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Based on review of facility documents and staff interview (EMP) it was determined the facility failed to suspend practitioners (OTH) with delinquent medical records as per the Medical Staff Rules and Regulation Administrative Suspension procedure for 62 of 62 applicable practitioners (OTH1 through OTH62).

Review on April 16, 2019, of facility policy "Medical Records," approved on April 16, 2019, revealed "Policy: The medical record documents the health care experience of the patient. As such, it is important that the medical records be completed in a proper and timely fashion. ... The attending physician will be ultimately responsible for completion of the chart. Procedure I. Completion of Medical Records Completion of records will be performed in the Electronic Health Record (EHR) system or on paper forms during downtime within 30 days of discharge. A. Delinquent Records Any medical record not completed within 30 days after discharge shall be considered delinquent. Physicians with delinquent records shall be subject to Administrative Suspension of admitting privileges and possible relinquishment of clinical privileges as per Rules and Regulations of the Medical Staff. ..."

Review on April 17, 2019, of facility "Medical Staff Rules and Regulations, " last approved December 17, 2018, revealed "... Section V: Health Information Management (HIM) - formerly Medical Records ... B. Delinquent and Incomplete Charts 1. All chart deficiencies must be completed within 30 days of discharge per the Pennsylvania Department of Health and these Medical Staff Rules and Regulations. Those that remain incomplete more than 30 days after discharge shall be considered delinquent and the physician shall be subject to Administrative Suspension as outlined in Section XV of these Medical Staff Rules and Regulations. ... Section XV: Administrative Suspension 1. The administrative department responsible for the administration of the MLH [Main Line Health] policy with which the member is not in compliance (e.g., infection control or medical records) will notify the Medical Staff Office. 2. The Medical Staff Office will notify the System Department Chair of the member's non compliance to initiate collegial intervention. If the System Department Chair can not [sic] resolve the issue by collegial intervention within two weeks, the System Department Chair will refer the matter back to the Medical Staff Office. 3. The Medical Staff Office will notify the VPMA [Vice President of Medical Affairs] at the hospital(s) where the staff member has privileges that the member is non-compliant. The VPMA, or the CMO [Chief Medical Officer] in the absence of the VPMA, shall place the non-compliant member on administrative suspension and notify him or her that their clinical privileges have been administratively suspended. The VPMA shall be responsible to ensure: Admission privilege flags are set to "no" in the patient registration system The member will not be able to accept new consultations Notification is sent to Admission, E.D. [Emergency Department], Administration, Quality, OR [Operating Room], Cath lab, Chiefs and Chairs, Hospital President, and Nursing Administration via email that the staff member is on administrative suspension and has automatically relinquished his or her clinical privileges until further notice ..."

Review on April 16, 2018, at 2:45 PM, of the Medical Record committee meeting minutes from June 1, 2018, revealed discussion of delinquent medical records and course of action followed. It was noted the new electronic medical record system was able to run a delinquent report. Senior leadership received the list and were going to be emailing the delinquent physicians. Medical Record committee meetings notes of July 6, 2018, revealed discussion that the EMR system was not correctly sending the emails to the physicians in-baskets. Starting July 6, 2018, the emails are to be manually rerouted. Medical Record committee meetings notes of September 7, 2018, revealed discussion on how to operationalize reinstating the administrative suspension. Medical Record committee meetings notes of October 10, 2018, revealed discussion to resume the administrative suspension on November 5, 2018. Medical Record committee meetings notes of December 7, 2018, revealed a discussion regarding putting the administrative suspension process on hold. Medical Record committee meetings notes of January 4, 2019, revealed the service chief would remind the physicians to complete delinquent records through calls and emails. Medical Record committee meetings notes of February 1, 2019, revealed the administrative suspension process was on hold. Medical Record committee meetings notes of March 1, 2019, revealed the administrative suspension process continued to be on hold. Discussion was noted of the consideration of using a consultant to help determine the next step.
Interview with EMP8 on April 16, 2018, at 2:45 PM, confirmed the content of Medical Record committee meetings notes of June 1, 2018, of July 6, 2018, August 3, 2018, September 7, 2018, October 10, 2018, December 7, 2018, January 4, 2019, February 1, 2019 and March 1, 2019.

