In reviewing charts lately, there seems to be a severe lack of therapy management in home health agencies that depend upon contracted therapy. It seems that in some parts of the country, therapists are in such high demand that we allow them to do as they please as long as they will see our patients. We choose between the lesser of two evils – having a rogue therapist or two or not providing therapy to our patients. This can result in poor care to the patient but most often it results in financial disasters. It doesn’t matter how much you are paid for an episode, if you spend more than you make. These are some of the problems I see regularly throughout agencies.
Referrals: An agency makes a referral to a therapist and when it is convenient, the therapist sees the patient. If therapy isn’t managed, the agency may not know that a therapist didn’t admit the patient until five days after referral. This results in poorly crafted OASIS assessments, impossible resource management and overall sloppy care. A surveyor would deem this practice as poor coordination of care and in some states, a serious hit on survey for admissions processes.
Subsequent Orders: I have never reviewed charts in an agency where all therapy orders were on the chart. In agencies that have solid therapy management plans, this happens less frequently. In agencies that take a haphazard approach to therapy management they have given the surveyors an easy tag.
Extension Orders: This happens when the agency and the therapy provider agree on a plan of care and then the therapist requests additional visits directly from the physician. One therapist I reviewed at an agency consistently did 19 visits because they knew CMS looked really hard at 20. (I don’t make this stuff up.) All home health services must be rendered under the guidance and supervision of the home health agency. I would think twice about paying for additional visits if they were requested outside of the processes of the agency.
Frequency Errors: Missed visit slips are often turned in weekly with therapy documentation. Most times the agency doesn’t even know the visits were missed prior to receiving the paperwork. If the missed visit occurred on the prior week, no agency intervention such as scheduling an alternative therapist can be made. When this results in five or thirteen visits for patients who truly needed seven or 14 visits, it makes me want to cry. Chances are my entire consulting bill could have been paid out of the loss incurred by the agency for sloppy therapy management.
Our biggest problem is that many agencies are okay with this sloppy case management because the alternative is not having a therapist. They will continue to be okay with it until a state agency places them on a termination track for repeated offenses. And no, they don’t often clear therapy related deficiencies on a desk review.
In order to manage therapy, agencies should have in place processes that include:
Additionally, agencies need to remember that all arrangements by third party providers conform to a written agreement that contains at least the following criteria as outlined by CMS:
……when a provider provides outpatient services under an arrangement with others, such services must be furnished in accordance with the terms of a written contract, which provides for retention by the provider of responsibility for and control and supervision of such services. The terms of the contract should include at least the following:
• Provide that the therapy services are to be furnished in accordance with the plan of care established according to Medicare policies for therapy plans of care in section 220.1.2 of this chapter;
• Specify the geographical areas in which the services are to be furnished;
• Provide that contracted personnel and services meet the same requirements as those which would be applicable if the personnel and services were furnished directly by the provider;
• Provide that the therapist will participate in conferences required to coordinate the care of an individual patient;
• Provide for the preparation of treatment records, with progress notes and observations, and for the prompt incorporation of such into the clinical records of the clinic;
• Specify the financial arrangements. The contracting organization or individual may not bill the patient or the health insurance program; and
• Specify the period of time the contract is to be in effect and the manner of termination or renewal.
If a therapy provider after signing such an agreement violates these terms and conditions, both the agency and the therapist may be held accountable. CMS really doesn’t care if there is an abundance or a shortage of therapists in your area!
As always, I am interested in your comments. If anyone has an effective way to manage therapy, please share it with your colleagues. You can email it to me directly to include as a blog post or paste it in the comments box below.
The OASIS-C dataset assesses whether or not the patient has had a fall risk assessment. In the item intent in Chapter 3 it further states that the multi-factor falls risk assessment that has been validated as effective in identifying falls risk in community-dwelling elders and which includes a standard response scale.
Although many falls risk assessments that meet these requirements are available, the one that is perhaps easiest to use and has been proven to be validated is the Timed Up and Go Test. This test uses only a chair and a tape measure and can be performed in just a few minutes. Patients who do not do well on a Timed Up and Go may be candidates for physical therapy and the use of this or a similar test will validate the patient’s need in a RAC audit.
OASIS-C asks us if we have taught on high alert medications on admission and resumption of care. The chapter 3 instructions state, “High-risk medications are those identified by quality organizations (Institute for Safe Medication Practices, JCAHO, etc.) as having considerable potential for causing significant patient harm when they are used erroneously.”
The link below is the list from the Institute of Safe Medication Practices. It is the one we like best becaue it was originally designed for community pharmacies and doesn’t include medications only found in ICU’s and Operating rooms. If you know of another list that might be worth taking a look at, please forward!
As always, we welcome your comments below and your emails at firstname.lastname@example.org.
If you want to drive a consultant crazy, be inconsistent in your wound care documentation. Document conflicting sizes, wounds that mysteriously migrate from the left buttock to the right and stage wounds according to stage of the moon as opposed to the degree of tissue involvement. That will do it. I promise.
But it seems that there are going to be even more reasons to improve your assessment and documentation of wounds even if you don’t care about the mental health of your consultant. The OASIS-C Integumentary Status is far more specific than the dataset we are currently using. It goes so far as to require actual measurements of all things. It also investigates wounds that develop while the patient is under your care and could conceivably hold you accountable. Epithelialization of wounds will be a key factor. Do all of your nurses recognize granulation and epithelization? Are they able to chart it accordingly?
Without these skills, your OASIS data will be useless at best and at worst, your outcomes will make you stand out like a pariah in the regulatory and referral worlds.
Wound assessment and documentation is an investment all home health care agencies should make now. We do not offer classes on Wound Care but there are many available. A good place to start is with your wound care supply vendor. Often companies who sell wound care products offer inservices to their clients at no cost. The WOCN might be a place to look for wound care classes. If you know of any really good sources, please write about them in the comments section so that everyone can be aware.
All nurses should be taught how to assess and document wound status. Registered Nurses should be taught the intricacies of staging and how to determine the level of healing. Don’t bother wait. This is something you can do now!
OASIS-C training will be held at our Education on November 12 and 19. Please contact us for more information or for questions about this or any blog post at email@example.com.