Long-Term Care Survey Alert

Come April 14 of next year, surveyors can cite your facility for not identifying and keeping up with all of a residents clinical record.

Under the Health Insurance Portability and Accountability Act, the resident has the right to know where his health record is and to inspect and copy it, says Jill Burrington-Brown, professional practice manager for the American Health Information Management Association. "So the facility has to define the patients designated record set to include those pieces that are not kept all in one place," she emphasizes. For example, many facilities maintain the medication administration record, care plans and therapy progress notes in separate locations even though the documentation is all part of the legal clinical record that will eventually catch up with the main file.

The so-called designated record set also includes any "shadow charts," unless they are exact duplicates of the residents clinical record. If the shadow chart differs from the original in any way, such as including notes from phone calls, then it becomes a record set that must be identified.

Surveyors will cite HIPAA violations under F492, which is a catchall that says the facility complies with all other state and federal regulations, according to Beth Klitch, a survey consultant in Columbus, OH.

In Klitchs view, surveyors who see medical privacy violations are more likely to hone in on whether staff has identified residents designated record sets and followed other HIPAA requirements.