Hospital improving, says state But record-keeping is still deficient

July 01, 1993|By Donna E. Boller | Donna E. Boller,Staff Writer

A state agency's progress report on Carroll County General Hospital shows that the hospital has fixed problems of time lags in completing patients' medical records, but still has some records that contain errors or lack required information.

Hospital officials said yesterday that they have brought their medical records up to federal standards that require them to be completed and signed by doctors within 30 days after a patient leaves the hospital.

That improvement spares CCGH from possible sanctions such as loss of eligibility for Medicare reimbursement.

The federal Health Care Financing Administration (HCFA) could have cut off Medicare payments if the hospital had failed to improve its record-keeping after reviewers found "significant deficiencies" in a September 1992 survey.

The hospital staff needs to work on making sure its records are accurate, complete and contain pertinent clinical information, a state survey team concluded after a follow-up inspection last month.

"They have doctors filling out medical records. Now what they have to do is improve what their doctors write in the records," said Carol Benner, director of licensing and certification for the state Department of Health and Mental Hygiene.

Ms. Benner released the progress report Tuesday, and the hospital provided copies of it at a news conference yesterday.

For the report, the state inspection team checked 45 medical records at random, 10 of them for psychiatric patients.

The psychiatric patients' records said that all 10 had received art therapy when in fact none had, the survey team reported.

Art therapy is not part of the treatment program in CCGH's psychiatric unit.

Linda Harder, the hospital's vice president for marketing, explained yesterday that a worker hired to dictate discharge summaries -- overviews of the patient's illness, treatment and recommended post-hospital care -- dictated the summaries from a master program that listed art therapy.

Ms. Harder said that the day after the DHMH team did its survey, the hospital notified Glass Mental Health Centers, its contractor for the psychiatric unit, that dictating the discharge summaries from a master plan is unacceptable.

"Our physicians are now doing their own discharge summaries," said hospital spokeswoman Gill Chamblin.

The DHMH survey team found anesthesia records that failed to note that patients were checked for drug and allergy problems before surgery, were monitored during surgery for amounts of intravenous fluids given, or checked for pulse rates and level of consciousness after surgery.

Hospital officials said yesterday that the procedures were done and recorded, but not always in the form or location that the HCFA sought.

The federal agency doesn't want an "I-spoke-with-the-patient-after-surgery" narrative, said Tricia Supik, director of medical, surgical and psychiatric nursing services.

The agency wants more of a check-off form, she said.

The HCFA had Carroll County General under direct state supervision for the last 10 months while the hospital staff worked on meeting federal standards for its medical records.

The state team's follow-up survey goes to HCFA, where agency officials must decide whether to restore the hospital's "deemed eligible" status for Medicare reimbursement.

David Sayen, a spokesman for HCFA, explained that if the "deemed eligible" status is restored, the state health department will not be required to continue monitoring the hospital.

The alternative is to continue monitoring and have DHMH make another follow-up visit, he said.

Deficiencies that the DHMH survey team found last month are the least serious of three types, Ms. Benner said.

She said the hospital is not in full compliance with regulations because it still has deficiencies, but the problems are not serious enough for HCFA to impose sanctions.

Ms. Benner said CCGH has corrected other problems, such as patients getting the wrong diets and the hospital lacking records showing that patients signed consent forms for radiology procedures that HCFA defined as invasive.

These deficiencies were identified in the 1992 survey, but the federal agency did not order the hospital to correct them because they were considered isolated incidents, Mr. Sayen said earlier.

Hospital officials emphasized yesterday that the language of the report makes deficiencies appear more serious than they are, and that CCGH should be compared with other hospitals surveyed by HCFA.

"It reads as more damaging than the reality," Ms. Harder said of the report.

She said the report gives the impression that the hospital does not have certain records, when in fact the records may have existed but not in the form HCFA wanted.

Ms. Benner declined to comment on hospital officials' interpretation of the report language.

She said that although DHMH does not have statistics, "it looks like we have been finding more and more medical records deficiencies" among Maryland hospitals.

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