Surveyor Guidance
May 27, 2010
Ask any nurse and he or she will likely tell you that state surveys are never pleasant times in an agency. The truth is that surveys cause stress and disruption in the best of circumstances. Complaint surveys are not uncommon and are not limited to agencies that deserve them. The state has a responsibility to investigate complaints. If a surveyor walked in your door tomorrow morning, would you be ready?
The following links are the CMS issued guidance for surveyors. This is what the state must survey in order to certify or recertify a home health agency or hospice. It is definitely worth the time to read through the files and look at your agency from the perspective of a surveyor. Even if you cannot demonstrate compliance to all standards, it will go a long way to have a plan in place before the surveyors arrive at your door.
This link is part of the CMS guidance for surveyors. It is often slow and doesn’t load completely. My suggestion is to save the PDF file once you have opened it to your hard drive.
http://cms.gov/manuals/Downloads/som107ap_b_hha.pdf
Here is the same thing for hospice:
http://cms.gov/manuals/Downloads/som107ap_m_hospice.pdf
UPDATE: a reader just sent this comment:
FYI for Hospices:
Below is the link to the Hospice interim surveyor interpretive guidelines that provide the most recent guidance related to the Hospice CoPs:
http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-19.pdf
Dollars and Sense
May 24, 2010
In reviewing clinical records in the last few weeks at several different agencies, it seems the same mistakes regarding payment repeat themselves over and over again. Keep an eye out for these mistakes if you want to bill your ethical maximum payment:
- ICD-9 Coding. Either the coding is good in an agency or nonexistent. If there is no one in your agency that is an expert coder, consider outsourcing your coding or investing in staff development. I saw tens of thousands of dollars lost in the past few weeks because of inaccurate coding. It pays to get your coding right.
- Functional Limitations. The functional status of the patient does not contribute nearly as much to overall payment as clinical or service domains but the frequency at which questions are under-scored is enough to seriously compromise clinical and financial outcomes. It continues to be difficult to convince nurses that what a patient does independently is not the same as being able to complete a task safely. Safety is always the key to answering questions in the functional domain. Additionally, architectural barriers affect these responses – i.e. a patient could use the bathroom but because of stairs leading to the bathroom, it is inaccessible. In this case, questions regarding bathing and toileting should be answered accordingly.
- Utilization. It seems that some agencies like to schedule patient weekly no matter what. Sometimes, they increase to twice a week. I know one agency who routinely schedules patient once every two weeks. None of these frequencies is bad. The problem is that they are assigned to patients without any regard to the patient’s need. By being conservative with visits, agencies can to increase frequencies for very high need patients without suffering financially.
- Home Health Aide Visits. Home health aide visits are not a marketing tool. Some agencies tend to oversupply home health aides in order to gain a competitive advantage in their market. This may work for a small percentage of market share but in general it is a costly way to market. Agencies that are providing a high level of care and solid outcomes should not need to give away free care to snag the few remaining patients who will change agencies if they do not receive home health aide visits. Allowing your agency to be held hostage by patients and letting unqualified individuals determine your nursing care plan is never healthy for the agency.
- Conversely, providing good care in home health actually means being present in the home. I always recommend being conservative. However, being cheap not only costs you money but also compromises patient care. If you want to perform at the level necessary to achieve good financial and clinical outcomes, you must budget for adequate utilization. If the OASIS data does not support the frequency that the patient needs, look at the data again. With few exceptions, the OASIS dataset will generate sufficient revenue to care for the patient.
None of this is new. However, ten years after the implementation of PPS, it is still prevalent in clinical records. The question isn’t what were we doing ten years ago but rather what will we be doing ten years in the future?
Your comments are always welcome below or you can email me personally.
Teaching and Training
May 21, 2010
Now that you have read all about my frustration in reviewing clinical records regarding teaching, let me offer a few tips to ensure that your documentation of teaching and training is fully reimbursable.
- Document the NEED for teaching. For instance, if your patient has been diabetic for ten years and your notes states that you are teaching insulin administration, explain yourself. It could be that the patient only recently began insulin or that you observed the patient self injecting and determined that reteaching was necessary.
- Do not teach the unteachable. If you have a patient with dementia, document exactly who was taught. As we grow older, our families become larger. You can teach the ‘caregiver’ several times and each time a different person is present. If there are multiple caregivers it makes sense to teach multiple times. It does not make sense to teach the same thing repeatedly.
- Teach only what is necessary. I once read a chart where the nurse taught the patient signs and symptoms of an intracranial bleed which could result from Coumadin. The patient was informed to call the MD for sudden loss of consciousness or seizures. It might have been better to teach safe use of Coumadin to avoid the worst case scenario.
