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.
- 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:
- Hospitalizations as reported on CMS along side your three biggest competitors.
- Average HHRG’s or payment if you can get it
- Other outcomes are not as useful but run them anyway. Choose your three biggest competitors and run the reports from Medicare.gov
- Number of call outs in the past 6 months from HR
- 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:
- Home Health Aide supervisory visits
- Weights recorded and reported as indicated
- Physician notification of out of range parameters
- 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.)
- Are diabetics taught foot care every episode and is it done per ordered?
- Is pain noted on the visit sheet and if so, what was done about it?
- 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.