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Posts tagged ‘julianne haydel. haydel consulting services’

What are you doing for others?


“Life’s most persistent and urgent question is, “What are you doing for others?'”

Today is the celebration of Martin Luther King Jr.’s birthday. Some of us will go to work as usual and others will enjoy a three day weekend and the majority of us will remember Martin Luther King, Jr. as someone who shaped our nation and inspired us to be better people. I know that he was not perfect but that’s okay. What he stood for and taught was perfect. According to the internet, even Mother Teresa and Gandhi had flaws.

As healthcare workers, we can answer the question posed by King on a daily basis. What are we doing for others? We take care of sick people; elderly people; the most vulnerable individuals in society. We have noble professions. We save lives and help people die peacefully in their home surrounded by family and friends when the time comes. We are compassionate. The support staff that ensure that nurses continue to have the ability to take care of patients are equally as important. We have answers to Dr. King’s question.

But can we do more?

In the spirit of Martin Luther King’s devotion to equality for all, we need to recognize that Healthcare disparities are very real. I am not talking about genetic factors that predispose various races and ethnicities to certain conditions but rather how long it takes someone to receive help and what happens after they are diagnosed.

Black Americans are three times more likely to have a leg amputated related to diabetes than their non-hispanic white counterparts. Areas in the rural south are most vulnerable. I did not need a study to reveal that little secret. The study alluded to the fact that Black Americans are less likely to have their total cholesterol screened and seek treatment later. Another study revealed that they are often checked for diabetic retinopathy later. Still more surprises.

The American Cancer Society reveals that the cancer death rate among African American men is 27% higher compared to non-Hispanic white men. For African American Women, it is 11% higher than non-hispanic white women. This study didn’t allude to any underlying cause but I doubt it has to do with early diagnosis or prompt treatment.

Hispanics have higher rates of cervical, liver, and stomach cancers than non-Hispanic whites.

Non-hispanic whites have a much higher incidence of death from heroin overdoses.

The list goes on as most of you know.

Martin Luther King, Jr. also said, “If I cannot do great things, I can do small things in a great way.”

If you are unable to establish equality in healthcare for everyone, start with your patients. For some, that might mean writing a list of screenings to take to their MD so they can be ordered or results reported to the agency. It might mean arranging transportation for Medicaid patients because getting to the doctor is difficult for rural patients. You might include the family in teaching about exercise to improve circulation to the lower extremities and even encourage them to walk together (because you nailed diabetic foot care). Learn some of the ethnic foods eaten by your patients and help your patients determine a healthy way to prepare them. Be creative. Individualize your care plans.

Statistically, your patients don’t amount to a hill of beans and the changes you effect won’t alter the statistics but your patients are not statistics. Leading a patient and their family to the changes that will forever improve the quality of their lives is a small act of greatness.

Making Time


It’s lonely being a Director of Nursing – doubly so when the agency Administrator is not a nurse.

There are subtle differences between states on the responsibilities of the Director of Nursing but together with the Clinical Supervisor’s role outlined in the Conditions of Participation, it is clear that a DON is responsible for almost everything that happens in a 200-mile radius.  These responsibilities include but are NOT limited to:

  • Oversight of all clinical personnel and all clinical services
  • Making sure that all patients have care plans
  • Patient Assignments
  • Developing and overseeing clinical policies and procedures
  • Infection Control
  • Quality Assurance
  • Staff education
  • Compliance
  • Hiring staff
  • Ensuring that all admission procedures are followed

That’s a pretty daunting list so I hesitate to say it is incomplete but… it is.  Although the tasks can be delegated the responsibility belongs to the DON alone.  Going to a non-clinical administrator about infection control or required education for staff may be a fun way to spend an afternoon but the surveyors will look to the DON for answers.

Before you quit your job and punch yourself in the face for accepting the responsibilities of the DON position, relax.  It can be handled and is handled every day by nurses who are no more skilled than you.

Like most overwhelming jobs, the position of DON is easier when broken down into smaller pieces.  It is also easier if you identify all the impediments to doing your job well before you try to do it better.

