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Posts from the ‘hospice’ Category

Feb 2

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Making Time

It’s lonely being a Director of Nursing – doubly so when the agency Administrator is not a nurse.

There are subtle differences between states on the responsibilities of the Director of Nursing but together with the Clinical Supervisor’s role outlined in the Conditions of Participation, it is clear that a DON is responsible for almost everything that happens in a 200-mile radius.  These responsibilities include but are NOT limited to:

  • Oversight of all clinical personnel and all clinical services
  • Making sure that all patients have care plans
  • Patient Assignments
  • Developing and overseeing clinical policies and procedures
  • Infection Control
  • Quality Assurance
  • Staff education
  • Compliance
  • Hiring staff
  • Ensuring that all admission procedures are followed

That’s a pretty daunting list so I hesitate to say it is incomplete but… it is.  Although the tasks can be delegated the responsibility belongs to the DON alone.  Going to a non-clinical administrator about infection control or required education for staff may be a fun way to spend an afternoon but the surveyors will look to the DON for answers.

Before you quit your job and punch yourself in the face for accepting the responsibilities of the DON position, relax.  It can be handled and is handled every day by nurses who are no more skilled than you.

Like most overwhelming jobs, the position of DON is easier when broken down into smaller pieces.  It is also easier if you identify all the impediments to doing your job well before you try to do it better.

Time Management

  • Open Door Policy – this sounds really good in company sound bites and recruiting campaigns but an open door policy can wreak havoc on your day. Instead, hold office hours like college professors do.  This doesn’t mean that nurses cannot interrupt your day for urgent matters but all non-urgent matters should be conducted during office hours.  During office hours, your visitors should have your full undivided attention.  If you want to make notes, wait until after they leave and write down your thoughts while still fresh in your head.
  • Meetings – Meetings are important but after a point, they become time-wasters. Eliminate all meetings that are not necessary and be prepared for necessary meetings.  Meetings should start on time.  Invite participants to arrive a few minutes early if they want to visit with coworkers.  Clinicians who are unprepared at case conference will be obvious.  Don’t rescue them.  After they flounder in front of their peers once or twice, they will be able to fully participate.  Or not.  If an adult cannot be responsible and prepared for meetings, maybe you should rethink their position in your company.
  • Delegation – most tasks of the DON can be delegated. Delegation consists of two parts – one is assigning the task and the other is the oft forgotten follow up.  Survey is a very bad time to find out that a nurse performing utilization review did not understand the process.   Send yourself an email to follow-up on an assignment you delegated.  Was a nurse tasked with collecting data for infection control?  Write it on your calendar to check in with the nurse in a month.  Look at the work done.  This takes a lot less time than trying to recreate data during a survey.   Taking the time to schedule QA, OASIS transmission, annual advisory board meetings and other infrequent but mandated events will reap an enormous return on investment.
  • Set aside some time each day when the phone does not ring in your office. Have the receptionist screen the calls and take messages.  Only take calls from patients who cannot be helped by their nurse, and referral sources.  When this policy was implemented at one agency, about half of all phone calls were handled before they got to the DON.

Hiring Process

 Learn how to interview potential candidates for a job. Listen to what they have to say.  Monster. com has a list of the 100 Most Asked Job Interview Questions. Consider asking candidates to teach you about falls precautions or injecting insulin as if you were a patient.  (Note:  do not ask about what kind of care they drive as suggested on Monster.  Ask what kind of car they dream about owning.  Avoid candidates who name a grey sedan.)

  • Schedule all interviews on the same day and set a mental timer to reduce the amount of time you spend on each interview.
  • In larger agencies, consider deferring the initial interview to a case manager who will be the direct supervisor of the new employee.
  • In all agencies, schedule a second interview that includes various people the candidate will work with on a daily basis. Your current staff is more likely to support a new employee if they endorsed the initial hire.

Staff Education

  • Get someone else to provide education to your staff. Call on drug reps to teach your staff about new and trendy drugs.    Get the wound care folks to teach about wounds.
  • Involve staff by assigning a five to ten-minute presentation on compliant documentation, a new drug or a condition not seen very often in your area to begin each case conference. (Note:  You can start to identify the next case managers or even your replacement by observing how well prepared they are and how comfortable they are talking to their peers.)

