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Posts tagged ‘documentation’

Five Steps to Improved Documentation


 

Paperwork is part of the job. Next to patient care, it is the most important part of your job. Wouldn’t it be nice to see your patients and document well in time to don your pearls and cook dinner for your family? Or maybe you just want a cocktail or two while you watch the evening news. Pretty much nobody wants to stay up until midnight documenting so that they can be paid on time.

  1. Turn off the Cut and Paste function. There are some clinicians who should have a neon sign on their forehead reading, ‘I document. Therefore I clone.’ Turn it off. If you survived nursing school or have an advanced degree in therapy, it stands to reason that you can compose an original note without copying the prior note.
  2. Write plans of care that address the patient’s issues. No more. No less. If there are two or three pages of orders, the important stuff will be buried in the minutia.
  3. Read the care plan. That sounds obvious but nurses cannot read care plans if they aren’t present and in the chart. This should be a priority and nurses should refuse to see the patient if they do not have one. At the very least, a verbal report from the admitting or recertifying nurse should be given and documented. It is easy to lower the bar on this but very difficult to raise it. But we are nurses. We do difficult things and we need care plans.
  4. Payment is often in the details. If you are not in a position to document in the house, keep a pocket sized notebook with you and write vitals and what was taught.
    1. Weights
    2. Blood pressures
    3. Pain
    4. Heart rate
    5. MD visits
    6. Medications
    7. MD and hospital documentation
  5. Teach only useful information that your patient can understand. The internet has no shortage of teaching guides available from the web. Look for teaching guides that have been published by reputable organizations such as the American Diabetes Association, the CDC, the National Institute of Health and University hospitals. That way, if the information is bad, you can at least credit a reputable source. Upload this information into the computer in the patient’s electronic record. Then you can chart, ‘reviewed pages 1 – 4 of DM teaching guide and taught page 5’. And remember that teaching guides should vary according to the patient’s needs.
  6. Complete a short pre-visit checklist the day before your visit that includes calling your patient to confirm the visit, ensuring that appropriate teaching guides are uploaded and available in printed format for the patient, determining if there are additional orders since your last visit and read any documentation that another clinician submitted. This will ensure that you are able to give the best care possible to your patient.

Although going through these steps may seem like more work, it isn’t. Consider driving 15 miles to a patient’s home only to discover they had an MD appointment. If you are unprepared for teaching, you may waste your time and the patient’s. Reconstructing notes and trying to remember vital signs is a task that is slightly less pleasant than a root canal and takes time. Doing the job right the first time saves so many headaches that the manufacturer of Advil would be in jeopardy if everybody bought into the concept

Perhaps the greatest delay in documentation is finding better things to do. It requires discipline to complete quality paperwork within 24 hours of a visit. It is a habit you need if you are to be in home health longer than a week.  Believe it or not, there is an app for that. Actually, there are fifteen apps for that. Try one. Because although clean documentation that doesn’t boomerang back to you and is submitted on time gets the agency paid, the effect on your life will be even more amazing.


Above is a very basic quiz on home health documentation.  It focuses on the type of errors that will result in claims being denied.  Is there a greater insult to a nurse than telling him or her that they do not deserve to be paid after going above and beyond to care for their patients?

Don’t let this happen to you.  Click the ‘Start Quiz’ link and find out how well your documentation measures up.  And call us if your agency might benefit from training from Haydel Consulting Services.

 

A Memorable Comment


Two years ago, I posted about Beverly Cooper who was convicted of multiple counts of fraud and was facing up to a ten-year sentence in Federal Prison.  See Press Release.   She admitted to signing visit notes when unlicensed personnel made the visits giving the impression that she made the visits; among other things – lots of other things.  Signing off on a visit that was made by someone without a license could have easily proved deadly to a patient.  Maybe Ms. Cooper is lucky that she didn’t kill someone.

Today, I received a message from someone, apparently a friend of Ms. Cooper’s pointing out that nowhere in the indictment (or my blog post) was Ms. Cooper’s 15-hour work days or dying relative noted.  The writer asked if I knew how wonderful Beverly Cooper was and pointed out that everybody makes mistakes.

Frankly, it would not surprise me if Ms. Cooper was a good hearted, likable woman.  Unlike less sophisticated crime, fraud on this scale is usually committed by people who are genuinely likable.

