The hidden damage of patient falls.
A good mystery is a delight but they should be reserved for leisure time reading. It should not be an element of Requests for Additional Information (ADRs) from Palmetto GBA or any other Medicare contractor. And yet, they are. Below are some examples that have come across my desk in recent months as the Targeted Probe and Educate (TPE) process marches forward. I admit that at times I am truly challenged.
There are two denial codes in particular that keep showing up and really, they could mean anything. The first is:
5F023 – No Plan of Care or Certification
Believe it not, there are some people who think this means that no plan of care or certification was included with the submission of documents. If it is found when the biller is checking claims status, he or she may simply fax over the plan of care thinking they are helping the agency get paid faster. There goes one round of appeals.
If they had taken the time to look up this reason for denial on Palmetto GBA’s website they may have found an explanation that confirmed their initial impression. It is prefaced by the following:
The services billed were not covered because the home health agency (HHA) did not have the plan of care (POC) established and approved by a physician, as required by Medicare, included in the medical records submitted for review and/or the service(s) billed were not covered because the documentation submitted did not include the physician’s signed certification or recertification.
So, when a letter arrives in the mail two days after the resubmission of the plan of care, agencies may be surprised to find out their claim was denied because the physician’s Face-to-Face encounter did not support homebound status in his clinic note. Maybe because it is not a requirement for their patients to be homebound so they don’t think about it.
You would think they would make a code just for homebound status so that the reason codes for denials would correspond with the reasons for denial. That’s what I would do.
To be fair, nobody is doubting homebound status. Rather, they are saying that the physician did not fully support homebound status.
Another claim denied for having no certification or plan of care was explained the same way. The Face-to-Face encounter documentation did not support homebound status. The physician documented that the beneficiary was having recurrent dizziness, continued incisional pain, low back pain and bilateral knee pain. The medication list included percocet, alprazolam and hydroxyzine. And yet, a reviewer at Palmetto does not understand how dizziness, knee pain, back pain and incisional pain might reduce the ability of a patient to leave the home and tolerate the outing with aplomb.
5FF2F – The physician certification was invalid because the required face‐to‐face encounter was missing/incomplete/untimely.
As an additional bonus, there is no shortage of claims denied for reason code 5FF2F – The physician certification was invalid because the required face‐to‐face encounter was missing/incomplete/untimely.
So which is it? Is the Face-to-Face missing or untimely or incomplete? Responding to a denial is not the time for guesswork.
On one appeal, Palmetto GBA asserted:
… The face to face encounter note indicated that the beneficiary required the use of a wheelchair, thus satisfying criterion one of the face to face requirements. However, criterion two was not met. There was no indication of a normal inability to leave the home or how leaving the home would require a considerable or taxing effort.
The physician wrote in the encounter documentation that the patient had a catheter, a prior CVA, dilated cardiomyopathy and he ordered a hospital bed and an alternating pressure mattress for the prevention of skin breakdown. An overnight pulse oximetry was ordered to determine if the patient qualified for supplemental oxygen. There was a previous stroke resulting in weakness and difficulty with speech. Could anyone (in their 90’s) have this combination of conditions and find it NOT taxing to leave home?
The physician does not follow the patient home and determine how the patient tolerated the outing. He or she doesn’t call the patient in the morning like the dentist who performed a root canal.
In all of the denial letters, the Medicare Benefit Policy Manual, Chapter 7, is referenced. Section 18.104.22.168 of that manual states:
The certifying physician and/or the acute/post-acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s:
Need for the skilled services; and
The key word here is ‘substantiate’. According to the Manual, the physician does not need to document specifically how the patient tolerated the outing from home. Rather, there must be sufficient information to substantiate that a patient can not leave home without a considerable or taxing effort.
Don’t get angry. I’m mad enough for us all and it isn’t healthy.
Call a consultant if you need help. (My number, 225-253-4876, is a good start.)
Meanwhile, I’m trying to figure out how they will handle Medical Review in PDGM. Could it be we get a break the way we did when PPS was first implemented?
Questions and comments are always welcome. Look for the comments section or email me at your convenience.
This is what happened…..
A nurse, Rodonda Vaught, filling a loosely defined role of ‘help-all nurse’ was asked by a Neuro Intensive Care Unit nurse to go to Radiology and give a patient Versed for anxiety prior to a PET scan.
She mistakenly took Vecuronium, otherwise known as Norcuron, instead of Versed, and gave an undetermined amount to the patient and then went about her next tasks which were in the Emergency Room. Norcuron and other drugs in its class are powerful paralytics used mostly as an adjunct to anesthesia and occasionally when a patient has life-threatening bronchospasms. It is similar to the ‘active’ ingredient in poison arrows used in the Amazon.
