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Posts tagged ‘home health’

Five Things 5 Days at Memorial gets Right

Seven of the eight episodes of 5 Days at Memorial have aired and thus far it stays true to Sheri Fink’s book of the same name. So far, the Apple TV series has gotten five things that may be relevant to us absolutely correct.  I recommend that you all watch the series or read the book and then talk about it in your next Emergency Preparedness table meeting.

  1. A strong leader from your organization must be chosen before a life threatening emergency occurs because regardless of what you have done, a strong leader will assume authority.  It would be in everyone’s best interest if you approved of the person. At Memorial, Anna Pou, an EMT assumed control for both Memorial and Life Care which was an LTAC leasing space from Memorial hospital. Do you really want a doctor you don’t  know or who has no affiliation with your agency running your show?  
  2. If you are fortunate to have ample warning of a natural disaster, encourage your patients to move.  Move them out of your service area if that’s what it takes.  Lose money if necessary.  For the sake of comparison, I had an LTAC client that leased space on the top floor of a building across the street from Memorial.  Prior to the storm, they moved patients to Baton Rouge. It was expensive and most inconvenient but everyone was safe.
  3. Communication sucks before, during and after a disaster.  There is no other way to state that in a ladylike or professional manner. As soon as there is an inkling of a possibility of a disaster on its way, the employees need to call the patients and families and find out where they might be should they evacuate.  Although this information is part of the admission process, things change.  For weeks after Katrina, we were getting emails from people looking for relatives and loved ones.
  4. Plans fail.  Katrina was likely a category two storm when it hit New Orleans down from Category 4 or 5 while it churned in the Gulf.  Everyone was fine the next day.  It was around mid morning when the first trickles of water from a breached levee started to flood the street.  A city prepared for a storm ended up suffering from some of the worst flooding in history.  The generators in place to maintain power were under water. Focus on keeping your patients foremost in your plan and don’t try to anticipate how a disaster will evolve.
  5. Even though plans fail, it is important to have one.  If you work for an agency or hospice provider, be available if there’s any way possible.  Know what the plan is and if you are knocked off course by an unforeseeable event, at least you will know where you should be and can work to get back on track.  

Many of you are wondering why I am stating the obvious.  It’s because many people don’t learn.  Last year, Hurricane Ida hit and one nursing home owner, Bob Dean, thought it would be a good idea to warehouse almost 800 people in a warehouse.  It flooded and the patients were moved to a dryer area.  Most patients were side by side on wet mattresses that were touching with no room for nurses to get through.  Eight people died as a direct result and more died in the following weeks.  It is impossible to care for 800 elderly patients in a dark warehouse with no electricity or running water. Bob Dean felt he was treated unfairly when his licenses were revoked.  When that was largely rejected by the public he went on to say that he suffered from temporary Dementia.  He thinks his licenses should be restored.  Maybe if he hadn’t been visiting friends in the cool dry climate of Connecticut and been out to the unsanitary (to be kind) warehouse, he would have a different opinion.

When we live through a once in a lifetime event, we tend to believe that it is just that – once in a lifetime.  These unimaginable events are exactly that – beyond the scope of our imaginations.  All we need to keep in mind is that bad things happen and our patients come first.

Save The Date

Your comments are needed on the 2023 proposed regulations

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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.

Work Place Violence (and free CE’s)

workplaceviolence_bannerI must say that everyone is pretty good about conducting a home safety assessment. Throw rugs are removed, lights are bright and shiny and and much of the work done by therapists is to reach the goal of the patient being able to safely navigate in the home environment. Geaux, Team!

We’re missing something. What about employee safety in the work environment? Everyday home health and hospice nurses, aides, MSW’s and social workers go into homes where they are separated from the agency and out of view of anyone who might help them. All but the most serious incidents are overlooked.

In addition to the injuries that happen regularly such as sprains, abrasions and other musculoskeletal injuries due to moving patients, these are routinely addressed in orientation and annual inservices. A risk of workplace violence also exists and recent research shows it is more prevalent than you may think.

Homecare workers (n = 1,214) reported past-year incidents of verbal aggression (50.3% of respondents), workplace aggression (26.9%), workplace violence (23.6%), sexual harassment (25.7%), and sexual aggression (12.8%). Exposure was associated with greater stress (p < .001), depression (p < .001), sleep problems (p < .001), and burnout (p < .001). Confidence in addressing workplace aggression buffered homecare workers against negative work and health outcomes.1

The CDC along with NIOSH has published an online Continuing Education course addressing workplace violence for healthcare workers. It is not specific to visiting nurses but does offer useful advice. It also offers 2.4 continuing education credit but if you want the credit, read the ‘instructions for credit on the first page. It is provided at no cost and includes short video clips, written text and discussion questions.

In taking this course, I learned that when adhering to the strict definitions of Workplace Violence, many homecare workers have experience with verbal and physical aggression. We also under report workplace violence and ‘forgive’ our patients. It may be a fact of life that nurses eat their young but it doesn’t have to be and agencies should not tolerate bullying of their employees. Regardless of the kind of workplace violence that takes place, visiting staff may suffer stress, depression, insomnia and burnout as noted in the study cited above. Without support from management, the agency’s morale will deteriorate to the point where nothing gets done.

If you know of any other resources to reduce the risk of workplace violence in the workplace, please share in the comments. Our workplace includes most zip codes in the country and all types of people. Reducing the risk of violence and supporting visiting workers can go a long way to making sure you’re agency doesn’t lose its best employees to burnout.

  1.  Hanson, G. C., Perrin, N. A., Moss, H., Laharnar, N., & Glass, N. (2015). Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study. BMC Public Health, 15, 11.

A 36 Billion Cottage Industry

How home health and hospice visiting nurses can recognize financial exploitation of the elderly and who to call when they do.

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