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Spelling Lesson

I received a request posted as a comment on a post written a while back called, ‘Documentation, Again!’  It reads as follows:

I wish you would follow up on this blog as it is connected to the number of visits that nurses are required to do on a daily basis. The “p” word – productivity is the game, as nurses will work off the clock to try not sink in case management and oasis issues. Somewhere in the world a daily productivity of 5.3 patients came around. However with the growth of paperwork and regulations, many nurses who are fighting to be there for their families in the evenings, work on paperwork out of fear. Home Health turnover is high because of this continued lie. You can’t tell nurses that they can completely finish 2 IAs and a visit, fully coding and doing 485 and 486 within 8 hours every time. I had a director who said that to do an IA you should stay in the home about 30 to 45 minutes then finish the paperwork later. Hum, check meds and do an assessment and ask oasis questions and go over plan of care in 45 minutes. How do we turn this lie around, without going to Labor Boards, etc. I believe that sometimes doing less turns out to be more money in the bank, if you focus on getting quality and consistency first, and building from there.

I am nothing if not accommodating, so please allow me to address this writers concerns directly.

Most people think that hell is spelled, H-E-L-L.  It is not.  Hell is spelled, Z-P-I-C.  However, if you are lucky enough to avoid a ZPIC, rest assured in the knowledge that more audits are coming our way.  The description sounds a lot like FMR pre-payment audits.  Don’t forget about the new Medicaid RAC’s.  Any way you look at it, you are likely to be scrutinized in the coming year or so by one or more payor sources who want their money back.

Two admits and a regular visit can be done but not every day. I couldn’t do it.  I am not that good and have no desire to be.

As far as charting after you leave the home, that’s not really such a good idea.  I think pretty much every nurse has been in McDonald’s or Starbucks charting when they realize they did not assess something.  Maybe they started but then the office called to see if they could do another admit and they got distracted.  A forgotten TUG score or temp are not really numbers you can just guestimate.  Well, you can but documenting your guesses is really crossing the line.

The flip side of not being a slave to an arbitrary number is that productivity often drops when nurses are paid salary.  It makes perfect sense on paper to have nurses on salary and ask them to maintain average and reasonable productivity standards but it just NEVER has worked.

I was in a client’s office about two and a half years ago reviewing clinical records when the Administrator, new to home health, asked me to look at productivity.  She wasn’t sure but she thought that maybe the RN’s should be able to do more than one or two visits a day.  I went about my business because obviously this home health newbie had her numbers confused.  Before I left, I asked to look at logged visits.  My next thought was that the person doing the logging was incredibly inept at clicking the mouse.  Productivity was so absurdly low that I didn’t believe it until I started asking the nurses.

Long story short, she went to pay per visit but didn’t want to cut their pay so she paid them more per visit than I have ever seen any nurse get paid per visit.  Sounds like a nut, doesn’t she?

If you think that, you would be wrongo.  Her agency, rural, had a greater margin than almost all of my other clients.  Her nurses suit up and show up and there is virtually no turn around unless someone is asked to leave.  Case conferences are attended.  Orders are written.  Follow up is a way of life at that agency.  Documentation is so good it bores me to tears and they are my only client who received a deficiency free survey this year.  If they are chosen for any other audit, I will not lose a minute’s sleep over it.

So my first thought is whether or not the 5.3’ers are salaried or pay per visit.  If they are paid per visit, are they making enough so that they can take care of their patients during working hours and be home with their families at a reasonable hour most nights?

I wonder how much those people who push for admissions to be submitted to the office within 8 hours are really losing.  Do they know what is in the clinical records?  Do they realize that unless nurses are blatantly committing fraud, the aggregate of errors is just about always in favor of Medicare?  Those agencies who are brag about 3 and 4 days from admit to RAP are flirting with regulatory and fiancial disaster. Speed and accuracy rarely go hand in hand.  The only time a nurse should not take a minute to reflect on her decision is when a patient isn’t breathing and they are turning blue.  Even then………..  you got four minutes to consider the most likely cause.

But you asked me specific questions.  First of all, I do not know where the 5.3 number comes from.  I do remember CMS publishing something like that many, many years ago but it wouldn’t be accurate now.  The next question is how to turn the lie around without a bunch of commotion, etc.  I can help you there.

