| Downtime Medication Order Management |
Paper-based Downtime Medication Order Forms are available and updated at least annually. Defined workflows route STAT and routine paper orders to Pharmacy for manual verification, and pharmacists use a Downtime Verification Log to record order review. Procedures ensure manual allergy, lab, and therapy checks are performed before dispensing. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
| Pharmacy Training, Education, and Drills |
All pharmacists and technicians receive annual downtime training covering manual verification, dispensing, MAR management, and charge capture. Semiannual downtime drills test documentation, labeling, inventory control, and communication workflows. Training logs are maintained for compliance and audit readiness. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
| Pharmacy Training, Education, and Drills |
All pharmacists and technicians receive annual downtime training covering manual verification, dispensing, MAR management, and charge capture. Semiannual downtime drills test documentation, labeling, inventory control, and communication workflows. Training logs are maintained for compliance and audit readiness. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
| Pharmacy Downtime Governance and Leadership |
The Pharmacy Department is represented in the organizational command center during a catastrophic downtime. A designated Pharmacy Downtime Lead is assigned on every shift, responsible for communication, prioritization, and coordination of pharmacy operations across inpatient and outpatient settings. Daily downtime huddles are conducted to align staff and track issues. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
| Continuous Review and Plan Improvement |
The downtime coding plan and toolkit are reviewed annually by Coding leadership, HIM, and Compliance. Lessons learned from downtime events or drills are incorporated into updates, ensuring continuous improvement and readiness for future disruptions. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
| Compliance, Privacy, and Audit Readiness |
Coding downtime processes comply with CMS, AHIMA, and OIG standards. All offline coding activity is documented in a defensible, auditable format with date, time, and coder identification. Safeguards protect PHI whether coders work onsite or remotely, and all offline documentation follows secure chain-of-custody and retention requirements. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
| Compliance, Privacy, and Audit Readiness |
Coding downtime processes comply with CMS, AHIMA, and OIG standards. All offline coding activity is documented in a defensible, auditable format with date, time, and coder identification. Safeguards protect PHI whether coders work onsite or remotely, and all offline documentation follows secure chain-of-custody and retention requirements. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
| Communication, Staffing, and Surge Readiness |
The coding downtime plan includes clear communication protocols between Coding, HIM, and CDI for prioritizing records and escalating missing documentation. It also defines surge staffing strategies, including overtime, cross-training, and credentialing of temporary or vendor coders. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
| Coding Reconciliation and Revenue Integrity Coordination |
A reconciliation process ensures that all manually coded encounters are reviewed, validated, and uploaded to the EHR post-restoration. HIM and CDI collaborate to confirm record completeness and coding accuracy prior to billing. Reconciliation logs are retained for audit purposes. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
| Manual Coding Workflow and Abstraction Procedures |
A standardized workflow for manual coding is maintained, including templates or trackers for diagnosis/procedure codes, DRGs, and modifiers. Coders are trained to abstract directly from paper documentation and record sufficient detail to support future billing and audit review. |
Joint Commission |
IM / LD / EM (dept applicable) |
CMS CoPs / DNV NIAHO |
