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Posts tagged ‘coordination of care’

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.

Mar 29

1 Comment

ZPIC Targets

Home Health and Hospice, as well as other post acute care providers have been under scrutiny before and this current emergence of ZPIC activity certainly won’t be the last time we are under scrutiny. But, unlike Focused Medical Review or even RACs, ZPIC audits begin with the presumption that the provider has committed fraud.

For our purposes, we will define Medicare Fraud as billing for services that were not covered under Medicare. Thats all the ZPICs are looking at – Billing. CMS instructs the ZPICs to refer serious quality issues to the state agency or QIO. In other words they do not care if your supervisory visits are made timely or if you followed orders and frequency. In fact, you may have had a stellar state survey and still find yourself in ZPIC sights.

To determine your risk level, first check your length of stay data on the top right corner of your case mix report from Casper. If your numbers are much higher than the reference mean, you may find yourself under scrutiny. If your average case mix weight is closer to three than two you are similarly at risk. Usually, high case mix weights are a result of therapy so be cognizant of how many of your patients receive therapy – especially when the number of visits is consistently at threshold levels. Finally, a high number of diagnoses that add to HHRGs can be suspect. If all of your patients have DM, you had better be able to explain why.

Hospices are looked at also for excessive lengths of stay and diagnoses that are not ordinairily terminal.



If your agency does not fit any of these profiles, you are most likely safe.  However, the ZPICs have a lot of freedom to look at who and what they want.  Multiple complaints to the Benefit Integrity Unit or state agencies may also spur an audit.


And remember, the vast majority of agencies will never undergo a ZPIC audit.  But should you find yourself in the ‘zone’ at least you will have a place to start damage control.


As always, I welcome your comments and shared experiences below.  And you can always email me.

							

		

			

			

				

					
May 27

				

									

						2 Comments					

			

			

				

					Surveyor Guidance
				

				


Ask any nurse and he or she will likely tell you that state surveys are never pleasant times in an agency.  The truth is that surveys cause stress and disruption in the best of circumstances.  Complaint surveys are not uncommon and are not limited to agencies that deserve them.  The state has a responsibility to investigate complaints.  If a surveyor walked in your door tomorrow morning, would you be ready?


The following links are the CMS issued guidance for surveyors.  This is what the state must survey in order to certify or recertify a home health agency or hospice.  It is definitely worth the time to read through the files and look at your agency from the perspective of a surveyor.  Even if you cannot demonstrate compliance to all standards, it will go a long way to have a plan in place before the surveyors arrive at your door.


This link is part of the CMS guidance for surveyors.  It is often slow and doesn’t load completely.  My suggestion is to save the PDF file once you have opened it to your hard drive.


http://cms.gov/manuals/Downloads/som107ap_b_hha.pdf


Here is the same thing for hospice:


http://cms.gov/manuals/Downloads/som107ap_m_hospice.pdf


UPDATE:  a reader just sent this comment:


FYI for Hospices:


Below is the link to the Hospice interim surveyor interpretive  guidelines that provide the most recent guidance related to the Hospice  CoPs:


http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-19.pdf

							

		

			

			

				

					
Feb 16

				

									

						4 Comments					

			

			

				

					Low Tech Telemedicine
				

				



 


An enormous amount of health care dollars are spend every year on high dollar telemedicine technology with the goal of improving patient care.  We support technology in health care.  It is clearly the way of the future and any and all tools available to agencies should be employed when they promote communication and patient care.



But before your agency purchases high dollar equipment, are you completely sure that all technology currently available to you is being used?  What about the expensive telephone system that decorates your office?



In determining frequencies, we generally try to establish how often the patient will require visits by the clinician.  Most Clinicians, in an effort to err on the side of caution, will schedule generously.  What many agencies have already discovered is that certain follow-up tasks can be accomplished with a short phone call in lieu of a visit.



Consider a newly diagnosed diabetic patient who is seen five times in succession on the first week of admission with plans to reduce visits to twice weekly after the skill of blood glucose monitoring is mastered by the patient.  At the end of the fifth visit, the patient is able to independently perform the skill but is still a little unsure.  The nurse might very easily perform a sixth visit to ensure that the patient is comfortable performing a new skill.  Or, maybe, all the patient really needs is a little reassurance in the form of a telephone call.



This same logic applies to reducing frequencies at time of recert or after an acute exacerbation.  It isn’t necessary to drop cold turkey to a lower frequency.  A phone call to check on the patient between visits goes a long way to ensure the nurse that the correct clinical decision has been made.  And obviously, should a need become apparent during a phone call, an additional visit can always be added to the schedule.



Other phone calls I would like to see made include:



    

  • Phone calls after visits missed due to no answer to locked door.

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  • Phone calls after MD visits

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  • Phone calls when there is a change in caregiver situations at the house

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  • 

    Follow up after the beginning of a new medication or the cessation of a long term medication

    

    
 
    

    • 



Of course, all the phone calls in the world won’t go far to protect you in a survey or payment review situation.  But considering that care coordination deficiencies are among the most commonly cited survey deficiency, the process of making phone calls and including documentation in the clinical record can go far to show the quality of care your agency gives.




 


To make it easy for nurses to improve care coordination through low tech telemedicine techniques, clean and uncluttered forms should be available.  Consider including a stack with weekly schedules.  Add checkboxes for physician and interdisciplinary communication to ensure that coordination is well documented.