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There comes a point when you are in this business long enough that you think you have seen everything.  Today I saw something that I never even thought existed.  A long term client received their ZPIC results from AdvanceMed.  In my life, I never thought I would see anything like this.   

Make no mistake.  This is a good client who acquired an agency several years ago and then called me to look at it.  I explained that most people performed due diligence before buying an agency.  As luck would have it, it was a great agency but once sold, there was nobody there who knew the business side of homecare and they were a little less than profitable.

So after a few months, a new administrator was hired.  She has an MBA but she sold drugs prior to accepting this position. (She will read this and get mad if I do not clarify that she sold pharmaceuticals.)  The only home health experience she had was well, frankly, none.

One of the first things I did was encourage her to pay her staff per visit instead of hourly because their overall productivity was about 2 visits per day.  That was a mistake.  I should have told her exactly how much to pay per visit.  But, I left that open and so she pays her nurses a ridiculously high per visit rate.  Her field nurses make more than I do and they only work three days a week.

And because they are down the bayou, their length of stay is about the twice the national average and they have a lot of therapy.  It is difficult to educate people who have never been to school and South Louisiana is known for its large Catholic families so lots of repeat teaching is needed as family members rotate in and out.   Two of their largest referral sources are orthopedic surgeons and as such an enormous amount of their patients require therapy. 

So what do these overpaid nurses with time on their hands do all day?  They talk on the phone and write stories.  They love the copy machine so they make copies of pretty much every piece of paper they can find and give it to people.  Then they call the people they gave them to just to be sure they got them.  They play with scissors and tape and send all these lengthy faxes to the MD with the med profiles taped on them so the doc can see everything they are taking.  I keep trying to show them how to cut and paste the meds on the faxes and remind them that even if the computer explodes, they will still be able to get to their documents.  I cannot begin to imagine what they spend on paper. 

Once or twice a week, they all sit down and have lunch together and talk about their patients in case conference.  This of course is documented.  It is rare that at least one or two nurses don’t come to the office to chart in the afternoons.  The geography is such that it makes more sense to chart in the office since they turn their notes in timely.  (What else do they have to do?)  In fact, some of the most entertaining reading I have done in the past year has been in their charts.  I am still on the fence about how much is appropriate to chart about the infected penile prosthesis but I know more than I wanted.

Probably the owners would take exception to their over paid, underworked employees but since they were making money they never really noticed.  And because they were paid per visit, it didn’t really cost them too much.

They are my only client who as had a deficiency free survey in the past several years.

And their ZPIC result?  AdvanceMed determined they were overpaid by a little less than 2 percent*.  

I am in awe. 

There are lessons here to be learned unless you are my client in which case, there is a well deserved good night’s sleep waiting for you.  Pleasant dreams.


*For those of you unfamiliar with the ZPIC process, most results are well over 50 percent and I have yet to see an overpayment assessed at less than a million.  This agency’s overpayment was measured in tens of thousands.

3 Errors

I’ve been reviewing charts all week and the same errors keep showing up over and over again.  I know the nurses doing the charting and they are not as dimwitted as they may seem on paper.  In fact, I would wager a bet that the only nurses who have never made at least one of these errors has only a passing acquaintance with the truth.

Charting Bilateral Pedal Pulses on an Amputee

The same nurses who did this also charted on the surgical wound, the therapy the patient was receiving and otherwise did an excellent job of documenting.  So, why are they charting about pedal pulses on an amputee?  Because they are used to checking the box that says a patient has bilateral pulses. The same thing happens in M1030 which asks about therapies the patient is receiving at home and when they overlook an Ostomy in the OASIS questions.  My theory is that if you give a nurse a check box, it will be checked.

Charting Tip

When a patient does not meet the response you typically chart greater than 90 percent of the time, mark it when  you notice it.  Even if you do not have time to complete the entire document, respond to those questions that you may answer incorrectly at a later time out of habit.  Outsmart yourself so you don’t end up trying to explain to some board of nursing how you were able to find a pedal pulse in some other part of the body.

Underscoring Functional Limitations

Look at the question about ‘locomotion’.  Response 2 reads: 

Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.

This response is usually selected when a patient requires a walker and it may be correct but keep reading.  If the patient requires human supervision or assistance to negotiate stairs or steps or uneven surfaces, the correct response is 2.  This is true even of patients who do not require a walker.

