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Based on record review and interview, the CAH failed to meet the Condition of Participation for Organizational Structure as evidenced by:

1) failure of the governing body to enforce the Medical Staff Bylaws for suspension of physician clinical privileges due to delinquent medical records for 4 (S5Physician,S6Physician,S7Physician,S8Physician) of 4 contracted emergency department physicians reviewed for delinquent medical records;

2) failure of the governing body to appoint S5Physician as Director of the CAH's Emergency Medicine Services as required by the Louisiana Hospital Licensing Standards; LAC 48:1.Chapter 93; Section 9327.Emergency Services; Organization; B.2. and

3) failure of the governing body to ensure all contracted physicians providing care in the CAH's emergency department were privileged and credentialed for 1 (S7Physician) of 5 physicians reviewed. (See findings in tag C-0241).

Based on record review and interview, the CAH failed to ensure the governing body implemented and monitored policies governing the CAH's total operation. This deficient practice was evidenced by
1) failure of the governing body to enforce the Medical Staff Bylaws for suspension of physician clinical privileges due to delinquent medical records for 4 (S5Physician,S6Physician,S7Physician,S8Physician) of 4 contracted emergency department physicians reviewed for delinquent medical records;
2) failure of the governing body to appoint S5Physician as Director of the CAH's Emergency Medicine Services as required by the Louisiana Hospital Licensing Standards; LAC 48:1.Chapter 93; Section 9327.Emergency Services; Organization; B.2. and
3) failure to ensure all contracted physicians providing care in the CAH's emergency department were privileged and credentialed for 1 (S7Physician) of 5 physicians reviewed.

Findings:

1) Failure of the governing body to enforce the Medical Staff Bylaws for suspension of physician clinical privileges due to delinquent medical records.

Review of the hospital policy titled,"Timeliness of Completion of the Medical Record" revealed in part:
Purpose: The Conditions of Participation by Centers for Medicare and Medicaid Services requires that the discharged patient charts must be completed promptly. Upon discharge of the patient the inpatient record is to be completed within 30 days per the hospital's Medical Staff By-laws, Rules and Regulations.

Review of the hospital's Medical Staff By-laws, Rules and Regulations revealed in part:
2. Medical Records: 2.1: The attending Practitioner shall be responsible for the preparation of a complete and legible medical record for each patient.
2.16: Suspension for incomplete medical records: Medical Records are considered delinquent when they remain incomplete for 30 days following discharge.
Written Notification: physicians having not completed any medical record within 20 days following discharge shall be delivered by certified mail, a written notification. The notice shall be generated by the Medical Records department and signed by the Chief of Medical Staff. The notice shall advise the physician of the specific record (s) that remain incomplete and if same is not complete within 10 days after receipt of notice, clinical privileges shall be suspended, until all delinquent records have been completed (dictation and signatures) including admissions, surgical procedures and medical procedures. Telephone notification following written notice (As courtesy to physicians). Three days prior to the suspension date, physicians or physician's office staff will be notified by the Medical Records staff of the date and time of proposed suspension and status of incomplete records. On the date of suspension clinical privileges shall be suspended.....


Review of a deficient emergency department medical record spreadsheet, provided by the contracted physician staffing agency, revealed the following medical record deficiencies:

S5Physician: 31-60 days deficient: 27; 61-90 days deficient: 73; 91 days or greater: 79; Total deficient records: 179;
S6Physician: 31-60 days deficient: 121; 61-90 days deficient: 87; 91 days or greater: 37; Total deficient records: 245;
S7Physician: 31-60 days deficient:0; 61-90 days deficient: 9; 91 days or greater: 14; Total deficient records: 23;
S8Physician: 31-60 days deficient: 15; 61-90 days deficient: 14; 91 days or greater: 12; Total deficient records: 41.
Further review revealed a grand total of 488 emergency department medical records that were 31 days deficient to greater than 91 days deficient from 8/2015-11/2015.


Review of the Governing Board meeting minutes from 1/27/15-10/27/15 revealed no documented evidence of discussion/addressing the issue of delinquent medical records.


In an interview on 12/7/15 at 1:37 p.m. with S1CEO, he indicated he had been CEO of the hospital for the past 1 ½ years. S1CEO indicated he had been aware that the hospital had issues with delinquent medical records. He confirmed that according to hospital policy and Medical Staff Bylaws physicians with delinquent emergency department medical records should have had their clinical privileges suspended. He also confirmed none of the above referenced physicians' clinical privileges had been suspended for delinquent emergency department patient medical records.


2) Failure of the governing body to appoint S5Physician as Director of Emergency Medicine Services.

Review of the Louisiana Hospital Licensing Standards; LAC 48:1.Chapter 93; Section 9327.Emergency Services; Organization: B.2. revealed in part: The emergency services shall be organized under the direction of a qualified member of the medical staff.