  1. Get all the information you can about the agency as a whole.  This is not about you or the administrator/DON.  It is about whether or not patient safety is protected at such a fast pace. Information that is relevant:
    1. Hospitalizations as reported on CMS along side your three biggest competitors.
    2. Average HHRG’s or payment if you can get it
    3. Other outcomes are not as useful but run them anyway.  Choose your three biggest competitors and run the reports from
    4. Number of call outs in the past 6 months from HR
    5. Do some research.  This problem wasn’t created overnight and it will not be solved overnight.  Two more weeks will not make a difference.  Once a day, look at 10 charts for one specific thing.  It will be real easy if you use point of care.  Suggestions:
      1. Home Health Aide supervisory visits
      2. Weights recorded and reported as indicated
      3. Physician notification of out of range parameters
      4. Lab drawn timely and reported.  If orders were issued as a result of the lab, are those documented and who was notified of them?  (Check your Coumadin patients.)
      5. Are diabetics taught foot care every episode and is it done per ordered?
      6. Is pain noted on the visit sheet and if so, what was done about it?
      7. I am willing to bet you ten thousand dollars that if you grab 10 485’s and look at all the medications, you will find issues.  Put them in the free Medscape interaction checker online or use iPhone/iPad app.  Look only at the most critical ones listed first.

When you bring these numbers to the administrator, present them in a way that is impersonal and spread throughout the entire body of nurses.  A lot of people want to know who did that, etc. with the goal being to fire the offender.  When it is a little bit of everyone, it is more likely a systems or process problem.   Explain why each area of compliance poses a threat to the agency.

Weights, lab and MD notification of out of range parameters are all deficiencies.  Weights are tied to Congestive Heart Failure and that is the only diagnosis that has been shown to have an influence on home health hospitalizations.  I hold Coumadin in the same esteem as I do Oxycontin bought off the street.  It is dangerous and a malpractice lawyer’s dream. If the agency is not performing in these areas they are at risk for so many things, it would require the whole internet to put together a complete list.

Payment per episode should be close to $2,200.00 if you have a modest amount of therapy.  It should be higher if a high percentage of your patients have therapy.  If it is lower, one of two things is affecting it.  The first is that the majority of your patients are old.  I guess technically they are all mostly old but I am referring to length of time on service with the agency.  The second reason may be because the nurses are underscoring in the OASIS dataset and time and education is required to do a complete and accurate assessment.

Now, if your administrator says that they are making a whole lot more than the average or if they say they will go ahead and write the supervisory visits or if they mistakenly believe that they are too large or too small to ever be of a concern to the feds, you need to take a hike.  It is Christmas.  Spend some time with your family.  Do some baking.  Start the New Year out in a new job.  Can’t afford it?  You can afford it more than you can afford to stay at an agency that cares more about arbitrary numbers than patient care.  Trust me.  I deal with this sort of stuff for a living.

Or have your administrator call me for an unbiased agency assessment by myself or a coworker.  As a consultant, I have the freedom to walk away and not have to worry about a job.

12 Comments Post a comment
  1. Mike #

    Good stuff…. couldn’t agree more.. keep it coming.

    December 5, 2011
  2. Dwelia Boyce #

    It has not failed yet, every time I read something from you,it seems to be EXACTLY what going on in the agency i work for. I plan to read this again because the quality of the work from the skilled professional here leave alot to be desired. For some strange reason after reading this I feel better because I can now realize that I am not the only person pulling my hair out at times because the IA arn’t comprehensive enough for a person to see the whole picture and code correctly. From referral source to SN,PT they are not assessing the patient properly and alot is being missed which means dollars. A zpic audit for us would mean Zero Pay for Incomplete Characterization of a patient

    December 6, 2011

    • A good nurse who knows assessment skills is worth a lot to a good agency. When one comes along, I encourage my clients to make a position for them. On the other hand, it is a little difficult getting a job if your prior agency went under due to regulatory concerns. If your management does not respect clinicians, you need to change management. Sometimes that means changing jobs.

      December 6, 2011
  3. Ronda #

    Our agency has gone to a 2 visit open, works well for front loading and has helped the clinicians have the time to collect all the information they need to do a thorough assessment. This also is helpful because of the time restraints in answering some of the oasis questions, “one calendar day” etc. We do not push productivity so much as monitor it. A visit is a visit, no extra productivity points are given for IA or mileage

    December 7, 2011
    • cristie miller #

      How do you document and charge for your visits for a 2visit assessment? Do you do 2 visit notes? Are you able to bill 2 charges?

      December 7, 2011
  4. cristie miller #

    5-6 in an 8hr day is standard in my area. A new open, resume, recert =2, revisits=1 and discharges =1.5 every day 5 days a week – covering a geographic area of two counties. Not easy. It is a challenge not to short cut patient care and also continue excellent and complete charting. Overtime will get you “called in” to the managers office. So there is plenty of charting “off the clock” I feel the nurses frustration in the original blog post. There is a lot of pressure about productivity, keeping the agency afloat otherwise there is not job. This is the home health climate currently at least here in central CA.
    ps.. from our ADR’s last year out of 120 reviewed only 7 were denied – those were for lack of supporting documentation. RAC’s haven’t hit us yet.