The writer of the message mentioned other people involved in the indictment.  She wanted to know why I didn’t mention them as well.  Frankly, they were not included in the press release.  Furthermore, Ms. Cooper was a Registered Nurse.   This blog is all about nursing and nurses and those who occupy our worlds.  That’s why Ms. Cooper made the blog post list.

I don’t know the person who wrote me the email and I never have met Ms. Cooper before.  I was nowhere near Detroit where all of this took place.  I cannot begin to speculate on what might have happened.  But, I can make reasonable assumptions based upon the criminal cases I have worked with and some former clients.

  1. Cooper was likely tired and emotionally fragile based upon what the writer said. Masterminds of fraud are incredibly smooth at exploiting the weaknesses of others.  She likely was not the mastermind.
  2. My bet is that Ms. Cooper was paid far more than an RN in a similar position. Should someone offer you twice as much as you are making now, be aware.  You are not worth that much.
  3. Cooper may have convinced herself or have been convinced that ‘everyone does it’. Wrongo.
  4. There may be somebody in the mix who could be legitimately diagnosed as a sociopath. Being without a conscience is mission critical to projecting the confidence required to persuade accomplices to achieve your purposes.
  5. I would bet the farm that at some point long before her arrest, Cooper figured out that she was committing fraud and had to make a decision. It could have been loyalty to her employer, a need for money, fear of extortion or just greed that convinced her to stay.  Sometimes, folks are too overwhelmed to think about a major life change.
  6. If this case was even remotely similar to other cases, the agency was investigated for years prior to an arrest. Beverly Cooper and her co-conspirators may have become complacent since there was so much time between the investigation and the arrest.

Let me reiterate that I do not know anything about these people.  They are not the usual fraudsters in Louisiana where we have enough home grown fraud that I don’t have to go looking in places like Detroit.  I have met many others who have faced a similar circumstance; enough to make assumptions.  I have enjoyed their company and worked hard for them and their lawyers and I took their money for my services.  But, when a clear pattern of fraud exists, there is nothing that I can do.  Criminal attorneys are brought to their knees trying to find a defense for their clients when there is none.   These are not thuggish criminals.  They are well dressed, well spoken professionals who say and do all the right things.

Your task if you are reading this is to know what a compliant agency looks like so you can find one to work with or create one to attract the kind of talent that you need to bring your agency to the next level.

The compliant agency:

  • Makes a lot of mistakes – it may seem like even more because they talk about mistakes, bring them out in the open and find ways to avoid repeat mistakes.
  • Has a lot of information scattered around the office about a code of conduct, employee hotlines and compliance committees.
  • Welcomes questions as a door for teaching.
  • Makes sure that employees have an anonymous way to report fraud.
  • Takes reports of fraud offered in good faith seriously.
  • Provides far more education in fraud than anyone wants.
  • Looks at processes and doesn’t blame employees for mistakes that involve multiple people and departments. There’s plenty of time to blame others if it happens again.  Fix it and move on.

Mistakes are costly to be sure but not nearly so much as hiding mistakes.  If you inadvertently make a mistake that affects billing and are fired after reporting it, smile on your way out of the door.  You don’t want to be there.  The agency has just sent a message to everyone else that they have a zero tolerance policy for mistakes and future mistakes will be hidden away.

Ms. Cooper may have been caught up in a storm she could not escape.  She may have discounted her actions as inconsequential or have been convinced she would never be caught.  She has lost her family, her marriage and her job according to the person who emailed me today.  She is completely without dignity.  On top of all of that, she is facing jail time.

I can’t help but feel compassion for her but more importantly, I am bound and determined to give all of you who take the time out of your day to read my blog the information you need to avoid a similar fate.  Unemployment is not half as bad as jail.

End in Sight for Home Health Services

A guide for documenting the continuing need for skilled services in home health.

Read more

But Our Survey was Perfect!


The state has come through and scrutinized every piece of paper in your office, gone on multiple home visits and even complimented you on your Infection Control Program.  There’s absolutely no reason to be concerned when some ADRs are received from Medicare.  How could an agency as perfect as yours be denied payment?

It happens every day.  Trust me.  I hear about perfect surveys and denials in the same sentence almost every day.