- Sometimes, the best teaching you can do is to tell the patient to take the yellow pill at bedtime. Always consider your patient’s ability to learn. An elderly patient with a fifth grade education probably will not be able to learn that Lasix causes electrolyte imbalances. They will be able to learn to always take their potassium if ordered and to always be present for lab appointments to make sure there are no serious side effects from the medication.
- If a patient is noncompliant, explore the reasons why. You can teach about low sodium diets until the cows come home but if the patient is dependent on someone else for meals, you may be teaching the wrong person. We all know that low budget foods often mean high fat and sodium but there are ways around financial constraints. It may mean that instead of teaching the patient low sodium diets, you change the focus to low sodium and low budget diets and assist the patient in identifying inexpensive alternatives to canned soups and ramen noodles.
Teaching is most of what we do in home health. It is certainly the most important skill that we offer but it also puts us at risk when medications and diets are documented as verbatim off of a printed text that has not been tailored to the patient’s individual needs.
Next week, I plan to write about teaching guides. If anyone has anything good, bad or indifferent to say about them, please email me or leave a comment.
What Were They Thinking
May 20, 2010
That is the question that runs through my mind when I review charts at agencies that do not have good quality review processes.
For instance, does the nurse who is teaching on Lortab know that the patient really doesn’t have an order for it on the plan of care?
What about the nurse teaching on Lasix for the sixth consecutive visit? How concerned is a nurse about her patient files a missed visit report but no follow up? Is the patient just laying there on the floor unable to answer the door? These are the questions that go through my mind when I read charts.
Then there is the documentation that is supposed to work as a catchall but actually serves as a ‘catch nothing’. Imagine reading on a chart of a patient with 22 medications that the nurse ‘taught side effects of meds’. That’s a lot of teaching for a single home health visit. It may have been a better use of time to choose one or two high risk medications and teach on those.
So are these just really crummy nurses? No. Does their documentation truly reflect the quality of the care they provide? I think not.
And it isn’t that these nurses are unable to learn. The problem is that it is difficult to teach an adult a skill that they have no use for. In the current regulatory environment, we are paid mainly because we send a bill to Medicare. No one is currently looking at the documentation to support claims. As such, documentation falls off on our priority list.
Can we say with any confidence that this will always be the case? Of course not. Too much attention is being placed on health care reform and how we are spending our Medicare dollar for us to expect the current level of scrutiny to continue.
And when the feds do come looking, it will likely be for clinical records that have long since been closed. In other words, the work you are doing now could be the subject of future reviews. Is your agency ready for that?
I hope so. If not, give us a call and we will get you ready. On the other hand, once the feds arrive, it may be too late!
Five Software Mistakes
May 7, 2010
It seems that everyone is concerned about what the future might hold for healthcare and in response, money is being spent very conservatively. Software is a significant expense for agencies but regardless of what software you use and how much you pay for it, there is a very good chance that you are wasting agency resources. Below are five common mistakes that I see with clients concerning software.
- Investing in software but not in staff. The staff must be knowledgeable about not only what the software does but the uses for these functions in an agency. There is a huge difference between a data entry clerk who enters claims and true billing staff who knows how to run reports to follow up on billing, ensure accuracy and preempt problems. In other words, why would someone run a delayed EOE report if they didn’t know what to do with it once it was printed.
- You’ve invested in a hotshot billing person who understands the software perfectly and then she goes out of town and billing is a wreck. Why? Mistake number two is hiring people who do not communicate and teach well. Every high level biller should be able to communicate with nurses, office staff and senior management. It is a very frequent occurrence that ‘nursing’ and ‘billing’ are at odds with each other. For all new hires, I recommend that new employees spend a day in the field with a nurse and a day in the billing office regardless of their position.
- Have you ever noticed how regardless of what a person feels about Microsoft, there is usually a copy of MS Office on their computer? There are other programs that will do what office does but we still spend big bucks on Microsoft products for a couple of reasons. First of all, everyone knows how to use them. Secondly, they are reliable. I resent having to pay for software. It is like buying gas for my car. Part of me feels as though I have already paid for the car – what more do they want from me??? But I buy gas to make sure my car runs and I pay for software so I can use my computer.
- Hardware today is basically cheap. Honestly. Five hundred bucks will buy a brand new, fast machine. So why, when I walk into offices do I see machines that could easily be in a museum somewhere? It is unreasonable to expect that your software will run efficiently on a machine that was top of the line in 1972.
- Finally, networked computers should be protected at all times. Nobody means to download viruses or other damaging programming to their machines. Furthermore, I personally don’t have a problem is someone sits at their desks during lunch and plays solitaire while they eat. However, unlimited internet access can lead to near fatal or fatal mistakes. You wouldn’t buy a Ferrari and neglect the insurance, would you?
Please feel free to add to the list. It could go on and on but before embarking on any software adventure, the priorities of the agency must be determined. If your agency is big enough that software can make or break you, go for the best – whatever that might be for you.
