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COVID-19 for Visiting Nurses

How should home health and hospice visiting employees address Covid19 and protect staff and patients?

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Company 1

Take heed

Suzanne May, age 61, served as the administrator of a hospice referred to by the Feds as Company 1 for more than a decade She was a both a registered nurse and a certified hospice administrator. She signed a plea deal admitting to fraud on December 3, 2019 and now faces five years in prison followed by three years supervised release, a $250,000.00 fine and to top it off, a $100.00 special assessment. Hopefully, her lawyer can negotiate a deal where the special assessment is knocked off of the overall penalties.

Altering Legal Documents

To keep it short and simple unlike the official documents, Ms. May has admitted to:

  1. Using white-out on a Certificate of Terminal Illness. If you can’t figure out why that might be a problem, it’s best that you resign now.
  2. Adding dates to Notices of Election after the clinical records were requested from Medicare. I do not know how Federal Investigators knew when the dates were added.
  3. Ms. May relieved some patients of the burden of initialing forms by adding their dated initials to forms. The Feds are alleging that it is not possible to sign and date documents after death.

In an impressive display of organizational skills, Company 1 employees, led by Ms. May, kept a log of all changes made to the documents after the request for records was received.

This audit, performed in 2017, followed a 2015 audit in which close to $400,000 was returned to Medicare. As a certified hospice administrator Ms. May knew what was required of the hospice in order to be paid. And, to her credit, she made sure every detail was complete but only after her clinical records were requested by Medicare. Timing is everything.

Look Again

This post teaches you how to go to jail. Free meals, a warm place to sleep and a break from your needy relatives may be your ticket to jolly holidays. Surely the worst prison food is better than fruit cake and squash casserole.

In no way am I condoning the actions of Ms. May. I also recognize that the criteria for payment is sometimes preposterous. Claims for reasonable and necessary care provided to eligible beneficiaries are denied payment every day but that is a subject for another post.

In this case no patients were harmed as a result of Ms. May’s actions. Nobody dies from a date added to a document after they die. If jail is your ideal vacation, this seems to be the way to go if you don’t want any patients to be hurt along the way.

If you wish to remain home with your loved ones, I assure you that no matter how tempting it is to add a date to a form because the patient didn’t, and you know the correct date and personally witnessed the patient sign the form, it isn’t worth it. When a physician doesn’t date his or her signature and you know when the orders were signed, adding the date seems more like a courtesy than a felony but you would be wrong in making that assumption.

If this sort of behavior was evident on a state survey and a plan of correction to the state was required, it would probably include an educational piece like, ‘The DON will hold an inservice to teach the nurses things that they already know but didn’t do.’

If you are finding these problems during clinical record and billing review despite teaching the nurses repeatedly it’s time to try something new.

Cut your employees some slack. Home health and hospice nurses who provide excellent care to your patients are worth a little extra time. Review their paperwork with them as it arrives at the agency – which usually occurs before the time (and possibly the patient) has passed to get an ethically dated signature. Help them develop habits.

On the other hand, if a nurse blatantly commits fraud, investigate first and then terminate them. You are also obligated to report them to Medicare and their State Board. A good orientation will ensure they know the rules. Protect your nurses and the agency by providing a complete orientation including compliance. 

Do not bill (or alternatively, pay back the money) if you have found out that a nurse was taking shortcuts. It is painful to take the right steps but not as painful as the quarter million fine Ms. May will pay (plus the assessment fee).

If you are a visiting nurse, you know the rules. You know what to do and mostly you get it right but it only takes a couple of bad care plans or notices of election to cost an agency tens of thousands of dollars.

More concerning to me is the probability that some nurses are encouraged to ‘do what it takes’ to get billing out the door. Without using the words, ‘go commit fraud’, some employers leave employees feeling like their jobs are on the line if they hold up billing. If you feel that the only way to keep your job is to fill in the blanks omitted by a patient or a physician, I guarantee that unemployment is a better option.

Everything else aside, ask how Medicare knew the documents were altered by Ms. May and friends after the patient died. The Feds are not psychic. They did not have a seance summoning J. Edgar Hoover who revealed the exact time that dates were placed on documents. They obviously knew something that was solid enough for them to request 100 charts.

I’m willing to bet that Company 1 is not the real name of the hospice and that this story has just begun. Until we find out more, do yourself and your patients a favor and do things the right way. If you are preoccupied with compiling charts for an audit, care to your patients will be compromised. I’ve seen it too many times.

As always, your comments are welcome or you can email your thoughts.

Breaking Bad with Mama

The hidden damage of patient falls.

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The Real Reason your Claim was Denied

A good mystery is a delight but they should be reserved for leisure time reading. It should not be an element of Requests for Additional Information (ADRs) from Palmetto GBA or any other Medicare contractor. And yet, they are. Below are some examples that have come across my desk in recent months as the Targeted Probe and Educate (TPE) process marches forward. I admit that at times I am truly challenged.

