If a CMS surveyor showed up at your door tomorrow would be prepared? Are you up to date on the changes that went into effect recently? Did you know that all the medical records standards apply to all departments including lab and x-ray?

CMS made changes to the hospital CoPs on November 29, 2019, from two separate sets of federal regulations. The changes include the history and physicals for healthy outpatients and discharge planning, specifically, access to medical records. It also included changes in the final Hospital Improvement rule. CMS also changed the website to get copies of all the manuals and the email address to ask questions so this information will be provided.

This program will cover in detail the CMS regulations and interpretive guidelines for medical records. This is an extremely important section and includes hot issues like verbal orders, history and physicals, access to medical records, standing orders, discharge summary, medication orders, and more. There will also be a brief discussion of the pandemic 1135 waivers as the waivers affect medical records.

CMS publishes a list of deficiencies received by hospitals and this will be discussed. The number of deficiencies in the medical records section has gone up significantly.

This program will cover some information on HIPAA from the Office of Civil Rights including the difference between patient access versus when authorization is needed. OCR is now fining hospitals if patients are not given access to medical records timely.  Recent fines were two for $85,000 each and one for $100,000.00.

It is important to ensure that the required CMS documentation elements are contained in the electronic medical record (EMR) as hospitals move toward a completely integrated EMR. These should also be reflected in the hospital P&Ps. The number of deficiencies in each of the CMS medical records sections will be discussed.

Most every hospital in America accepts Medicare and Medicaid reimbursement and as such must comply with the CMS Conditions of Participation (CoPs) for hospitals. There have been many past changes to these over the recent past. This includes changes to Tag 454 (verbal orders), 457 (standing orders), and 458 (H&P update). Hospitals ask many questions regarding the regulations for standing orders, order sets, protocols, and preprinted orders.

CMS also issued several important memos regarding medical records, including one that addressed confidentiality and privacy. These are important given the recent large fines related to HIPAA being assessed by the Office of Civil Rights. This webinar will also discuss the OIG document on access versus authorization which is final, and which is also discussed in the CMS final rules.

The CMS Conditions of Participation medical records section has many important standards including informed consent, history and physicals, verbal orders, discharge summaries, and more. The CMS worksheet section about getting discharge summaries into the hands of the primary care doctor to prevent unnecessary readmissions will be discussed.

There will be a discussion of MOON law which requires written information to be given to all observation patients. The IM notice and detailed notice forms were updated in 2020. The federal law on substance use disorder records also been amended.

Joint Commission has also recently changed many of their standards to comply with the CMS CoP requirements so not doing this right could also result in being out of compliance with standards from the Joint Commission. CMS states that all their medical record regulations also apply to documents maintained by radiology and the lab.

Objectives:-

• Recall that CMS has specific informed consent requirements
• Describe when history and physical must be done and what is required by CMS and the Joint Commission
• Discuss that both CMS and TJS have standards on verbal orders
• Recall that CMS has standards for preprinted orders, standing orders, and protocols.

Agenda:-

• Introduction to the CMS hospital CoPs
• How to obtain a copy
• CMS Survey memos
• Interpretive guidelines issued
  • Changes to verbal orders and H&P update
• How to keep posted of new changes
• Confidentiality and privacy memo
• MOON form
• IM and detailed notice forms
• Transfer form requirements and proposed changes
• OCR information on HIPAA on patient access versus authorization
• TJC changes to comply with CoPs
• Autopsies requirement changed
• AHIMA practice guidelines
• HITECH and Breach Notification law
• Final changes to privacy, security, HITECH
• Verbal orders and changes
• History and physicals and November 29, 2019 changes
• Grievances
• Incident reports
• Medical record service requirements
• Medical record education and personnel
• Author identification
• Content of records
• Standing orders and protocols
• Legibility and authentication requirements
• Informed consent
• List of procedures for consent requirements
• Discharge summaries
• Completed medical records
• Other sections of CoPs that are important for documentation in the medical record
  • Restraint and seclusion
  • Medication documentation
  • Pre anesthesia assessment
  • Post-anesthesia assessment
  • Visitation with changes to advance directives, consent, and plan of care
  • Notification of OPO in deaths
  • Organ donation documentation
  • Anesthesia standards

Who Will Benefit?

• Director of Health Information Management
• Health Information Management staff
• Chief Nursing Officer (CNO)
• Compliance Officer
• Director of Radiology
• Lab Director
• Hospital Legal Counsel
• Chief Executive Officer (CEO)
• Chief Operating Officer (COO)
• Chief Medical Officer (CMO)
• Joint Commission Coordinator
• Quality Improvement Coordinator
• Risk Managers
• Nurse Educator
• Patient Safety Officer
• Emergency Department Manager
• Nurse Managers/Supervisors
• Staff Nurses
• Clinic Managers
• Medical Department Nurse Manager
• Surgery Department Nurse Manager
• OR Nurse Director
• ICU Nurse Director
• CCU Nurse Director
• Outpatient Director
• IS Director
• Policy and procedure committee
• Anyone involved in the implementation of the CMS or Joint Commission medical record and documentation standards