Charting Tip

Mentally break this question in two. 

  • Does the patient need a two handed device? 
  • Can they negotiate stairs and uneven surfaces without human assistance or supervision?


Most people think of transferring as moving from one place to the other.  In general terms, that’s close but OASIS gives us a very complicated and lengthy definition of transferring.  Here it is step by step (there should be an app for this one).

  • Begin with the patient in a supine position (laid out flat on their back)
  • The patient then gets to a position sitting on the side of the bed.  The methodology must be chosen by the patient  because there is an uncharacteristic lack of instructions in the manual.
  • The patient then stands and pivots. (I had entire tennis lessons which focused on pivoting.  If your patient is a retired tennis pro you might be in luck).
  • Then the patient sits.

But Wait!  That’s not all.

  • The patient must now be able to stand again
  • Pivot
  • Sit on the side of the bed
  • Somehow get flat on his back again.

Could there possibly be more to it than this?  Absolutely.  There are some patients who do not have a place to sit next to their bed.  Their instructions are even lengthier. 

  • Begin with the patient laid out flat again
  • The patient then gets to a position sitting on the side of the bed.
  • The patient then stands and pivots.
  • The patient safely proceeds to the place where he or she normally sits.  This may be the kitchen or the porch or the toilet.  The destination is not defined but I’m going to out on a limb and tell you that it does mean a seated position on the floor because they could not support their weight.
  • Then the patient sits.  I suspect that there may be a little pivoting involved here as well but the directions are not clear. 
  • The patient must now be able to stand again
  • The patient makes his or her way back to the bedroom as the return trip begins
  • Once again they pivot (Group and Individual Pivoting lessons are available from HCS)
  • Sit on the side of the bed
  • Somehow get flat on his back again.

Here’s the fun part.  If your patient typically gets up in the morning and goes outside on the porch to enjoy his coffee but requires help to make the distance, you can greatly improve your outcomes by….  wait for it…  putting a chair next to his bed.  There are some patients who because of shortness of breath, weakness from a recent injury or pain, just need to sit for a few minutes before continuing their journey to the great outdoors or wherever they sit.  Not only will your outcomes improve but a patient who previously had to wait on someone to help them get up is no longer trapped in the bed until someone has the time to get to them. 

What’s more, if you recall that the definition of the day in question refers to the 24 hours prior to and including the visit, you can still improve outcomes even if you put the chair in place on admit. 

Charting Tip

Print the list and keep it with you.   It is rather complicated.

That’s all for today folks but there is sadly more where that came from.  If you have never made any of these errors, it is probable that nobody is reviewing assessments at your agency.  One of the best investments is a data scrubbing program.  My personal favorite is Episode Master although I am angling to have the name changed to Episode Mistress.

Look for more next week.

Guiding Principles

Last week the Robert Wood Johnson Foundation published the The Guided Principles for Patient Engagement developed by the The Nursing Alliance for Quality Care.  My first thought was, yeah yeah yeah yeah, someone has too much time on their hands.  The article went on to describe many people and organizations were involved in the creation of these principles and I decided to give it a second look.  Here they are.

  • There must be a dynamic partnership among patients, their families, and the providers of their health care, which at the same time respects the boundaries of privacy, competent decision-making, and ethical behavior.
  • This relationship is grounded in confidentiality, where the patient defines the scope of the confidentiality. Patients are the best and ultimate source of information about their health status and retain the right to make their own decisions about care.
  • In this relationship, there are mutual responsibilities and accountabilities among the patient, the family, and the provider that make it effective.
  • Providers must recognize that the extent to which patients and family members are able to engage or choose to engage may vary greatly based on individual circumstances. Advocacy for patients who are unable to participate fully is a fundamental nursing role.
  • All encounters and transactions with the patient and family occur while respecting the boundaries that protect recipients of care as well as providers of that care.
  • Patient advocacy is the demonstration of how all of the components of the relationship fit together.
  • This relationship is grounded in an appreciation of patient’s rights and expands on the rights to include mutuality.
  • Mutuality includes sharing of information, creation of consensus, and shared decision-making.
  • Health care literacy is essential for patient, family, and provider to understand the components of patient engagement. Providers must maintain awareness of the health care literacy level of the patient and family and respond accordingly. Acknowledgment and appreciation of diverse backgrounds is an essential part of the engagement process.

