Report - Disability Rights Texas

# Provision Assessment of Status Compliance
years, each Facility shall establish
and maintain a unified record for
each individual consistent with the
guidelines in Appendix D.
Residential and Vocational), Master Record, Overflow (which remains in the Master
Record until the retention period is completed), and the Clinical Work Station (CWS).
The CWS, an electronic system, included progress notes, medical progress notes, and
nutritional reports (not including PNM). In addition, assessments and some other
information were copied to a share drive that was not considered part of the unified
record but allowed information to be easily accessible to members of the IDT.
The process for filing in and purging of records at RGSC differed from that at the other
facilities reviewed by this Monitoring Team. At RGSC, all filing an purging was done by
the Health Information Management department staff. When monthly documentation
was to be moved from the individual notebook to the active record, HIM staff were
responsible for moving the documents. Because HIM staff did all purging, they could
assure that all materials to be moved to overflow in the Master Record were filed there.
Nearly all DADS policy requirements were covered in Facility policy. However, Facility
policy did not include the statements from DADS policy that “Medical Progress Notes
must be integrated, including entries from at least Physicians, Physician Assistants,
Psychiatrists, Dentist, Nurses, and Therapists.” As noted below in discussion of the CWS,
the current system makes integrating these progress notes cumbersome.
Records were generally well‐organized, and it was not difficult to find documents.
Policies Governing Recordkeeping
Several policies governed recordkeeping.
RGSC SOP HIM 400‐07 ICF Documentation Guidelines guides documentation
practices. Although worded somewhat differently from DADS Recordkeeping
policy, it included (and for some requirements, provided additional guidance) all
documentation requirements. Furthermore, the SOP included information
needed regarding documentation in the CWS. This policy was revised to add
guidance on correcting errors, legibility, and using identification or job title, and
to emphasize not leaving lines or spaces between entries.
RGSC SOP HIM 400‐14 Filing and Purging of Information Policy/Procedure
governed (as the title states) how filing and purging are to be done; this policy
was revised to require identification or job title.
RGSC SOP HIM 400‐20 ICF‐DD Monthly Record Review covered the requirement
for monthly audit of the unified record (including CWS documentation) and
individual notebooks; it provided a detailed process for this review. This policy
was revised to add the process for inter‐rater audits and to require corrective
action plans for interview tools not completed and returned timely.
Policy 400‐02, which was initially a policy for the whole facility, was revised to
Rio Grande State Center, November 19, 2012
388