This week’s Ftag of the Week on the CMSCG Blog is F842 Resident Records – Identifiable Information, which is part of the Administration regulatory group. There are multiple requirements under this regulation, of which the following are included:
- Requirements for the release of resident-identifiable information – Facilities are prohibited from releasing information to the public that is resident-identifiable. Information of this type may only be released when a contract is in place where the agent agrees that the information will not be used or disclosed in a manner that is greater than the facility itself is permitted to disclose/use.
- Protection and retention of medical records – The facility is responsible for protecting the residents’ medical records from loss, destruction or unauthorized use. The records must be retained for the period required by applicable state law. If there is no state law, then the information must be retained for five years from the date of discharge (or for three years after a minor reaches the state’s legal age if the resident was a minor). Facilities have been cited for records being unavailable to surveyors upon request for this information.
Medical Records
Much of this regulation addresses requirements for the Medical Record. Providers are required to maintain medical records for each resident, in accordance with accepted professional standards/practices, that are complete, accurate, systematically organized and readily accessible. Medical records must contain sufficient information to identify the resident, include a record of the resident’s assessments and the comprehensive plan of care and services provided. It should also include progress notes from physicians, nurses and other licensed professionals to reflect how the plan of care is being implemented and should include lab, radiology and other diagnostic service reports in addition to results of pre-admission screening/evaluations required by the state. If surveyors request this information and cannot find the associated documentation, the facility is likely to be cited under F842 for failure to have a complete and accurate medical record.
The Interpretive Guidance (IG) at F842 states that staff are required to document residents’ medical and non-medical status when there is a change in condition, whether positive or negative, in addition to documenting periodic reassessments and annual comprehensive assessments. The goal is the ensure there is sufficient information about each resident’s condition, plan of care and services being provided so that the Interdisciplinary team has sufficient information for decision-making and to facilitate communication between disciplines.
Due to the sensitive nature of this information, facilities are required to keep all information in the medical record confidential except under a few allowable circumstances as permitted by regulation:
- Release to the resident (or resident representative where permitted by law)
- For the purposes of public health activities or health oversight activities
- For the purpose of reporting abuse, neglect or domestic violence
- For release required by law, for law enforcement purposes and judicial or administrative proceedings
- For the purposes of averting a serious threat to health or safety
- For payment purposes
- For treatment or health care operations
- For organ donation or research purposes
- Release to medical examiners, coroners and/or funeral directors
Electronic Health Records
The Interpretive Guidance also discusses the use of Electronic Health Records (EHR) in facilities. Facilities using electronic documentation formats are required to be compliant with HIPAA rules, as well as ensuring the data is backed up and kept secure. With the growing number of ransomware attacks on the rise that have impacted healthcare entities, these are valid concerns that should be considered when selecting a vendor if a facility is transitioning to an EHR. When a facility is in survey, it is required to give access to the EHR to the survey team before the end of the first day of survey. The Long-Term Care Survey Process information includes a form for ensuring surveyors have access, know how to access information, and have a staff member available to assist them if needed. Prolonged delays in providing access to the survey team can result in a survey deficiency. It is also important to note that surveyors are instructed to observe if computer screens are left unattended and open, allowing unauthorized access to patient health information, which can result in a deficiency.
The amount of information that may need to be captured for an individual resident can be cumbersome, particularly if there are a lot of consults or diagnostic tests being done. The information that is included in the medical records needs to be sufficient for staff to have access to the necessary and relevant information to implement the plan of care and recognize the resident’s status, but this need should be balanced with periodic thinning of the medical record (the infamous paper chart) to archive older documentation while still ensuring availability of these documents for review. Staff also need to know where to look for information, so having a sound system in place to ensure consistency in where and how notes and documents are kept is essential to maintaining a useful, well-organized record.