|Survey Date: 5/25/2010|
Regulation Title: CFC-MEDICAL RECORDS
Based on the number and nature of deficiencies cited, the facility failed to comply with the Condition for Coverage of Medical Records. The facility failed to maintain complete and accurate records and protect them against loss and unauthorized use.
The facility failed to meet the following standards under the Condition of Medical Records:
V 0726 Maintenance of a complete, accurate and accessible record on all patients
The facility failed to maintain a complete, accurate and accessible patient record on all patients. Original physician progress notes and physician orders left the premises of the facility and were absent from the patient's record during review of the patients' records. This failure created the potential for patient care to be compromised. The failure also compromised the continuity of patient care.
V 0727 Protection of patient's record
The facility failed to ensure that the patients' medical records were protected from loss, destruction or unauthorized use. The facility also failed to ensure that patient information was kept confidential. Patient records were not safeguarded from loss or unauthorized use after business hours. Original physician orders and progress notes left the premises and were not available during review of the patients' records during the survey.
V 0729 Completion of patient records promptly
The facility failed to appropriately complete medical records in six (#1 through #6) of six medical records reviewed. Entries were lacking documentation of the time of the entries. This failure created the potential for patient care to be compromised.
V 0730 Centralization of clinical information
The facility failed to maintain a centralized patient record that was accessible to all members of the interdisciplinary team. This failure created the potential for patient care to be compromised.
Facility Plan of Correction:
Members of the Governing Body (GB)
have reviewed the Statement of
Deficiencies (SOD) and formulated the
Plan of Correction (POC). The standards
under Condition: Medical Records (V725)
that is not met as well as other standards
contains specifics of corrective plans. The
Medical Director is accountable to the GB
and will ensure the security of medical
records, be involved in the quality
improvement process in evaluation and
prevention of medical errors, and ensure
teammates adhere to policies and
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. Policy
#3-02-02 Medical Record Preparation
Charting Guidelines has been reviewed
with the teammates with the emphasis on
that all entries are to be dated and signed at
the time of entry.
AA's are to complete all filing and audit
100% of the patient charts by
6/21/10followed by monthly audits of 10%
of the charts. In addition compliance will
be evidenced by random audits conducted
by the FA of monthly physician Rounding
Reports X 3 months. Results of audits will
be reported in QIFMM and addressed as
necessary. FA and Medical Director are
responsible for ongoing compliance with