Documentation mistakes trip up home health survey
Here’s how to avoid record-keeping pitfalls
[Editor’s note: As managed care continues making inroads into the health care system, efforts at reigning in costs are resulting in treatment of greater numbers of patients at home, where costs are lower than in nursing homes and hospitals. In addition, more hospitals are finding themselves aligned, as part of a larger, vertically integrated system with home health care providers — a new piece in an ever-evolving health care puzzle. This month, Hospital Payment & Information Management looks at some of the challenges of managing home health information.]A Texas home care agency nurse was a little too chatty when a Joint Commission surveyor accompanied her on a visit earlier this year. As the pair approached a patient’s house, the nurse commented that when she had walked to the patient’s home that winter she slipped and fell on the sidewalk. She wasn’t hurt but merely stood up and continued with her work.
That off-hand comment cost the agency some points in its first survey with the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
The nurse had failed to document the incident or tell anyone at the agency about it and, therefore, violated the agency’s reporting policy, says Joni Wysinger, RN, administrator and clinical director of Compassionate Home Health Care, a full-service agency that serves a 50-mile radius of Dallas and Ft. Worth.
Also, the survey turned up another problem: A home health aide failed to turn in her notes within seven days of a visit, despite the agency’s protocol that everything needs to be in the chart within that time frame.
During Joint Commission surveys, even seemingly minor documentation details can cost plenty of points.
The standards that cover documentation as a whole are in the management of information section of the Joint Commission’s survey. These standards are the same for both freestanding home health agencies and hospital-based agencies, according to Joint Commission spokeswoman Janet McIntyre. "The idea is that it doesn’t matter whether it’s freestanding or hospital-based. If it’s surveyed under our standards, it’s the same home care manual," she explains. The lengthy section on information management contains 41 standards, covering nearly all aspects of a home care agency’s paper trail.
Many home care agencies have problems with one or more standards in the information management section.
Data security is a compliance problem
Security of information is one common problem area, says Debra Payne, RN, BSN, CRRN, associate director of the department of standards for the Joint Commission. "The internal and external demands for information can sometimes cause compliance problems with them."Another common problem is that home care agencies often have an excellent process for gathering information, but they fail to give themselves credit by documenting it, Payne says.
"Typically you can interview a nurse, and she can tell you everything about a patient’s care, including goals, care plans, how they addressed a patient’s care and needs," she explains. "But when you go to the record, you don’t see any of that because it’s not documented."
Payne says the way to shape up this sloppy documentation is by teaching staff that "if it wasn’t documented, it wasn’t done."
One Arkansas company that provides respiratory infusion services and durable medical equipment had a number of problems with management information services.
The problem was that the company relied on a manual documentation system that was terribly inefficient, says Rick Ferris, PharmD, MBA, MPH, BCNSP, vice president of infusion services for National Medical Systems in Little Rock, AR. Ferris, who previously was a Joint Commission surveyor, helped the company automate its information system, basically dragging it out of the dark ages.
"By automating this whole thing, we were able to cut our collectibles in half, meaning the time it took to collect our money was literally cut in half," Ferris says. "More importantly, the interface between the clinical side and reimbursement side was nonexistent," he adds.
But now the two sides are connected through an automatic communication system, Ferris explains. So whenever some service is provided on the clinical side, it is automatically recorded on the reimbursement side.
Payne offers these guidelines to complying with the main standards for information management:
• IM.2 — Maintaining confidentiality, security, and integrity of data.
Agencies often fail to document who is allowed to receive information about a patient’s record. "They need to remember to include a release of information to accrediting bodies," Payne states.
"Another common pitfall: Often, organizations will consider only the confidentiality of the clinical record," Payne adds. "But there are other [kinds of] information gathered and stored by the organization, such as personnel files and financial information that need to be identified and handled as confidential information."
A third trouble area involves the circulation of charts during off-hours. "Sometimes charts go out at night because nurses are going to see patients in the morning, and [agencies] need to think about how nurses keep charts when they’re out of the office," Payne explains.
Payne says many of these confidentiality issues can be resolved through written policies about who has access to which confidential information and when release of this information is permitted.
Agencies need to consider how to maintain confidentiality of field charts and records during off-hours when on-call staff employees may need to review them. Some agencies handle this issue by giving staff small file folders that close and lock. Employees can carry records locked in the folders while they have them at home over night.
• IM.9 — Maintaining home care records for every patient.
Agencies sometimes fail to select a consistent format for documenting all services provided to a patient.
"We’re not prescriptive about what format they use," Payne says. "It’s more important that whatever format they use is standardized, promotes consistency and ease of data retrieval, and is useful to the staff."
Computer documentation is one example of a standardized format.
• IM9.19 — Providing evidence of consent for care, when required.
An agency, for instance, might obtain a consent form when providing infusion services but fails to obtain consent for oral medications. If the agency’s policies requires written consent for pharmaceutical care, then this would be a violation.
Stay consistent with policies
The solution is to be consistent with policies and regulations. The Joint Commission only requires agencies to have written consent from patients if their policies and procedures or government regulations require it, Payne says.• IM9.24 — Documenting communication when patients transfer.
An agency can fail to establish a policy and procedure that describes what information will be communicated and how it will be provided.
The solution: Set up a policy that answers the following questions:
— What is the process for providing information?
— Is the information written or verbal?
— What information will be provided when a patient is transferred?
— Will the information be provided to someone within the same organization to another level of service, or will it be provided to another organization altogether?
Interim HealthCare Inc. in Port Richey, FL, received high marks for its information management during a recent Joint Commission survey, partly due to the agency’s strong focus on communication. "The Joint Commission thought we did an excellent job with communication and case conferencing," says Denise Grosman, LPN, quality improvement manager of the Port Richey branch.
"If any one cog in the wheel holds up this communication, it gets lost down the line," Grosman says. "We have many checks and balances in place, including clinical chart reviews and a twice-a-month team conference."
• IM25.1 — Completing patient’s home care record within specified time frame.
Home care organizations sometimes fail to complete a certain percentage of home care records within the three-month time frame they have established.
The solution is to specify in a policy when a discharged patient’s records must be completed and include the following:
— date and reason for discharge;
— treatment goals;
— care plan summary;
— progress report;
— problems and special needs;
— patient’s current status.
"We want to look at the whole system," Payne says. "We would want to see how it determines what is an appropriate time frame."
• IM.3 — Collecting data in a timely, economical, and efficient manner.
Mistakes often occur when an agency has no standard way of documenting a patient’s date of birth. So on one form, it might be listed as a month and year, and on another form it might be listed as a day, month, year. "Sometimes it’s just illegibly documented," Payne says.
The remedy is to standardize documentation of this vital piece of information.
Another inconsistency could occur depending on whether an agency lists a patient’s weight in pounds or kilograms and whether it’s listed with or without clothing.
The agency needs to be meticulous and consistent in all of its documentation, including the use of diagnostic coding for billing, record documentation, performance-improvement data, and other systems.
"What the surveyor would be looking for, in this standard is timely, efficient, and consistent definitions of data across the organization," Payne says. "We’re going to be looking at medical records from all of the care sites and all clinical services to see if everybody uses a standardized system."
Interim HealthCare gives staff positive reinforcement, supervision, and inservices to encourage consistent documentation, Grosman says. "We have one-on-one reviews with them."
For further information, contact Debra Payne, RN, BSN, CRRN, Associate Director of Department of Standards, Joint Commission on Accreditation of Healthcare Organizations, 1 Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5898.
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