Observations:
Based on review of facility documentation and medical records (MR), as well as employee interview (EMP), it was determined that the facility failed to ensure that the record of a discharged patient was completed within 30 days following discharge for one of one MR (MR1).
Findings include:
Review, at approximately 12:30 PM on April 3, 2023, of "PAM Specialty Hospital at Heritage Valley Medical Staff Rules and Regulations," revised August 2019, revealed, "... All members of the Medical Staff Bylaws, and these Rules and Regulations ... F. Medical Records ... 4. The attending physician shall be responsible for the preparation of a complete medical record for each patient. This record shall include the following: ... f. Discharge Summary (1) Hospital Course (2) Discharge Condition (3) Discharge Diagnosis ... 7. All medical records will be completed within 30 days post discharge. ..."
Review, at approximately 12:45 PM on April 3, 2023, of Policy Number HIM I-01, "General Documentation Guidelines," revised March 28, 2022, revealed, "... Policy The policy of PAM Health, LLC. to ensure the following: ... 3. To facilitate consistency and continuity in patient care, the medical record contains very specific data and information including: ... aa. Discharge summaries, or a final progress note or transfer summary. ... 14. Discharge Summary: A discharge summary must be written or dictated and authenticated by the responsible medical provider on the medical record within 30 days post discharge. ... 17. The medical record is complete when its contents: a. Are assembled, analyzed and authenticated. The time period for completion of the medical record is specified in the Medical Staff Rules and Regulations and cannot exceed 30 days after discharge. ..."
Review, at approximately 1:00 PM on April 3, 2023, of Policy Number HIM III-02, "Medical Staff Chart Completion, Medical Provider Notification of Deficient/Delinquent Medical Records and the Suspension Process," revised April 20, 2022, revealed, "... Policy: PAM Health LLC. (PAM) is committed to practices that ensure timely medical record completion in order to meet patient care, regulatory, and financial requirements according to ... Department of health [sic] and Medical Staff Bylaws, Rules, Regulations and Policies. ... Definitions: Deficient Record - A record that is incomplete and less than or equal to 30 days after discharge. Delinquent Record - A record that is incomplete and equal to or greater than 31 days after discharge. ... Procedure: In order to maintain an effective process for timely chart completion, medical providers should make every attempt to complete medical records on an ongoing bases [sic]. If this is not accomplished, the following procedure has been implemented for tracking and notifying physicians of charts requiring completion. HIM Director Responsibilities 1. HIM Director to maintain an ongoing accurate list of deficient and delinquent discharged medical records. ... Physician Responsibilities 1. It is the responsibility of the medical providers to complete records on an ongoing basis. ..."
Review, at approximately 1:15 PM on April 3, 2023, of the facility, "Bi-Weekly Medical Record Delinquency Notification Log," dated March 27, 2023, revealed two physicians with 17 delinquent medical records.
1. On February 16, 2023, at approximately 12:05 PM, EMP1 confirmed that there was no discharge summary for MR1, who was discharged from care on November 28, 2022.
| | Plan of Correction - To be completed: 07/01/2023
WHO: The Chief Executive Officer (CEO) is responsible for overall and ongoing compliance and continued implementation of the plan of correction.
WHAT: The CEO had communicated to the two physicians in question at the time of the findings. The physicians completed their delinquent medical records to be compliant with the Med Staff Rules and Regs. The CEO will re-educate members of the Medical Staff regarding the Rules and Regulations, specifically, Discharge Summary: A discharge summary must be written or dictated and authenticated by the responsible medical provider on the medical record within 30 days post discharge.
WHEN: Education will be completed by July 1, 2023
HOW: The physicians will have a written or dictated and authenticated discharge summary by the responsible medical provider on the medical record within 30 days post discharge.
MONITORING ONGOING COMPLIANCE: The HIM Director will audit the discharge medical records to ensure that there is a written or dictated and authenticated Discharge Summary by the responsible medical provider on the medical record within 30 days post discharge. Monitoring will continue for two (2) consecutive months until compliance has been demonstrated. Once compliance is demonstrated, monitoring will occur for two (2) weeks to determine sustainability. If sustainability is not demonstrated, monitoring will continue for two (2) more weeks. Non-compliance will be addressed immediately, re-education will be instituted, if non-compliance by a physician remains the issue will be escalated to the Medical Director and MEC for further guidance. Audit results will be reported to Medical Executive Committee and Governing Board.
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