How to conduct a proper Closed Record review

How to conducted a closed record review. Using federal survey tags to conduct a record review for ensuring proper information is included.

1. CLOSED RECORD REVIEW
Investigative Issues & Tag Review
Ophelia McDaniels
10/2004

2. CLOSED RECORD REVIEW
*Describe the procedures for “Closed Record
Review.”
*State Federal Regulations pertaining to
transfer, discharge and bed-hold.
*Determine Facility compliance with Federal
Regulations

3. SOURCES OF INFORMATION
*Handouts
*State Operations Manual
*DHS Licensing & Certification Policy &
Procedure Manual
*CMS Principles of Documentation 2004

4. EXERCISE
Read the F-tag
Regulation and the
Guidance to Surveyors
assigned to your Team
(5 Minutes)
Answer the questions
thoroughly (10 Minutes)
Select a Team member to
describe the intent of the
regulation and discuss
strategies the Team would
use.

5. CLOSED RECORD REVIEW
F201 Transfer and Discharge Requirements
F202 Documentation

6. CLOSED RECORD REVIEW
F201 Transfer & Discharge Requirements
F202 Documentation
Mr.Smith was admitted to Pleasant Care SNF
with respiratory failure 11/7/01 and was on
mechanical ventilation. He was transferred
to another SNF. The attached letter was in
the closed record.
What investigative strategies would you
employ?

8. CLOSED RECORD REVIEW
F203 Notice Before Transfer
Timing of the Notice
Contents of the Notice

9. CLOSED RECORD REVIEW
F203 Notice Before Transfer
Timing of the Notice
Contents of the Notice
Mr.Fritz was admitted to Pleasant Care SNF 6/26/02
after a roll over motor vehicle accident. He was
discharged to another SNF 5/19/04. The transfer
summary indicated “he was admitted in a
vegetative state with essentially no change in the
past 12 years.” The attached letter was in the
closed record.
What investigative strategies would you employ?

11. CLOSED RECORD REVEIW
CITATION
F 201 Transfer and Discharge Requirements
F 203 Notice Before Transfer
Timing of the Notice
Contents of the Notice

12. CLOSED RECORD REVIEW
F204 Orientation for Transfer Discharge

13. CLOSED RECORD REVIEW
F204 Orientation for Transfer Discharge
Mrs.Curtis was admitted to Pleasant Care SNF S/P lumbar
decompression laminectomy with lumbar epidural
abscess. She was discharged home. The Post Discharge
Plan of Care identified the resident needed assistance
with ambulation, meal preparation/diet,
grooming/dressing, bathing, transportation to MD and
therapy.
What investigative strategies would you employ?

14. CLOSED RECORD REVIEW
DEFICIENCY
F204 Orientation for Transfer Discharge

15. CLOSED RECORD REVIEW
F205 Notice of Bed-hold Policy and Readmission
Notice Before Transfer
Bed-hold Notice Upon Transfer

16. CLOSED RECORD REVIEW
F205 Notice of Bed-hold Policy and Readmission
Notice Before Transfer
Bed-hold Notice Upon Transfer
Mr. Housani was discharged on 1/8/04 to an acute care
hospital due to “uncontrollable aggression/assaults.”
Per Nurses Notes the family was notified via
telephone answering machine the same time the
resident was discharged from the SNF.
What investigative strategies would you employ?

17. CLOSED RECORD REVIEW
F206 Permitting Residents to Return to the
Facility

18. CLOSED RECORD REVIEW
F206 Permitting Residents to Return to the Facility
Mr.Housani was discharged on 1/8/04 to an acute
care hospital due to “uncontrollable
aggression/assaults.” An entry in the social
worker’s notes revealed “. . . Decision was made
not to accept the resident back due to his history of
being physically abusive and socially inappropriate
behavior. Resident is high risk for further
aggressive behavior to staff or residents.”
What investigative strategies would you employ?

19. CLOSED RECORD REVIEW
CITATION
F205 Notice of Bed-Hold Policy and Readmission
Notice Before Transfer
Bed-hold Notice Before Transfer
F206 Permitting Resident to Return to Facility

20. CLOSED RECORD REVIEW
QUESTIONS