Will your agency’s IM satisfy a surveyor?
Here’s what to do and what mistakes to avoid
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 that patient’s home that winter she had slipped and fallen on the sidewalk. She wasn’t hurt; she 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 around the Dallas-Ft. Worth area.
Likewise, the survey turned up another problem: a home health aide failed to turn in her notes within seven days, despite the agency’s protocol stating that everything needs to be in the chart within seven days after a visit.
These seemingly minor documentation details can cost an agency plenty during a Joint Commission survey, and they may also lead to state license revocation, as Olsten Health Services’ Seattle branch office learned recently. (See story in Homecare Quality Management, October 1997, p. 133.)
The standards that cover documentation as a whole are in the management of information section of the Joint Commission’s survey. This lengthy section has 41 standards, covering nearly all aspects of a home care agency’s paper trail. Not surprisingly, many agencies have problems with one or more standards in this section.
Security of information, for example, 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," she says.
Another common problem is that agencies often have an excellent process for gathering information, but they fail to give themselves credit by documenting the information, 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 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 of Little Rock, AR.
Ferris, who previously was a Joint Commission surveyor, helped the company automate its information system, basically bringing 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 automatic communication, Ferris explains. When a service is provided on the clinical side, it is automatically recorded on the reimbursement side.
Payne offers these tips for complying with the main standards for information management:
• IM.2 Maintaining confidentiality, security, and integrity of data
Mistake: Agencies 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.
Mistake: "Another common pitfall is organizations often will consider only the confidentiality of the clinical record," Payne adds. "But there is other information gathered and stored by the organization, such as personnel files and financial information, that needs to be identified and handled as confidential information."
Mistake: Another 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 they need to think about how nurses keep charts when they’re out of the office," Payne explains.
Solution: Payne says many of these confidentiality issues can be resolved through written policies governing who has access to which confidential information, and when the 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 problem by giving staff small file folders that close and lock. Employees can carry records locked in the folders while they have them at home overnight.
• IM.9 Maintaining home care record for every patient
Mistake: An agency fails to select a consistent format for documenting all services provided to a patient.
Solution: "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 obvious example of a standardized format.
• IM9.19 Providing evidence of consent for care, when required
Mistake: An agency, for instance, might obtain a consent form when the agency provides infusion services, but it fails to obtain consent for oral medications. If the agency’s policies require written consent for pharmaceutical care, then this would be a violation.
Solution: Be consistent with one’s policy and regulations. The Joint Commission only requires them to have written consent from the patient if their policy and procedures or government regulations require it, Payne says.
• IM9.24 Documenting communication when patient transfers
Mistake: An agency fails to establish a policy and procedure that describes which information will be communicated and how it will be provided.
Solution: The agency should set up a policy that answers the following questions:
What is the process for providing information?
Is the information written or verbal?
Which information will be provided when a patient is transferred?
Will the information be provided to someone within the same organization on another level of service, or will it be provided to another organization altogether?
Interim HealthCare in Port Richey, FL, received high marks for its information management during a recent Joint Commission survey, and this was 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
Mistake: An organization fails to complete a certain percentage of home care records within the three-month time frame it has established.
Solution: Specify in a policy when a discharged patient’s records must be made complete, 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 their whole system," Payne says. "We would want to see how they determine what is an appropriate time frame."
• IM.3 Collecting data in timely, economical, efficient manner
Mistake: 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.
Mistake: 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.
Solution: 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 their 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."
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