Time Management

  • Open Door Policy – this sounds really good in company sound bites and recruiting campaigns but an open door policy can wreak havoc on your day. Instead, hold office hours like college professors do.  This doesn’t mean that nurses cannot interrupt your day for urgent matters but all non-urgent matters should be conducted during office hours.  During office hours, your visitors should have your full undivided attention.  If you want to make notes, wait until after they leave and write down your thoughts while still fresh in your head.
  • Meetings – Meetings are important but after a point, they become time-wasters. Eliminate all meetings that are not necessary and be prepared for necessary meetings.  Meetings should start on time.  Invite participants to arrive a few minutes early if they want to visit with coworkers.  Clinicians who are unprepared at case conference will be obvious.  Don’t rescue them.  After they flounder in front of their peers once or twice, they will be able to fully participate.  Or not.  If an adult cannot be responsible and prepared for meetings, maybe you should rethink their position in your company.
  • Delegation – most tasks of the DON can be delegated. Delegation consists of two parts – one is assigning the task and the other is the oft forgotten follow up.  Survey is a very bad time to find out that a nurse performing utilization review did not understand the process.   Send yourself an email to follow-up on an assignment you delegated.  Was a nurse tasked with collecting data for infection control?  Write it on your calendar to check in with the nurse in a month.  Look at the work done.  This takes a lot less time than trying to recreate data during a survey.   Taking the time to schedule QA, OASIS transmission, annual advisory board meetings and other infrequent but mandated events will reap an enormous return on investment.
  • Set aside some time each day when the phone does not ring in your office. Have the receptionist screen the calls and take messages.  Only take calls from patients who cannot be helped by their nurse, and referral sources.  When this policy was implemented at one agency, about half of all phone calls were handled before they got to the DON.

Hiring Process

 Learn how to interview potential candidates for a job. Listen to what they have to say.  Monster. com has a list of the 100 Most Asked Job Interview Questions. Consider asking candidates to teach you about falls precautions or injecting insulin as if you were a patient.  (Note:  do not ask about what kind of care they drive as suggested on Monster.  Ask what kind of car they dream about owning.  Avoid candidates who name a grey sedan.)

  • Schedule all interviews on the same day and set a mental timer to reduce the amount of time you spend on each interview.
  • In larger agencies, consider deferring the initial interview to a case manager who will be the direct supervisor of the new employee.
  • In all agencies, schedule a second interview that includes various people the candidate will work with on a daily basis. Your current staff is more likely to support a new employee if they endorsed the initial hire.

Staff Education

  • Get someone else to provide education to your staff. Call on drug reps to teach your staff about new and trendy drugs.    Get the wound care folks to teach about wounds.
  • Involve staff by assigning a five to ten-minute presentation on compliant documentation, a new drug or a condition not seen very often in your area to begin each case conference. (Note:  You can start to identify the next case managers or even your replacement by observing how well prepared they are and how comfortable they are talking to their peers.)

Perks of Managers

Setting up your work environment to allow for focus and completion of the tasks and follow-up on coworker’s projects will leave you feeling accomplished. Your stress level will automatically decrease as deadlines are no longer looming over you.  Your ability to trust your staff will improve when you follow-up up on their projects allowing you to appreciate the support you have.   Most importantly, you’ll get home in time for dinner with the fam.

Got any other ideas?  Post in comments!

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.

The Z-Factor

Nurses have been trained to not bother physicians, especially referral sources with petty concerns. But, there is a balance between irritating a physician to the point that your competitors gain a new referral source and responsible patient care. If you have to choose, go for responsible patient care.

Read more

Physical Therapy Goals


The following is from a denial a client sent last week.  The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document.  That denial was overturned in favor of my client but the claim was denied again for a new reason.  You have to see this in order to believe it:

Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.

So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals. 

Did you happen to notice that the entire course of therapy was three weeks? 

Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted?  That really gets under my skin.

In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document.  They agency lost a full round of appeals before the reviewers found something else wrong with the chart.  Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met.  I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal.  In actuality, there were five of these I worked last week.

You have two choices.  First, you can write a short term goal or you can write a very long term goal.   The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged.   I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed.  Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?

An alternative solution would be to write a goal or two for the first visit or first week of therapy.  Some examples that come to mind from who knows where because I am not a therapist are:

  • The patient will agree to participate in their course of therapy by the end of the first visit.  (Chances are this is pretty accurate if the patient allows you in for a second visit).
  • The patient will have all prescriptions for pain filled prior to next visit.  (I do not like the way it sounds when therapists work with un-medicated patients.)
  • The patient will have DME delivered by end of day 4 of episode.  (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.

I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh.  I assure you that is not the case.  All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation.  Be bold about it.  Include page numbers.

I would be interested to hear what is happening in your offices.  Has anyone else seen denials like these?  If so, what contractor?  (Palmetto, NGS, CGS, etc.)  Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below. 

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