4. Resident had capacity to understand and make decisions to sign per MDS and did

sign admission papers.

5. Resident did NOT have capacity to understand and make decision to sign per MDS

and did sign admission papers.

6. Resident representative signed admission papers and resident had capacity to

understand and make decision and sign per MDS.

7 Resident had capacity to understand and make decision per M.D.

8. Resident did NOT have capacity to understand and make decision per M.D.

Percent Met = (total number met/*total number reviewed? X 100 *Do not include N/A in total number reviewed.Attachment

Page of

QUALITY ASSESSMENT/ IMPROVEMENT INDICATORS

Quality IndicatorsPercent

Met0% or 100%

Measure

CQI –QA – Quality Services The Focus is identified based on the

standards of care in the facility. Share Best Practices and ‘quality in

action’

QA/I PRESENTATIONS

Presentations

YOUR FACILITY’S GOALS AND SOLUTIONS Identify goals and solutions .

1. Best Practices2. Identify how you will use this information

or choose another QA/I focus.

LEGALITIES OF RECORDS GOAL: The legalities of the

medical record must be intact; discharge records complete within the legal limits and meet the standard documentation practices

LEGALITIES OF RECORDS -2

Documentation must meet the needs of the resident, regulatory requirements using standards/legal requirements of clinical record practices. Handout #7 (Security & Legal

Completion)

LEGALITIES OF RECORDS -3

The medical record shall remain secure in an organized record system both at: The nursing station Within the Health Information

Management/Record Department (HIM/Record).

LEGALITIES OF RECORDS -4

The legalities of the medical record intact; discharge records completed within required times frames; maintained secured. This includes records of residents sent to

the acute hospital, ER and admitted residents. This includes records of residents sent to the acute hospital, ER and admitted residents

LEGALITIES OF RECORDS -5

Discharge records during the day; The Unit Coordinator will: Secure the record obtain all loose papers

for filing, medication, treatment/therapy records immediately following discharge;

Take the record to the Record Department

LEGALITIES OF RECORDS -6

Residents transferred to ER/Acute the UC will: Secure the record Obtain all loose papers Place the record in a secure location in

the medication room

LEGALITIES OF RECORDS -7

Discharge records after hours and on weekends Nurse in Charge

Place these discharges in the Medication Room;

Secure the medical record in a location specified in the Medication Room

LEGALITIES OF RECORDS -8

The DNS and HIM/Record Designee will: 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;

LEGALITIES OF RECORDS -9

Check the summary of care for completion/ determine if the post-discharge plan of care was complete and provided to the resident as indicated

Transfers 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.

RECORD DEPARTMENT SECURITY The Health Information

Management/Record Department shall be, unauthorized staff shall not enter the record department unless the HIM/Record Director is there and the person has a purpose for record completion or other legal reason to review a record.

RECORD DEPARTMENT SECURITY -2

HIM/Records Department Designee/s. Keep the record secure Assure the record does not leave the

Medical Record Department except to the DNS for his/her review

Obtain completion from any of the staff as needed; (preferably within the HIM/Record Department

RECORD DEPARTMENT SECURITY -3

HIM/Records Department Designee(s) (cont.) If the record is taken by the DNS-assure

it is signed out by using the sign out log Follow up within the same day. (Handout #8 (Chart Locator System)) NOTE: Do not leave at the end of the

day with any record signed out and not returned to the HIM/Record Dept

Follow up with the physician using your standard discharge procedures.

RECORD DEPARTMENT SECURITY -4

HIM/Record Department will be locked at all times when the HIM/Record Designee/assistants are not in the Department

CHART LOG Chart Log will be used uniformly at

each nursing station and in the HIM/Record Department. The log shall be placed on a clip board and posted in a location easy to find, but that does not violate HIPAA requirements

CHART LOG -2

HIM/Record Designee and Unit Clerk will in-service all staff re: the CHART Sign out system. Handout #8 (Chart Locator System)

CHART LOG -3

Unit Clerk will monitor sign out of records during their working hours. No record is to be left out at the station at the end of the shift (without Administrator/DNS approval).

CHART LOG -4

The Chart Sign Out Log will be placed in a location that does not make it easily read by the public or other residents Handout #8 (Chart Locator System)

LOCATOR GUIDE IN HIM/DEPT. HIM/Record Department LOCATOR

GUIDE and LIST is complete, current and POSTED in the HIM Department for easy reference in case of emergency, survey after hours, etc. Handout #9 (The Item Locator

Guide)

SCHEDULES Audit schedules and compliance

will be an ongoing focus and coordination with the Unit Coordinators as well as qualitative and qualitative training and monitoring (to be worked out with the DNS and Administrator).

SCHEDULES -2

Reconciliation of duties of the Unit Coordinator and HIM/Record Designee will be part of the ongoing working with the facility (in coordination with the Administrator and DNS).

SCHEDULES -3

Review of schedules – MRD, Unit Coordinator – Review of the assigned responsibilities Handout #10 (Unit Coord & HID Audit

Schedule) Evaluate the above and determine if

there is effective use of the MRD and Unit Coordinator or areas where you could improve to meet the overall goals of the facility.

SCHEDULES -4

HIM/Record Consultant’s role and plans for QA/I improvement in both the Record Department, HIPAA, Quality Assurance Activities and qualitative monitoring of documentation, especially high risk areas.

RECAP and DIRECTION!!! Review of status and discussion

ACTION PLAN What you will include in your Quality

Assurance Process and your Health Information/Medical Record - Action Plan

Action Plan – LIST 1. 2. 3.

THANK YOU FOR ATTENDING!! Best ALWAYS!!!