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Posts tagged ‘Home Health Nursing’

Apr 1

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How to Bomb a Survey

Agencies often ask what they can do in order to pass survey. Frankly, there’s so much to do in order to pass survey that it is easier to ask how to bomb survey. And I have firsthand knowledge on how to completely bomb a survey. Follow the instructions below and it is almost guaranteed that you will find yourself in survey hell shortly after the state comes knocking on your door.

  1. Hire anyone who is available. Do not waste your time checking references or verifying licensure. Supervise staff only when convenient. Play ignorant when you learn that the DON doesn’t have the required experience to be in position.
  2. Honesty may be the best policy but not if you want to bomb survey. Give a surveyor just a hint that you might be fudging on the facts and your survey will go south in a heartbeat.
  3. Show your creative side by manufacturing notes and documents as they are requested from the surveyor.
  4. Explain to the surveyors that your referring physicians are too busy to address patient problems so you haven’t actually contacted any of them when blood sugars fall or blood pressures rise.
  5. Write your therapy frequencies after the visits are made to ensure they are accurate.
  6. Admit numerous patients from physicians who are not licensed to practice. This strategy works best if you can produce documentation that you tried to verify their license but couldn’t find their name in the Medical Board’s database.
  7. If you are the Director or an owner of an agency, distance yourself from the staff by calling them stupid. It will make you look brilliant and undoubtedly cause questions about agency leadership ensuring poor survey results.
  8. Explain that your hospitalization rate is higher than state average because your on call nurse drinks most weekends and you have no choice but to send your patients to the hospital.
  9. Refuse to let the surveyors in the door. I’ve only seen this once (not our client by the way) but thus far, this technique has a 100 percent success rate when it comes to having a license revoked.
  10. And obviously the easiest and surest way to bomb survey is to forge signatures.

If you refuse to follow these guidelines, it is entirely possible that you will pass survey regardless of how many honest mistakes you have made. When it comes time for survey, agencies that tend to their patients’ needs, pay close attention to documentation and are open and honest with surveyors usually pass. Deficiency free surveys are bragging rights but an honest survey with one or two tags that don’t relate to patient care is a huge success.

So my best advice to anyone seeking to pass survey is just breath. It will be fine. You really have to put some effort into bombing a survey if you take good care of your patients and your documentation matches what you do.

Please note that Haydel Consulting Services LLC does not enter into business relationships with agencies who wish to fail survey. For other purposes we can be reached at Haydelconsulting@bellsouth.net or at 225-216-1241.

Mar 23

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Getting Ready for OASIS-C

Anyone who has been in home care for any length of time knows better than to change all their processes for changes slated to occur in nine months. And yet, if you have been in home care that long, you know that waiting to the last minute is also not a viable option. The question I am facing with my clients currently is how to prepare for OASIS-C now so that when it is time for complete implementation it won’t be as painful. The answers I want to give are those that benefit the agency now and will ease the pain of OASIS-C implementation.

Below are five things that you can do now in order to prepare for OASIS-C. More than ever we want your comments so that we can add to the list for everyone’s benefit in the coming weeks and months.

  1. Implement a ‘real’ fall prevention program. Monitor results. Fall Precautions are about more than removing throw rugs! Get physical therapy and occupational therapy involved.
  2. Assign a staff member to begin preparing for next year’s flu season so that a plan exists to monitor the vaccination status of all patients. Prepare consent forms and order templates to ensure that your staff are ready to attack the flu head on in October.
  3. Call your wound care supply vendors. Ask for education. An abundance of programs are out there, free of charge to agencies. Wound care needs to be taken to the next level in home health.
  4. Run a list of all patients with heart failure as a diagnosis. See if your agency is weighing patients, monitoring electrolytes, and preventing hospitalizations. Design a program to meet your agency’s needs.
  5. Begin use of the PHQ-2© Pfizer Depression screen or determine the screen you will be using and implement now.

This list is just a beginning. But hopefully everything on this list will benefit patients beginning now. It is simple and can be fully completed within a month. Hopefully by then, we can publish another to do list.

Please comment below or send emails to Haydelconsulting@bellsouth.net.

