3 Common EHR Mistakes That Lead to Medicare CoP Deficiencies (42 CFR § 482.24(c))

Electronic Health Records (EHRs) have become the backbone of modern healthcare. For small clinics and hospitals, EHRs promise efficiency, streamlined documentation, and improved continuity of care. Yet, under 42 CFR § 482.24(c), the Medicare Conditions of Participation (CoPs) place strict requirements on medical record services, including electronic systems.

While EHRs can help practices meet compliance standards, they can also create new risks. CMS surveyors often find deficiencies when small practices fail to properly configure, use, or monitor their EHR systems. These deficiencies can lead to audit findings, corrective action plans, financial penalties, and threats to Medicare participation.

This article examines three of the most common EHR mistakes that cause CoP deficiencies, provides practical examples, and offers actionable checklists to help small practices align their EHR systems with federal requirements.

Understanding § 482.24(c): Medical Record Services and EHRs

The regulation requires that medical records, whether paper or electronic, must be:

• Accurate, complete, and promptly documented.

• Accessible to authorized staff for ongoing patient care.

• Confidential and secure from unauthorized access or disclosure.

• Properly authenticated with signatures, dates, or electronic credentials.

For EHRs, this translates into ensuring proper system configuration, user training, audit trails, and access controls.

Why It Happens

Small clinics often assume that EHR templates will automatically ensure compliance. However, surveyors frequently discover:

• Missing progress notes.

• Incomplete medication records.

• Copy-and-paste errors that duplicate outdated information.

• Failure to sign or authenticate records promptly.

Example

In one CMS audit, a community clinic was formally cited after surveyors discovered that several EHR entries lacked proper provider authentication. The missing signatures created the impression that clinical decisions, progress notes, and treatment orders had not been reviewed or approved by licensed professionals. This raised concerns about both the accuracy of the medical record and the integrity of patient care oversight. Without clear authentication, regulators questioned whether the documentation could be trusted, exposing the clinic to citations, corrective action requirements, and potential liability 42 CFR § 482.24(c)).

Compliance Checklist

• Require all entries to be signed and dated electronically (42 CFR § 482.24(c)(1)).

• Prohibit unchecked copy-and-paste practices.

• Review records weekly to confirm completeness and accuracy.

• Train staff on the importance of real-time documentation.

Why It Happens

EHRs often give staff broad access privileges, increasing the risk of HIPAA and CoP violations. Common issues include:

• Shared login credentials.

• Role-based access not configured correctly.

• Staff accessing records of patients outside their care duties.

Example

A small practice faced a Conditions of Participation (CoP) deficiency after a CMS surveyor discovered that front-desk staff had unrestricted access to patient clinical notes, including highly sensitive psychiatric documentation. This level of access was unnecessary for their role and created serious privacy concerns. The lack of role-based controls was deemed a clear violation under both CoPs and HIPAA privacy standards.

Compliance Checklist

• Implement role-based access controls with least-privilege settings.

• Prohibit staff from sharing passwords.

• Conduct quarterly audits of EHR access logs.

• Train staff on confidentiality and appropriate record access.

Why It Happens

Many small practices fail to monitor EHR systems regularly. Without audit trails, CMS surveyors cannot verify that records are being managed properly.

Common problems include:

• No monitoring of who accessed or altered records.

• Failure to track deleted or modified entries.

• Lack of documentation showing compliance reviews.

Example

During a CoP audit, a rural clinic was cited because its EHR system did not log when staff modified medication records. CMS required the practice to implement a new audit trail system and retrain staff.

Compliance Checklist

• Ensure the EHR system maintains a tamper-proof audit trail (42 CFR § 482.24(c)(3)).

• Review audit logs monthly for unusual activity.

• Document corrective actions taken for irregularities.

• Include EHR monitoring in the clinic’s compliance program.

A small family practice relied heavily on its electronic health record (EHR) system to manage patient care and documentation. However, the practice failed to implement role-based access controls, meaning staff at all levels had the same level of access to patient charts. During a CMS survey, inspectors discovered that a staff member had accessed the records of family members without any clinical need or authorization. The violation not only breached patient privacy, it also revealed a gap in the clinic’s compliance infrastructure.

Consequences

• CMS issued a deficiency citation under § 482.24(c), which requires facilities to safeguard medical records against unauthorized use.

• The practice was ordered to submit a corrective action plan, which included reconfiguring the EHR system to enforce role-based access controls and restrict records to only those with a legitimate need.

• All staff underwent retraining on patient privacy, EHR use, and HIPAA’s minimum necessary standard.

• The incident caused reputational harm within the local community, as patients expressed concerns about whether their personal information was safe.

Lesson Learned

This case demonstrates how seemingly simple oversights in EHR configuration can lead to significant compliance failures. For small practices, privacy safeguards must be built into the system itself, supported by ongoing training and monitoring.

Common Pitfalls and How to Avoid Them

1. Over-reliance on templates → Leads to incomplete or duplicated records.

• Solution: Customize templates and review for accuracy.

2. Inadequate staff training → Employees unaware of compliance obligations.

• Solution: Conduct annual training focused on EHR compliance.

3. No monitoring of audit trails → Inability to prove accountability.

• Solution: Implement log reviews as part of routine compliance checks.

4. Lack of policy updates → Policies fail to reflect EHR-related risks.

• Solution: Update medical record policies annually.

1. Conduct Mock CMS Audits: Simulate surveyor questions and record requests.

2. Designate an EHR Compliance Officer: Assign responsibility for monitoring logs and updating policies.

3. Leverage Technology: Use EHR alerts to flag unsigned notes or incomplete fields.

4. Integrate Retention Policies: Align EHR data retention with federal and state laws.

5. Engage Vendors: Ensure your EHR vendor provides compliance support and system updates.

6. Enable Real-Time Electronic Notifications: Under 42 CFR § 482.24(d), hospitals and clinics that use certified electronic health record (EHR) technology must configure their systems to send real-time notifications of admissions, discharges, and transfers. These alerts must go to the patient’s established care providers, such as primary care physicians, post-acute providers, or other practitioners responsible for follow-up care.

Building a Culture of Documentation Excellence

The best defense against CoP deficiencies is a compliance culture where staff understand that EHRs are not just clinical tools, but compliance instruments. Reinforce that:

• “If it’s not documented, it didn’t happen.”

• Every entry must be accurate, authenticated, and secure.

• Regular reviews are part of patient safety, not just regulatory compliance.

Under 42 CFR § 482.24(c), EHR compliance is about more than digital record keeping. The three most common mistakes, incomplete documentation, weak access controls, and failure to maintain audit trails, can quickly lead to CMS citations.

For small practices, preventing these errors requires written policies, staff training, secure system configurations, and ongoing monitoring. By addressing these areas proactively, small clinics can avoid deficiencies, protect patient safety, and maintain Medicare certification.

Consider leveraging a compliance automation tool to streamline your efforts. Such platforms help you document and manage obligations, conduct regular risk assessments, and remain audit-ready, reducing liabilities while signaling accountability to regulators and patients alike.

An effective way to reinforce compliance is through a regulatory platform. Such systems track evolving requirements, generate ongoing risk insights, and ensure your practice remains audit-ready, minimizing liabilities while strengthening patient trust.

1. 42 CFR § 482.24(c) – Condition of Participation: Medical Record Services (Electronic Health Records). Legal Information Institute

2. Centers for Medicare & Medicaid Services (CMS) – State Operations Manual, Appendix A: Survey Protocol for Hospitals

3. Office of Inspector General (OIG) – Compliance Guidance for Physician Practices