Okay, so I’m still not overly fond of some of the academic language and some of this should be ingrained in us during nursing school.  That is not to say that these guiding principles do not have merit.

Look at the second bullet.  We got the confidentiality thing down – even before HIPAA.  The second sentence goes on to say that ‘patients are the best and ultimate source of information about their health status…’  Okay, so nobody ever says anything aloud but isn’t this just a little different and little better than the attitude that the patients really don’t know what we know and as such, we take their information lightly?  We have all been burned by bad information and outright lies from patients.  Maybe the semi-truths and lies tell us as much about the patient as the credible information.

I love the idea of ‘mutual responsibilities and accountabilities’.  We always hear about patient rights.  I do not begrudge patients’ rights but as nurses, we have rights that should be respected by patients, employers and even clients.

Respecting boundaries was never an issue in the hospital.  In home health, I have heard a lot of really interesting stories.   The most extreme story was one where the patient tipped a nurse for extra services not covered by Medicare and are only legal in some parts of Nevada.  Long before you reach that extreme, keeping a professional distance between yourself and your patient in the home environment can be difficult.  You are treated like family and begin to feel like family and families don’t discharge each other simply because there is no Medicare skill.

Advocacy for patients is a fundamental role of nursing.  I would estimate that half of all MSW referrals are issues related to advocacy that should be part of our job.  We need to quit giving our jobs away. Usually we are pretty good about it but I have read far too many charts of patients who do  not meet Medicare coverage guidelines discharged with no soft landing.

The last bullet says something very important as well.  It is the one worth reading first:

Providers must maintain awareness of the health care literacy level of the patient and family and respond accordingly. Acknowledgment and appreciation of diverse backgrounds is an essential part of the engagement process.

I think that may be a way of saying we have to meet the patient where they are.   In fact a lot of these guiding principles can be restated as ‘Meet the Patient where they are’.

I might have simplified the language a bit and included something about patient goals but I wasn’t invited to participate.  Overall, I am grateful to the National Alliance for Quality Nursing Care and believe they have spoken very well on behalf of nurses.

We’ve come a long way from being the handmaiden of the physician.  Thanks National Alliance for Quality Nursing Care.  Next time y’all get together give me a call.

What do y’all think?  Would you add anything?  Delete a bullet or two?  Do you think we need such a statement?  Why or why not?

Memorial Day

Basically, I’m doing nothing today.  I am at the office sorting through paperwork that was waiting for me when I got back from being gone for over a week and doing a little computer maintenance.   Its 94 degrees outside and I am dressed appropriately and I am at the office by myself.

Isn’t that wonderful?  It is such a mundane kind of day that it hardly seems worth celebrating but it is nothing short of miraculous that I can hang out at my office and tidy up a few loose ends before the real work week starts.

In the Middle East, I would not be allowed out without a male escort and I would likely suffer for wearing a light cotton shift and flip flops in public where everyone could see me.  In China, many mothers are spending today and every day mourning the loss of their second child.  There are people who have to secretly practice their religion and others who live in countries so corrupt that even when the US tries to assist, the aide we send is diverted to the elite ruling party while their citizens starve.  Last week I read about the frustration of a doctor from Doctors without Borders because donated blood was reserved for the army of the ruling party even though everyone bleeds the same.

Sadly, some of the men and women who made it possible for me to goof off at my office today did not live to tell about it.  Their families gave the ultimate sacrifice for our country and I cannot begin to express how grateful I am to them.

Other veterans – too many to count – did make it home in bits and  pieces,  physically and emotionally scarred with broken spirits.  Some of them have become our most challenging patients.

Here are some alarming facts about veterans.

  1. A soldier today has a greater chance of dying from suicide than being killed in action.  6,500 veterans commit suicide every year.
  2. One in five suicides is a veteran but only one percent of the population will join the armed forces.
  3. 1 in 4 Veterans ages 18-25 met the criteria for substance abuse disorder in 2006
  4. 1.8 million Veterans of any age met the criteria for having a substance abuse disorder in 2006
  5. There are 140,000 U.S. Veterans in prison, and 60% of those have a substance abuse problem
  6. There are 130,000 homeless U.S. Veterans, and 75% of them suffer from substance abuse problems
  7. The number of veterans with service related disabilities is astronomical.  One report says that almost half of all veterans who have served are disabled up to 50 percent.  I will have to research that more but it just doesn’t seem possible.

