Long-Term Care Survey Alert

Published on Wed Jan 28, 2009 PDF

Refusing to do this task can put your facility on the road to decertification.

If your facility has electronic health records, the last thing you want to do during the survey is hold up the inspection by trying to figure out how to give surveyors access to the records.

Stern warning: A survey & cert memo on EHRs and the survey notes that "undue delays in the production of records are unacceptable." And "refusing access to any patient/resident records is a basis for termination of the facility's Medicare agreement."

The memo directs surveyors to "verify" with the facility during the entrance conference the process for gaining "unrestricted access to the medical record." The survey team should request the facility to provide a terminal(s) where surveyors can review the electronic records. If the survey asks for access to an EHR, the memo says the facility should:

1. provide the surveyor with a tutorial on how to use its particular electronic system; and

2. designate an individual to help the surveyor, if needed, access the surveyor has.

Prevent inadvertent changes: "Whenever possible," the memo directs, "the facility must provide surveyors electronic access to records in a read-only format or other secure format to avoid any inadvertent changes to the record."

Good idea: Given that surveyors are having to learn many new EHR systems, "discuss a new EHR system with the surveyors before a survey," suggests Nathan Lake, RN, BSN, MSHA, director, clinical design for American HealthTech, an MDS software developer.

CMS reminds surveyors to print or request paper copies only for the parts of records they need to support noncompliance findings, unless protocol dictates otherwise.

Facilities that aren't able to provide surveyors printer capability should print out records required by surveyors "in a timeframe that does not impede the survey process," the memo directs.

Smart move: Assign a staff person to print what the surveyors need in order to keep tabs on what the surveyors are looking at, advises Patricia Boyer, RN, MSM, NHA, principal of Boyer & Associates Inc. in Brookfield, Wis.

In addition, surveyors shouldn't have access to quality assurance type information on the facility's computer system, says Boyer. "Most electronic systems allow you to put limits on what users are allowed to see," she adds.

Heads up: CMS' memo reiterates that the agency supports and encourages the use of EHRs and is "committed to a goal that by 2014, most Americans will have access to health care providers who use EHRs." Access the full text of the memo at www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_53.pdf.