Review on April 16, 2019, of the facility delinquent medical record list revealed 62 practitioners had delinquent medical records:
OTH1 had two delinquent medical records.
OTH2 had one delinquent medical record.
OTH3 had four delinquent medical records.
OTH4 had one delinquent medical record.
OTH5 had nine delinquent medical records.
OTH6 had two delinquent medical records.
OTH7 had 12 delinquent medical records.
OTH8 had six delinquent medical records.
OTH9 had one delinquent medical record.
OTH10 had one delinquent medical record.
OTH11 had one delinquent medical record.
OTH12 had one delinquent medical record.
OTH13 had one delinquent medical record.
OTH14 had 23 delinquent medical records.
OTH15 had one delinquent medical record.
OTH16 had five delinquent medical records.
OTH17 had two delinquent medical records.
OTH18 had one delinquent medical record.
OTH19 had one delinquent medical record.
OTH20 had one delinquent medical record.
OTH21 had seven delinquent medical records.
OTH22 had one delinquent medical record.
OTH23 had one delinquent medical record.
OTH24 had one delinquent medical record.
OTH25 had eight delinquent medical records.
OTH26 had one delinquent medical record.
OTH27 had one delinquent medical record.
OTH28 had 12 delinquent medical records.
OTH29 had one delinquent medical record.
OTH30 had one delinquent medical record.
OTH31 had one delinquent medical record.
OTH32 had one delinquent medical record.
OTH33 had one delinquent medical record.
OTH34 had one delinquent medical record.
OTH35 had two delinquent medical records.
OTH36 had ten delinquent medical records.
OTH37 had 16 delinquent medical records.
OTH38 had one delinquent medical record.
OTH39 had one delinquent medical record.
OTH40 had one delinquent medical record.
OTH41 had two delinquent medical records.
OTH42 had one delinquent medical record.
OTH43 had one delinquent medical record.
OTH44 had one delinquent medical record.
OTH45 had one delinquent medical record.
OTH46 had one delinquent medical record.
OTH47 had two delinquent medical records.
OTH48 had six delinquent medical records.
OTH49 had three delinquent medical records.
OTH50 had one delinquent medical record.
OTH51 had one delinquent medical record.
OTH52 had one delinquent medical record.
OTH53 had one delinquent medical record.
OTH54 had 14 delinquent medical records.
OTH55 had 12 delinquent medical records.
OTH56 had one delinquent medical record.
OTH57 had one delinquent medical record.
OTH58 had one delinquent medical record.
OTH59 had one delinquent medical record.
OTH60 had three delinquent medical records.
OTH61 had one delinquent medical record.
OTH62 had one delinquent medical record.

Further review of the delinquent medical record list revealed OTH1 through OTH62 received weekly delinquent chart notifications.

Interview with EMP8 and EMP9 on April 17, 2019, at 1300 confirmed OTH1 through OTH62 had delinquent medical records, received notifications of delinquent medical records and were not placed on administrative suspension as per facility procedure.

Interview with EMP9 on April 18, 2019, at approximately 9:45 AM, confirmed the suspension process has not been initiated as of this date, April 18, 2019.

Cross Reference:
482.24(b)
482.24(c)(1)

This condition is not met as evidenced by:

Based on the systemic nature of the standard-level deficiencies related to Medical Records, the facility failed to comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to Medical Records as follows:

(482.24(b) Tag - 0438)
The information reviewed during the survey provided evidence the facility failed to ensure medical records were completed within 30 days of discharge for 202 of 223 applicable medical records reviewed.

(482.24(c)(1) Tag - 0450)
The information reviewed during the survey provided evidence the facility failed to ensure the medical records were complete as per hospital policy for 202 of 223 applicable medical records.

Based on review of facility documents and staff interview (EMP) it was determined the facility failed to ensure medical records were completed within 30 days of discharge for 202 of 231 applicable medical records.

Review on April 16, 2019, of facility policy "Medical Records," approved on April 16, 2019, revealed "Policy: The medical record documents the health care experience of the patient. As such, it is important that the medical records be completed in a proper and timely fashion. ... Procedure I. Completion of Medical Records Completion of records will be performed in the Electronic Health Record (EHR) system or on paper forms during downtime within 30 days of discharge..."

