By Walter F. Roche Jr.
A state agency has cited Philadelphia's Wills Eye Hospital for failing to correct a series of deficiencies uncovered in a full licensure inspection more than six months ago.
According to an inspection report recently made public when state inspectors returned to Wills Eye in November, they found many of the same defciencies the facility had been cited for in an annual April licensure inspection and the hospital had failed to implement a promised plan of correction.
"It was determined that Wills Eye Hospital failed to correct the deficient practice and/or follow the plan of correction submitted and accepted by the department," the 26-page report states.
Among the repeat deficiencies cited was a failure to provide documentation that patients or their responsible parties had been notified of a serious event that occurred on July 22. Details of that "serious event" were not disclosed.
Contacted late last week a Wills Eye spokesperson said that a second plan of correction has been submitted to the state and is being implemented.
In the new plan of correction the hospital promised to set up a monitoring system to ensure that serious events were reported and proper notifications to patients were sent.
In a similar repeat finding, the state inspectors found that patient grievances were nor properly handled and there was no documentation the complaining patients were informed of the resulting action or findings.
The inspectors also found that Wills Eye had failed to appoint two community members to a patient safety committee. When cited for the same deficiency in April, Wills had promised to correct the problem and make the needed appointments by June 30.
Appointments to the patient safety panel were finally made in October, according to the latest plan filed with the state.
In yet another finding the inspectors found Wills Eye failed initiate disciplinary action against physicians who failed to submit required medical records within 30 days of a patient's discharge.
"A review on October 21, 2015, of the facility's Medical Records Discrepancy report dated June 19, 2015, revealed five physicians had missing signatures on operative reports greater that 30 days," the inspection report states.
Wills, in its recent response, said a new notification and monitoring system already had been put in place to ensure records were completed within the 30 day time limit.
Contact: wfrochejr999@gmail.com
| WILLS EYE HOSPITAL Health Inspection Results For: There are 4 surveys for this facility. Please select a date to view the survey results.
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Initial Comments: This report is the result of a revisit conducted on October 21, 2015, at Wills Eye Hospital as a result of a previous full state licensure survey that was conducted on April 13-14, 2015. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 Pa Code, Part IV, Subparts A and B, November 1987, as amended June 1998. Plan of Correction: 101.111 LICENSURE CORRECTION OF DEFICIENCY Name - Component - 00 101.111 Policy Whenever any hospital notifies the Department that it has completed a plan of correction and corrected its deficiencies, the Department will conduct a survey to ascertain completion of the plan of correction. Upon finding full or substantial compliance, as defined in 101.92(b), the Department may issue a regular license. Observations: Based on an unannounced on-site revisit survey completed on October 21, 2015, review of the facility's Plan of Correction (PoC), documents provided by the facility and interview with staff (EMP), it was determined that Wills Eye Hospital failed to correct the deficient practice and/or follow the PoC submitted to and accepted by the Department. Findings include: 1. A review of 103.4 (3) Functions, Section 308, Patient Safety, Act 13-2002, revealed the facility continued to be out of compliance with this regulation. The deficient practice was identified during a full State Licensure survey conducted on April 13-14, 2015. The final anticipated PoC completion date for the citation was May 22, 2015. A review conducted on October 21, 2015, of the facility's Patient Safety Plan revised May 6, 2015 revealed "...4. Written notification to the patient will be sent within 7 days of the occurrence or discovery of a serious event." A review on October 21, 2015, of MR5, revealed that that the facility was unable to produce documentation that the patient or patient representative received notification of a serious event which occurred July 2015. An interview conducted on October 21, 2015, at 11:10 AM with EMP1 and EMP2 confirmed that the facility had no documentation that the patient or patient representative had received notification of the serious event which occurred July 22, 2015. An interview conducted on October 21, 2015, at 11:15 