PIN CAH CMS Standards Review

Conference Call Notes

Call: February 17, 2015

Attendees: Mineral Community Hospital, Broadwater Health Center, Cabinet Peaks Medical Center, Missouri River Medical Center, Pondera Medical Center, Roosevelt Medical Center, Central Montana Medical Center, Mountainview Medical Center, Roundup Memorial Hospital, Northern Rockies Medical Center, Prairie Community Hospital, Daniels Memorial Healthcare, Barrett Hospital and Healthcare

C-1001 – 1002 A CAH must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the CAH may need to place on such rights and the reasons for the clinical restriction or limitation. A CAH must meet requirements noted in the SOM.

  • Broadwater: Are there certain items required to be in the policy? Have a patient flyer.
  • Cabinet Peaks (CPMC): policy shared (see PIN website) developed policy and include in patient rights given to all admitted patients instead of putting in a separate brochure.
  • Central MT (CMMC): policy shared (see PIN website). Julie indicated that when writing the policy wording needs to be careful in the policy. Received guidance and re-wrote policy to address patient visitation and when hospital could place clinical restriction.
  • Prairie Community: Had a visitation policy posted in the hallway by the admitting desk. Met all the COPs, one page, simple. Was accepted at Survey.
  • CMMC: While in policy review, they noticed in 1001, “review sample of med records to determine documentation.” Discovered this was not documented in the medical record. Has gone back and made part of the admission process that the patient initials that they received their visitation rights.
  • Roundup: Have patients sign then scan into computerized system.

C-301 The CAH maintains a clinical records system in accordance with written policies and procedures.

  • Pondera: What is everyone doing to comply with the requirement of current list of authenticated signatures? They ask providers on a year basis (when they are filling out HIPAA stuff) to indicate initials they use to authenticate records.
  • Mineral: Signature Verification Book – Binder broken out into categories of MD, Mid-Level, RN, etc. Everyone has to print, sign and initial in the book.
  • Electronic record is signed according to system configuration based on log-in. Will sign everything as the person logged-in.
  • Travelors? Supposed to come to Medical Records to sign before they start their shift. Once in a while missed if they are there on the night shift.
  • CPMC: CMS SOM indicates records retained for 6 years, however MONTANA is 10 and for minors longer. This overrides federal rules. Administrative Rules of Montana (ARM). Link:

C-302 The records are legible, complete, accurately documented, readily accessible, and systematically organized.

  • Medical record format for survey:
  • Mineral Community was requested to give auditor access to the record, they did not have to print
  • Barrett Hospital just had trauma re-certification. They refused to look at electronic medical record so all records had to be printed.
  • CMMC had licensure audit and auditor had IT pull up records and assist in viewing electronically.

C-303 A designated member of the professional staff is responsible for maintaining the records and for ensuring that they are completely and accurately documented, readily accessible, and systematically organized.

  • This is HIM staff at all facilities on the call.
  • Broadwater has a checklist for chart completion. Shared (see PIN website)

C-304 -307For each patient receiving health care services, the CAH maintains a record that includes, as applicable: Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient. Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings. All orders of doctors of medicine or osteopathy or other practitioners, reports of treatments and medications, nursing notes and documentation of complications, and other pertinent information necessary to monitor the patient's progress, such as temperature graphics, progress notes describing the patient's response to treatment; dated signatures of the doctor of medicine or osteopathy or other health care professional.

  • Prairie: Audit of every chart that MD signs to make sure all are signed. Does for a year. It used to be that the requirement was the record to be completed within 2 weeks. It has changed that it is within a reasonable amount of time and it is up to the facility to define “reasonable amount of time”. This COP change was in the January 2015 updates.
  • Discussion indicated that “reasonable amount of time” would vary per facility and provider make-up and when providers are there.
  • Mineral: If after 15 days the provider does not finish the chart then a report is sent to the Chief of Staff and CEO.
  • Barrett deadline is 7 days and after 14 HIM is to alert the CEO. They have a non-compliance policy but it never gets that far. Policy shared (see PIN Website)

C-308 The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use.

