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Based on interview and record review the facility failed to ensure policies for the Dietary Department; Health Information Management (HIM or Medical Records Department); and the Pharmacy Department were reviewed at least annually. This deficient practice had the potential to allow unapproved policies that were not current, acceptable practice to be used in patient care. The facility census was eight.

Findings included:

1. Record review of the following Dietary Department policies each showed review dates of 07/2011:
- Titled, "Diet Manual;"
- Titled, "Diet Orders;"
- Titled, "Nutrition Support Services;"
- Titled, "Personal Grooming and Dress Code."

2. Record review of the Dietary Department policy titled, "Quality Improvement," showed a review date of 08/2011.

3. During an interview on 11/10/14 at 4:05 PM, Staff H, Registered Dietitian, (RD and Director of Dietary) stated she had not reviewed the department policies and procedures since 2011 because she had not had the time to do the reviews.

4. Record review of the HIM policies:
- Titled, "Use and Disclosure of Protected Health Information," showed a review date of 05/2003;
- Titled, "Confidentiality," showed a review date of 06/2011;
- Titled, "Medical Record Security," showed a review date of 06/2011.

5. During an interview on 11/10/14 at 3:15 PM Staff G, Director of HIM stated the following:
- The HIM department policies had not been reviewed recently;
- She estimated there were approximately ten department policies that were not currently reviewed;
- She estimated that some had not been reviewed since 2003.

6. Record review of 31 of 31 Pharmacy policies showed:
- 29 policies had not been reviewed since 07/2011;
- One policy had not been reviewed since 09/2005;
- One policy had not been reviewed since 06/2005;
- There were approximately 150 policies in the Pharmacy policy binder;
- A blank/unsigned signature page (page that would have showed that current policy review had been accomplished and signed off by management staff) in the front of the binder.

7. During an interview on 11/10/14 at 3:25 PM, Staff A, Director of Pharmacy, stated that this was his sixth day at this facility and he was not sure of the status of policy review.

8. During an interview on 11/11/14 at 3:15 PM, Staff BB, Chief Operating Officer, stated that the Pharmacy Department reported to him and that recent managerial changes had prevented appropriate review of those policies.

9. During an interview on 11/12/14 at 10:15 AM, Staff DD, Chief Executive Officer, stated that:
- Each department was expected to review their policies on an annual basis;
- The review should be documented and authenticated by the signature of the Medical Director for that department;
- Additional signatures should include the signature of the executive responsible for that area and other appropriate staff;
- He was not aware of a facility policy that directed this process.


29511

Based on interview and record review the facility Health Information Management Department (HIM or Medical Records Department) failed to establish and maintain written policies and procedures directing the patient medical records functions (such as what pertinent information was included in the records; who should document in the records; how the confidentiality of the records was maintained). This deficient practice had the potential to permit unapproved or inappropriate procedures to be used in the construction and handling of protected health information in the facility's patient medical records. The facility HIM staff handled approximately 80 to 90 medical records of discharged patients per month. The facility census was eight.

Findings included:

1. During an interview on 11/10/14 at 3:15 PM, Staff G, Director of HIM, stated the following:
- She did not have written HIM policies and procedures directing what information a patient medical record should contain; who should document in the record; how those staff were identified; how the confidentiality of the medical records (both paper and on the computer) were protected against unauthorized access;
- The facility did not have a written HIM policy directing that a medical record should be constructed for each patient receiving care in the facility;
- The facility did not have a written HIM policy directing each patient medical records should have information documenting the results of tests; physical examinations; diagnoses; laboratory reports or justification for the admission to the facility;
- The facility did not have a written HIM policy directing staff to include physician's orders; reports of treatments for diagnoses; nurse's notes and other pertinent information;
- The facility did not have a written HIM policy directing physicians to sign their entries.
- She stated HIM staff used department specific checklists to assemble medical records of patients after discharge.

2. Record review of the HIM Department's chart (medical record) assembly checklists dated 02/96, (used by HIM staff to assemble documents in records of discharged patients) showed three separate lists each with titles of documents for Medical unit patients; for newborns and for Obstetrical unit patients but, no specific direction regarding medical record assembly with specific policies and procedures.

3. During an interview and concurrent record review on 11/11/14 at 1:55 PM, Staff G:
- Provided a hand written list of 37 titles of some policies without review dates;
- She stated that the listed policies directed the work of HIM staff;
- She stated that these policies were reviewed by the HIM Committee;
- The list contained titles including, "Internet and E-mail usage;" Overhead Paging;" "Privacy Officer Job Description," and "Voicemail."

4. During an interview on 11/11/14 at approximately 2:05 PM, Staff BB, Chief Operating Officer (COO), stated the facility did not have an HIM Committee and the HIM committee that Staff G referred to was actually the Utilization Management (UM) Committee.

5. Record review of the UM Committee description (function and members) dated 10/2014 to 10/2015 (provided by the COO) showed the committee was not directed to review HIM policies and procedures.

Based on observation, interview and record review the facility Health Information Management Department (HIM or Medical Records Department) failed to ensure the confidentiality of paper patient medical records was maintained by establishing safeguards against loss, destruction and unauthorized use. The facility census was eight.

Findings included:

1. Record review of the facility's policy titled, "Medical Record Security," reviewed 06/2011 showed the following direction:
- Patient information should only be available to staff in patient care areas;
- The Medical Record Department (HIM) staff was on duty Monday through Friday from 6:00 AM through 5:30 PM;
- The HIM department was locked when HIM staff was not on duty;
- If a patient's medical record was needed by staff when the HIM staff was not on duty, the House Supervisor (nurse supervisor in charge) would verify the need and grant access to a key to the HIM department.

2. During an interview on 11/10/14 at 3:15 PM, Staff G, Director of HIM, stated the following:
- The facility was in the process of changing from paper medical records to electronic (on computer) medical records;
- Currently, some of any patient's medical record was on paper and some was maintained on computer;
- Upon discharge, the paper documents of the medical records were sent to the HIM department for storage;
- Those paper documents were kept on open shelving in the HIM office area.
- There were multiple staff (maintenance department; Bio-Medical staff; admission office staff and each of her nine HIM staff who had keys to the HIM office area/department;
- She estimated that there were 13 keys "out" but she wasn't sure;
- She stated that the maintenance department had keys due to their need to respond to fire alarms;
- She stated that the admission office staff had one key that was "locked up" and used to retrieve files for newly admitted patients;
- She stated that the Bio-Medical staff had keys because of their need to access the department on weekends so, Bio-Medical staff could repair HIM equipment;
- She did not know if any Bio-Medical staff had been in the department and had no way of knowing if any paper patient medical records had been accessed (read, taken or destroyed) during those entries into the HIM department.

3. Observation and concurrent interview on 11/10/14 at 3:15 PM showed multiple rows of ceiling to floor shelving packed with folders of paper patient medical records. Staff G confirmed that the shelves held paper medical records of patients who had been discharged during the past two years.

4. During a telephone interview on 11/12/14 at 8:37 AM, Staff CC, Director of Bio-Medical stated the following:
- He, plus two of his staff each, had "master" keys that opened all areas of the facility including the HIM department;
- He did not know why they each had access to all areas of the building and stated, "that's a question for Administration."
- They did not access the HIM department often and preferred to go in there when the HIM staff was present.