with EMP1 and EMP2 confirmed that the staff had not been inserviced on the revisions made to the patient safety plan nor the revisions to the patient safety hotline process. ________________________________ During the revisit survey conducted on October 21, 2015, 103.4 (3) Functions, Section 310. Patient Safety Committee. Composition, deficient practice related to the facility's failure to include two residents of the community served by the medical facility who are not agents, employees or contractors of the medical facility at the patient safety committee. The deficient practice was identified during the state licensure survey completed on April 13-14, 2015. The final anticipated PoC completion date for the citation was June 30, 2015. 2. A review of the facility's patient safety committee meeting minutes for June, July, August, September 2015, revealed that the facility failed to appoint two residents of the community to serve on the committee. An interview conducted on October 21, 2015, at 11:45AM with EMP1 and EMP2 confirmed that two residents of the community had not been appointed to serve on the patient safety committee. Futher interview revealed that no residents of the community attended the patient safety committee meetings in June, July, August and September 2015. ______________________________ Plan of Correction:Section 308 The Director of Nursing confirmed a letter was sent to the patient. The letter was scanned and attached in the electronic variance system. Completed on 10/22/15 The CNO performed an audit of all serious events from 7/1/15 to 10/21/15. All records were found to be in compliance in accordance with ACT 13. Completed on 11/1/15 The Patient Safety Plan was revised as of the Patient Safety Committee meeting on October 29, 2015 to include definitions for incident, infrastructure, infrastructure failure and serious event to provide additional guidance on what events must be reported as incidents and serious events under ACT 13. Completed on 10/29/15 The WillsEye Committee, of the Board of Directors, will audit monthly the Patient Safety Committee minutes and PSO reports to ensure compliance with reporting of serious events in accordance with ACT 13. Completed by 1/6/16 Hospital staff will be in-serviced on the patient safety plan and safety hotline. This will include a Power Point presentation, distribution of the Patient Safety Plan and a sign-in sheet with signatures. In-servicing of the Patient Safety Plan and patient safety hotline process will become a mandatory online training component conducted on an annual basis. Completed on 11/17/15 Quality Assurance The electronic variance system has been programmed to immediately notify the PSO and CNO of the filing of a serious event. The PSO will generate written notification to patients in accordance with the timeframe prescribed by the authority. The PSO will scan a copy of the letter into the electronic variance system beginning November 2015. The Patient Safety Officer will provide monthly reports on serious events to include compliance with the 7 day notification period and follow-up to the Patient Safety Committee for review beginning November 2015. The Chief Nursing Officer or designee will perform monthly audits of the reporting completed by the Patient Safety Officer, beginning November 2015, to ensure reporting of serious events within 24hrs and written notification to patients within 7 days. The CNO will provide a monthly summary of the audits to the Safety Committee beginning November 2015. The Chief Nursing Officer or designee will immediately address non-compliance. The Chief Nursing Officer will audit for 3 months then quarterly the Patient Safety Committee minutes to ensure event reports and follow-up are being reviewed beginning November 2015. The WillsEye Committee, of the Board of Directors, will audit monthly for 3 months then quarterly, the Patient Safety Committee minutes and PSO reports to ensure compliance with reporting of serious events in accordance with ACT 13 beginning December 2015. The Executive Committee will review for 3 months then quarterly the minutes of the Patient Safety Committee and recommendations to monitor the patient safety process beginning November 2015. The Executive Committee will provide minutes for 3 months then quarterly to demonstrate approval of the Patient Safety Committee report to the Board of Directors beginning December 2015. The Chief Nursing Officer and Patient Safety Officer are responsible for the Patient Safety Plan. Section 310 The CEO and administrative team immediately interviewed and selected two community members to the Patient Safety Committee as evidenced by acceptance letters dated October 26, 2015. Completed on 10/26/15 Both community members were present at the Patient Safety Committee meeting on October 29, 2015 as