Finding Mr. or Ms. Right
April 15, 2012
Too often, we settle on Mr. or Ms. Right Now when it comes to hiring nurses. This is especially of the Director of Nursing position because we are compelled to have a DON who meets requirements and to notify CMS and most states if the position is vacant and it should never be vacant for any length of time.
Ideally, most agencies have an RN already groomed for the position in their team leader positions. For these agencies, the burden then goes to hiring the right team leaders or whatever title your agency calls these alternate RN’s in the office.
Sadly, experience only goes so far in home health. It all depends on where the employee candidate was employed in the past. My suggestion is that when you hire any Registered Nurse for the office, you hire them with the awareness that they may be your director one day. After you determine that they meet al the paper qualifications, call them back in for a more in depth interview and ask some hard questions.
- What do you feel the biggest challenge to field nurses is at this time?
- If I told you that our average case mix weight I less than 1.0, what would concern you?
- If the average case mix weight was 1.9, would you be concerned?
- Describe your idea of quality management? What tasks do you feel are most important?
- In your opinion, which is more important? Getting paperwork in on time or getting it correct?
- Several nurses have threatened to quit because they believe they are not paid as much as your competitor pays their nurses. What do you do?
- Your patient has diabetes and arthritis. Which is the best code to use?
- What are three reasons that you might get in touch with the administrator over the weekend?
- Describe your computer skills. Do you use the computer only for work? Do you enjoy social websites? Do you use the computer a lot at home?
- What do you think a good average number of visits per episode should be?
There are no right or wrong answers and if a candidate is unfamiliar with the area discussed, it should not automatically disqualify them. If you are a legitimate agency, the response to number 7 is that the best code for the patient is the one that describes the patient’s condition. Number 8 will give you an idea of how comfortable the nurses is in taking responsibility.
The most important thing when hiring a nurse isn’t that she know all the answers. The important thing is that you are fully aware of where her shortcomings are and that the candidate is willing to learn. These questions will also give you an idea of the character and business sense of the potential candidate.
Agencies who use this level of scrutiny when filling all RN positions in the office are generally able to transition a current nurse into the DON position in the event of an sudden event. This has happened to my clients numerous times over the years. Losing a DON suddenly due to an accident or an abrupt termination is painful but it doesn’t have to be devastating if you have someone ready to assume the position.
It is so very difficult to work short handed. It is even more difficult to work when one or more of your RN’s is not able to perform. That’s when both clinical and financial health take a huge hit. Take the time to hire the right people. Trust me.
ADR Checklist
March 22, 2012
Prissy the Pit Bull available at no charge to review your records. We guarantee they will not be denied for lack of signature. We do not guarantee they will be paid.
Make no mistake that what I am about to say is shameless self promotion. The safest way to ensure that any medical records requested by a payor source meet standards are to have them reviewed by someone with experience and who does not know the patients or the agency. This doesn’t always ensure payment but it can alert you to your vulnerabilities so that you can make a plan before the next dance with your MAC.
Short of the the level of security offered by Haydel Consulting Services, you can do your own reviews. More important than the actual content of the review is the attitude of the person doing the review. Attacking the charts like a rabid Pit Bull will ensure that most errors are identified but Pit Bulls do not implement action plans. Your reviewer needs to be cognizant of the fact that any errors or omissions identified are tools to help cover their coworkers back and they need to be willing to help out their colleagues. If they can be ethically corrected, they should be. If they cannot, a team with members from every part of the organization needs to implement a plan to prevent repeat errors.
Here is what I look for:
- Orders signed and dated by physician.
- Face to face in all charts.
- Medications
- Diagnoses – note meds came first. Are there any meds for dx’s not listed.
- Frequency – does it correspond to the patients’ needs?
- Functional status – if the patient is minimally impaired in the functional domain, are they homebound for psychiatric reasons?
- Is teaching original and relevant?
- If re-teaching is present, is the reason why re-teaching was necessary explained?
- Does teaching require the skills of a nurse? It does not require the skills of a licensed nurse to tell a patient to take medications timely.
- ARE THERE ORDERS FOR THERAPY?
- Are therapy re-evals done on schedule?
- Is there any lab or other diagnostic tests that support care for the patient even if they were performed in a prior episode?
- If subcutaneous injections are given, is there a reason why the patient cannot be taught?
- Is there a documented predictable end to daily skilled visits when daily nursing visits exceed 21 days?
- If the patient is seen for Management and Evaluation, is an RN performing the visit?
- If Observation and Assessment is documented as a skill, are there any clear indications that the patient is likely to become unstable?
- Are patient and clinician signatures consistent throughout the record?
- Are there any hospital or MD reports that will support services?
- Does the clinical note contents support OASIS?
- Is the primary diagnosis the focus of care?
Notice again that two questions that are critical to payment are asked last. It is only after reading the entire episode that you can truly answer these questions.
There are so many other important elements in a chart that are required in order to reflect good clinical care. This is a payment review only. So, if the patient had 12 nursing visits scheduled and two were missed, that will not affect payment but I want to go on record as saying that it is unacceptable to find out about two missed visits on ADR review.
