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Posts tagged ‘Home Health Nursing’

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.

Letter to Santa 2011

Dear Santa:

First of all, please let me apologize for the letter I sent to you earlier this month. In retrospect, the two word message I sent was a bit impulsive and it ceclip_image001rtainly isn’t fit for publication on a site that doesn’t require readers to verify that they are of legal age in their state. If you recall (and I seriously doubt that you do), ever since the kitten mix up, you have yet to get my wish list straight. I know that you drink a lot and if they could grow tropical plants on the North Pole I might suspect your short term memory loss was partly due to cannabis. This year I am going to clarify my wishes in writing so you will have a reference to keep with you next year. Please contact me directly and immediately should you lose your copy.

If you recall, last year I asked you to provide home care nurses with relief from the stressors of too much paperwork. In all fairness, you did that. I just didn’t expect so many nurses to have no paperwork whatsoever as a result of agencies closing subsequent to ZPIC overpayments. It never pays, Santa, to take me literally. You might have have learned that from the two word message I sent earlier this month.

What I really wanted was iPads or laptops for all field staff complete with voice recognition, mileage tracking, GPS capability and wireless connectability. I want Social Security to have everyone sign blanket consents and privacy notices when they apply for social security. That would definitely cut back on paperwork. Is that too much? I think not.

I also asked for Medicare to kind to the home health industry. I gather you are responsible for the vast improvement in manners in all correspondence from Medicare and their contractors. It is so much more pleasant to read about a multimillion dollar overpayment (AKA death sentence) when the notice is written by a well mannered author.

Here’s a clue, Santa. I do not care if Medicare says ‘please’ and ‘thank you’ in letters and I could give a flying flip about telephone etiquette at AdvanceMed (although I must admit, April is delightful even when she denies my requests).

I know that it is considered vulgar in certain social circles to discuss money but I choose to violate my social contract with fellow southerners and ask outright for cash. That’s right, Santa. I want cold, hard cash with which to afford the resources required to care for patients. I think I speak for all nurses when I say we have no objection to accepting money from strange men and you definitely fit that criteria. If you have some time after the holidays please feel free to call me and we’ll run by the Gap and buy you some more contemporary clothing. That red suit you wear is worse than anything John Travolta wore in the 70’s.

Now, I don’t want to be ugly but has it ever occurred to you that you may need us one day? You certainly don’t act like it. Ever since I have known you, you’ve carried extra weight around your midsection putting you at risk for heart disease, joint pain and a lot of other conditions that respond nicely to narcotic pain relief. We can help you get the medications you need. Judging by your spontaneous outbursts regarding ‘Ho’s’, both you and Mrs. Claus are at risk for conditions for which you may prefer discreet treatment in your own home. Do you have any idea what a dent in your lifestyle uncontrolled diabetes or heart failure will make in your lifestyle? Please click here for more information.

Let me recap with two brief sentences. Read carefully and commit to memory if you can.

1. It never pays to get on the bad side of nurses.

2. If you cannot provide what is on my tiny little list, then please let LSU win the Bowl game and the Saints win the Super Bowl.



Medicare 101

We have a lot of challenges in Home Health next year.   No savior came to our rescue.  Congress has absolutely no reason whatsoever to overlook home health when cutting the budget.  They also  have every reason in the world to come after home health for fraud and abuse and they have with a vengeance.  They show no signs of stopping now and if you have been paying attention, nobody is safe.  I have clients with as few as 100 patients undergoing a ZPIC audit and we know that the larger companies are not excused from scrutiny, either.

So before you get serious about implementing new programs and creating new ways to improve care while reducing costs, spend a little to make sure that you as a nurse or you as agency are building upon a sound foundation that protects you if you find yourself under scrutiny.

Take the Medicare Quiz and when you are through, you will see your results immediately.  Let me know what you think of it.

Good Luck.