evidenced by the meeting sign-in sheet and minutes. One community member was present, and one community member was excused due to travel out of the country, at the Patient Safety Committee meeting on November 11, 2015 as evidenced by the meeting sign-in sheet and minutes. Completed on 11/11/15 Quality Assurance The Chief Nursing Officer or designee will audit monthly for 3 months then quarterly the minutes of the Patient Safety Committee to ensure the presence of two community members at the meeting. This began October 2015. The audits will be sent to the Executive Committee for review beginning November 2015. Citation P0147 will be completed by January 19, 2016 103.4 (3) LICENSURE FUNCTIONS Name - Component - 00 (3) Take all reasonable steps to conform to all applicable Federal, State, and local laws and regulations. Observations: Based on an unannounced on-site revisit survey completed on October 21, 2015, review of the facility's Plan of Correction (PoC), documents provided by the facility, and interview with staff (EMP), it was determined that Wills Eye Hospital failed to correct the deficient practice and/or follow the PoC submitted to and accepted by the Department. Findings include: 1. A review of 103.4 (3) Functions, Section 308, Patient Safety, Act 13-2002, revealed the facility continued to be out of compliance with this regulation. The deficient practice was identified during a full State Licensure survey conducted on April 13-14, 2015. The final anticipated PoC completion date for the citation was May 22, 2015. A review conducted on October 21, 2015, of the facility's Patient Safety Plan revised May 6, 2015 revealed "...4. Written notification to the patient will be sent within 7 days of the occurrence or discovery of a serious event." A review on October 21, 2015, of MR5, revealed that the facility was unable to produce documentation that the patient or patient representative received notification of a serious event which occurred July 2015. An interview conducted on October 21, 2015, at 11:10 AM with EMP1 and EMP2 confirmed that the facility had no documentation that the patient or patient representative had received notification of the serious event which occurred July 22, 2015. An interview conducted on October 21, 2015, at 11:15 with EMP1 and EMP2 confirmed that the staff had not been inserviced on the revisions made to the patient safety plan nor the revisions to the patient safety hotline process. ____________________________________________ During the revisit survey conducted on October 21, 2015, 103.4 (3) Functions, Section 310. Patient Safety Committee. Composition, deficient practice related to the facility's failure to include two residents of the community served by the medical facility who are not agents, employees or contractors of the medical facility at the patient safety committee. The deficient practice was identified during the state licensure survey completed on April 13-14, 2015. The final anticipated PoC completion date for the citation was June 30, 2015. 2. A review of the facility's patient safety committee meeting minutes for June, July, August, September 2015, revealed that the facility failed to appoint two residents of the community to serve on the committee. An interview conducted on October 21, 2015, at 11:45AM with EMP1 and EMP2 confirmed that two residents of the community had not been appointed to serve on the patient safety committee. Futher interview revealed that no residents of the community attended the patient safety committee meetings in June, July, August and September 2015. _____________________________________________ Plan of Correction:Section 308 The Director of Nursing confirmed a letter was sent to the patient. The letter was scanned and attached in the electronic variance system. Completed on 10/22/15 The CNO performed an audit of all serious events from 7/1/15 to 10/21/15. All records were found to be in compliance in accordance with ACT 13. Completed on 11/1/15 The Patient Safety Plan was revised as of the Patient Safety Committee meeting on October 29, 2015 to include definitions for incident, infrastructure, infrastructure failure and serious event to provide additional guidance on what events must be reported as incidents and serious events under ACT 13. Completed on 10/29/15 The WillsEye Committee, of the Board of Directors, will audit monthly the Patient Safety Committee minutes and PSO reports to ensure compliance with reporting of serious events in accordance with ACT 13. Completed by 1/6/16 Hospital staff will be in-serviced on the patient safety plan and safety hotline. This will include a Power Point presentation, distribution of the Patient Safety Plan and a sign-in sheet with signatures. In-servicing of the Patient Safety Plan and patient safety hotline process will become a mandatory