Perks of Managers

Setting up your work environment to allow for focus and completion of the tasks and follow-up on coworker’s projects will leave you feeling accomplished. Your stress level will automatically decrease as deadlines are no longer looming over you.  Your ability to trust your staff will improve when you follow-up up on their projects allowing you to appreciate the support you have.   Most importantly, you’ll get home in time for dinner with the fam.

Got any other ideas?  Post in comments!

Sep 21

7 Comments

Through the Eyes of a Nurse

 

hospice hands

What would you hold in your hands if you were asked to hold something that told the world all about you?

Elaine Zelker is a photographer who was working as a hospice nurse a couple of years ago and began to ask hospice patients and residents of long term care facilities that very question and photographed the responses.  I found one her photos on another website and immediately stopped everything to find out more about her.

The pictures are amazing.

I contacted her and asked if I could share on the blog and she graciously agreed.  She didn’t make it easy though.  Click here  and on the top you will see a link to her galleries.   As  you run your mouse over ‘galleries’, six options will appear.  The last one is ‘these hands….’.  Click it and sit back and be inspired.

After you have done that, come back here and tell us all, what would you hold in your hands that best described you.  Better yet, take a pic and email it.  I’ll post it.

Elaine is going to publish a book with this collection around the holiday season.  I will keep you posted on her progress.  I don’t know who would appreciate it more – a nurse working with the elderly or better yet, a non-nurse who doesn’t always understand a nurse’s devotion.

Kind of interesting that I just posted an entire blog about the work of someone I didn’t even know existed until a couple of hours ago.

NOTE:  I found the above photograph on another site.  I noted that Elaine’s photographs were protected and not downloadable which is a good thing for a professional photographer.  I was the one who put the tacky watermark smack in the middle of the photo.  Her website is free and clear of tackiness. 

May 26

2 Comments

Forgery and Narcotics

I read a story over the weekend where a hospice nurse had forged prescriptions for narcotics to a patient and picked them up at a pharmacy for her own use.  The patient was getting their medications from the hospice contracted pharmacy.  A quality assurance nurse saw the discrepancies and notified the pharmacy to verify they were filled.  The next time the nurse went to fill a forged script, the pharmacist refused to do so and the nurse was turned into the police by her employer.

The employer’s name was in the newspaper as was the nurse’s and I can just imagine all their referral sources saying, ‘Yeah, right.  Let’s refer to the hospice where the nurses forge prescriptions for their own personal use.’  I understand this attitude.  I would not refer to a hospice where the nurses were on drugs or forging physician names; much less both. 

The disconnect in thinking is that the hospice who turned their nurse into the police is probably the one least likely to have a recurrence of nurses diverting drugs through forgery or any other means.  It certainly would be an unattractive place for me to work if I had an appetite for narcotics.

It was incredibly courageous for the hospice to do this.  I do not know them and I have no idea how they arrived at calling the police instead of referring the nurse to treatment or the state board.  Make no mistake, in and of itself, forgery or altering a legal document is a crime.   I don’t think they had much of a choice other than to sweep it under the rug to avoid the bad publicity or to turn her in to the police.

We have seen what sweeping things under the rug can do.  The obvious example is the VA hospitals but who hasn’t seen numerous examples of companies or government agencies pretending everything is fine when it is not?  Nothing is seen until it is brought out into the light.

Heroic Efforts to Save Lives

The most important result of this action has nothing to do with compliance, or a company’s reputation or even narcotics.  We all know about the high prevalence of drug and alcohol use in nurses and we didn’t need another lost soul to illustrate it for us. 

Consider that the  nurse who found the problem and those involved in making this decision may very well have saved the life of the nurse.   Its not often that hospice providers engage in heroic efforts to save lives so it must have felt strange to them.  In my eyes, they are heroes in an industry where we need a few heroes.   Desperate people do desperate things and altering a legal document knowing the consequences is pretty desperate.  A nurse that desperate is not far removed from taking herself out of the game permanently.

So, because the company decided to do the right thing, a nurse has a whole lot to lose including her freedom.  Just remember;  dead people stand to lose nothing.  And that’s a fact.

My gratitude is with the QA nurse and her employer for setting the bar for the rest of us and my thoughts and prayers go out to the desperate nurse and her family so that they may find peace and freedom from disease. 