    December 7, 2011

    • Seven out of 120 denied? Why so many? Just kidding. I suspect the RACs and ZPICs will not bother with you if your other numbers are where they need to be such as length of stay and none of your physicians are currently guests of the Federal Government.

      The middle is where I continuously find myself. Productivity monitoring is critical to the future of an agency especially if the nurses are paid salary. On the other hand, numbers should be used as a tool. We should be looking at averages over time instead of daily production. One admit for a bad patient can take four hours. Another admission may take one. The answer isn’t to hold everyone to the fire literally but to ask for explanations for the variances. When too many reasonable explanations are given for variances, then it is time to revisit the way the agency does things or take a second look at the numbers.

      One problem I see is not taking into account the invariable unscheduled PRN visits, post hospitals and admissions. What is scheduled for a nurse at the beginning of the week is seldom what is done by the end of the week.

      I love having gauges to measure against. Benchmarks give us a point of reference. It is when numbers start dictating decisions without any reference to other considerations that problems occur. Pretty graphs, reliable benchmarks and so called ‘industry standards’ do no substitute for critical thinking performed by a intelligent nurse.

      December 10, 2011
  5. Sherry C. Falls #

    Here is what is happening at our agency. We reassigned 4 supervisors to Oasis auditors. Reviewing oasis is all they do. They then tried to put a 24 hour window on getting corrections done, or you get reported to other supervisors, who may call you into an office. We needed to drop bills quicker, as we were above the national average. Well, they had to relax that when nurses quit. They quit because at the same time they said if we dropped a visit and went down to 5 visits, we had to try and pull another visit in. I had 7 regular visits today but had oasis corrections to do as well.It has not been good enough to average 5.3 for the week. In order to hire more we had to show that we saw more on a daily basis. They tell us it is against the law to work off the clock on case management issues, but somehow the productivity word comes back into play. We have 2 superivisors that track everyday your mileage and number of visits that you do now, and check to see if documents are closed and corrections are done. Oh! they also email you about getting discharges done quickly, some of which you may not have done a visit for and that the MD just discharged them, or the patient calls and says no more services needed. They ask us not to come to the office as the socialization can cut down on productive time. We are to text people and supervisors. We use to set aside a couple hours during the day at Christmas, for a small party. But we would see more patients on the prior days to make up for it. No more. We are a Magna facility, so they want us to do research but not pay for it really. We are to share it I guess by email, handouts, and posters. Our oasis document has this intervention sheet which duplicates the addendum, but the clinic bought it, so we have to do both. They are starting to train nurses from the start on how to do IAs. We use to let the new nurses get comfortable with case management and notes for 6 months.We are all paid hourly. We have had incredible turnover since they instituted all these changes in a year. I continue to believe that if you have 3 or 4 IA nurses that specialize in oasis and working with the oasis auditors, you will relieve stress on the other staff and get better outcomes. I also believe that in the perfect world a case manager that has 5 visits half of the time can case manage patients better and get the patients out quicker. Adn there will be no overtime. I have had patients that were seen by 8 or 9 nurses because we would not turn down referrals and called flex time people in to cover. I would just love any feedback.

    December 7, 2011

    • Wow! Are you otherwise unemployable?

      You didn’t state averages but there are some grave concerns with what you are reporting. The first is the 24 hour window on getting corrections done. It may not be possible without compromising something else.

      The case managers see five patients a day? That is not a case manager. That is a field nurse. Who sits in the office and holds case conferences with the field nurses? Who coordinates therapy? Who ensures that all labs are received and forwarded to the MD? Who takes verbal orders about your patients? I usually recommend one in office case manager for 50 – 75 patients who does all of that and allows the field nurses to focus on patients. In the best agencies nurses come in and sit down with there case managers when work is handed in so a review can occur concurrently.

      The next concern I have is how much money the agency is wasting on four OASIS auditors. If the work was done right and electronically monitored for discrepancies, it shouldn’t require any. In the above case management system, the case managers review OASIS’s as they come in together with the nurse who performed the assessment.

      But the agency obviously needs a ton of auditors to tell you what you are doing wrong because there is no provision for quality assurance or education in this scenario.

      I have heard that there are labor laws about LPN’s working off the clock to do paperwork but each state is different and I am far from a labor attorney so I cannot speak to the legalities of the scheduling.

      So, you have someone tracking visits and mileage? They don’t let you come into the office because, heaven forbid, you may socialize and disrupt productivity?

      I fully appreciate that you are frustrated and that I am only hearing one side of the story but no matter how you spin these facts, there are serious operational and clinical problems with the agency.