online training component conducted on an annual basis. Completed on 11/17/15 Quality Assurance The electronic variance system has been programmed to immediately notify the PSO and CNO of the filing of a serious event. The PSO will generate written notification to patients in accordance with the timeframe prescribed by the authority. The PSO will scan a copy of the letter into the electronic variance system beginning November 2015. The Patient Safety Officer will provide monthly reports on serious events to include compliance with the 7 day notification period and follow-up to the Patient Safety Committee for review beginning November 2015. The Chief Nursing Officer or designee will perform monthly audits of the reporting completed by the Patient Safety Officer, beginning November 2015, to ensure reporting of serious events within 24hrs and written notification to patients within 7 days. The CNO will provide a monthly summary of the audits to the Safety Committee beginning November 2015. The Chief Nursing Officer or designee will immediately address non-compliance. The Chief Nursing Officer will audit for 3 months then quarterly the Patient Safety Committee minutes to ensure event reports and follow-up are being reviewed beginning November 2015. The WillsEye Committee, of the Board of Directors, will audit monthly for 3 months then quarterly, the Patient Safety Committee minutes and PSO reports to ensure compliance with reporting of serious events in accordance with ACT 13 beginning December 2015. The Executive Committee will review for 3 months then quarterly the minutes of the Patient Safety Committee and recommendations to monitor the patient safety process beginning November 2015. The Executive Committee will provide minutes for 3 months then quarterly to demonstrate approval of the Patient Safety Committee report to the Board of Directors beginning December 2015. The Chief Nursing Officer and Patient Safety Officer are responsible for the Patient Safety Plan. Section 310 The CEO and administrative team immediately interviewed and selected two community members to the Patient Safety Committee as evidenced by acceptance letters dated October 26, 2015. Completed on 10/26/15 Both community members were present at the Patient Safety Committee meeting on October 29, 2015 as evidenced by the meeting sign-in sheet and minutes. One community member was present, and one community member was excused due to travel out of the country, at the Patient Safety Committee meeting on November 11, 2015 as evidenced by the meeting sign-in sheet and minutes. Completed on 11/11/15 Quality Assurance The Chief Nursing Officer or designee will audit monthly for 3 months then quarterly the minutes of the Patient Safety Committee to ensure the presence of two community members at the meeting. This began October 2015. The audits will be sent to the Executive Committee for review beginning November 2015. Citation P0317 will be completed by January 19, 2016 103.24 (2) LICENSURE INVESTIGATION/ENFORCEMENT PROCEDURES Name - Component - 00 103.24 (2) formal written complaints are recorded and investigated; Observations: Based on an unannounced on-site revisit survey, completed on October 21, 2015, review of the facility's Plan of Correction (PoC), documents provided by the facility, medical records (MR) and interview with staff (EMP), it was determined that Wills Eye Hospital failed to correct the deficient practice and/or follow the PoC submitted to and accepted by the Department. Findings include: 1) During the revisit survey conducted October 21, 2015, 103.24 (2) Formal Written Complaints are Recorded and Investigated, deficient practice related to the Grievances was found to be uncorrected. The PoC was partially implemented by the facility. The PoC failed to correct the deficient practice. The deficient practice was identified during the state licensure survey completed on April 13-14, 2015. The final anticipated PoC completion date for the citation was May 26, 2015. A review on October 21, 2015, of facility audit documentation for grievances in the months of July, August and September 2015 revealed that MR6 had documentation that a grievance was filed on July 22, 2015. The facility could not produce documentation that a written resolution had been sent to the patient or patient representative. An interview conducted on October 21, 2015, at 12:45PM with EMP1 and EMP2 confirmed that the facility had no documentation that a written resolution had been sent to the patient or patient representative. EMP1 also confirmed that the grievance audit did not contain documentation that the written resolution had been sent to the patient or patient representative. Plan of Correction:Section 103.24 The Patient Safety Officer sent a written resolution letter for the grievance filed on 7/22/15 to the patient