Apr 13

2 Comments

Compliance is Good Business

In my experience, the greatest barrier to compliance is that it costs money to be compliant.   Compliance plans are cheap compared to turning away referrals that competitors eat up like candy.  Discharging patients when you think you could maybe squeeze one more episode out of them is hard for some people to do.  Marketers working to develop a new referral source are horrified when an admitting nurse turns down a referral because she doesn’t believe they meet Medicare criteria.  There is no doubt about it.  Compliance costs money.

The real question in business is whether or not your investment will show a return.  We all know the businesses who spend far too much money, those that are conservative with their cash and some that are just plain cheap.  The cheap ones will never get it. If you are cheap, you can head on over to Ebay and buy some second hand computers and forget about the rest of this post.  Those that spend far too much money might have already found themselves in a position where their entire operation depends on making use of the gray area which is getting smaller by the minute.  The providers I am talking to are the ones in the middle.  It is hard to get a good provider who has no compliance problems to buy into implementing a compliance plan.  What’s the point?

Here’s the point.

Every day, you sell nursing care and therapy to physicians and other referral sources.  You charge the same amount as your competitor and you cannot offer any discounts, specials or coupons.  You even sell to the same ultimate buyer – Medicare.  You tell the referral source that your agency is the best in the market and that you are trying new and innovative things to keep patients out of the hospital.  You share a donut or a brownie, perhaps and ask about those Cubs even though you hate baseball because you know the referral source loves the Cubs.

Five minutes after you leave, in walks your competitor who says the exact same thing.

Nobody says, ‘Yeah, well we offer mediocre care but we’re no worse than anyone else.’  Even when it’s true nobody says, ‘we suck at what we do but we offer more cash under the table.’  If it really isn’t your day, the doc has a new flat screen delivered to his house or the discharge planner finds a few loose diamonds in the pocket of her scrub jacket after they talk with your competitor.

So, what’s the point of marketing compliance?

Read carefully.  This is important.

You Do Not Sell What You Do.  You Sell Who You Are. 

Is that clear?  The entire healthcare industry has been under what feels like an attack for the past three or so years.  People are running scared.  The FBI is out and about in a big way in the south.  Three physicians in New Orleans involved with a home health agency were raided a couple of weeks ago.  Regardless of the outcome of the FBI raid, no referral source will work with the agency or any of it’s owners/managers again.

Let the FBI be part of your marketing team since they seem to have no desire to go away.  They are not conducting training exercises and there will be casualties.   Work it!

When legitimate referral sources hear about their colleagues getting raided, it does not mean they will no longer have legitimate referrals for ethical home care agencies and hospices.   You need to be ready for their referrals because the providers who are known for their integrity and ethics will be the first ones called.  They are going to choose the one who never breaks the rules, can speak intelligently about the regulations and provide them with substantiated guidance assuring them that what you are asking them to sign meets all known rules and regulations.

Consider the referral you turn away because the patient doesn’t meet hospice guidelines.  Sure your competitor will take it but when you get the chance to explain why you made the decision, a message is delivered that your competitor was operating in reckless disregard of the regulations or maybe just stupidity.  There won’t be too many of those referrals in the future as more docs are having their lives turned upside down because of a relationship with a less than ethical provider.

A compliance plan has other benefits, too.  A soundly implemented compliance plan can distance you from any wrongdoing by a rogue employee.  In other words, if a new hire doesn’t make visits and hands in notes anyway, you can find yourself in a costly situation of returning money to Medicare or you can find yourself arrested.  The deciding factor will be if the employee was working in a culture where effort was made to verify the integrity of the work submitted vs a finding that a rogue employee was part of a culture of fraud.  Ignorance is not an excuse, y’all.  You have an obligation to look for compliance issues.

Compliance Plans

We regularly work with providers who want to establish a culture of compliance.  I find that if the FBI arrives before I do, the motivation is there to do the right thing.  If a compliance plan is just a binder in the corner that looks impressive and compliance training is given with a wink wink nod nod attitude, it is worse than useless.  It can cause more harm to the provider because a reasonable expectation that their employees know how to be compliant has been established and there were no internal audits to identify areas of non-compliance.

We don’t want to work with you if you think implementing compliance looks good in the likely event that you will have company soon.  On the other hand, if you believe like we do that compliance is good business, we can help you.  We feel so strongly about compliance that I’m willing to tell you that a half baked, ugly as home-made compliance plan implemented with full hearted commitment is better than the most expensive and complicated plan ever created that sits on a shelf.

