§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.
§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.
§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
|
Observations:
Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to maintain complete and accurate records for one of 21 residents reviewed (Resident R44).
Findings include:
Resident R44's clinical record revealed an admission date of 9/08/23, with diagnoses that included stroke with left-sided weakness, arthritis of the hips, migraine headaches, nausea, and major depression.
Review of Resident R44's medical diagnoses revealed a diagnosis of Schizophrenia (a serious mental health condition that affects how people think, feel and behave, and may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) added to the clinical record on 12/15/23.
Continued review of Resident R44's diagnosis reports signed by the physician on 6/11/24, 9/04/24, 11/15/24, revealed the Schizophrenia diagnosis remained on his/her clinical record.
Review of Resident R44's Pennsylvania Preadmission Screening Resident Review (federal requirement to help ensure that individuals with serious mental illness are not inappropriately placed in nursing facilities for long term care) dated 9/08/23, lacked evidence of a history of Schizophrenia prior to admission.
Review of Resident R44's Order Summary Reports signed by the physician on 3/04/25, and 4/15/25 revealed a diagnosis of Schizophrenia listed.
Review of Resident R44's Neuropsychology assessments dated 9/21/23, 12/07/23, and 7/11/24, lacked evidence of a diagnosis of Schizophrenia, and a Psychiatric Evaluation dated 12/30/24, that indicated Resident R44 had a psychiatric history of Schizophrenia.
Review of Resident R44's Minimum Data Sets (MDS- a standardized assessment tool that measures health status in nursing home residents) revealed the Quarterly MDS dated 6/25/24, Annual MDS dated 9/18/24, Quarterly MDS dated 11/20/24, and Quarterly MDS dated 2/15/25, Section I-Active Diagnoses were coded to indicate that Schizophrenia was an active diagnosis.
A departmental progress note dated 5/22/25, at 8:52 a.m. revealed that upon conversation with Resident R44, his/her physician, and family it was determined that Resident R44 did not have a history of Schizophrenia and that adding the diagnosis to the clinical record was a clerical error.
During an interview on 5/22/25, at 9:05, a.m. the Director of Nursing confirmed that there is no evidence that Resident R44 had a history of schizophrenia and that the inclusion of the diagnosis in the clinical record was inaccurate.
28 Pa. Code 211.5(f)(iv) Medical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 06/25/2025
Resident R44's clinical record, medical diagnosis list, and Minimum Data Sheet were corrected to reflect no history or active diagnosis of Schizophrenia.
Director of Nursing completed an audit of current residents with a diagnosis of Schizophrenia to ensure proper & sufficient documentation to support an accurate diagnosis was verifiable.
Nursing Home Administrator will educate Registered Nurse Assessment Coordinators and nursing leadership on the process of proper coding of medical diagnosis and the supporting documentation required to verify the accurate coding of a medical diagnosis.
The Director of Nursing or designee will audit newly added diagnosis codes of Schizophrenia, Bipolar Disorder, Unspecified Dementia, Unspecified Severity, with Psychotic Disturbances to verify accuracy of coding and sufficient supportive documentation is present. These audits will be conducted once a week for four weeks, then monthly for three months. Results of these audits will be reviewed by the Quality Assurance Process Improvement committee until substantial compliance is achieved.
|
|
