1. Quality Assurance / Quality Assurance Performance Improvement & Monitoring For The Health Information Management/Record Department February 12, 2014 (Bakersfield, CA) February 13, 2014 (San Jose, CA) February 14, 2014 (Riverside, CA)

2. OBJECTIVES  Participants will identify the key management principles for:  Managing the HIM/Record Department  Assuring a HIM/Record Department Evaluation is followed up 2

3. OBJECTIVES -2  Participants will:  Identify those QA processes that are used as a guiding principal for managing the facility  Specifically review the QA process as it relates to managing audits  Develop a plan for your own audit process and follow up action plan  Will identify the ADM, MRD and HIM/Record Consultant action/follow up 3

4. QI GOAL  Identify systems breakdown in audit process and develop and monitor interventions 4

5. QA PROCESS  Review of the QA Process  Identify areas of concern/continuous quality improvement processes, set out the goals, identify the criteria, collect data, identify measurement, evaluate and assess the information, analyze the causative factors, develop action plans and follow up – recycle!! 5

6. QA  Responsible for the overall direction of the facility’s quality improvement functions through a quality assessment/improvement program/plan  Will spend more time on this in future workshops 6

7. QUICK MANUAL REVIEW  Let’s look at the manual Table of Contents  Key focus areas today  QA audits and monitoring  Audit tools  HIM Dept Evaluation (H.O. #1) HIM Dept Evaluation (H.O. #1 7

8. HIM / RECORD DEPARTMENT ORGANIZATION  Review of the HIM/Record Department organization and expectations  HIM/Record Department Evaluation (H.O. #1) HIM/Record Department Evaluation (H.O. #1) 1.Location of Items in the HIM/Record Dept. 2.The Basics of organization 3. Auditing and monitoring policy/schedule/organization/follow-up – QA reports 8

9. ORGANIZATION OF HIM / RECORD DEPT.  Review the Organization of the HIM/Record Dept (refer to HIM #4005)  Identify those Health Information Department items for improvement and documentation items from the HIM/Record Consultant 9

10. ORGANIZATION OF HIM / RECORD DEPT. -2  PRACTICE  Determine for your facility those areas that need improvement. List them from your knowledge.  Reconcile for all the facilities 10

11. TOP 20 DEFICIENCIES & FOCUSED AUDITS  Top 20 Deficiencies (H.O. #2) Top 20 Deficiencies (H.O. #2)  #1 Quality of Care – Identify those audits that would measure documentation, i.e., behavior drugs, falls, restraints, pain, 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 Pharmacy Procedures – results from the new pharmacy survey, RECAPS, med/tx. Documentation, etc. 11

12. TOP 20 DEFICIENCIES & FOCUSED AUDITS -2  Measure against Unnecessary Drugs – Pharmacy QI include in QA process (refer to HIM #7050 Behavior Drugs Monitors  Antipsychotic (H.O. #3.1) Antipsychotic (H.O. #3.1)  Non-Antipsychotic (H.O. #3.2) Non-Antipsychotic (H.O. #3.2)  Complete Records – Discharge Summary to be reviewed later Note: Reference only – cover during audit discussion 12

13. WHY PLAN FOR AUDITS AS PART OF QA?  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. 13

14. QA PROCESS  Identifies and addresses quality issues; including documentation items.  Provides a tool to coordinates the qualitative documentation activities of all departments.  Establishes assessment and improvement priorities for audits and follow up.  Sets expected outcomes for documentation o0f resident care, services and related administrative services; 14

15. QA AUDITS AND MONITORING  REVIEW of the Medical Records Compliance Audit – this is the “standard” (H.O. #4)Medical Records Compliance Audit – this is the “standard” (H.O. #4)  Let’s agree on a standard. (Get input from the facilities). 15

16. QA - PLANNING  Identify those standard audits that need to be carried out  Identify the LifeHouse priorities – the rating of where LifeHouse stands against those CMS identified areas where improvement is needed  Determine which audits will apply to your facility 16

17. COLLECT INFORMATION  Establish the Medical Record Director’s schedule for auditing  Standard Audits – those are the required audits as set by LifeHouse  Review and determine agreement on the Medical Records Compliance Audit (H.O. #4) Medical Records Compliance Audit (H.O. #4)  Determine the required without exception – identify those audits/monitoring 17