There are two denial codes in particular that keep showing up and really, they could mean anything. The first is:

5F023 – No Plan of Care or Certification

Believe it not, there are some people who think this means that no plan of care or certification was included with the submission of documents. If it is found when the biller is checking claims status, he or she may simply fax over the plan of care thinking they are helping the agency get paid faster. There goes one round of appeals.

If they had taken the time to look up this reason for denial on Palmetto GBA’s website they may have found an explanation that confirmed their initial impression. It is prefaced by the following:

The services billed were not covered because the home health agency (HHA) did not have the plan of care (POC) established and approved by a physician, as required by Medicare, included in the medical records submitted for review and/or the service(s) billed were not covered because the documentation submitted did not include the physician’s signed certification or recertification.

So, when a letter arrives in the mail two days after the resubmission of the plan of care, agencies may be surprised to find out their claim was denied because the physician’s Face-to-Face encounter did not support homebound status in his clinic note. Maybe because it is not a requirement for their patients to be homebound so they don’t think about it.

You would think they would make a code just for homebound status so that the reason codes for denials would correspond with the reasons for denial. That’s what I would do.

To be fair, nobody is doubting homebound status. Rather, they are saying that the physician did not fully support homebound status.

Another claim denied for having no certification or plan of care was explained the same way. The Face-to-Face encounter documentation did not support homebound status. The physician documented that the beneficiary was having recurrent dizziness, continued incisional pain, low back pain and bilateral knee pain. The medication list included percocet, alprazolam and hydroxyzine. And yet, a reviewer at Palmetto does not understand how dizziness, knee pain, back pain and incisional pain might reduce the ability of a patient to leave the home and tolerate the outing with aplomb.

5FF2F – The physician certification was invalid because the required face‐to‐face encounter was missing/incomplete/untimely.

As an additional bonus, there is no shortage of claims denied for reason code 5FF2F – The physician certification was invalid because the required face‐to‐face encounter was missing/incomplete/untimely.

So which is it? Is the Face-to-Face missing or untimely or incomplete? Responding to a denial is not the time for guesswork.

On one appeal, Palmetto GBA asserted:

… The face to face encounter note indicated that the beneficiary required the use of a wheelchair, thus satisfying criterion one of the face to face requirements. However, criterion two was not met. There was no indication of a normal inability to leave the home or how leaving the home would require a considerable or taxing effort.

The physician wrote in the encounter documentation that the patient had a catheter, a prior CVA, dilated cardiomyopathy and he ordered a hospital bed and an alternating pressure mattress for the prevention of skin breakdown.  An overnight pulse oximetry was ordered to determine if the patient qualified for supplemental oxygen. There was a previous stroke resulting in weakness and difficulty with speech. Could anyone (in their 90’s) have this combination of conditions and find it NOT taxing to leave home?

The physician does not follow the patient home and determine how the patient tolerated the outing.  He or she doesn’t call the patient in the morning like the dentist who performed a root canal.  

In all of the denial letters, the Medicare Benefit Policy Manual, Chapter 7, is referenced.  Section of that manual states:

The certifying physician and/or the acute/post-acute care facility medical record (if the patient was directly admitted to home health) for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s: 

Need for the skilled services; and 
Homebound status; 

The key word here is ‘substantiate’.  According to the Manual, the physician does not need to document specifically how the patient tolerated the outing from home.  Rather, there must be sufficient information to substantiate that a patient can not leave home without a considerable or taxing effort. 

Don’t get angry.  I’m mad enough for us all and it isn’t healthy.

Call a consultant if you need help.  (My number, 225-253-4876, is a good start.)

Meanwhile, I’m trying to figure out how they will handle Medical Review in PDGM.  Could it be we get a break the way we did when PPS was first implemented?

Questions and comments are always welcome.  Look for the comments section or email me at your convenience.


close up of white syringe

This is what happened…..

A nurse, Rodonda Vaught, filling a loosely defined role of ‘help-all nurse’ was asked by a Neuro Intensive Care Unit nurse to go to Radiology and give a patient Versed for anxiety prior to a PET scan.

She mistakenly took Vecuronium, otherwise known as Norcuron, instead of Versed, and gave an undetermined amount to the patient and then went about her next tasks which were in the Emergency Room. Norcuron and other drugs in its class are powerful paralytics used mostly as an adjunct to anesthesia and occasionally when a patient has life-threatening bronchospasms. It is similar to the ‘active’ ingredient in poison arrows used in the Amazon.

Approximately 30 minutes after the order was given, the patient was found to be without a pulse and not breathing. A code ensued and a heart rate was established and the patient, now being mechanically ventilated, was taken to the Neuro ICU.