Spelling Lesson

I received a request posted as a comment on a post written a while back called, ‘Documentation, Again!’  It reads as follows:

I wish you would follow up on this blog as it is connected to the number of visits that nurses are required to do on a daily basis. The “p” word – productivity is the game, as nurses will work off the clock to try not sink in case management and oasis issues. Somewhere in the world a daily productivity of 5.3 patients came around. However with the growth of paperwork and regulations, many nurses who are fighting to be there for their families in the evenings, work on paperwork out of fear. Home Health turnover is high because of this continued lie. You can’t tell nurses that they can completely finish 2 IAs and a visit, fully coding and doing 485 and 486 within 8 hours every time. I had a director who said that to do an IA you should stay in the home about 30 to 45 minutes then finish the paperwork later. Hum, check meds and do an assessment and ask oasis questions and go over plan of care in 45 minutes. How do we turn this lie around, without going to Labor Boards, etc. I believe that sometimes doing less turns out to be more money in the bank, if you focus on getting quality and consistency first, and building from there.

I am nothing if not accommodating, so please allow me to address this writers concerns directly.

Most people think that hell is spelled, H-E-L-L.  It is not.  Hell is spelled, Z-P-I-C.  However, if you are lucky enough to avoid a ZPIC, rest assured in the knowledge that more audits are coming our way.  The description sounds a lot like FMR pre-payment audits.  Don’t forget about the new Medicaid RAC’s.  Any way you look at it, you are likely to be scrutinized in the coming year or so by one or more payor sources who want their money back.

Two admits and a regular visit can be done but not every day. I couldn’t do it.  I am not that good and have no desire to be.

As far as charting after you leave the home, that’s not really such a good idea.  I think pretty much every nurse has been in McDonald’s or Starbucks charting when they realize they did not assess something.  Maybe they started but then the office called to see if they could do another admit and they got distracted.  A forgotten TUG score or temp are not really numbers you can just guestimate.  Well, you can but documenting your guesses is really crossing the line.

The flip side of not being a slave to an arbitrary number is that productivity often drops when nurses are paid salary.  It makes perfect sense on paper to have nurses on salary and ask them to maintain average and reasonable productivity standards but it just NEVER has worked.

I was in a client’s office about two and a half years ago reviewing clinical records when the Administrator, new to home health, asked me to look at productivity.  She wasn’t sure but she thought that maybe the RN’s should be able to do more than one or two visits a day.  I went about my business because obviously this home health newbie had her numbers confused.  Before I left, I asked to look at logged visits.  My next thought was that the person doing the logging was incredibly inept at clicking the mouse.  Productivity was so absurdly low that I didn’t believe it until I started asking the nurses.

Long story short, she went to pay per visit but didn’t want to cut their pay so she paid them more per visit than I have ever seen any nurse get paid per visit.  Sounds like a nut, doesn’t she?

If you think that, you would be wrongo.  Her agency, rural, had a greater margin than almost all of my other clients.  Her nurses suit up and show up and there is virtually no turn around unless someone is asked to leave.  Case conferences are attended.  Orders are written.  Follow up is a way of life at that agency.  Documentation is so good it bores me to tears and they are my only client who received a deficiency free survey this year.  If they are chosen for any other audit, I will not lose a minute’s sleep over it.

So my first thought is whether or not the 5.3’ers are salaried or pay per visit.  If they are paid per visit, are they making enough so that they can take care of their patients during working hours and be home with their families at a reasonable hour most nights?

I wonder how much those people who push for admissions to be submitted to the office within 8 hours are really losing.  Do they know what is in the clinical records?  Do they realize that unless nurses are blatantly committing fraud, the aggregate of errors is just about always in favor of Medicare?  Those agencies who are brag about 3 and 4 days from admit to RAP are flirting with regulatory and fiancial disaster. Speed and accuracy rarely go hand in hand.  The only time a nurse should not take a minute to reflect on her decision is when a patient isn’t breathing and they are turning blue.  Even then………..  you got four minutes to consider the most likely cause.

But you asked me specific questions.  First of all, I do not know where the 5.3 number comes from.  I do remember CMS publishing something like that many, many years ago but it wouldn’t be accurate now.  The next question is how to turn the lie around without a bunch of commotion, etc.  I can help you there.