Review of the credentialing file for S5Physician revealed no documented evidence that he was appointed as the Medical Director of Emergency Services by the CAH's governing body.

In an interview on 12/7/15 at 2:07 p.m. with S5Physician he indicated he is the CAH's Medical Director of Emergency Services.

In an interview on 12/8/15 at 4:04 p.m. with S1CEO he confirmed, after review of S5Physician's credentialing file, that there was no documentation of S5Physician's appointment as Director of Emergency Services by the CAH's governing body. He indicated he had assumed that the paperwork appointing S5Physician as Medical Director of Emergency Services had been completed. S1CEO indicated he should have followed up to ensure it was completed.


3) Failure to ensure all contracted physicians providing care in the CAH's emergency department were privileged and credentialed.

Review of the credentialing file for S7Physician revealed no documented evidence that she had been credentialed and privileged by the CAH's governing body.

In an interview on 12/8/15 at 4:04 p.m. with S1CEO he confirmed there was no documented evidence that S7Physician had been credentialed,privileged and appointed by the CAH's governing body. He also confirmed S7Physician had been working in the CAH's emergency department since 1/2015. S1CEO indicated S7Physician should have been credentialed, privileged and appointed by the CAH's governing body.

Based on interview and record review, the CAH's CEO failed to ensure that a contractor of services furnished services that enabled the CAH to comply with all applicable conditions of participation and standards for the contracted services. This deficient practice was evidenced by the CEO's failure to ensure the contracted emergency department physicians completed medical records within the timeframe specified in the CAH's Medical record policies and Medical Staff By-laws-Rules and Regulations.

Findings:

Review of the hospital policy titled," Timeliness of Completion of the Medical Record" revealed in part:
Purpose: The Conditions of Participation by Centers for Medicare and Medicaid Services requires that the discharged patient charts must be completed promptly. Upon discharge of the patient the inpatient record is to be completed within 30 days per the hospital's Medical Staff By-laws, Rules and Regulations.


Review of the hospital's Medical Staff By-laws, Rules and Regulations revealed in part:
2. Medical Records: 2.1: The attending Practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. This record shall show identification date; complaint; personal history; family history; history of present illness; physical examination; special reports such as consultations; clinical, laboratory and radiology services and others; provisional diagnosis; medical or surgical treatment; operative report; pathological findings; progress notes; final diagnosis; condition on discharge; summary or discharge note and autopsy report when performed.
2.16: Suspension for incomplete medical records: Medical Records are considered delinquent when they remain incomplete for 30 days following discharge.
Written Notification: physicians having not completed any medical record within 20 days following discharge shall be delivered by certified mail, a written notification. The notice shall be generated by the Medical Records department and signed by the Chief of Medical Staff. The notice shall advise the physician of the specific record (s) that remain incomplete and if same is not complete within 10 days after receipt of notice, clinical privileges shall be suspended, until all delinquent records have been completed (dictation and signatures) including admissions, surgical procedures and medical procedures. Telephone notification following written notice (As courtesy to physicians). Three days prior to the suspension date, physicians or physician's office staff will be notified by the Medical Records staff of the date and time of proposed suspension and status of incomplete records. On the date of suspension clinical privileges shall be suspended.....


Review of a deficient emergency department medical record spreadsheet, provided by the contracted physician staffing agency, revealed the following medical record deficiencies:

S5Physician: 31-60 days deficient: 27; 61-90 days deficient: 73; 91 days or greater: 79; Total deficient records: 179;
S6Physician: 31-60 days deficient: 121; 61-90 days deficient: 87; 91 days or greater: 37; Total deficient records: 245;
S7Physician: 31-60 days deficient:0; 61-90 days deficient: 9; 91 days or greater: 14; Total deficient records: 23;
S8Physician: 31-60 days deficient: 15; 61-90 days deficient: 14; 91 days or greater: 12; Total deficient records: 41.
Further review revealed a grand total of 488 emergency department medical records that were 31 days deficient to greater than 91 days deficient from 8/2015-11/2015.

In an interview on 12/7/15 at 1:37 p.m. with S1CEO, he indicated he had been CEO of the hospital for the past 1 ½ years. S1CEO indicated he had been aware that the hospital had issues with delinquent medical records. He confirmed that according to hospital policy and Medical Staff Bylaws physicians with delinquent emergency department medical records should have had their clinical privileges suspended. He also confirmed none of the above referenced physicians' clinical privileges had been suspended for delinquent emergency department patient medical records.

Based on record review, interview and observation, the CAH failed to meet the Conditions of Participation for Clinical Records as evidenced by:

1) failure to ensure the clinical records system was maintained in accordance with written policies and procedures as evidenced by failure to ensure medical records of patients treated in the hospital's emergency department were promptly completed as set forth in the CAH's policies for completion of medical records. (See findings in tag C-0301).

