HIM in Skilled Nursing Facilities
At a minimum, the healthcare professionals working in skilled
nursing facilities or nursing homes wear six or seven hats, says
Mary Ann P. Leonard, MSL, RHIA, RAC-CT, principal, supervising consultant with Health Information Professionals. As
a result, the HIM department is frequently a department of
one, with a single individual holding the title HIM director or
medical records manager. This person might carry out release
of information, perform the duties of a privacy and/or security
officer, and be in charge of minimum data set (MDS) assessments and coding. For the most part, though, Leonard says
registered nurses do ICD- 10 coding, and the codes are built
into the MDS software.
One of the challenges for HIM at skilled nursing facilities is
that the hierarchy of leadership is flat compared to hospitals.
Whereas a hospital HIM department could have a vice president, a HIM director, an assistant director, a medical records
manager, and five or six people under that manager, a skilled
nursing facility has far fewer levels. HIM might report solely
to an administrator or executive director or director of nursing, and have tasks as varied as scheduling transportation,
doing payroll, and coding—as well as developing nursing staff
schedules. As a result, HIM professionals are spread thin and
are asked to do more with less staff.
Like acute care, new regulations have also impacted HIM in
skilled nursing facilities. Passed in 2014, the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) is just
starting to be implemented in skilled nursing facilities and
other long-term and post-acute care settings, including inpatient rehab facilities, home health agencies, and long-term
care hospitals. It requires these settings to report standardized assessment data based on the assessment tools used by
each setting, such as the OASIS tool in home health or the MDS
in skilled nursing facilities. It also requires CMS to make all
that data interoperable so that it can be shared among other
post-acute care facilities and other providers.
RTI’s Dougherty says programs like the IMPACT Act give
HIM professionals an opportunity to show off their expertise
in post-acute settings. “There’s a tremendous role for visibility
[of HIM] in long-term care. Our understanding of data quality,
information governance, and the intersection of care delivery,
those things are critically important,” Dougherty says.
She notes that as a result of the IMPAC T Act HIM professionals have been really focused on the quality of the data, as well
as monitoring or overseeing the quality assurance programs.
They have been key in understanding, in intimate detail, all of
the different measures and investigating the factors that result
in lower quality scores.
A relatively new HIPAA concern for skilled nursing facilities
is a recent wave of cases in which skilled nursing employees
have taken photos of residents and uploaded them to social
media platforms such as Snapchat and Facebook. This has
been happening so often that US lawmakers have asked regu-
lators to take action. 2 Leonard attributes this trend to the fact
that skilled nursing facility employees do their best to create a
home-like environment for residents—after all, 80 percent of
skilled nursing facility residents are there for a year or longer.
And it’s the homey atmosphere that can seem to lower the pri-
vacy threshold—though not in the eyes of the law.
“Information that would be identified as private in a hospital
is not necessarily seen as private [in a skilled nursing facility],”
Leonard says. “…For the most part it’s just employees sharing
photos on Facebook saying, ‘Look at my lovely lady,’ not realizing that’s nobody else’s business, and they’re breaking the
HIM in Home Health
The nature of home health means that the healthcare professionals providing care in this setting walk into an environment over which they have little control. They can’t control the
cleanliness of the homes they visit, nor can they control the
technological circumstances that are the norm in other outpatient or inpatient settings.
“This may come as a surprise, but there are large parts of this
country where people live and need care in their home, that do
not have reliable broadband access. So the ability to even access a medical record—never mind charting or communicating in real time—is significantly impaired in those environments,” says Danielle Pierotti, PhD, RN, CENP, vice president,
quality and performance improvement, at Elevating Home,
formerly known as the Visiting Nurse Association of America.
If a home doesn’t have an Internet connection to help a nurse
complete their OASIS assessment, he or she might go to a nearby Starbucks with WiFi access—which comes with concerns
about the WiFi net work’s security.
“In an ideal world, real time charting is still the gold standard. As a profession, nursing tries to do documentation as
close to the point of care as possible because it reduces the risk
of memory problems, which we are all subject to,” Pierotti says.
According to Tricia Twombly, RN, BSN, HCS-D, HCS-O, COS-C, CHCE, HCS-C, CEO of the Board of Medical Specialty Coding and Compliance, the CEO for the Association of Home Care
Coding and Compliance, and senior director with Decision
Health, in recent years home health has started to centralize
its coding. While nurses used to do coding during a patient assessment, most home health agencies now have certified coding professionals who review charts after the completion of a
Home-based care also opens clinicians to a number of additional HIPAA-related concerns. It’s becoming common for
nurses to take photos of pressure wounds and surgical wounds
using mobile devices. While that’s a legitimate part of the
medical record, nurses can be uncertain about how to permanently remove those images from their phones to prevent any
risk of a privacy breach.
Because of these issues—as well as perennial HIM challenges such as interoperability and coding—Pierotti is hoping to
welcome more HIM professionals into the home health fold.
Of particular interest to Pierotti is spreading the information
governance (IG) message to home health.
“I think that technology in general is moving into home-based care at a very, very fast rate. We are adopting a lot of