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Jul 14

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OASIS-C Version 12.4

The OASIS-C revised version 12.4 can now be accessed by clicking on the link to your left under the Blogroll. The 12.2 dataset has been removed from our site to avoid confusion. Changes are minimal and we look forward to telling you more about this important change in our industry.

Also, it is time to think about compliance with the Red Flags Rule. Please click the link for more information on how to become compliant.

As always, if you have any questions, please comment below or send email to haydelconsulting@bellsouth.net.

Jul 13

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Who Signs What

Nurse Practitioner and Physician Assistant Signatures: Although talk of Physician Assistants and Nurse Practitioners being able to sign orders began several years ago, the fact remains that Physician Assistants and Nurse Practitioners cannot sign orders for any post acute care. This includes hospice, home health, nursing homes and rehab facilities. Any orders received by a Physician Assistant or Nurse Practitioner should be treated the same way that you receive orders from anyone at a physician’s office. The signature must be received by the physician supervising the practitioner prior to billing.

Nurses Signatures on the 485: The 485 asks for the Nurse’s signature and the verbal SOC date. The verbal SOC date is the Start of Care date for that episode. Many nurses, when new to writing 485’s often date their signature the day they sign their name out of habit. This can cause regulatory issues if the date of signature is after the episode is started. If there is no other recert order, this means that care has begun without physician orders. Therefore, the date on the nurses signature line should include a date that is no later than day one of the episode OR a separate recert order must be in the clinical record.

Visit Note Signatures: Visit notes should be signed by the patient whenever possible. If the patient is not able to sign a visit note, a caregiver or family member may sign. There should always be an indication of who actually signed the piece of paper. A common mistake is to see multiple patient signatures on the visit notes. This is easily misinterpreted as fraud. Lisa Selman-Holman advises that in Texas, the correct way for a caregiver to sign order is:

Patient name/your initials by permission (John Doe/jh by permission).

Alternatively, if you are not in Texas and you so prefer, caregivers can sign as such:

Julianne Haydel (caregiver) for John Doe

When creating nursing documentation, your primary goal should be to communicate relevant information about the patient in order to facilitate care between caregivers. But never forget that each and every piece of documentation in a clinical record is also a legal record. Protect yourself.

If you have any questions or comments, please feel free to leave them below in the comment section or email us at haydelcnonsulting@bellsouth.net

 

 


 

Jul 9

What are You doing about CHF?

What have you done lately to reduce your acute care hospitalization rate? If you don’t do anything else this year, a campaign to educate your staff about Congestive Heart Failure may make an appreciable difference. In March of this year, the American College of Cardiology published updated research and guidelines on Congestive Heart Failure which can be found here. Found within the paper are common factors precipitating hospitalization. Many of these factors are easily addressed in the course of a home health visit. Please share with your staff.

• Noncompliance with medical regimen, sodium and/or fluid restriction

• Acute myocardial ischemia

• Uncorrected high blood pressure

• Atrial fibrillation and other arrhythmias

• Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem, beta blockers)

• Pulmonary embolus

• Nonsteroidal anti-inflammatory drugs (Note: Ibuprofen worsens the risk of hospitalization in heart failure patients by 43 percent. Other NSAIDS increase risk even more!)

• Excessive alcohol or illicit drug use

• Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism)

• Concurrent infections (e.g., pneumonia, viral illnesses)

Knowing that CHF patients have these risk factors prior to hospitalization is not enough.  Addressing these conditions as they arise can prevent a hospitalization.  Many agencies are using phone encounters between visits to assess weight fluctuations, new medications, control of diabetes and comorbidities.   In reviewing charts, it is amazing how many patients with a diagnosis of CHF have NSAIDS ordered that probably can be replaced with other pain relievers.

It is rare that an agency is so large or has a hospitalization rate so high that avoiding even a couple of high risk hospitalizations a month for CHF patients won’t make a difference in reported outcomes.  However, these efforts must be sustained and agencies must be patient to see their efforts reflected on the CMS reported outcomes.

If you have any questions or comments, please leave a comment below or contact us at haydelconsulting@bellsouth.net.

Jul 8

Easy Tags

We all know how to bomb a survey. If you missed my explicit instructions, click here. But without bombing a survey because of blatant disregard for the regulations, there are a number of tags that I see repeatedly at agencies that should never happen.

