Discussion on Most Common Deficiencies – Part Three
In Part Three of our discussion, we will address one of the most common deficiencies cited by our surveyors in 2020. TCT surveyors have documented this standard level citation as one of the top ten most cited deficient practices.
- The Standard: ADM 9.0.2
There is evidence the clinic periodically audits its Patient Health Records for completeness and the results are documented at QI meetings. The number of records is identified in clinic policy. The leadership reviews and documents the chart review findings and takes corrective actions.
The Deficiency: Not auditing Patient Health Records and properly documenting, specifically for the following:
- Documentation of audit results (including number of records reviewed) in QI meeting minutes
- Documentation of leaderships review, findings and any corrective action taken
- Ensuring the number of patient health records and how often they are to be audited is clearly identified in the clinic policy
QI meeting minutes must include documentation of periodic audits of Patient Health Records based on the number of records identified in the clinic’s policy. The minutes should include the names of leadership who reviewed the audit findings and any corrective action taken when issues are identified. The results of the corrective action should be documented in future QI meeting minutes to complete the QI process.
The clinic must ensure that the number of records to be audited and how often the audit will be conducted is delineated in the clinic’s policy.