Approximately 30 minutes after the order was given, the patient was found to be without a pulse and not breathing. A code ensued and a heart rate was established and the patient, now being mechanically ventilated, was taken to the Neuro ICU.
After the patient was returned to the Neuro Intensive Care Unit, the nurse who made the error went to the patient’s room. The physician, a Nurse Practitioner and a couple of residents were all at the bedside. She explained her error and the team of doctors and residents were then able to understand what had happened to the patient.
The following day, the patient was extubated and died ten minutes later. Within a few more days, Vaught was terminated.
Surprisingly, all of this happened at the prestigious Vanderbilt University Medical Center Hospital.
Fast forward eleven months. State surveyors entered the hospital for a complaint survey. It seems unlikely that the state of Tennessee sat on this complaint for eleven months prior to the survey but who knows? The survey resulted in a scathing survey report that included an ‘Immediate Jeopardy’ tag. It included interviews with the nurse who made the error, the radiology personnel and multiple hospital executives. My notes are on the survey report attached to the link.
Shortly after the survey, Vaught was indicted for reckless homicide and patient neglect.
As noted, Vaught took full responsibility for her error when it happened. This is in stark contrast to the behavior of Vanderbilt’s leadership. This is a quote from the survey by Vaught (RN#1):
I was asked if it was documented he/she had administered the Vecuronium in Patient #1’s medical record. RN #1 stated, “I did not. I spoke with [Named Nurse Manager] and he/she told me the new system would capture it on the MAR [Medication Administration Record]. I asked and [the Nurse Manager] said it would show up in a special area in a different color.
In other words, they told her NOT to chart the error. I disagree with that advice. I would not use words like ‘error’ or ‘major catastrophe’ or even the acronym, ‘OMG’, but the med should have been charted.
She was then asked if she talked to anyone in the days following her medication error. Really? That was Vanderbilt’s focus. Who knows about this?
Vanderbilt had a policy and a list of high risk medications that included Vecuronium (Norcuron) which would have been relevant had the nurse knew that was what she had given. Even so, the policy did not have any procedures in place for monitoring after the administration of a high risk medication.
Vanderbilt overlooked numerous reporting responsibilities after terminating the nurse. Management seemed to mostly forget about the incident. The information reported to the coroner’s office was incorrect. No medication error was reported as required.
In fact, Ms. Vaught has a license that is current and free of disciplinary action. Nevermind that the Tennessee state board of nursing mandates reporting unsafe practice and unsafe practice conditions to recognized legal authorities and to the Board where appropriate. I would hope that a patient death met that standard.
When asked why the event was not reported, the Senior Quality and Patient Advisor and the Regulatory Officer could not provide an answer and deferred the question to Risk Management. The Senior Quality and Patient Advisor later reported back to the surveyors that Risk Management had provided the following response:
I talked to Risk Management about reporting to the state, and [he/she] stated we [Risk Management] follow the 2009 state rules on reporting and it includes abuse, any, exploitation, fire with disruption of service, strikes, external disasters, misappropriation and injury of a patient in a nursing home of unknown nature. [He/She] said for you to see the state regs,[regulations], page 31, 6d.
I had to read that several times to ensure that I understood it. Apparently, the Risk Manager couldn’t be bothered to meet with the surveyors and instead told them to read the regs. Those regulations can be found here.
The Director of Patient Safety told the surveyors: ‘In the end, there were so many things the nurse did – the 5 rights, basic nursing care’. The Director of Patient Safety had a very narrow scope of vision.
Nobody can argue that the nurse gravely and egregiously erred and as a result of her mistake, a patient died. But there is a flip side to this coin. Nurses who inadvertently harm patients are the second victim of medication errors. Please read the linked article. Apparently, many people are sympathetic to Ms. Vaught. A GoFundMe campaign to pay for her legal support has collected 43k in three days.
But, Ms. Vaught was not the only one who made a grave and egregious mistake. Vanderbilt came out of the gate with flawed judgment. If all of the factors contributing to this event were investigated instead of limiting the scope to pointing fingers, both nurses and patients would enjoy a safer environment. It’s not much in light of a patient death but it would be something.
Instead, Vanderbilt leadership failed to report the incident or implement a plan of corrections that included nursing education about high risk medications and use of the Automatic Medication dispenser. They did not reeducate the nurse who made the error. They seem to be okay with a nurse dispatching another RN who has no experience with a patient to give conscious sedation. Seriously, who thought a ‘help-all’ nurse was a good idea?
Vanderbilt Hospital has very low scores on Medicare reported outcomes. Is this because the Vanderbilt way of addressing problems is sweeping them under the rug? Or, did they choose to ignore the reporting requirements because they were aiming for Medicare Stars. Inquiring minds want to know.
Every nurse needs to be held accountable for their mistakes. It is painful but growth comes from pain. Being indicted on homicide charges? That’s too much. What do you think?