The first and easiest is to write orders and not follow them. To wit, ‘weigh patient q visit and report weight gain of x pounds’. My first issue with tags related to these orders is that many of them do not need to be written at all. But if they do need to be written, they must be followed.

There are two ways to deal with these types of orders. The first is to write a blanket order for every patient and verify that weights are on each and every note. Generally speaking in my experience, it takes about three months for a new process to be implemented and followed consistently. The second way to deal with these types of tags is to be very careful about writing unnecessary orders and then monitor those patients’ charts weekly. Either way, it is a given that some patients must be weighed in order to deliver appropriate care. Your processes must protect these patients.

Another tag that is very common and should never be seen relates to medications. It is not at all unusual for a visit note to state that a patient’s pain is relieved by Tylenol, Advil or some other pain medication and yet, when reviewing the medication profile, the medication is not listed.

This is a serious tag. On a grand scale, giving a patient medications that are not ordered puts your patients at much greater risk than weighing a patient who really doesn’t need to be weighed each visit. Consider that Tylenol may cause liver damage and since home health patients are typically on numerous medications that are metabolized by the liver it is important to consider even seemingly benign medications in the context of an entire medication profile. Additionally, some narcotic pain meds such as Darvocet and Percocet already have Tylenol as a primary ingredient and therefore, an overdose situation may occur if the patient takes OTC Tylenol for breakthrough pain.

Finally, one of the most frequent tags that I see is related to coordination of care. This is largely a documentation error but a serious one. If important changes to the plan of care or the patient response to treatment are not documented, it can compromise care. Although most times, staff is aware of these changes, we must always be prepared for the time when emergency situations exist and clinicians MUST rely on the written information available. As someone who has lived through numerous hurricanes in the past few years, I can assure you that every piece of documentation counts when a patient is separated from their usual caregiving staff and family.

If you spend most days in the field, make your life easier by weighing patients if you are uncertain of the orders. If you encounter an order for a patient who cannot weigh, document why and send a change order to the physician so the order can be discontinued. When anything at all happens to a patient that is not captured on a visit note, document it. Anyone who complains to you about too much documentation is generally not worth listening to as long as your documentation is accurate and timely.

As always, if you have any questions or comments, we are delighted to hear them. If you see any other tags with alarming frequency, send them my way to include on the blog. Your comments may be posted below and we are available by email at haydelconsulting@bellsouth.net.

Jul 6

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Red Flags Rule

Red Flags rule

The Red Flags Rule to be implemented no later than August 1, 2009, is a federal mandate stating that any creditor must protect customer information from identity theft. Although on the surface it doesn’t seem like health care providers would be subject to this rule, a closer examination of the Red Flags Rules reveals that we are.

According to the Red Flags Rule, health care providers are considered creditors because we provide services and later bill for them. Additionally, we collect billing information from the patient that could be used to steal a patient’s identity.

This is not an uncommon experience. Examples are all over the internet including a woman who was being billed for an operation to amputate her foot. Although the hospital released her from the bill, she was later haunted by erroneous medical information in her records.

In Florida, a hospital employee was found to have stolen billing information for numerous patients that allowed a fraudulent laboratory to bill over 2 million dollars to Medicare.

And one of the worst possible breaches of security was a Massachusetts psychiatrist who billed visits to a client’s insurance company that were never made and also billed visits for the patient’s children who never saw the doctor. Consequently, the children are noted on medical records to suffer from severe depression.

Medical Identity Theft is not a joke!

The Red Flags Rule mandates that we do four things:

  1. Design a written plan to protect your patients’ specific information
  2. Identify risks within your organization
  3. Design procedures for addressing risks and breaches of information
  4. Review the plan annually.

Additionally, it is written in the federal register that all ‘relevant’ employees be educated in the plan. Because so many documents contain pertinent billing information such as social security numbers, Medicare or insurance card numbers, etc., all employees privy to this information should be educated.

Remember, Medical Identity Theft is on the rise and it is suspected that further harm may come to patients as the current administration’s plan to share health care data across providers is implemented.

Questions about the Red Flags Rule can be addressed to Haydelconsultingservices@bellsouth.net or you may leave a comment below. As always, we enjoy hearing from you.

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