|Survey Date: 5/24/2010|
Regulation Title: QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL
Regulation Description: The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility's organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS.
Based on review of facility documents, staff interviews and review of medical records, it was determined that the facility failed to identify and correct deficiencies in the completeness of medical records as part of the QAPI program. Missing physician orders and progress noted in patient medical records could cause potential negative patient outcomes.
The findings were:
A review of the facility's internal documents was conducted on 5/21/10. Minutes from the Quality Improvement & Facility Management Meeting (QIFMM) dated 5/4/10 were reviewed. The section titled Quality Management Audits included a section for medical record file audits and indicated they are to be performed monthly. In the section was an area for the percentage of charts audited to be input. These sections were left blank for all of the year 2010. There is no mention of physician progress notes or orders not being present or leaving the facility.
The medical records of eight in-center hemodialysis patients were reviewed throughout the survey from 5/20/10 through 5/24/10. In three (#5, #6, and #7) of eight records original physician progress notes and written physician orders were absent from the chart for the month of April, 2010. The facility was unable to provide the absent physician progress notes and written physician orders.
An interview with the medical director was conducted on 5/19/2010 at approximately 3:30 PM. S/he stated the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers against the facility's policies. S/he also stated that the providers had been removing the rounding sheets on a regular basis and that office staff from their offices would return the sheets after the office was done with them.
Facility Plan of Correction:
The Governing Body will ensure the facility maintains an effective, data driven, quality assessment and performance improvement program (QIFMM) that includes a monthly medical record review. Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. AA’s are to complete all filing and audit 100% of the patient charts by 06/21/10, followed by monthly audits of 10% of the charts.
These medical records audits will be documented on the QIFMM form and reviewed in QIFMM meeting with action plans developed and implemented as needed.
A letter was written to XXX Nephrology Associates on May 20, 2010 by the Medical Director, stating that no documents are to be removed from the facility from that date forward. FA and Medical Director are responsible for ongoing compliance with POC.