  1. Get all the information you can about the agency as a whole.  This is not about you or the administrator/DON.  It is about whether or not patient safety is protected at such a fast pace. Information that is relevant:
    1. Hospitalizations as reported on CMS along side your three biggest competitors.
    2. Average HHRG’s or payment if you can get it
    3. Other outcomes are not as useful but run them anyway.  Choose your three biggest competitors and run the reports from
    4. Number of call outs in the past 6 months from HR
    5. Do some research.  This problem wasn’t created overnight and it will not be solved overnight.  Two more weeks will not make a difference.  Once a day, look at 10 charts for one specific thing.  It will be real easy if you use point of care.  Suggestions:
      1. Home Health Aide supervisory visits
      2. Weights recorded and reported as indicated
      3. Physician notification of out of range parameters
      4. Lab drawn timely and reported.  If orders were issued as a result of the lab, are those documented and who was notified of them?  (Check your Coumadin patients.)
      5. Are diabetics taught foot care every episode and is it done per ordered?
      6. Is pain noted on the visit sheet and if so, what was done about it?
      7. I am willing to bet you ten thousand dollars that if you grab 10 485’s and look at all the medications, you will find issues.  Put them in the free Medscape interaction checker online or use iPhone/iPad app.  Look only at the most critical ones listed first.

When you bring these numbers to the administrator, present them in a way that is impersonal and spread throughout the entire body of nurses.  A lot of people want to know who did that, etc. with the goal being to fire the offender.  When it is a little bit of everyone, it is more likely a systems or process problem.   Explain why each area of compliance poses a threat to the agency.

Weights, lab and MD notification of out of range parameters are all deficiencies.  Weights are tied to Congestive Heart Failure and that is the only diagnosis that has been shown to have an influence on home health hospitalizations.  I hold Coumadin in the same esteem as I do Oxycontin bought off the street.  It is dangerous and a malpractice lawyer’s dream. If the agency is not performing in these areas they are at risk for so many things, it would require the whole internet to put together a complete list.

Payment per episode should be close to $2,200.00 if you have a modest amount of therapy.  It should be higher if a high percentage of your patients have therapy.  If it is lower, one of two things is affecting it.  The first is that the majority of your patients are old.  I guess technically they are all mostly old but I am referring to length of time on service with the agency.  The second reason may be because the nurses are underscoring in the OASIS dataset and time and education is required to do a complete and accurate assessment.

Now, if your administrator says that they are making a whole lot more than the average or if they say they will go ahead and write the supervisory visits or if they mistakenly believe that they are too large or too small to ever be of a concern to the feds, you need to take a hike.  It is Christmas.  Spend some time with your family.  Do some baking.  Start the New Year out in a new job.  Can’t afford it?  You can afford it more than you can afford to stay at an agency that cares more about arbitrary numbers than patient care.  Trust me.  I deal with this sort of stuff for a living.

Or have your administrator call me for an unbiased agency assessment by myself or a coworker.  As a consultant, I have the freedom to walk away and not have to worry about a job.

No More Patient Education, Please

Before the New Year, we need to step back and figure out how to add value to our patient care starting at the level of the visit.  This is the only way that we are going to improve outcomes and reduce costs simultaneously.  Both cost reduction and outcomes improvement are imperative for survival in 2012.

One way we can do this is to turn our attention away from patient education.  It does not work.  Every day I read something like, ‘taught to eat low sodium diet.  Pt. Verbalized Understanding.’  I can easily see how such highly skilled care would keep a patient out of the hospital especially when his hypertension has exacerbated three times over two episodes.

In order for our patents to get better, they must change their behavior.  They must develop skills that they didn’t have before.

I love sports.   Once I suffered through an incredibly boring conversation with my Dad (an engineer) about the physics involved in hitting a home run so I know a lot about hitting homers and my Dad knows even more.  Neither of us has ever hit one, though.  My son, on the other hand, regularly hit the ball out of the field (and onto cars passing by but that’s another whole blog about auto safety near ballparks).

Sadly, my son really doesn’t know a lot about physics; nor does he care.  In fact, nobody ever really ‘taught’ my son to play ball.  A couple of men over the years coached my son and countless other boys and young men into becoming competent players.

