Clinic Management

Managing clinical processes can ensure smooth sailing through CMS audits

The financial health of a dialysis facility increasingly depends on the clinical team for proper documentation of delivered services and administrative compliance, especially considering the focus on cost-cutting at CMS. This article will explain how clinical processes can help a dialysis facility succeed with the inevitable CMS audit.

Nothing is more gut-wrenching than having your front desk manager or your charge nurse quietly, or sometimes not so quietly, enter your office and say, “The CMS surveyor is here.” All the blood rushes from your brain, and feelings of foreboding doom and panic set in. Staff is already frantically calling the medical director and administration. All you can do is straighten yourself up and greet them with a forced smile, all the while trying to remember that the surveyors want to help you. They are not the enemy — if you are prepared, that is.

Jerry Spears

While enduring this process every other year or 2 years is a necessary evil, basic preparation can go a long way toward getting the results you want. After all, you learned everything you need to pass the audit in kindergarten: be polite, share everything, clean up your own mess, wash your hands, learn and think, hold hands and stick together. Being ready is critical and requires policies and procedures that reflect best practices. In short, all you are asked to do is to create a “culture of safety.” Following the steps outlined in this article will help you do that, as well as pass a CMS inspection with flying colors.

Audit process

It is important to remember that the beginning of the audit sets the tone for what is to come. Your friendliness and charm can open doors for constructive help or can slam these doors shut while the survey tags start flying. Being mindful of how you approach the surveyor can pay dividends down the road.

Figure 1. A sample of a dialysis EMR clinical manager dashboard is shown.

Source: Jerry Spears, RN, CHN

Most audits start with introductions. Bring out your key players: licensed practical nurses, charge nurses, social workers, dietitians, biomed techs and team leaders. These people — as well as patients in the clinic — will have a conversation with the auditor before it is over. The surveyor will likely speak to the medical director as well, but often by phone.

The surveyor’s first request will likely be a tour of the facility. You will not have a warning, so consistently keeping your facility clean and in top condition is mandatory. During this stage, the auditor will study the facility’s cleanliness, calmness, competence and culture of safety, looking for red flags or “triggers.” Depending on what the auditor sees, along with perhaps a gut feeling, the tour can last 5 minutes to an hour or longer. During the tour, the inspector will be looking for clear-cut problems — something that might show the clinic is in trouble. The inspector will be particularly focused on infection control, cleanlines, and charting.

After the tour, the auditor will need a workspace to review materials. Pre-plan a quiet, comfortable area for the auditor. Have ample workspace for a computer, phone and manuals. Afford access to phone extensions and personnel. During this time, the auditor will also request documentation, which the clinic must provide, in hard copy, within a brief time frame. For example, within 3 hours, the facility must provide documentation listed in the CORE Survey Data Worksheet, which, among other things, includes the following:

  • a list of current patients;
  • a list of people who are doing dialysis at the facility, at a nursing home or at home;
  • a list of patients who have been unstable within the last 3 months;
  • a list of patients who were involuntarily discharged in the last year;
  • a list of discharged patients categorized as “lost to follow-up” in the last year;
  • hospitalization logs with diagnoses for the last 6 months;
  • a list of patients readmitted to the hospital within 30 days of discharge in the last 6 months;
  • infection logs for the last 6 months; and
  • documentation of adverse events (eg, clinical variances and medical errors) for the last 6 months.

 If your clinic uses paper documents for the water room or tasks like machine maintenance, make sure these are legible, clean, dry and protected by plastic sleeves. As for your electronic medical records, make sure you have a reliable computer for the auditor to use if needed. The surveyor should be able to easily maneuver through a patient’s chart, as well as access the Quality Assurance and Performance Improvement process and action plans.

The surveyor will review the data provided, looking for triggers that might require further investigation. The key to passing the audit is to have a rigorous documentation procedure instilled in staff well ahead of any audit.

Document for success

During the audit, the EMR can be your best friend or your worst enemy. An EMR that is easy to use and thoroughly captures patients’ medical care is essential and that begins with daily processes grounded in sound protocols, but what processes do you need to do each day to ensure your system is audit-proof?

First, document everything you can when you are in the system. Three key areas are typical triggers for surveyor attention:

  • hospitalizations;
  • infections; and
  • patients who have been lost to follow-up.

 Many clinics fail to track patients’ hospitalizations, though they need to document why, where and when patients were hospitalized. To rectify this problem, clinics need a consistent documentation process for hospital admissions and discharges. The clinic’s transition of care coordinator must follow up with the hospital and document all records in the EMR. The key is to have a certified EMR system that allows them to access and scan medical records from other certified hospital systems from any location, including critical documents such as discharge summaries and medication lists.