I know Elizabeth Holmes. Chances are you do, too.
I have never met her or spoken with her but I recognize her. I see some former clients in the pages of John Carreyrou’s, Bad Blood: Secrets and Lies in a Silicon Valley Startup. Holmes has the distinction of being the youngest female billionaire but fraud evens out the playing field. Right now she is worth about nothing and Theranos, her company, is but a memory.
Theranos was going to revolutionize the lab industry with a device that would run over a hundred lab tests with blood from a single fingerstick.
My first thought was who needs that much information?
It doesn’t matter who needed it because it never worked. In order to use the blood, the sample had to be diluted and that never turns out well when there are tiny variations in concentrations of very little blood causing major deviations in results.
Reading Carreyrou’s book was like reading a clinical record of a psych patient without authorization. Elizabeth Holmes had but a passing acquaintance with the truth and it’s anybody’s guess where her fantasies stopped and her lies began.
It helped that she was very well connected. Her board of directors could take down small countries before lunch just for fun. Henry Kissinger, George Schultz, Sam Nunn and more believed in her. George Schultz’s grandson, Tyler worked for Theranos for a period of time that ended with estrangement from his family and almost a half a million dollars in legal fees.
As far as employees went, she hired the best but nobody lasted. Problems brought to her attention about the product not working were met with the proverbial axe. Others had a life outside of work and that was clearly contrary to the company’s unwritten policy. They quit.
Can you imagine hiding your operations from CMS auditors?
When an employee on leave committed suicide, Theranos barely recognized the employee’s absence. When her idol, Steve Jobs, died, an Apple flag was flown at half mast outside of Theranos.
Anyone who has ever worked for a fraudulent agency will recognize Theranos. I am sure that every one of her former employees is embarrassed for having believed in her ‘vision’. All of them can see the lies in hindsight and are kicking themselves for not asking the hard questions earlier. There should be an address to send sympathy cards to former Theranos employees.
If you haven’t ever had close contact with a truly fraudulent employer, read Carreyrou’s book and maybe you never will. But don’t count on it.
“Life’s most persistent and urgent question is, “What are you doing for others?'”
Today is the celebration of Martin Luther King Jr.’s birthday. Some of us will go to work as usual and others will enjoy a three day weekend and the majority of us will remember Martin Luther King, Jr. as someone who shaped our nation and inspired us to be better people. I know that he was not perfect but that’s okay. What he stood for and taught was perfect. According to the internet, even Mother Teresa and Gandhi had flaws.
As healthcare workers, we can answer the question posed by King on a daily basis. What are we doing for others? We take care of sick people; elderly people; the most vulnerable individuals in society. We have noble professions. We save lives and help people die peacefully in their home surrounded by family and friends when the time comes. We are compassionate. The support staff that ensure that nurses continue to have the ability to take care of patients are equally as important. We have answers to Dr. King’s question.
But can we do more?
In the spirit of Martin Luther King’s devotion to equality for all, we need to recognize that Healthcare disparities are very real. I am not talking about genetic factors that predispose various races and ethnicities to certain conditions but rather how long it takes someone to receive help and what happens after they are diagnosed.
Black Americans are three times more likely to have a leg amputated related to diabetes than their non-hispanic white counterparts. Areas in the rural south are most vulnerable. I did not need a study to reveal that little secret. The study alluded to the fact that Black Americans are less likely to have their total cholesterol screened and seek treatment later. Another study revealed that they are often checked for diabetic retinopathy later. Still more surprises.
The American Cancer Society reveals that the cancer death rate among African American men is 27% higher compared to non-Hispanic white men. For African American Women, it is 11% higher than non-hispanic white women. This study didn’t allude to any underlying cause but I doubt it has to do with early diagnosis or prompt treatment.
Hispanics have higher rates of cervical, liver, and stomach cancers than non-Hispanic whites.
Non-hispanic whites have a much higher incidence of death from heroin overdoses.
The list goes on as most of you know.
Martin Luther King, Jr. also said, “If I cannot do great things, I can do small things in a great way.”
If you are unable to establish equality in healthcare for everyone, start with your patients. For some, that might mean writing a list of screenings to take to their MD so they can be ordered or results reported to the agency. It might mean arranging transportation for Medicaid patients because getting to the doctor is difficult for rural patients. You might include the family in teaching about exercise to improve circulation to the lower extremities and even encourage them to walk together (because you nailed diabetic foot care). Learn some of the ethnic foods eaten by your patients and help your patients determine a healthy way to prepare them. Be creative. Individualize your care plans.
Statistically, your patients don’t amount to a hill of beans and the changes you effect won’t alter the statistics but your patients are not statistics. Leading a patient and their family to the changes that will forever improve the quality of their lives is a small act of greatness.