18. ADMISSION MONITOR  Let’s walk the Admit audit process  Admission Monitor (H.O. #5.1) Admission Monitor (H.O. #5.1)  Admission 7-14-21-30 Day Combined Monitor (H.O. #5.2) Admission 7-14-21-30 Day Combined Monitor (H.O. #5.2)  Admission JCAHO Subacute Monitor (H.O. #5.3) Admission JCAHO Subacute Monitor (H.O. #5.3)  Note: We may change to a Discharge from Medicare and at discharge 18

19. ADMISSION MONITOR -2  PRACTICE  Discussion Q&A from last 5 admit audits  Identify out of the 3 audit items best meet your needs and AHIS will reconcile 19

20. DAILY QUALITY ASSURANCE REVIEW SYSTEM – CHANGE OF CONDITION  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 20

21. SYSTEM BENEFITS  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” 21

22. SYSTEM BENEFITS -2  Utilizes time spent in daily stand up meeting to maximize results – quality outcomes  Promotes ID team involvement in problem identification and problem solving 22

23. SYSTEM COMPONENTS  24 hour report/shift report  Incident reports  Change of condition monitor  Reports of resident/family concerns/complaints  Daily quality assurance review form (log)  Daily standup meeting 23

24. 24 HOUR REPORT  Centralizes nursing communications on a shift by shift basis  Helps to ensure timely follow up from shift to shift or day to day  Usually the first documented indication of a new or impending problem or change of condition  An important link in the audit trail  Important source of information for the IDT as well as nursing 24

25. INCIDENT REPORTS  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 25

26. CHANGE OF CONDITION MONITOR  Reviews information given in the 24 hour report, incident reports and telephone orders  Identifies changes and problems requiring follow up in the last 24 hours (or 72 hrs. over the weekend)  Centralizes and identifies changes and any deficiencies or “loose ends” in documentation 26

27. RESIDENT/FAMILY CONCERNS AND COMPLAINTS  Frequently not picked up and processed in a methodical manner  An important source of information about the resident, impending or actual problems and changes of condition  Need to be identified and addressed by the IDT in a timely manner  IDT involvement and reporting is critical 27

28. CHANGE OF CONDITION MONITOR -2  Complete daily prior to the standup meeting  Review 24 hour report, incident reports and telephone orders that denote a change of condition  List all changes of condition on the monitor form 28

29. WHAT MAY INDICATE A CHANGE OF CONDITION?  Changes can be physical, mental or psychosocial  Change can  Be slow to develop and show subtle signs or  Develop rapidly with more obvious signs and symptoms 29

30. WHAT MAY INDICATE A CHANGE OF CONDITION? -2  When reviewing the 24 hr. report look for  Reports to nursing by family, C.N.A.’S, R.N.A.’S, ancillary services that something has occurred or is changing in the resident’s condition  Don’t overlook resident/family complaints 30

31. WHAT MAY INDICATE A CHANGE OF CONDITION? -3  New orders for:  An antibiotic  Treatment  Physical or chemical restraint  New support or assistive device  Weight loss or gain  X-rays and labs 31

32. WHAT MAY INDICATE A CHANGE OF CONDITION? -4  Changes in orders can also indicate a change of condition. For example:  Increase in dose of psychotropic medication  A change from one type of physical restraint to another type  A change in type of assistive device used to treat a condition or maintain mobility  Change in treatment order because the site is not responding 32

33. WHAT MAY INDICATE A CHANGE OF CONDITION? -5  When reviewing incident reports look for:  Falls  Medication errors  Injuries/death resulting from defective equipment  Resident to resident or resident to staff altercations 33

34. COMPLETING THE COC MONITOR  Look at the audit form (H.O. #6) – reference HIM #7050audit form (H.O. #6) – reference HIM #7050  Review the Legend at the bottom of the form  These are the codes used to complete the form  Review the Incidents and Accidents box  These are some general related guidelines 34

35. COMPLETING THE COC MONITOR -2  PRACTICE  Review of the last 3 change of condition monitors from each facility in your group  Summarize issues  Plan for facility and Corporate-wide 35

36. STANDARD AUDITS  Change of Condition – daily  Weekly skin report (done by the treatment nurse and audited by the MRD for qualitative documentation). (HIM/Record Consultant may need to assist with the quality training.)  Quantitative Reviews – Is it or isn’t it there?  Clinical Record Monitor (reference HIM #7050) 36