Mar 18

Ten Things about OASIS-C

  1. Say Goodbye to MO numbers. We now have M numbers.
  2. Most of the assessment numbers have changed completely from what we are used to.
  3. The question that has replaced MO440 about the presence of a wound or lesion has been modified to specify skin lesions and open wounds receiving intervention by the home health agency.
  4. Those of you expecting the time for assessments to be increased may be pleasantly surprised. With the exception of the transfer assessment, other OASIS assessments have been increased by one or two questions only.
  5. The date of referral is now an OASIS item. Could it be that someone is interested in seeing if your agency admits patients within 48 hours of referral as mandated by the Conditions of Participation?
  6. MO660 assessing the frequency of disruptive behavior problems has been assessed with M1745. M17454 reads: Frequency of Disruptive Behavior Symptoms (reported or observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardizes personal safety.
  7. The OASIS-C dataset asks about ‘formal’ screens for depression, pain and pressure ulcer risk. This does not refer to attire.
  8. Vaccination status will be assessed. Note that the flu season is October 31 through March 31. If your agency does not have a flu vaccination program then many assessments in January will reflect that your patient has not received a flu vaccine.
  9. Actual wound measurements are included in the dataset
  10. A comprehensive Care Management Grid is included as part of the assessment that covers ADL/IADLs, meds, treatments, equipment manager, supervision and advocacy.

We are preparing education material for agencies to help them get ready for OASIS-C. Look for updates next week. As always we welcome your comments and questions below in the comments section or by email to haydelconsulting@bellsouth.net.

Feb 26

2 Comments

The Intoxicated Patient

This week, I was visiting with a client and read a Resumption of Care assessment where the nurse had charted that a patient had, “a strong odor of alcohol, slurred speech and problems with balance”. I thought this was a very appropriate description of a patient who was ‘drunker than Cooter Brown’. Further on in the assessment that I noted very minimal, if any, impairment documented in the functional domain. The patient used a cane but was able to transfer, bathe, and dress independently.

This became a lively debate at the agency that day. The patient who had been on service long before his readmission was capable of living independently in the home. He had not been drinking prior to the hospitalization but had a history of alcohol abuse and liver disease. One nurse said that because alcohol impairment was temporary and he was able to perform these tasks on a regular basis, that the chart should reflect his usual ability more than fifty percent of the time.

Another nurse stated that the patient had a prior history of alcohol abuse that it was unlikely that this was an isolated event and thus the patient wouldn’t be safe the majority of the time in the future.

I just sat in the corner and wondered if ever the day would come when I heard everything. But as I thought more about the issue, it occurs to me that many patients are temporarily impaired on a regular basis, not just the occasional patient who abuses alcohol. This could be the result of pain medications or anesthesia/sedation after an outpatient procedure or varying abilities secondary to a disease process. Therefore, even though we don’t get many intoxicated patients, the answer was very important.

Here is what the OASIS manual, chapter 8 says about scoring the functional domain questions:

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to do on the day of the assessment. If ability varies, choose the response describing the patient’s ability more than 50% of the time.

The time period being assessed is the day of assessment. So if a client is able to perform a task more than 50 percent of the time on the day of assessment, questions would be answered accordingly. A patient who awakens with pain in the mornings might not be safe to bathe or dress independently for an hour or so until pain medication takes effect but assuming the medications do not have side effects, the patient would be able to safely perform the tasks mentioned more than 50 percent of the day of assessment.

Conversely, a patient who is admitted following an outpatient procedure where strong sedatives were used might not be safe to bathe or dress independently for the rest of the day. In this case, the degree of functional impairment should reflect the patient’s ability under the lingering effects of sedation.

Patients taking powerful narcotic pain relievers might also be temporarily impaired. The key to answering the questions in the functional domain is how often the patient requires narcotic pain relief.

In recent clinical work, we have clearly uncovered the need for additional OASIS/PPS training. In the next week, we will be making available web based training for all clients and other interested agencies. Please email us at haydelconsulting@bellsouth.com if you have an interest in providing additional training for your clinicians.

As always, your comments, stories and questions are most welcome.

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.
  • Phone calls after MD visits
  • Phone calls when there is a change in caregiver situations at the house
  • 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.

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