After the patient was returned to the Neuro Intensive Care Unit, the nurse who made the error went to the patient’s room. The physician, a Nurse Practitioner and a couple of residents were all at the bedside. She explained her error and the team of doctors and residents were then able to understand what had happened to the patient.

The following day, the patient was extubated and died ten minutes later.  Within a few more days, Vaught was terminated.

Surprisingly, all of this happened at the prestigious Vanderbilt University Medical Center Hospital.

Fast forward eleven months. State surveyors entered the hospital for a complaint survey. It seems unlikely that the state of Tennessee sat on this complaint for eleven months prior to the survey but who knows? The survey resulted in a scathing survey report that included an ‘Immediate Jeopardy’ tag. It included interviews with the nurse who made the error, the radiology personnel and multiple hospital executives.  My notes are on the survey report attached to the link.

Shortly after the survey, Vaught was indicted for reckless homicide and patient neglect.

As noted, Vaught took full responsibility for her error when it happened. This is in stark contrast to the behavior of Vanderbilt’s leadership. This is a quote from the survey by Vaught (RN#1):

I was asked if it was documented he/she had administered the Vecuronium in Patient #1’s medical record. RN #1 stated, “I did not. I spoke with [Named Nurse Manager] and he/she told me the new system would capture it on the MAR [Medication Administration Record]. I asked and [the Nurse Manager] said it would show up in a special area in a different color.

In other words, they told her NOT to chart the error. I disagree with that advice.  I would not use words like ‘error’ or ‘major catastrophe’ or even the acronym, ‘OMG’, but the med should have been charted.

She was then asked if she talked to anyone in the days following her medication error. Really? That was Vanderbilt’s focus. Who knows about this?

Vanderbilt had a policy and a list of high risk medications that included Vecuronium (Norcuron) which would have been relevant had the nurse knew that was what she had given. Even so, the policy did not have any procedures in place for monitoring after the administration of a high risk medication.

Vanderbilt overlooked numerous reporting responsibilities after terminating the nurse. Management seemed to mostly forget about the incident. The information reported to the coroner’s office was incorrect. No medication error was reported as required.

In fact, Ms. Vaught has a license that is current and free of disciplinary action. Nevermind that the Tennessee state board of nursing mandates reporting unsafe practice and unsafe practice conditions to recognized legal authorities and to the Board where appropriate.  I would hope that a patient death met that standard.

When asked why the event was not reported, the Senior Quality and Patient Advisor and the Regulatory Officer could not provide an answer and deferred the question to Risk Management. The Senior Quality and Patient Advisor later reported back to the surveyors that Risk Management had provided the following response:

I talked to Risk Management about reporting to the state, and [he/she] stated we [Risk Management] follow the 2009 state rules on reporting and it includes abuse, any, exploitation, fire with disruption of service, strikes, external disasters, misappropriation and injury of a patient in a nursing home of unknown nature. [He/She] said for you to see the state regs,[regulations], page 31, 6d.

I had to read that several times to ensure that I understood it. Apparently, the Risk Manager couldn’t be bothered to meet with the surveyors and instead told them to read the regs. Those regulations can be found here.

The Director of Patient Safety told the surveyors: ‘In the end, there were so many things the nurse did – the 5 rights, basic nursing care’.  The Director of Patient Safety had a very narrow scope of vision.

Nobody can argue that the nurse gravely and egregiously erred and as a result of her mistake, a patient died. But there is a flip side to this coin. Nurses who inadvertently harm patients are the second victim of medication errors. Please read the linked article. Apparently, many people are sympathetic to Ms. Vaught. A GoFundMe campaign to pay for her legal support has collected 43k in three days.

But, Ms. Vaught was not the only one who made a grave and egregious mistake. Vanderbilt came out of the gate with flawed judgment. If all of the factors contributing to this event were investigated instead of limiting the scope to pointing fingers, both nurses and patients would enjoy a safer environment. It’s not much in light of a patient death but it would be something.

Instead, Vanderbilt leadership failed to report the incident or implement a plan of corrections that included nursing education about high risk medications and use of the Automatic Medication dispenser. They did not reeducate the nurse who made the error. They seem to be okay with a nurse dispatching another RN who has no experience with a patient to give conscious sedation. Seriously, who thought a ‘help-all’ nurse was a good idea?

Vanderbilt Hospital has very low scores on Medicare reported outcomes. Is this because the Vanderbilt way of addressing problems is sweeping them under the rug? Or, did they choose to ignore the reporting requirements because they were aiming for Medicare Stars. Inquiring minds want to know.

Every nurse needs to be held accountable for their mistakes.  It is painful but growth comes from pain.  Being indicted on homicide charges?  That’s too much.  What do you think?

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