  • CMMC written in a couple different areas – Security of the department and of the storage area where old records are kept. Also policies regarding HIPAA and protection of the EMR and how to make sure computers are locked, etc.
  • Barrett – auditing of records was a challenge. Randomly chose employees and what they looked at and high-provide, high-community interest cases were also audited. It was difficult to get to a success audit standpoint.
  • CMMC – IT staff will walk around offices without notice when staff isn’t there to make sure computers are locked and passwords are not accessible.

C-309 Written policies and procedures govern the use and removal of records from the CAH and the conditions for the release of information.

  • Only a few people have the key to medical records – DON and 4 medical records staff. Nurses must go through one of those staff members for records needed over 4 years old.
  • NRMC: Making policy changes to go along with Meaningful Use process.

C310 Patient’s written consent is required for lease of information not required by law.

Medical Staff Bylaws

  • CMMC – cannot find anything discussing the requirement for them to be routinely reviewed.
  • Mineral – check with insurance carrier for guidelines. Yellowstone has ‘em. Unwritten guideline of every two years.

Next Call: March 17; 2:00 pm

Tags 311-326. Begins on Page 160 of the SOM:

C-311 Record Retention

The records are retained for at least 6 years from date of last entry, and longer if required by State statute, or if the records may be needed in any pending proceeding. Montana is 10 years. Administrative Rules of Montana (ARM):

Yep, no 312-319!

C-320Surgical Services.

If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section.

C-321 Designation of Qualified Practitioners

The CAH designates the practitioners who are allowed to perform surgery for CAH patients, in accordance with its approved policies and procedures, and with State scope of practice laws. Surgery is performed only by--

(1) A doctor of medicine or osteopathy, including an osteopathic practitioner recognized under section 1101(a)(7) of the Act; (2) A doctor of dental surgery or dental medicine; or (3) A doctor of podiatric medicine.

C-0322 Anesthetic Risk and Evaluation

(1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed.

(2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia.

(3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in paragraph (c) of this section.

C-323 Administration of Anesthesia

The CAH designates the person who is allowed to administer anesthesia to CAH patients in accordance with its approved policies and procedures and with State scope-of-practice laws.

(1) Anesthesia must be administered by only--

(i) A qualified anesthesiologist;

(ii) A doctor of medicine or osteopathy other than an anesthesiologist; including an osteopathic practitioner recognized under section 1101(a)(7) of the Act;

(iii) A doctor of dental surgery or dental medicine;

(iv) A doctor of podiatric medicine;

(v) A certified registered nurse anesthetist (CRNA), as defined in Sec. 410.69(b) of this chapter;

(vi) An anesthesiologist’s assistant, as defined in Sec. 410.69(b) of this chapter; or

(vii) A supervised trainee in an approved educational program, as described in §§ 413.85 or 413.86 of this chapter.

C-324Administration of Anesthesia

In those cases in which a CRNA administers the anesthesia, the anesthetist must be under the supervision of the operating practitioner except as provided in paragraph (e) of this section. An anesthesiologist's assistant who administers anesthesia must be under the supervision of an anesthesiologist.

C-325 Discharge

All patients are discharged in the company of a responsible adult, except those exempted by the practitioner who performed the surgical procedure.

C-326 State Exemption

(1) A CAH may be exempted from the requirement for MD/DO supervision of CRNAs as described in paragraph (c)(2) of this section, if the State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation with the State’s Boards of Medicine and Nursing, requesting exemption from MD/DO supervision for CRNAs. The letter from the Governor must attest that he or she has consulted with the State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interests of the State’s citizens to opt-out of the current MD/DO supervision requirement, and that the opt-out is consistent with State law.

(2) The request for exemption and recognition of State laws and the withdrawal of the request may be submitted at any time, and are effective upon submission.