The first thing that a coach assesses is who really wants to play ball.  Until college, all that’s required to play is willingness.  There are good players and bad players but everyone gets a little better as the season goes on because they like playing ball.

Coaches always build on the basics.  They start off with fundamentals before they move onto more complicated plays.

Coaches set goals.  They obviously like to win but long before the season even starts, they are coaching players to improve their stats a little at a time.

Coaches ‘motivate’ players.  Some of us are a bit put off when coaches call players ‘sissies’ and use language no child under 35 should ever hear but I must admit it is effective.

Finally, there isn’t a coach worth their whistle that doesn’t keep up with the numbers.  Baseball is all about statistics.  Football – not so much – but I guarantee you that every coach knows the number of yards, field goals, etc. that their team accomplished during last week’s game.

How do we apply that to patient care?  Starting at the beginning we have to get our patients to ‘want to be on the field’.  But we also know that less than one percent of people who play sports growing up become a professional athlete.  (We also know that some people willingly play football for Alabama and I can only guess it is because they are desperate for an education or just love football and this blog could not begin to cover that psychopathology).  In other words, for most athletes, the reason why they play is because it adds quality to their life.  So start by finding out what your patient considers important to his or her quality of life.  Here are a few suggestions I wrote a few weeks ago.

Build on the basics.  If you are admitting a patient newly diagnosed with hypertension, what is the first thing that he should know?  For most people it would be how to take medications safely but not always.  Your patient may be obsessive about medications but feels that with all the pills he or she is taking they can eat anything they want.  That would be the first basic need for that patient – adhering to a low sodium diet.

We are very much aware of our nursing goals on the care plan but what about the patient’s goals?  How does he or she know how well they are doing?  Feedback is critical when changing a behavior.  Setting small goals is important so that our patients can enjoy some success on their way to the big leagues and we can intervene when the numbers move too much in the wrong direction.

Obviously, no matter what kind of day we are having, we are not allowed to yell at patients or to call them sissies.  We are not allowed to threaten them, bribe them with money or chocolate (esp if diabetic) or otherwise coerce or harass them into doing what we want them to do.  Isn’t that just like Medicare?  They task us with making homebound patients well and then they tie our hands with all these stupid rights and responsibilities.

So, that leaves us with motivating a patient by turning their goals to our goals.  The patient’s goal may be to get clearance from his MD to drive a car again.  Your nursing goal may be to get the patient to comply with a reduced sodium diet and lose weight.  Work it, baby!  Coach the patient on keeping a food diary and daily weights.  Give the patient tools to monitor his numbers.  Get the patient to practice!  Involve the patient as much as possible.

How many times do you get the feeling that a patient has just given up?  They have tried for years to cope with their hypertension and blood sugars, etc. and quit caring a long time ago.  Let them see some success.  Regularly.  Remember, they may have tried before but this time they have you as a nurse and let that be the difference between past failures and future success.

Finally, keep up with the numbers.  Don’t set a system in place for a patient and never follow-up.  It is a very powerful tool to hold someone accountable for their behavior.  Often, just knowing that the nurse is going to weigh them and look at their food diary and daily weights is enough to get them through a rough spot.  Call them once or twice a week if they have forgotten to weigh themselves in the past week.   Use a free internet text messaging system to text them in the mornings.  Be creative.

As the patient begins to experience success they will undoubtedly enjoy feeling better, too.  Each week, keep adding to their playbook.  Replace one or two visits with a phone call if the patient is doing very well.  This will give you the resources to take care of the patient in the unlikely event of another exacerbation.

When the patient has enjoyed a stable blood pressure for a few weeks and has lost weight and is eating well on a low sodium diet, do not discharge the patient.  Graduate them!  Give them a certificate of recognition for taking back control over the disease process that was controlling them.  They deserve it.  After all, if you did your job right, most of the real work was done by the patient.  You were just the coach.

That kind of care and follow up is something I would pay 120.00 for if my mom or dad needed it.   I would pay a bonus if you were subjected to a spontaneous informercial on the physics of home runs and why an ultra-light baseball bat is important to the process.   I would understand, however, if you quit when he decided it was time that you learned how to use a slide rule.  No one gets paid that much.

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