State regulations often follow the Medicare Conditions of Participation.  If your survey was perfect or even just good, you have likely met the CoP’s.  However, off to the side, in another area of the manual are the Medicare Conditions for Payment.  They are separate and apart from the CoP’s because not all payor sources have these requirements for payment. 

They are:

  • The patient is confined to the home
  • The patient is under the care of a physician (or as we say in the south, under the doctor)
  • The patient has a need for recurring, intermittent skilled care.
  • A Face-to-Face Encounter must occur within a designated time frame
  • The patient is an eligible beneficiary
  • OASIS data has been collected and submitted.
  • The agency is certified by Medicare.

Most patients meet the homebound criteria but many patients do not have homebound criteria documented well enough to warrant payment.  In case you missed it, here is a post about how to document homebound status.   

The patient is under the care of a physician should be obvious, right?  Not so fast, grasshoppers.  Not just any physician counts.  It has to be one that is licensed in your state or your state must allow physicians from nearby counties in another state to write orders.  Each state is different so read your physician practice acts and call the board of medicine if you still aren’t clear. 

The way that Medicare determines that a patient is under the care of a physician is by looking at signatures.   For years, we were told that if the physician failed to date his or her signature, we could simply enter the date the signed plan of care was received by the agency.  They changed their minds on that one a few years ago but not everyone got the memo, apparently.  Everyone in the agency who sees plans of care on a regular basis should be taught to look for dated signatures.  The earlier you find an undated signature, the more likely the physician will be able to sign an attestation statement with confidence.

Recurring, intermittent services sounds like someone is trying to confuse you.  In short, you may not see a patient indefinitely and you may not arrange to see a patient only once.

Daily nursing visits must have a written ‘end in sight’ to daily skilled nursing care included in the documentation.  The single exception to this rule is daily visits for insulin injections.   You can document this anywhere but I like to see it under the frequency or in the goals section.  Similarly, you may not plan to visit a patient once.  Physicians may call and ask for you to go to the house to remove sutures or administer a flu vaccine.  These visits would not be covered under the Medicare home care benefit although you can give a flu shot.  If a patient dies, moves out of town or refuses services after the admission visit, you may bill for it because you fully expected to see the patient again.

I think we have covered, recovered and stripped bare the Face-to-Face documentation requirements in prior posts.  If you continue to have questions, read here

Skilled care is defined in the Medicare Benefits Manual, chapter 7.   I always have a copy on my iPad and my desktop but whenever I can, I go to the online version because changes are fairly frequent.  You can identify the changes by the red font.

Everyone checks eligibility right?  I seldom see a problem with that but when one occurs, it occurs in a very big way.  Usually, an unfortunate soul without Medicare or insurance will borrow someone else’s card.  Although you are completely clueless, it is still non-billable.  That means you have to give the money back.  If you find out about it before Medicare does, you have 60 days before the money is considered fraudulent (that applies to all overpayments).  Whenever possible, check identification on admission.

It seems that until recently, agencies sent OASIS data in one direction and claims in another and the two never met up and the penalty for not submitting OASIS data was very scarcely enforced.  At some point, the OIG got wind of this and jumped all over Medicare in a long and boring report last year.  Now now you will be denied on an ADR if the OASIS data has not been submitted. 

I think you will know if ever your agency becomes decertified so let’s just skip that one.  (Hint:  one big clue is the lack of payment.)

Your state surveyors do not know much at all about billing.  The Face-to-Face requirement is not a requirement for licensure.  In all likelihood, you probably know more about OASIS and coding than a surveyor does because they do not do it every day.  The state really doesn’t survey your length of stay.  The state wants to know if you meet the basic requirements to provide care for patients.  If you are still confused, consider that the state employees are paid by state taxes to protect the citizens of the state.  Medicare pays contractors to protect the trust funds (large piles of money) used to pay for the care.

If you have a perfect survey, it means that you are doing many things right.  In fact, if you get in trouble with your state agency, there will come a point in time where they will communicate with Medicare and your provider number will be at risk.  I’ve only seen that happen a few times by people who do not read stuff like this. 

Now think about all the reasons agencies have claims denied.  They are not included in your state survey.  And that is how you can have a perfect survey and still get denials or worse. 

Now you know. 

Questions and comments are always welcome.

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