      1. Communication. I am a firm believer in emails and texts as a way to reduce distractions and to put documentation into a format that can be used as reminders. I love that. However, writing, especially texting, does not now nor will it ever take the place of face to face communication. Furthermore, texting scares me because of the security issues. If I lost my phone you could read my texts. My email is more secure but still……

      2. 5.3 visits a day seems to be an arbitrary number chosen based upon the results of a study. If you are seeing five or six patients in a single assisted living facility, you can have it done by one or two o’clock, tidy up your documentation and do corrections and be home for five. If you have to drive long distances or spend a lot of time in traffic, you will never make dinner on time.

      3. As managers, it is utterly ridiculous to discourage staff from going to the office. I really do get the distraction thing but how else do you get to know your employees, set standards and examples and grow a company if the people who are bringing in the revenue are not made to feel welcome at the company? Most times I hear complaints because nurses do not go into the office enough. I go onsite at agencies a lot. Yes, I socialize and the nurses socialize with each other. But, as adults we all get back to work after a few minutes. This so called ‘socialization’ is also the vehicle for a lot of unwritten communication about patients. I have heard about who refuses to answer the door without removing their curlers, who has a grandson they are suspicious of and which is the best Taco Bell. This is important. All of it. It builds a sense of community.

      4. If they used experienced nurses to do admissions, maybe they wouldn’t need 4 full time reviewers? That’s close to 300k (probably more in CA) to fix errors that people who couldn’t expect to know better made. It also leads me to question the integrity of the data since the ones fixing it are emailing and texting instead of discussing it with their case managers. Oh wait. The case managers are out seeing patients.

      5. No Christmas gathering? Really?

      6. They want you to do research? I seriously question the quality of any research that comes out of your facility.

      So, without knowing your position within the agency, my first round of advice would be:

      Pay per visit. Full time benefits if average of 25 visits a week are made.
      Pay a high enough rate per visit to include inservice and case conference time. If this is not done, the agency will fail. I promise.
      Teach the field nurses about OASIS and PPS.
      In addition to productivity standards, implement a program to monitor the integrity of the agency operations (QA).
      Add self paced learning activities to the standards that are being monitored.
      Hire real case managers.
      Have the managers call me. I guarantee you that I can show them how to make more money while treating their employees fairly AND reducing regulatory risk.

      It sounds to me as though the people making the decisions do not know their industry very well and using valuable resources poorly. I hope this is due to lack of knowledge. The alternative is that they simply have no respect for nurses. In that case, may I recommend that you complete a few job applications elsewhere? Oh wait. You don’t have time for that.

      Privately email the name of the agency to me. I wanna look them up.

      December 10, 2011
  6. Ronda #

    You have 5 days to collect your oasis data. The first day most of the data is collected such as meds etc consents signed, the initial assessment is completed along with certain elements of the comprehensive assessment the next day we do what we call the oasis visit, we complete the oasis on this visit along with a much smaller routine assessment. As long as there is a skilled need both visits are billable. You would be surprised how much you learn on this second visit and are able to score them more accurately.

    December 8, 2011

    • Your comment reminds me of a dear priest I took care of years ago in CCU. He was pleasant and indicated understanding of everything i said to him and I had him sign consents for surgery and off he went. Being a retired priest from out of town, there was no family. He comes back from surgery is able to follow commands and does well for the first day or two. He continues to progress but he keeps asking the same questions repeatedly as though he can’t remember anything. I called the surgeon reported it and got an order for a neurologist. Isn’t it lucky that the neurologist who was on call that weekend was the patients very own neurologist who had been seeing the patient for years related to his Alzheimer’s disease? So, yes. Your assessment will be more complete if it is divided into two visits.

      Many agencies do not allow for this split between two visits because it is already hard to get admits in the office timely. It only works when field staff are good about getting paperwork turned in early.

      December 10, 2011
  7. Sherry C. Falls #

    We do not have in office case managers, and that is our main problem. The nurses are considered the case manager and field nurse. You have to be responsible for case managing 25 to 35 people, and try to see about 6 people. Our IAs are 2.5 because the RN does the coding and the 485 and 486. Then the oasis auditors adjust it. My office did 197 admissions last month. We do not have Oasis/IA RNs.They are trying to train everyone to do it. But the problem becomes when you see 6 patients one day, then an IA and lets say a recert (1.5) and 2 patients the next day, then 6 patients, and try to take calls in between about case management, it gets very unbalanced. The problem seems to be with I think alot of agencies is that they don’t see case management as a bottom line number, It is alloted in the time allotted for each visit. HUGE problem. We have had a turn over of managment and we are pushing for having IA nurses, with other staff nurses to be able to perform IAs as needed but stay with straight visits. I am also recommending, as some of our oasis auditors agree, that some of them that were supervisors be pulled into the case management positions. Many of them are coding certified, and use to go over our IAs when they were supervisors. Not sure if they should not do the 485 and 486 as well – I know some other agencies do that.

    December 17, 2011

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