2) failure to ensure all emergency department patient medical records included a physician medical screening examination for 18 ( #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20) of 20 emergency department patient records reviewed. (See findings in tag C-0304).

3) failure to ensure patient medical records were protected against loss or destruction as evidenced by failure to protect approxiamtely 10,000 patient medical records that had not been scanned, copied or backed up from potential destruction/damage from fire and/or water. (See findings in tag C-0308).

Based on record review and interview, the CAH failed to ensure the clinical records system was maintained in accordance with written policies and procedures. This deficient practice was evidenced by failure to ensure medical records of patients treated in the hospital's emergency department were promptly completed as set forth in the CAH's policies for completion of medical records.

Findings:

Review of the hospital policy titled," Timeliness of Completion of the Medical Record" revealed in part:
Purpose: The Conditions of Participation by Centers for Medicare and Medicaid Services requires that the discharged patient charts must be completed promptly. Upon discharge of the patient the inpatient record is to be completed within 30 days per the hospital's Medical Staff By-laws, Rules and Regulations.


Review of the hospital's Medical Staff By-laws, Rules and Regulations revealed in part:
2. Medical Records: 2.1: The attending Practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. This record shall show identification date; complaint; personal history; family history; history of present illness; physical examination; special reports such as consultations; clinical, laboratory and radiology services and others; provisional diagnosis; medical or surgical treatment; operative report; pathological findings; progress notes; final diagnosis; condition on discharge; summary or discharge note and autopsy report when performed.
2.16: Suspension for incomplete medical records: Medical Records are considered delinquent when they remain incomplete for 30 days following discharge.
Written Notification: physicians having not completed any medical record within 20 days following discharge shall be delivered by certified mail, a written notification. The notice shall be generated by the Medical Records department and signed by the Chief of Medical Staff. The notice shall advise the physician of the specific record (s) that remain incomplete and if same is not complete within 10 days after receipt of notice, clinical privileges shall be suspended, until all delinquent records have been completed (dictation and signatures) including admissions, surgical procedures and medical procedures. Telephone notification following written notice (As courtesy to physicians). Three days prior to the suspension date, physicians or physician's office staff will be notified by the Medical Records staff of the date and time of proposed suspension and status of incomplete records. On the date of suspension clinical privileges shall be suspended.....


Review of a deficient emergency department medical record spreadsheet, provided by the contracted physician staffing agency, revealed the following medical record deficiencies:

S5Physician: 31-60 days deficient: 27; 61-90 days deficient: 73; 91 days or greater: 79; Total deficient records: 179;
S6Physician: 31-60 days deficient: 121; 61-90 days deficient: 87; 91 days or greater: 37; Total deficient records: 245;
S7Physician: 31-60 days deficient:0; 61-90 days deficient: 9; 91 days or greater: 14; Total deficient records: 23;
S8Physician: 31-60 days deficient: 15; 61-90 days deficient: 14; 91 days or greater: 12; Total deficient records: 41.
Further review revealed a grand total of 488 emergency department medical records that were 31 days deficient to greater than 91 days deficient from 8/2015-11/2015.

In an interview on 12/7/15 at 11:30 a.m. S4RHIT, she confirmed the hospital had not maintained a log of delinquent medical records for the emergency department records. She indicated the deficient emergency department medical record spreadsheet was provided by the contracted physician staffing agency. She confirmed she had not issued any letters of suspension for delinquent emergency department medical records. S4RHIT also confirmed the above referenced physicians had not had their clinical privileges suspended.

In an interview on 12/7/15 at 12:44 p.m. with S2DON, she confirmed the hospital had not maintained a log of delinquent medical records for the emergency department records. S2DON indicated the contracted physician staffing agency was keeping track of the deficient emergency department medical records. She confirmed none of the above referenced physicians had been issued letters of suspension for delinquent emergency department medical records. S2DON also confirmed the above referenced physicians had not had their clinical privileges suspended as set forth in the hospital's medical records policies and Medical Staff By-laws-Rules and Regulations.

In an interview on 12/7/15 at 1:37 p.m. with S1CEO, he indicated he had been CEO of the hospital for the past 1 ½ years. S1CEO indicated he had been aware that the hospital had issues with delinquent medical records. S1CEO confirmed that according to hospital policy and Medical Staff Bylaws physicians with delinquent emergency department medical records should have had their clinical privileges suspended. He also confirmed none of the above referenced physicians ' clinical privileges had been suspended.

Based on record review and interview, the CAH failed to ensure all emergency department patient medical records included a physician medical screening examination for 18 ( #1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20) of 20 emergency department patient records reviewed.

