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Implications of CMS Changes to H&P Requirements

Accreditation Monthly

December 19, 2006

Dear Colleague,

I want to bring to your attention that the Centers for Medicare & Medicaid Services (CMS) published a final rule revising requirements in the hospital Conditions of Participation (CoPs) for completion of history and physical (H&P) examinations, authentication of verbal orders, securing medications, and completion of post-anesthesia evaluations.  The full text of the final rule along with comments and responses stemming from the comment period that followed the March 2005 announcement of the proposed rule changes may be accessed at http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/E6-19957.pdf
The changes go into effect January 26, 2007.  This month I want to focus on the changes to the H&P requirements and their implications for your hospital.

This new requirement expands the timeframe for completion of the H&P to no more than 30 days before or 24 hours after an admission. (Note: The term "admission" is used broadly to apply to either an admission as an inpatient or an admission to an outpatient service for which an H&P is required.)  When the H&P is completed within 30 days before admission an examination to determine any changes in the patient's current condition is to be completed and documented or entered into the medical record within 24 hours of admission or prior to surgery or other procedures that you have deemed requires completion of an H&P.

So, the first thing we need to do is delete from our thinking and from our rules and regulations or other such policies any reference to the old CMS language that required an "interval note" for any H&P that was older than 7 days.  The 7 day rule no longer exists.  Instead, CMS now matches JCAHO with respect to the H&P time frame requirements (although, in a response to a comment, CMS stated that JCAHO remains more stringent than CMS when it comes to updating the H&P completed within 30 days prior to an admission by requiring that the H&P be updated at the time of admission rather than within 24 hours of admission.  In fact, in a February 2006 FAQ JCAHO clarified that they would accept the update within 24 hours of admission, something CMS must have overlooked when writing their response to this comment.)

On the other hand, there remain several possible discrepancies between these new CMS rules and JCAHO standards and it will be interesting to watch whether JCAHO moves quickly in 2007 to reconcile these subtle differences.

I alluded to the first of these discrepancies in a paragraph above when I underlined the word examination. In calling for an "update to the patient's condition since the assessment." in PC.2.120 EP 7 JCAHO does not use the word examination. In other elements of performance JCAHO leaves it to the organization to define the scope of the H&P examination.  For its part, CMS offers no explanation of what constitutes an examination.  So, is eyeballing the patient sufficient?  Asking a few questions?  Listening to heart and lung sounds and reviewing vital signs?   In response to a comment, CMS suggests the update be documented along the lines of "the H&P has been reviewed, the patient has been examined, and (I) concur with the findings of the (month/day/year) H&P."  Or, if there are changes in the patient's condition, this sample language for the update would go on further to state, "with the following additions and/or exceptions.."

A second possible discrepancy that, in any event, needs further clarification, is when it comes to the pre-surgical or pre-procedure update, what is meant by "prior to" the procedure? I continue to encounter clients that believe this can mean that the update is documented up to 24 hours prior to the procedure, as in, potentially, the day before the procedure.  In fact, JCAHO has told me they intended the term "prior to" to mean "the day of" the procedure.

Third, the new rule expands the number of permissible professional categories of individuals who may perform the H&P and no longer requires that the H&P be completed by a practitioner credentialed and privileged by the hospital.  This is going to be especially helpful to rural referral center hospitals that often want to accept H&Ps performed by a referring physician that desires no appointment or privileges at the receiving hospital.  However, JCAHO standard MS.2.10 EP 8 continues to call for the practitioner performing H&Ps to be granted privileges by the hospital accepting the H&P.

And a fourth discrepancy that actually extends far beyond the issue of H&Ps, is that the new CMS rule for Medical Record Services requires that all patient medical record entries must be legible, complete, dated, timed, and authenticated.  Currently, JCAHO standard IM.6.10 EP 4 requires that all medical record entries be dated, the author identified, and when required by law, regulation or policy, authenticated.  JCAHO goes on to require that at a minimum H&Ps, operative reports, consultations and discharge summaries must be authenticated.  But, JCAHO says nothing about timing entries and I can assure you the timing of all entries is going to be a very difficult requirement to comply with, at least up until such time that all entries are made electronically and are thus time stamped electronically.

Speaking on behalf of my colleagues at The Greeley Company, any of us would be happy to assist you in fine-tuning your response to these changes including helping to craft policies and effective processes designed specifically to fit your organization. 

It may also be time to schedule an Unannounced Compliance Test-Run visit by one of our Greeley Company mock survey teams.  For more information please call Stacey Koch, Director of Client Relations at 888-749-3054, ext. 3193 or skoch@greeley.com.

Sincerely,

John Rosing, MHA, FACHE
Practice Director, Accreditation and Regulatory Compliance
The Greeley Company

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