NORTH AMERICAN HEALTH CARE, INC. DOCUMENTATION–DOCUMENTATION– DOCUMENTATION DOCUMENTATION

PRESENTED BY Rhonda L. Anderson, RHIA President, AHIS 940 W. 17 th Street, Ste. B Santa Ana, California Fax:

DATE & LOCATION  July 17, 2008 Northern California  August 20, 2008 Southern 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) – IN REVIEW MRD and the Unit Coordinator’s responsibilities Legal Records – IN REVIEW - The record location and guidance when resident is out of the facility. “Review of the MRD and the Unit Coordinator’s responsibilities CQI – Quality Assurance Processes and best practices CQI – Quality Assurance Processes and 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 _fivestar.asp _fivestar.asp Medicare Compare can be found at

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)

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

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 Practices 2. 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

THANK YOU FOR ATTENDING!!  Best ALWAYS!!!