and scanned it into the electronic grievance system. Completed on 11/20/15 The CNO audited all hospital grievances from 7/1/15 to 10/21/15. All the grievances during this time period were resolved verbally with the patient and a confirmation letter was sent. Completed on 11/5/15 The facility amended its policy 1.5.4, Patient Grievance Process. The policy states, The Patient Safety Officer may not mark a grievance closed until the Patient Safety Officer verifies, by visual confirmation of documentation uploaded to the Sklira grievance record that written resolution has been sent to the patient or patient representative. Completed on 10/26/15 The WillsEye Committee, of the Board of Directors, will audit monthly for 3 months then quarterly, the Patient Safety Committee minutes and PSO reports to ensure that written resolution letters for grievances are sent to the patient or patient representative. Completed by 1/6/16 The CNO Audit tool has been updated to confirm written resolution letters for grievances are sent to the patient or patient representative. The CNO will audit monthly for 6 months then quarterly. Completed on 11/12/15 Quality Assurance The PSO will receive all written, verbal and telephonic grievances beginning November 2015. The PSO will monitor and document that a resolution was attempted within 24hrs. If not resolved within 24hrs the PSO will ensure a written reply sent is to patients within the 7 day period in accordance with policy 1.5.4, Patient Grievance Process beginning November 2015. The Patient Safety Officer will provide a monthly summary report and accompanying documentation of all grievances to the Patient Safety Committee for review beginning November 2015. The Patient Safety Officer will audit monthly metrics associated with patient grievances. Monitoring will include number of grievances, resolutions, outstanding items and trends and monthly report will be sent to the Patient Safety Committee for review beginning November 2015. The CNO will audit the completion of the grievance process for each patient grievance for 3 months then quarterly and include this in the monthly audit submitted to the Patient Safety Committee beginning November 2015. The WillsEye Committee, of the Board of Directors, will audit monthly the Patient Safety Committee minutes and PSO reports to ensure that written resolution letters for grievances are sent to the patient or patient representative beginning December 2015 for 3 months then quarterly. Monthly reports will be sent from the Patient Safety Committee to the Executive Committee for approval beginning November 2015 for three months then quarterly. The Patient Safety Officer and Chief Nursing Officer are responsible for the patient grievance process. Citation P0370 will be completed by 2/29/16 111.25 LICENSURE INFECTION CONTROL Name - Component - 00 111.25 Infection Control. There shall be procedures to control employes with infections and open lesions. Routine health examinations and infection control procedures shall meet at least the standards set forth in 7 Pa. Code § § 78.41-78.43 (Reserved). A dietician, dietetic technician, or dietetic assistant shall serve on any appropriate hospital infection control committees. These committees may be combined, and dietetic services infection control activities may be included among the responsibilities of the committee established pursuant to § 147.21 (relating to infection control). Observations: Based on an unannounced on-site revisit survey completed on October 21, 2015, review of facility's Plan of Correction (PoC), documents provided by the facility and interview with staff (EMP, it was determined that Wills Eye Hospital failed to correct the deficient practice and or/follow the PoC submitted to and accepted by the Department. During the revisit survey conducted on October 21, 2015, 111.25, Infection Control, deficient practice was found to be uncorrected. The PoC failed to correct the deficient practice. The deficient practice was identified during the state licensure survey completed on April 13-14, 2015. The final anticipated PoC completion date for the citation was May 22, 2015 A review on October 21, 2015, of the facility document "Amendment to Agreement to Provide Consultant Services" dated July 8, 2015, revealed the facility failed to require a representative from dietary to serve on the Infection Control Committee. An interview conducted on October 21, 2015, at 1:30PM with EMP1 confirmed the facility document "Amendment to Agreement to Provide Consultant Services" did not require a representative from dietary to attend the Infection Control Committee. Further interview with EMP1 confirmed there had been no corrective action taken to amend the document. Plan of Correction:Section 111.25 A new contract was signed by the consulting dietician and