Review on April 17, 2019, of facility "Medical Staff Rules and Regulations," last approved December 17, 2018, revealed " ... Section V: Health Information Management (HIM) - formerly Medical Records ... B. Delinquent and Incomplete Charts 1. All chart deficiencies must be completed within 30 days of discharge per the Pennsylvania Department of Health and these Medical Staff Rules and Regulations. Those that remain incomplete more than 30 days after discharge shall be considered delinquent and the physician shall be subject to Administrative Suspension as outlined in Section XV of these Medical Staff Rules and Regulations..."

Review on April 16, 2018, at 2:45 PM, of the Medical Record committee meeting minutes of June 1, 2018, revealed discussion of delinquent medical records. It was noted the new electronic medical record system was able to run a delinquent report. The facility was noted at 1.7 percent medical record delinquency. Medical Record committee meetings notes of July 6, 2018, the facility had a 15 percent medical record delinquency. Medical Record committee meetings notes of August 3, 2018, revealed the facility had a 11 percent medical record delinquency. Medical Record committee meetings notes of September 7, 2018, revealed the facility had at 9.4 percent medical record delinquency. Medical Record committee meetings notes of October 10, 2018, revealed the facility had an 8.5 percent medical record delinquency. Medical Record committee meetings notes of December 7, 2018, revealed the facility had a seven percent medical record delinquency. Medical Record committee meetings notes of January 4, 2019, revealed the facility had a 6.3 percent medical record delinquency. Medical Record committee meetings notes of February 1, 2019, revealed the facility had a 6.7 percent medical record delinquency. Medical Record committee meetings notes of March 1, 2019, revealed the facility had a six percent medical record delinquency.

Interview with EMP8 on April 16, 2018, at 2:45 PM, confirmed the content of Medical Record committee meetings notes of June 1, 2018, July 6, 2018, August 3, 2018, September 7, 2018, October 10, 2018, December 7, 2018, January 4, 2019, February 1, 2019 and March 1, 2019.

Review on April 16, 2019 of facility delinquent medical record list as of April 16, 2019, revealed:
60 Medical records were 31-59 days delinquent
44 Medical records were 60-89 days delinquent
31 Medical records were 90-119 days delinquent
15 Medical records were 122-148 days delinquent
14 Medical records were 152-179 days delinquent
13 Medical records were 183-209 days delinquent
6 Medical records were 210-238 days delinquent
6 Medical records were 242-268 days delinquent
5 Medical records were 274-293 days delinquent
5 Medical records were 301-320 days delinquent
3 Medical records were over 365 days delinquent

Interview with EMP8 on April 18, 2019, at approximately 9:15 AM, confirmed the above listed delinquent medical records.

Cross Reference:
482.22(c)
482.24(c)(1)

Based on review of facility documents and staff interview (EMP) it was determined the facility failed to ensure the medical record was complete as per hospital policy for 202 of 231 applicable medical records.

Review on April 16, 2019, of facility policy "Medical Records," approved on April 16, 2019, revealed "Policy: The medical record documents the health care experience of the patient. As such, it is important that the medical records be completed in a proper and timely fashion. ... Procedure I. Completion of Medical Records Completion of records will be performed in the Electronic Health Record (EHR) system or on paper forms during downtime within 30 days of discharge. B. Operative and Procedure Reports 1. Operative reports should be dictated immediately upon completion of the operation or procedure. ... C. Discharge Diagnoses Discharge diagnoses and procedures performed are to be recorded on the discharge summary and operative report. D. Discharge Summaries Discharge summaries are to be dictated at the time of discharge ..."

Review on April 18, 2019 of the facility medical record list for delinquent medical records from April 16, 2019, revealed 174 medical records were missing signatures, 11 medical records were missing document dictation and 17 medical records were missing required reviews.

Interview with EMP8 on April 16, 2019, at approximately 2:15 PM, confirmed the above information on the facility medical record list for delinquent physicians.

Cross Reference:
482.22(c)
482.24(b)

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on March 5-7, 2019. Further details are outlined in that Division of Life Safety Survey Report.