Findings:

Review of the hospital's Medical Staff By-laws, Rules and Regulations revealed in part:
2. Medical Records: 2.1: The attending Practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. This record shall show identification date; complaint; personal history; family history; history of present illness; physical examination; special reports such as consultations; clinical, laboratory and radiology services and others; provisional diagnosis; medical or surgical treatment; operative report; pathological findings; progress notes; final diagnosis; condition on discharge; summary or discharge note and autopsy report when performed.

Review of the medical records for patients #1 (date of service: 9/5/15); #4 (date of service: 9/9/15); #5 (date of service: 8/13/15); #6 (date of service: 9/23/15); #7 (date of service: 8/13/15); #8 (date of service: 9/10/15); #9 (date of service: 11/8/15); #10 (date of service: 8/13/15); #11(date of service: 10/10/15); #12 (date of service: 8/28/15); #13 (date of service: 8/29/15); #14 (date of service: 11/3/15); #15 (date of service: 11/7/15); #16 (date of service: 10/21/15); #17 (date of service:10/20/15); #18 (date of service: 9/20/15); #19 (date of service: 9/28/15) and #20 (date of service) revealed no documentation to indicate that a qualified medical practitioner performed a pertinent medical history and/or an assessment of the health status and health care needs of the patient during their respective visits to the hospital's emergency department.

In an interview on 12/7/15 at 12:07 p.m. with S4RHIT, she confirmed there was no documentation to indicate that a qualified medical practitioner performed a pertinent medical history and/or an assessment of the health status and health care needs of the patient during their respective visits to the hospital's emergency department. She certified the copies of the above referenced patients' medical records after she verified that the records were incomplete.

Based on observation and interview, the CAH failed to ensure patient medical records were protected against loss or destruction as evidenced by failure to protect approximately 10,000 patient medical records that had not been scanned, copied or backed up from potential destruction/damage from fire and/or water.

Findings:

An observation was made of the hospital's medical records storage area on 12/7/15 at 10:55 a.m. The medical records were noted to be stored on 5 sets of shelving units with 2 sided shelves. The shelving units were approximately 6 1/2 feet tall, 6-7 feet long and 7 shelves high on each side. Paper patient medical records were stored on shelves on both sides of the shelving unit. The room contained no sprinklers and when the shelving units were cranked closed there was a 2-3 inch gap between the shelving units and the records were not protected on the top of the shelving units. An open area was also noted in the ceiling tile above the shelving units.

On 12/7/15 at 10:55 a.m. S4RHIT indicated, during the observation of the hospital's medical record storage area, that the above referenced records dated back 10 years. She approximated the shelves contained 10,000 records that had not been scanned, copied or backed up in any way. She confirmed there had been a ceiling leak above the records in the past. She also confirmed the records had nothing in place to protect the records from water and/or fire damage.

Based on record review and interview, the CAH failed to ensure all patient care services and other services affecting patient health and safety were evaluated by the hospital's QAPI program. This deficient practice was evidenced by failure of the CAH to include tracking, trending and monitoring of deficient emergency department records in the hospital wide QAPI program.

Findings:

Review of a deficient emergency department medical record spreadsheet, provided by the contracted physician staffing agency, revealed the following medical record deficiencies:

S5Physician: 31-60 days deficient: 27; 61-90 days deficient: 73; 91 days or greater: 79; Total deficient records: 179;
S6Physician: 31-60 days deficient: 121; 61-90 days deficient: 87; 91 days or greater: 37; Total deficient records: 245;
S7Physician: 31-60 days deficient:0; 61-90 days deficient: 9; 91 days or greater: 14; Total deficient records: 23;
S8Physician: 31-60 days deficient: 15; 61-90 days deficient: 14; 91 days or greater: 12; Total deficient records: 41.
Further review revealed a grand total of 488 emergency department medical records that were 31 days deficient to greater than 91 days deficient from 8/2015-11/2015.

Review of the QAPI program plan, presented as current by S2DON, revealed no documented evidence that the issue with deficient emergency department medical records had been identified as a problem to addressed through QAPI.


In an interview on 12/7/15 at 11:30 a.m. with S4RHIT, she confirmed the hospital had not maintained a log of delinquent medical records for the emergency department records. She indicated the deficient emergency department medical record spreadsheet was provided by the contracted physician staffing agency. She also confirmed the issue with deficient emergency department medical records had not been identified as a problem to addressed through QAPI.

In an interview on 12/7/15 at 12:44 p.m. with S2DON, she confirmed the hospital had not maintained a log of delinquent medical records for the emergency department records. S2DON indicated the contracted physician staffing agency was keeping track of the deficient emergency department medical records. She confirmed the issue with deficient emergency department medical records had not been identified as a problem to addressed through QAPI.