WillsEye hospital on November 6, 2015 and includes the requirement of the dietician to attend the Infection Control Committee meetings. Completed on 11/6/15 The electronic contract manager has been updated to include email notification of expiring contracts. The CNO will review the renewal of the dieticians contract to ensure attendance at the Infection Control Committee meeting is a requirement of the contract. Completed on 11/6/15 Quality Assurance The CNO or designee will monitor monthly for 3 months and then quarterly the attendance of the dietician at the Infection Control Committee beginning November 2015. The CNO will report audit findings and corrective actions if needed to the Patient Safety Committee for review and recommendations beginning November 2015. Quarterly reports will be sent from the Patient Safety Committee to the Executive Committee beginning November 2015. Quarterly reports will be sent from the Executive Committee to the Board of Directors beginning November 2015. The Chief Nursing Officer is responsible to ensure contractual obligations by the consulting dietician are met. Citation P1121 will be completed by January 19, 2016 115.34 (b)(1) LICENSURE MEDICAL RECORDS REVIEW Name - Component - 00 115.34 (b) the medical records committee: (1) shall review records for completeness and shall establish requirements regarding completion of medical records, including a system for disciplinary actions for those who do not complete records in a timely manner; Observations: Based on review of facility documentation, medical records (MR) and interview with staff (EMP), it was determined the facility failed to enforce disciplinary actions for physicians who failed to complete medical records within 30 days of patient discharge. Findings include: During the revisit survey conducted on October 21, 2015, 115.34 (b)(1) Medical Records Review, deficient practice related to the completion of Medical Records was found to be uncorrected. The facility failed to follow the PoC that was submitted and accepted by the Department. The deficient practice was identified during the state licensure survey completed on April 13-14, 2015. The final anticipated PoC completion date for the citation was June 15, 2015. A review on October 21, 2015, of facility policy "Delinquent Records and Suspension Process" effective date August 1, 2013, revealed, "Policy. Records are delinquent 30 days after Date of Service or discharge from the hospital. Procedure. ...2. Any Physician and/or Licensed Independent Practitioner (LIP) with records that remain incomplete after 20 days will receive a pre-suspension letter notifying them of impending suspension as result of delinquent records. 3. A reminder letter will be sent on day 25. 4. A hold will be placed on their scheduling of admissions and/or procedures if the records are not current by day 30...8. At noon the suspension goes into effect if records are not completed." A review on October 21, 2015, of the facility's Medical Records Discrepancy report dated June 19, 2015, revealed five physicians had missing signatures on operative reports greater that 30 days as follows: EMP6, three forms from May 12, 2015. EMP7, two forms from May 12, 2015. EMP8, three forms from May 13, 2015. EMP9, one form from May 14, 2015. EMP10, two forms from May 14, 2015. A review on October 21, 2015, of the facility's medical record discrepancy report dated July 2, 2015, revealed five physicians had missing signatures on dictated operative reports and missing signatures on forms other than operative reports greater than 30 days as follows: EMP5, six missing signatures on dictated operative reports from May 26, 2015. EMP11, one missing signature on dictated operative report from June 1, 2015. EMP7, two forms missing signatures other than an operative report from May 12, 2015, (continued discrepancy from medical records discrepancy report dated June 19, 2015). EMP10, two forms missing signatures other than an operative report from May 14, 2015, (continued discrepancy from medical records discrepancy report dated June 19, 2015). EMP12, one form missing signature other than an operative report from May 26, 2015. A review on October 21, 2015, of the facility's Executive Council Meeting minutes dated June 17, 2015 and September 16, 2015, and the Board of Directors of City Trusts Meeting minutes dated September 30, 2015, revealed that the Medical Records Discrepancy Reports for June 19, and July 2, 2015, had not been reported. An interview conducted on October 21, 2015, at 2:45PM with EMP1, EMP3, and EMP4 confirmed that the physicians had medical record delinquencies greater than 30 days and had not received written notification for suspension of hospital privileges, nor had any of the physicians been suspended due to delinquent records greater than 30 days. Further