Clinics also need a process to record infections. Sometimes clinicians document the administration of an antibiotic but forget to document the infection and vice versa. If a patient is in the hospital with an infection, clinics must document it, so they are not tagged as the cause of an infection that started elsewhere. Further, because the administration of any antibiotic is reportable to the National Healthcare Safety Network, it is key for them to track antibiotics in their EMR and ensure every antibiotic is tied to a specific infection.

In addition, clinics must be able to identify any patient who gets an initial treatment but never came back. Although this is not a common occurrence, it is a huge red flag. Typically, either the patient has not been educated about the severity of the disease or does not understand the importance of the treatment. Therefore, clinics must create a process that requires their staff to document efforts to educate, follow up and retain patients. An EMR should offer a shift closeout screen that identifies all patients who did not show for treatment, so it reminds staff to document retention efforts appropriately.

Finally, the inspector will closely study the data in the Clinical Outcomes Threshold Table from the End-stage Renal Disease Core Survey Data Worksheet. Clinics must be able to readily provide the required information on hemodialysis and peritoneal dialysis indicators. Your EMR should be regularly tracking these data and alerting staff through a dashboard if the reportable levels exceed the CMS thresholds.

Best practice: Self-audits

Continuing education for the staff on the release notes and upgrades of the EMR system will ensure charting with the latest tools for easy, accurate and timely documentation. Including a brief in-service during staff meetings can be useful in self-auditing routines.

The EMR itself can also be a valuable self-check for clinics and with a clinical manager dashboard can provide not only the manager, but also members of the dialysis care team, the daily information they need to identify root causes and develop plans of correction. They can review this information every day to identify potential risks and deal with these before these become real problems. The ability to “drill down” to the outliers on a daily basis means there are no surprises at the end of the month. A dashboard instills confidence that you have addressed all actionable events that may draw a surveyor’s attention.

Additionally, facilities can conduct their own regularly scheduled record audits to ensure staff members are properly documenting patient care. Internal audits will show where facilities need to provide better education about policies, procedures and documentation requirements to “chart smart.”

Having your own audit processes in place will make the actual audit easier. Build your own audit templates and conduct mock audits at least quarterly. If possible, have members from your other facilities come in and perform the mock audits for you and return the favor.

The secret to a successful audit is to make sure the actions your staff takes every day follow best practices for documentation. High-quality compliance, memorialized timely in a sound EMR, will get you through that audit with fewer tags and corrective actions, resulting in higher ratings in the Dialysis Facility Compare Star Ratings program and smaller, if any, financial penalties.

Disclosure: Spears has no relevant financial disclosures.

The financial health of a dialysis facility increasingly depends on the clinical team for proper documentation of delivered services and administrative compliance, especially considering the focus on cost-cutting at CMS. This article will explain how clinical processes can help a dialysis facility succeed with the inevitable CMS audit.

Nothing is more gut-wrenching than having your front desk manager or your charge nurse quietly, or sometimes not so quietly, enter your office and say, “The CMS surveyor is here.” All the blood rushes from your brain, and feelings of foreboding doom and panic set in. Staff is already frantically calling the medical director and administration. All you can do is straighten yourself up and greet them with a forced smile, all the while trying to remember that the surveyors want to help you. They are not the enemy — if you are prepared, that is.

Jerry Spears

While enduring this process every other year or 2 years is a necessary evil, basic preparation can go a long way toward getting the results you want. After all, you learned everything you need to pass the audit in kindergarten: be polite, share everything, clean up your own mess, wash your hands, learn and think, hold hands and stick together. Being ready is critical and requires policies and procedures that reflect best practices. In short, all you are asked to do is to create a “culture of safety.” Following the steps outlined in this article will help you do that, as well as pass a CMS inspection with flying colors.

Audit process

It is important to remember that the beginning of the audit sets the tone for what is to come. Your friendliness and charm can open doors for constructive help or can slam these doors shut while the survey tags start flying. Being mindful of how you approach the surveyor can pay dividends down the road.

Figure 1. A sample of a dialysis EMR clinical manager dashboard is shown.

Source: Jerry Spears, RN, CHN

Most audits start with introductions. Bring out your key players: licensed practical nurses, charge nurses, social workers, dietitians, biomed techs and team leaders. These people — as well as patients in the clinic — will have a conversation with the auditor before it is over. The surveyor will likely speak to the medical director as well, but often by phone.

The surveyor’s first request will likely be a tour of the facility. You will not have a warning, so consistently keeping your facility clean and in top condition is mandatory. During this stage, the auditor will study the facility’s cleanliness, calmness, competence and culture of safety, looking for red flags or “triggers.” Depending on what the auditor sees, along with perhaps a gut feeling, the tour can last 5 minutes to an hour or longer. During the tour, the inspector will be looking for clear-cut problems — something that might show the clinic is in trouble. The inspector will be particularly focused on infection control, cleanlines, and charting.

