|Survey Date: 5/25/2010|
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.
The findings were:
A review of the facilities internal documents was conducted on 5/19/10. Minutes from the Quality Improvement & Facility Management Meeting (QIFMM) dated 3/2/10 were reviewed. The section titled Quality Management Audits lists that 10% of the patient records were reviewed monthly. There was no mention of physician progress notes or orders not being present or leaving the facility.
The medical records of six patients were reviewed throughout the survey. In four (#1, #2, #3, #5) of six records original physician progress notes and written physician orders were absent from the chart for the months of March and April 2010. In two (#2 and #6) of six records original physician progress notes and written physician orders were absent from the chart for the month of October 2009. In one (#2) of six records original physician progress notes and written physician orders were absent from the chart for the month of February 2010. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for April 2010 on four (#1, #2, #3 & #5) of the five patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for March 2010 on two (#1 and #2) of the four patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for February 2010 on the one (#2) patient. The facility was unable to provide the absent physician progress notes and written physician orders from October 2009.
An interview with the medical director was conducted on 5/19/2010 at approximately 3:30 PM. S/he stated that 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.
An interview with the Facility Administrator for the Acute Care Program was conducted on 5/19/2010 at approximately 8:30 AM. S/he stated, when asked where the physician rounding reports were for Sample patient #3, that they may be in the patient's treating physician's office.
An interview with the Facility Administrator was conducted on 5/19/10 at approximately 2:00 PM. S/he stated that the provider's office would use the rounding sheets for billing and that they were normally returned when they were done with them. S/he stated that there was no tracking process in place to determine where the rounding sheets were currently and when they were returned to the facility each month.
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
06/21/2010, 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