interview with EMP1 and EMP4 confirmed that the Medical Records Discrepancy Report results dated June 19 and July 1, 2015, had not been reported to the Executive Council and the Board of Directors of City Trusts meetings. Plan of Correction:Section 115.34 The CNO reviewed medical records from discrepancy reports dated 7/2/15 and 6/19/15 and found that all records are complete. Completed on 10/22/15 Delinquent Records and Suspension Process policy 3.9.7 was amended to provide that the Medical Records Coordinator will prepare an interim Medical Records Discrepancy Report on the Friday of each week which will include a summary of 7-day reminder emails. This will be distributed to the CNO, the CEO, and the Ophthalmologist-in-Chief (OIC). Completed on 10/26/15 Delinquent Records and Suspension Process policy 3.9.7 will be updated to include delinquency of medical records at 30 days in accordance with CMS conditions of participation. Completed by 12/1/15 The amended Policy will be circulated to all members of the active medical staff by the Ophthalmologist-in-Chief (OIC). Completed by 12/15/15 Chief Nursing Officer will educate the HIM staff on the amended policy to include a PowerPoint presentation and sign-in sheet with signatures from the HIM staff. Completed by 12/15/15 The CNO audited 7 day medical records discrepancy reports from HIM to include 10/26/15, 11/2/15, 11/9/15 and 11/16/15. During this time period the delinquent medical records policy was followed. In August, 5 physicians were sent a total of 18 (7) day reminder emails and there were no 30 day delinquencies. In September a total of 9 physicians were sent 23 (7) day reminder emails and there were no 30 day delinquencies. In October, a total of 7 physicians received 11 (7) day reminder emails. At the time of the audit all records were found to be complete. Completed on 11/19/15 The Medical Record Discrepancy Reports for August 2015, September 2015 and October 2015 were incorporated into a quarterly Medical Records Report. The Report was submitted at the Patient Safety Committee on November 11, 2015. Completed on 11/11/15 The quarterly Medical Records Report was presented to Executive Committee on November 17, 2015. The report was delivered to the Board before Executive Committee by the CEO since there would have been a number of weeks before the Board meeting following the next meeting of Executive Council. Completed on 11/17/15 The WillsEye Committee, of the Board of Directors, will audit monthly for 3 months then quarterly, the Medical Records Committee minutes to ensure that the medical records delinquency policy is being followed beginning December 2015. Completed by 1/19/16 The Medical Records Report for August, September and October was submitted and reviewed in the November 2015 meeting of the Patient Safety Committee. The Patient Safety Committee submitted the report for review at the November Executive Committee meeting. Completed on 11/18/15 June 2015 and July 2015 will be presented to the Patient Safety Committee at its next scheduled meeting in December 2015. The results will be sent for review to the Executive Committee December 2015 meeting. The Executive Committee will send their minutes, reflecting the review of the June and July medical records report, for the January 2016 WillsEye Hospital Board meeting. Completed by 1/19/16 Quality Assurance The Medical Records Coordinator will aggregate the interim Medical Records Discrepancy Reports for the prior month into a monthly Medical Records Discrepancy Report, which will be submitted to the Medical Records Committee each month beginning November 2015. The revised CNO Audit tool requires confirmation of the Medical Records Discrepancy Report and has been extended for an additional 3 months beginning November 2015. The CNO will provide the audit to the Medical Records Committee beginning December 2015. The Medical Records Committee will provide recommendations to the HIM Coordinator and a summary report to the Patient Safety Committee beginning December 2015. The Patient Safety Committee will approve any changes from the Medical Records Committee beginning December 2015. The Patient Safety Committee will provide minutes to the Executive Committee beginning December 2015. The WillsEye Committee, of the Board of Directors, will audit monthly for 3 months then quarterly, the Medical Records Committee minutes to ensure that the medical records delinquency policy is being followed beginning December 2015. The CEO will provide quarterly compliance reports to the Board of Directors to include delinquency rates, holds and suspensions beginning November 2015. The Ophthalmologist-In-Chief and CEO are responsible for the delinquent record process. Citation P1539 will be completed by January 19, 2016 |
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