If you find egregious mistakes that cannot be ethically corrected, back out the claim. For instance, if there were no therapy orders after the initial order to evaluate and treat, back out the claim and resubmit it less the therapy. Print all paperwork and send it with the ADR. This will not prevent a denial but you won’t look stupid either. After that, find the therapist culprit and violate your work place violence policy.
I am very interested in knowing who is getting denied for what. Please email me privately if you have the goods.
And if you are not pleased with what you are finding, do not hesitate to call us.
A Slap in the Face
February 26, 2012
So last week I was reviewing clinical records at the office of one of my favorite clients. A patient had been admitted six months after having half of her foot removed. She had not walked since the surgery and was confined to the bed and the chair.
The first thing I noticed was that the description of the surgical wound sounded as though it were partially granulated instead of fully granulated. Six months is a long time but remember, amputations are not cosmetic surgery. It would not be unheard of to have a wound slow to heal in someone with circulation impaired to the extent that part of a foot needed to be removed.
I also questioned the diagnosis sequence and a couple of the OASIS questions in the functional domain.
Med orders on the 485 indicated that the patient was on both Dilaudid an Lortab but the chart only mentioned Lortab as being used for pain. My most humble opinion is that if pain is being managed with Lortab, the Dilaudid should come off the orders – especially after the first episode. The reason I feel this way is because if the patient had a sudden need for stronger pain relief, she may have other needs than Dilaudid that should be addressed immediately.
She had both therapy and nursing ordered. The nurse was quick to realize that the new orthopedic ‘boot’ designed to help her walk was causing the surgical wound to become red and irritated. Both the nurse and the therapist addressed this with the MD and the people who made the boot. I certainly cannot complain about that. But, after the boot was refitted properly, the nurse stayed in the home weekly even though therapists should be able to assess wounds.
In summary, I saw was that OASIS scoring left the agency with less payment than they were ethically entitled to for a very expensive patient and services being provided that may not have been required. And of course, there was the regulatory issue with duplicate pain meds.
While I was busy finding fault left and right, the most important thing almost escaped my attention.
After two episodes the patient who had part of their foot removed and had not walked in six months prior to admission was ambulating with a walker. The last nursing note state that the patient was in the kitchen upon arrival making coffee and using her assist device.
I am still not happy with the chart. My slap in the face comes from the fact that sometimes we forget that documentation is second to our real mission of providing care in the home. It is a very close second but failure to acknowledge what these incredible nurses and therapists did for the patient is the kind of attitude that deserves a slap in the face. If those of us who review charts on a regular basis cannot read between the lines and respect the care given to patients, we have no right to expect respect from field clinicians when we tell them all the things they did wrong.
Having said that, I have seen like a billion ADR’s and ZPIC denial letters but I have never seen one like the following. Please forward to me if you have.
Dear Administrator:
After careful review, our Medical Review department has determined that the cases mix weight determined by your OASIS data is in error. Specifically, a surgical wound and the functional domain were underscored resulting in a lower payment for this patient. In light of these egregious errors, Palmetto GBA (ZONE contractor or MAC of your choice) is adjusting your claim to reflect the correct diagnosis, surgical wound and functional status of your patient. This will affect the overall denial rate on your current edit.
As a provider, you have certain rights to appeal. Please see attachments on how to appeal a Medicare decision regarding payment.
Sincerely,
(Insert the name of your MAC or Zone Contractor)
PS please advise your nurse to take Dilaudid off the current med list and ask the patient to place it in a Ziplock bag with a large note that tells the patient to please call the nurse immediately should it be required in the future.
Driving Me Nuts!
February 20, 2012
So, people call me. They email me. I get the occasional comment on my blog. These are the ‘little things’ that make me useful to the home health community. I am aware of what is going on at the front lines of our industry. Usually, I can answer questions. Sometimes, I take a while and look things up. But sometimes, I get stumped. that’s when I turn to y’all.
In the past several weeks, I have had calls about two patients. Both are men. Both have been referred to clients. The question is the same for both of them. Do they meet the homebound status requirement?
Patient 1:
This is a man who drives a car. Not every day but at least weekly. It is a smaller economy car that gets ideal gas mileage. I sincerely hope that if this were all that you knew about the patient that you would declare him ineligible for services in a heart beat.
However, this gentleman weighs 400 pounds. He cannot get in the car by himself; nor can he get out of the car by himself. He just likes to drive and sit by the lake while his wife works. If he had to, he could drive up to the ER but then someone would have to come and get him out of the car. Fast food is available as are banks and dry cleaners who offer in car service. He cannot buy gas unless someone else pumps it for him, go to the MD’s office or outpatient therapy. In fact, he was at outpatient therapy for a while. His wife would get him in the car somehow and the therapy employees would get him out. At some point, it was deemed to dangerous for them to do that in the black asphalt parking lot.
I have a lot of issues with this patient besides homebound status. Blood clots seem a very real possibility. It is rumored that he pees in a jar. I am having a hard time imagining that he can do this without some spillage. So, now I have immobility, acidic urine and obesity threatening this patient. I get all that.
But, is he homebound?