These are our patients.  Or they are the sons and daughters, brothers and sisters of our patients and even parents of our pediatric patients.  The Veterans Administration does offer help but the channels are often difficult to navigate and almost impossible for someone suffering from mental illness.  Click here for an interactive tool to find your patient help.

It isn’t only the soldiers who died who lost their lives fighting for our freedom.  The homeless and the addicted  veterans gave their lives for us, too.   Let’s give a little back.

Let’s Make a Deal!

There has never been any shortage of factors that add or decrease value to a home health agency.  I am asked all the time if a home health agency is still a good investment.  Watching my 401 (through a microscope), it occurs to me that most home health agencies are a better investment than anything related to the markets.  The tricky part in making a deal lies in the fact that the number of unknowns has increased considerably with health care reform and regulatory scrutiny.


When any healthcare facility transfers ownership, there are three options. 

  1. The buyer assumes the provider agreement of the seller.  This transaction can be done without any interruption in billing.  There is no change in the provider number or license and the new owner completes paperwork in order for the change in ownership to be recognized by Medicare.  
  2. Stock (or any organization that issues units or shares) is transferred from one party to another.  An LLC for instance may have only have one member.  If the member sells his interest in the LLC to another person, there has been no change of ownership because the LLC still owns the agency.
  3. The buyer buys the operations of an agency (license only) and has to reapply to become certified by Medicare.  Nothing is billable until the last day of a successful certification survey.  After that day passes, it may be another 3 months until claims can be dropped.


This used to be simple and I always steered clients to option 1.  Option 2 is much easier but the buyer assumes all of the liability of the LLC, not just the Medicare history.  Option 3 has never been attractive because the certification process is long and complicated and very expensive.   

Things have changed, folks.  A couple of weeks ago I was asked to help out an agency who had 30 claims requested by the Zone Contractor in 2009.  The dates of service went back as far as 2006.  In 2012 they received a letter stating that they owed CMS 1.96M.  Oops.  If that agency had been sold during those three years, the new owner would be responsible for the overpayment.  Of course it will be appealed but lawyers and consultants need to be paid, too.  And there is  no guarantee that the appeals will be successful.

While a prospective buyer can query Medicare to determine if there are any outstanding liabilities, they cannot be assured that the agency will not be subjected to scrutiny that hasn’t occurred yet for claims submitted prior to the purchase.  That ups the risk factor for option 1 considerably.  In Louisiana alone, there are 128 ZPIC investigations and they are not public information. 

Indemnity clauses address potential liabilities that have not been revealed at the time of sale but I have never seen any agreements that held the buyer harmless for the amount even approaching some of the ZPIC overpayments we have seen over the last year. 

Effective last year, both option 1 and option 2 have a restriction on selling the agency within 36 months after the agency was certified or last changed ownership or until after 2 cost reports are filed.  Buying late in the year and filing cost reports early can reduce the amount of time to closer to 24 months.  That means that if the agency begins to tank and the only sane course of action is to sell out, the option may not be available.  This restriction applies to stock transfers only when a majority of the stock is moved.

The third option – the expensive one is undoubtedly the safest.  The agency, because it is licensed must be fully functional.  That means a lease, an administrator/DON, patients (2), and all the other expenses that go along with an agency.  Upon purchase, the agency must apply for accreditation through an accrediting body such as JCAHO or CHAP.  This takes time and is an additional significant expense.  It is becoming more attractive every day because this option offers something that the other two options do not – a squeaky clean provider number.

So a lot of people are steering clear of health care in general these days.  That should mean that the demand for agencies is lower in general.  Consider the agencies who are under scrutiny from a Zone contractor and are not expected to do well. One option is to simply procure another provider number while awaiting results.  When the results and extrapolations are complete, the agency negotiates a settlement, files bankruptcy and runs its operations out of the new agency.  By the way, this doesn’t mean the agency escapes the Medicare debt – they merely get to prolong their agony.

What that means for potential sellers is that there is a lot of desperate buyers out there.  So while people who have never been in the industry are staying away for now, there are others who are facing certain demise who will pay more than an agency is worth to ensure their future business.  How do you calculate these factors into the price? 

You ready to make a deal?  Call us.  We’ll make sure you understand the pros and cons of each option and recommend a physician who can medicate you throughout the process.

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