Carroll hospital told to fix record-keeping Eligibility for Medicare payments is at risk

February 14, 1993|By Donna E. Boller | Donna E. Boller,Staff Writer

Carroll County General Hospital faces the loss of eligibility for Medicare payments -- a financial nightmare -- if the hospital and the physicians who practice there don't bring their medical records up to federal standards.

The hospital is under direct state government supervision while it carries out a plan to improve its record-keeping. If it fails to meet standards in a follow-up survey or a subsequent 90-day grace period, the federal Health Care Financing Administration will cut off its Medicare payments, said William McNeal, a survey certification program specialist at the administration.

Losing eligibility for Medicare reimbursement would be "devastating," said Pamela B. Shafer, the hospital's assistant vice president for quality assurance and risk management. An average of 50 percent of the hospital's beds are filled by patients on Medicare, she said.

Mrs. Shafer said she expects the hospital to meet the medical records standards by the follow-up survey.

"We're full steam ahead with achieving that. I think we've already made a lot of progress," she said.

The federal agency placed Carroll County General under state Department of Health and Mental Hygiene supervision after a survey team found what it called "significant deficiencies" in medical records last fall.

The survey report was obtained by The Sun under the federal Freedom of Information Act.

Team members also found and noted problems in other areas of Carroll County General's operation. But those did not constitute failures to meet the Health Care Financing Administration's requirements.

"If we just find isolated things, we just give the hospital a report on it," said David Sayen, a spokesman for the administration. Hospital officials voluntarily submitted correction plans or explanations for the other defects identified.

A sampling of medical records showed the following deficiencies:

* Orders for some patients' treatments were not written down, in violation of medical staff rules.

* Physical exams and patient histories were not completed within 24 hours after the patients' admission to the hospital.

* Some 43 of 49 closed medical records sampled by the team were incomplete.

* Nurses failed to record assessments and effectiveness of medications for psychiatric patients.

* Records lacked patient consent forms for invasive radiology procedures.

* Care plans were not updated.

* Incomplete blood transfusion reports.

* Lab reports missing from patients' records.

Medical records "are not just an historical artifact," Mr. Sayen said. He said the first thing a doctor does when he goes into a patient's room is pick up the chart and read it. "You couldn't

treat patients if you didn't have good medical records," he said.

Mrs. Shafer said Carroll County General is working hard to get its records in shape before the follow-up inspection. The hospital staff is trying to lure doctors into the medical records department with a new private office -- formerly the department head's office -- and free coffee.

The staff also is trying to cut turnaround time between a physician's dictation of a note for medical records and the written transcriptions from seven to four days.

The hospital has the right to suspend the practicing privileges of doctors who let their records lag, but suspension is almost never invoked. Mrs. Shafer said medical records suspensions average two or three a year among the 200 doctors on staff at Carroll County General.

State health officials have accepted Carroll County General's improvement plan to bring its records up to standards, but Tori Leonard, a Department of Health and Mental Hygiene spokeswoman, said she didn't know whether anyone reviewed the plan before accepting it.

The survey of Carroll County General was a random check. The federal agency extends Medicare eligibility to hospitals accredited by the Joint Commission on Accreditation of Health Care Organizations, but does its own surveys for a small percentage of hospitals on the commission's list.

The commission gave Carroll County General a three-year accreditation in 1992, but the independent agency's medical records standards are not as strict as the Health Care Financing Administration's, Mrs. Shafer said.

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