Inpatient Facility Coding & Compliance Alert

 Prove you’ve implemented policies and have impeccable documentation

CMS has laid down new requirements of minimum health and safety standards that could affect your facility’s protocols known as conditions of participation (“CoPs”). You can’t refuse a survey since that would lead to your facility being excluded from the Medicare program. So, here’s your scoop on what the CoPs tell the surveyors to look for when they surprise you one morning. 

Starting point: The formal survey auditing process consists of six tasks for the surveyors: 

1. Offsite survey preparation,
2. Entrance activities,
3. Information gathering / investigation,
4. Preliminary decision making and analysis of finding,
5. Exit conference,
6. Post survey activities. 

- Read on to see how to graciously present your facility with a little more precision in what you already do and have.

Keep Your Medical Records Ready 

Make sure that medical records reflect any standing orders and the authorized practitioner’s order for care. For example, surveyors may check the records to see that proper medication was given in accordance with a well documented authorized practitioner’s order. They would even try to weed out any discrepancies with respect to dosage, administration route, and patient identity.

Heads up: Be ready to provide a sample of open and closed patient medical records. Remember that the sample should be weighted to include more inpatient records. “I don’t have any idea why they lean on the inpatient side; in my personal experience,  I see more protocols on the outpatient side than I do on the inpatient side”, says Duane C. Abbey, Ph.D., president of Abbey and Abbey Consultants Inc., in Ames, IA. “But nonetheless, this is what the surveyors are supposed to do.” 

Clear and complete: Keep the records entries completely clear and legible so that there is no chance of misinterpretation. The medical record as per the CoPs requirement should contain “sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.”

Be sure that progress notes, nursing notes, or other entries in the medical record are complete. The requisite standing orders should be incorporated in the record.

Plus: Instruct your team to be very particular to the fact that record entries are dated, timed, and appropriately authenticated by the person who is responsible for ordering, providing, or evaluating the services provided.

Pre-printed order sets: To comply with the pre-printed order set usage requirement stated in § 482.24(c)(1), make sure the practitioner signs the last page along with date and time and writes the total number of pages in the order. He should sign both the top and bottom of any other internal pages of the order set where selections or changes have been made. He should even initial each place in the pre-printed order set where changes such as additions, deletions or strike-outs of components that do not apply have been made.

”If they’re removing some drug for instance, from the order, they really need to initial that. Or if they are adding something in, those things all need to be initialed. We need to know that it was the practitioner that was actually doing this,” explains Abbey.

Integrity matters: You may need to prove that your practitioner signatures are legitimate. According to the States Operation Manual (SOM Appendix A-TAG A-0450), “Hospital has a means for verifying signatures, both written and electronic, written initials, codes, and stamps when such are used for authorship identification. For electronic medical records, they may ask the hospital to demonstrate the security features that maintain the integrity of entries and verification of electronic signatures and authorizations. Examine the hospital’s policies and procedures for using the system, and determine if documents are being authenticated after they are created.” 

Know What’s Expected When Dealing With Biologicals

The surveyor is going to verify that your facility has policies and procedures approved by the medical staff and governing body concerning practitioners ordering drugs and biologicals.

“If a surveyor is going to judge whether or not you’re meeting this requirement…, they’re going to have to have your policies and procedures. So you have to be prepared to provide those to the surveyors, “cautions Abbey.

Surveyors would also like to know if you have implemented standing orders that relate to systematic administration of drugs and biological. “Make sure to attach them to the medical record so that they are readily available,” urges Abbey. “Who’s going to have these? Where are they located...? Your challenge is … to have access to them to prove, verify, attest that you have been following all the rules, and surveyor is going to verify that there are policies and procedures and they’ve been approved.”

They are even supposed to observe and verify the preparation of drugs and their administration to patients. Abbey tells you to be ready with evidence for queries like:

• Do you confirm the patient identity before you administer a drug? 
• How do you ensure that the correct procedures for medication, dose and route are followed? 
• Are the drugs administered in accordance with the hospital's established policies and procedures? 
• Does the nurse remain with the patient until medication is taken?
• Are all orders for drugs and biologicals, with the exception of influenza and pneumococcal included in the patient's record and authenticated by a practitioner as per § 482.12(c)?
• If the care was initiated by the nurse based on standing orders, was the record eventually authenticated by an authorized practitioner?
• Do your standing orders contain all the required elements?

“Keep in mind … that standing orders change over time, advises Abbey.”So we need to know what the standing order was at the time it was initiated. That’s why we need to have that standing order in the medical record.” 

Verify Your Provider’s CoPs Eligibility 

Be very clear on the requirements a practitioner should fulfill before ordering hospital inpatient or outpatient services. He should be responsible for the care of the patient; licensed to practice in your state; acting within his/her scope of practice; and authorized under a written hospital policy that is approved by the governing body. 

The requirement includes both practitioners who are part of the hospital medical staff as well the non-hospital medical staff that satisfy the hospital’s policies for ordering applicable services. 

“We’re seeing a lot more attention paid to non-physician practitioners because a lot more of them are providing services,” Abbey says. In “…the Medicare rules and regulations, these folks are equated to physicians in certain areas and in some cases they aren’t.”

Prepare Your Staff for the Interview

The surveyor may interview personnel who administer medications to verify their understanding of the policies regarding timeliness of medication administration. They are expected to have no less than “full knowledge of how they’re supposed to do it. And of course, that requires ongoing training and education,” Abbey says. “Make sure you know what you have and that you are properly using it.” 

Just to check, try asking the nursing staff the protocol for an existing standing order and let them justify how their practice conforms to the protocol. Educate them on the gaps if you find any, take corrective action, and educate as appropriate.  Internal mock surveys may also be useful.  By taking these kinds of steps, you should be better prepared for a survey.