37. STANDARD AUDITS -2  Weight audit – (may be done by others)  Admission Audit  Discharge Audits  Psychotherapeutic drugs  Specialized monitoring, i.e., review H.O. #4 37

38. AUDITS AND THE FOLLOW UP  Audit schedule with required audits and QA reporting and schedule  Audit/Monitor Schedule  Audit/Monitor Schedule on the Administrator’s and DNS desk; follow up to assure MRD audits carried out as planned.  HIM/Record Consultants assists with above and provides training and monitoring to assist with the quality of the process 38

39. MEDICAL RECORDS AUDIT SCHEDULE  H.O. #7 H.O. #7  Monitored by HIM/Record Consultant 39

40. DISCHARGE SUMMARY REQUIREMENTS  Review HIM Policies/Procedures  Discharge Chart Monitor (HIM #3520)  Order of Filing – Shortened Discharge Chart (HIM #3506)  Inhouse Order of Filing (HIM #4035) 40

41. GENERAL DOCUMENTATION REQUIREMENTS  Willful Omission and Willful Falsification of Records….”AVOID THE RISKS” 41

42. OBJECTIVES  Participants will  Identify the correct method to document, timely, accurately  Identify what is willful falsification and willful omission  Recognize documentation correction issues 42

43. GENERAL DOCUMENTATION GUIDELINES  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 43

44. ENTRIES accurate!!  Complete, concise, accurate!!  Made by the person carrying out the care/tx (not by another person for someone else)  Chronological  Used abbreviations only if approved by the facility and in the manuals 44

45. ENTRIES -2  In black or dark blue ink or typewritten – e-record  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 appl.)  Signed by appropriate person with professional title, i.e., C.N.A., R.N., L.V.N. 45

46. EXERCISES  Are there situations when documentation is carried out late?  A fellow staff member tells you they observed Mrs. Jones (the fellow staff members resident) sitting and falling to one side and she wasn’t sure what was wrong but informed the nurse. Please document that in the record. What should be done?  When documenting is it necessary to include position title, i.e., C.N.A., R.N., L.V.N., etc.? 46

47. 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”  Leave blank spaces  Document before an entry occurs 47

48. EXERCISES  Falsification of records may be interpreted in the following situations. 1. White out is used and then someone wrote over the white out. Is this allowed for legal documentation? 2. It is o.k. to leave a blank line between your note and the last note written? 48

49. EXERCISES  Now that we have computer documentation, order entry in your situation – and the med/tx records are printed there is no way to have a record that is incomplete or not accurate?  What could be a question??  If you do not have time you can leave the space for charting until the next day. Is that correct? 49

50. CORRECTION  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.  Computer system – each system has a method of correcting the documentation and ability to track. Follow the guide. 50

51. WILLFUL FALSIFICATION  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 51

52. 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 52

53. WILLFUL OMISSION  If staff are aware of any untoward event that affects the resident, and not documenting that information correctly, therefore causes the record to falsely reflect the condition of the resident, or the care or services provided shall be considered to be a “willful material omission” 53

54. EXERCISE  A staff member observed the resident and found the resident on the floor. The person did not know what happened, however documented that the resident had sat down on the floor and did not seem to be in any distress. The resident was complaining of pain. The fact was that the resident was found on the floor, the resident was complaining of pain and this was reported to the nurse, but did not include a note. Is this willful falsification or willful omission? 54

55. WHAT TO DO ABOUT AUDITS!!  Correction or late entries are possible but care needs to be taken between falsification and accurate correction. Practice Examples: Q & A 55

56. AHIS CONTACTS Elizabeth Rumbin, RHIT, HI Consultant smrumbin@aol.comsmrumbin@aol.com or 805-895-4517  Khaleelah Wagner, RHIA, HI Consultant khaleelahwagner@hotmail.comkhaleelahwagner@hotmail.com or 909-717-7102  Staci LePage, RHIT, HI Consultant stacilepage@comcast.netstacilepage@comcast.net or 916-202-5797  Rhonda Anderson, RHIA, President rhonda@ahis.netrhonda@ahis.net or 714-299-0573 56

57. THANK YOU FOR ATTENDING!! 57