You do not sell what you do.  You sell who you are.

Be the provider that referral sources trust and respect.

Feb 11

2 Comments

Personal Care Services

Who else do you know that has been assaulted by one personal care attendant and threatened (as recently as an hour ago) by another?  None of this had anything to do with work.  I could tell you stories for days but I want this uploaded to the internet soon in case I unexpectedly die.  I want you to read it so that you can look a little harder at the personal care attendants taking care of your patients.

Let me start by saying that some of the most wonderful caregivers in the world are PCA’s.  They have saved more lives than we’ll ever know simply by alleviating loneliness, keeping our elderly safe in the home and making sure they are properly nourished.  You couldn’t count the number of broken hips, bedsores, falls, infections and accidents they have prevented.  A personal care attendant can prevent nursing home placement which many elderly people fear and become part of the family.  The majority of PCA’s are give more than they take.

There are other personal care attendants and companies who are no more useful to society than your run of the mill crack whore.  Consider the following cases:

  • Numerous indictments have been obtained because personal care assistants continued to bill for patients who had moved out-of-state
  • Countless hours have been billed fraudulently.  Many times, the PCA’s do not meet minimum employment standards.
  • Others continued to bill when patients were in hospitals and nursing homes.
  • A PCA boyfriend billed for providing personal care to his girlfriend while she was in jail.  The girlfriend got mad and turned her boyfriend in when he would not use the fraudulently obtained Medicaid money for bail her out of jail.
  • According to an indictment which has not gone to court yet, a beneficiary got out of jail for a one day furlough to meet with his case worker at home so he could continue receiving Personal Care Services. Allegedly, he was approved for the services and then returned to jail while Medicaid continued to foot the bill.
  • A personal care attendant admitted to forging  a personal check in the amount $10,000.00 from her patient’s personal checking account.  She then deposited it into her mother’s account.  The check did not clear.  This is almost forgivable.  There must be a diagnosis that prevented her from understanding how bank checks worked.
  • A New York provider will be paying back over 2M because they billed for services not rendered and inflated hours on billing.

This paints a pretty bleak picture of the personal care industry.  Keep in mind that there are no OIG press releases about legitimate companies who provide excellent care.

What can you do?

  • If you are discharging your patient to PCS services after skilled care is no longer needed, try to overlap a week or so if your state allows it.  You can spend some time training the PCS on the proper way to care for your patient’s unique needs.
  • If your patient has personal care services established when you admit the patient, check up on them.  In the situations where I have been threatened it was because a friend who was afraid to talk to the aide was eager to talk to me.  Ask direct questions about the quality of care and the level of satisfaction.  Pay attention to both what the patient says and doesn’t say.
  • Ask to view the home folder.  Call the PCS company and speak with the RN responsible for creating and overseeing the plan of care for the home worker.  To coordinate care, there should be a copy of the most recent care plan in the home.
  • Review the home folder for accurate contact and grievance information.  Verify the phone numbers and the name of the owner/Director of Nursing.  Write the number in large print for your patient to see.
  • If you frequently find your patient alone, ask about the home worker’s hours and care plan.  Check the time sheets if they are kept in the home binder.

The OIG looks a lot at the dollars spent on fraudulent visits.  Medicaid costs for personal care services in 2011 totaled $12.7 billion, a thirty five percent increase since 2005. The U.S. Department of Labor projects that the employment of personal assistants and home health care workers will grow by 46 percent by 2018.

We should look more at the care given to our patients.  In most cases, people who are willing to commit fraud are not overly committed to the wellbeing of their patients.  There is no shortage of personal care attendants looking for work and some of them are very competent and dedicated to their patients.

If you’re thinking this is not your job, I beg to differ.  You have a responsibility to ensure that caregivers, paid or unpaid, are responsible and capable.  Remember you are a mandated reporter of abuse and neglect.  Coordination of care is a Condition of Participation for all Medicare Providers.  More importantly, it is one of the underlying principles of sound clinical practice.

The last threatening phone call I got was a little while ago.  If this ends up being the last post I write, it was good knowing you but don’t lose any sleep fretting about me.  I am too stupid to be afraid and that tends to confuse people who mean to harm me.

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