HCFA’s proposed changes to COPs focus on patient

Plan of care must be added within 24 hours

The Health Care Financing Administration (HCFA) has proposed changes to Medicare and Medicaid hospital conditions of participation (COP) that emphasize patient care results rather than processes and allow hospitals more flexibility in the ways they meet the requirements.

While the proposal does not represent a complete overhaul of the COPs, which haven’t been revised since 1986, if approved, the changes could add new responsibilities for health information management professionals. HCFA plans to finalize the changes within the year, after staff have reviewed public comments on the proposal.

The changes focus on the following COPs:

Patient assessment.

The changes would require that new patients receive a comprehensive assessment of their needs and a written multidisciplinary plan of care, created specifically for the patient, which must be added to the patient’s medical record within 24 hours of admission.

Under current conditions of participation, a patient’s plan of care is addressed under various separate COPs, including governing body, medical staff, and nursing services, but there is no time limit on when they must appear in the patient’s medical record.

The proposed changes recognize the fact that many disciplines within a hospital work together to assess a patient’s medical needs at the time of admission — physicians, nurses, pharmacy, and dietary personnel — says a senior health insurance specialist at HCFA. Hospital departments don’t work in isolation, so in effect, the proposed change would formalize the multidisciplinary approach to patient care that already exists.

"The 24-hour time frame should pose no burden for the well-managed hospital, since in all likelihood it would already be performing assessments within this time frame for initial care planning and decision-making purposes," HCFA’s proposal states.

In the interests of flexibility, responsibility for signing the plan of care would be left up to the hospital to decide, the HCFA specialist says. The goal of the requirement is that any caregiver could pick up the patient’s chart and know what’s going on with that patient, and everyone involved in that patient’s care would have a role in creating the plan of care, the HCFA specialist explains.

Some info must be added within 12 hours

Another proposed change affecting the medical record would require that any assessment information collected prior to hospital admission be placed in the patient’s medical record within 12 hours. For example, a patient may have had a health history and physical exam (H&P) in a doctor’s office before admission. Placing a copy of that H&P in the hospital record within 12 hours would eliminate duplication in creating these records, especially if the findings during the doctor’s office visit were the basis of the hospital admission, the HCFA proposal argues.

There has to be something on the patient’s chart that says that the problems that necessitated the hospital visit still exist, the HCFA specialist says, adding that Medicare shouldn’t have to pay for two H&Ps.

Current COPs permit use of a physical exam or medical history done within seven days of a patient’s hospital admission.

The changes also require that assessment information recorded before admission be updated to reflect the patient’s condition upon admission.

Patient rights.

The proposed changes would require hospitals to notify patients of their rights as follows:

— to be informed of their rights, to participate in the development and implementation of the individual’s plan of care, and to make decisions regarding that care;

— to formulate advance directives and have those directives followed;

— to have privacy and to receive care in a safe setting;

— to be free from verbal or physical abuse and harassment;

— to be guaranteed confidentiality of clinical records;

— to access information contained in their clinical records within a reasonable time.

HCFA decided to formalize patient rights to access the information in their medical record because they have received complaints from patients saying they have not been given that access, the specialist says.

HCFA is careful not to propose a specific time limit on when a hospital must make patients’ clinical information available, the HCFA health insurance specialist says. That’s because some medical records are more accessible than others. For example, the medical record of a Medicare patient who was examined only the previous week could take only hours to access, but the records of an adoption that occurred years before could be in an off-site storage facility and require days or even weeks to obtain, the HCFA specialist explains.

Quality assessment.

The proposed changes would require hospitals to monitor the quality of care they provide in an objective way, focusing on things like patient satisfaction and medication errors.

Performance improvement.

The changes would require hospitals to enact systematic plans for improving the quality of care and demonstrate they are improving that quality.

HCFA planned to accept public comments to its proposed changes until Feb. 17, the HCFA specialist says. At that time, staff will begin their assessments of the comments and start work on finalizing the changes within the next several months.

A spokesman for the American Health Information Management Association in Chicago says the organization is still reviewing the proposed changes and will reserve comment until they have been thoroughly analyzed.

[Editor’s note: The proposed changes to Medicare and Medicaid hospital conditions of participation were published in the Dec. 19, 1997 Federal Register. They can be downloaded from the Government Printing Office Web site at http://www.access.gpo. gov/su_docs/aces/aces140.html. Printed copies can be ordered by calling (202) 512-1530. Each copy costs $8.00.]