PAGE BREAK

After the tour, the auditor will need a workspace to review materials. Pre-plan a quiet, comfortable area for the auditor. Have ample workspace for a computer, phone and manuals. Afford access to phone extensions and personnel. During this time, the auditor will also request documentation, which the clinic must provide, in hard copy, within a brief time frame. For example, within 3 hours, the facility must provide documentation listed in the CORE Survey Data Worksheet, which, among other things, includes the following:

  • a list of current patients;
  • a list of people who are doing dialysis at the facility, at a nursing home or at home;
  • a list of patients who have been unstable within the last 3 months;
  • a list of patients who were involuntarily discharged in the last year;
  • a list of discharged patients categorized as “lost to follow-up” in the last year;
  • hospitalization logs with diagnoses for the last 6 months;
  • a list of patients readmitted to the hospital within 30 days of discharge in the last 6 months;
  • infection logs for the last 6 months; and
  • documentation of adverse events (eg, clinical variances and medical errors) for the last 6 months.

 If your clinic uses paper documents for the water room or tasks like machine maintenance, make sure these are legible, clean, dry and protected by plastic sleeves. As for your electronic medical records, make sure you have a reliable computer for the auditor to use if needed. The surveyor should be able to easily maneuver through a patient’s chart, as well as access the Quality Assurance and Performance Improvement process and action plans.

The surveyor will review the data provided, looking for triggers that might require further investigation. The key to passing the audit is to have a rigorous documentation procedure instilled in staff well ahead of any audit.

Document for success

During the audit, the EMR can be your best friend or your worst enemy. An EMR that is easy to use and thoroughly captures patients’ medical care is essential and that begins with daily processes grounded in sound protocols, but what processes do you need to do each day to ensure your system is audit-proof?

First, document everything you can when you are in the system. Three key areas are typical triggers for surveyor attention:

  • hospitalizations;
  • infections; and
  • patients who have been lost to follow-up.

 Many clinics fail to track patients’ hospitalizations, though they need to document why, where and when patients were hospitalized. To rectify this problem, clinics need a consistent documentation process for hospital admissions and discharges. The clinic’s transition of care coordinator must follow up with the hospital and document all records in the EMR. The key is to have a certified EMR system that allows them to access and scan medical records from other certified hospital systems from any location, including critical documents such as discharge summaries and medication lists.

PAGE BREAK

Clinics also need a process to record infections. Sometimes clinicians document the administration of an antibiotic but forget to document the infection and vice versa. If a patient is in the hospital with an infection, clinics must document it, so they are not tagged as the cause of an infection that started elsewhere. Further, because the administration of any antibiotic is reportable to the National Healthcare Safety Network, it is key for them to track antibiotics in their EMR and ensure every antibiotic is tied to a specific infection.

In addition, clinics must be able to identify any patient who gets an initial treatment but never came back. Although this is not a common occurrence, it is a huge red flag. Typically, either the patient has not been educated about the severity of the disease or does not understand the importance of the treatment. Therefore, clinics must create a process that requires their staff to document efforts to educate, follow up and retain patients. An EMR should offer a shift closeout screen that identifies all patients who did not show for treatment, so it reminds staff to document retention efforts appropriately.

Finally, the inspector will closely study the data in the Clinical Outcomes Threshold Table from the End-stage Renal Disease Core Survey Data Worksheet. Clinics must be able to readily provide the required information on hemodialysis and peritoneal dialysis indicators. Your EMR should be regularly tracking these data and alerting staff through a dashboard if the reportable levels exceed the CMS thresholds.

Best practice: Self-audits

Continuing education for the staff on the release notes and upgrades of the EMR system will ensure charting with the latest tools for easy, accurate and timely documentation. Including a brief in-service during staff meetings can be useful in self-auditing routines.

The EMR itself can also be a valuable self-check for clinics and with a clinical manager dashboard can provide not only the manager, but also members of the dialysis care team, the daily information they need to identify root causes and develop plans of correction. They can review this information every day to identify potential risks and deal with these before these become real problems. The ability to “drill down” to the outliers on a daily basis means there are no surprises at the end of the month. A dashboard instills confidence that you have addressed all actionable events that may draw a surveyor’s attention.

Additionally, facilities can conduct their own regularly scheduled record audits to ensure staff members are properly documenting patient care. Internal audits will show where facilities need to provide better education about policies, procedures and documentation requirements to “chart smart.”

PAGE BREAK

Having your own audit processes in place will make the actual audit easier. Build your own audit templates and conduct mock audits at least quarterly. If possible, have members from your other facilities come in and perform the mock audits for you and return the favor.

The secret to a successful audit is to make sure the actions your staff takes every day follow best practices for documentation. High-quality compliance, memorialized timely in a sound EMR, will get you through that audit with fewer tags and corrective actions, resulting in higher ratings in the Dialysis Facility Compare Star Ratings program and smaller, if any, financial penalties.

Disclosure: Spears has no relevant financial disclosures.