Patient 2:
This patient has dementia with episodes of moderate confusion. Like the patient above they drive. They are not supposed to drive. Everyone knows that this is dangerous to the patient and to the community but no one has taken his keys away from him, yet.
Again, I have real issues with this. If the family is okay with him risking his life, that is up to them. I am not okay with his risking someone else’s life because they don’t want to take away the car keys. But it isn’t my feelings that we are assessing here.
I suggested that they approach the MD to get a medical restriction on his license and let him be the bad guy. But what should happen is again, not the question.
Is this patient homebound?
What do you think? Email me or comment below. I will share my thoughts after I hear some of yours.
Patient Recruitment
February 12, 2012
Today, in Baton Rouge, someone was sentenced to prison for recruiting patients. While goofing off on the internet, I came across this story by Investigative Reporter Terri Langston published in the Houston Chronicle. Click on the image to read the full text which involves over 100M dollars in fraud and again, patient recruitment.
Now, color me clueless, but I really do not understand the difference between recruitment and marketing in the context that normal people use the terms in daily life. If you look up ‘patient recruitment’ you find tons of articles on how to recruit patients………. for clinical trials.
The dictionary defines recruit as, ‘to seek to enroll’ as students. This does not seem worthy of jail time either. Solicitation doesn’t seem all that horrible either. When I write a post and tell you to please call if you need help, wouldn’t that be soliciting your business?
So who better to consult than a health care lawyer.
Christopher Johnston has the distinction of knowing more people who have been or will go to jail than anyone else I know. (It is relevant that I have a very good friend on the SWAT team.) This is because he is one of the best lawyers for keeping healthcare providers out of jail or reducing their sentences. He also has to work with what he gets from clients and sometimes, well…… a couple of years is better than twenty. Chris’s success rate for clients who call him before they are in trouble is stellar.
He has a list of commandments to follow should you want to stay clear of any accusations of inappropriate marketing. Read them and share with your marketers. Chris is not a cheap lawyer and I am giving away his advice for free. Take it and run with it. Or don’t. Just remember that in this period of intense scrutiny, a reduction in your sentence may be the best anyone can do for you after you get caught.
- Do not bribe, harass, coerce, or intimidate any patient into selecting or changing agencies. (Julianne’s note: In reading Animal Husbandry Weekly, I gather it is okay to sell cattle per head. In reading the HEAT Task Force News page, I gather it is NOT okay to sell or buy referrals per head.)
- Do not allow any of your employees to bribe, harass, coerce or intimidate any patient into selecting or changing and agency. (Julianne’s note: What do you think a marketer will tell the investigators when they are caught? Do you think they will say their employer knew nothing about it or will they throw you under the bus?)
- Do not falsely advertise about any services, awards or credentials or anything that may mislead the public. (Julianne’s note: A nurse without a license is not a nurse for the purposes of home health. If you advertise nursing care, please send licensed nurses only.)
- You may certainly respond to inquiries about home health but DO NOT initiate the conversation. (Julianne’s admission of guilt: I might have to go to jail if I heard of someone who really needed home health but I would NOT – and do not – recommend specific agencies.)
- Do recommend that the patient contact his or her physician but do not recommend a physician to the patient. Under NO circumstances should you ever bring a patient to the physician or the physician to the patient’s home. (Julianne’s note: If you do not believe this happens, talk to your folks at MD offices. The waiting rooms are filled with aides bringing patients to MD offices.)
- Do not go into people’s homes or call them on the phone to tell them about the availability of home health. (Julianne’s note: We did not need a lawyer to tell us this, I hope and yet, I know of instances where it has happened.)
- Do not conduct marketing inservices in people’s homes. Stick to the physician’s office.
- Never, ever offer anything of value to anyone in an effort to select your agency or refer to your agency. (Julianne’s note: See the way Chris used both of the words, ‘never’ and ‘ever’ in his advice. I know from experience this means he is deadly serious about giving people cool stuff in return for being your patient or referring to your agency.)
Specifically excluded from these guidelines is community education. If you think about it, when providing support groups and speakers for community functions, you are generally not interacting with people who would meet the home health requirements for homebound status so there are no ‘patients’ involved.
The truth of the matter is that every time an agency gets closed down or someone goes to jail, it reduces my pool of potential clients. And remember, it is all about me.
And it is about you. My experience is that nurses who violate these guidelines typically are unaware that they exist. I am not completely innocent here. I have paid for drugs on occasion and also food. (Attention: if you are a federal agent or work for a contractor who has the authority to arrest fraudulent nurses, I haven’t been in the field since the 90’s. Surely there is a statute of limitations. If not, can I write my blog from prison?)
We can’t do this anymore. We absolutely must put safeguards in place to protect us from having to tell a client we are so sorry they have no meds or food but can’t anything about it. Because nurses are not wired to do that and we will end up in trouble if we don’t act preemptively. This means hooking up with your local food banks and indigent pharmacies and getting to know how they work before you need them. And when you have a few dollars to give away, donate them to the pharmacy or food bank.
And if you don’t have a formal compliance plan, contact me. If you have unwittingly participated in any of the above, contact Chris. We can help you. There I go again – soliciting business. It actually works. Sorry you can’t participate.
