Posts by Julianne Haydel

This is the blog for Haydel Consulting Services LLC, a full complement of regulatory skills and consulting for small and medium providers. We love regulatory work, change of ownership paperwork, medicare guidelines, OASIS data and teaching nurses.

Pandemic Covid19


It’s tempting to dive into the politics here but nobody ever recovered from anything as a result of winning a political argument. Our immediate needs are to take care of and educate patients, ourselves, our coworkers and sometimes bosses especially if they are not clinical.

The Short List

1. You must protect yourself if you want to protect your patients and those you go home to after work. Nurses in hospitals report seeing people without proper equipment or using. PPE inappropriately headed towards patient rooms Visiting caregivers in home health and hospice have nobody watching them. Have employees demonstrate how to put on PPE so you can be confident they are well protected.

2. Covid19 may not be a one time deal like measles or chicken pox. Those (former) childhood diseases resulted in immunity due to the antibodies formed in response to being ill. Covid19 also spurs the formation is antibodies but they may not protect patients from future infection. This point is important to share with your patients who are recovering or know people promoting this idea. Deliberately catching Covid19 is about as dumb as a bunch of fence posts.

3. Our patients mostly stay at home but their family members may have to work. If this is the case with any of your patients, include the family in your teaching. The working person may choose to stay in their room and, when possible, stake a bathroom that is not shared with other family members. Emphasize to your patient that they are being protected and not ignored.

If your patient has medical appointments scheduled call their practitioner and ask if the appointment can be delayed or if there is something you can do to make it unnecessary for now. Lab and assessment results and medications administered in the a clinic are all within your skill set.

4. If a person is diagnosed with Covid19, there’s a very good chance they were contagious before the onset on symptoms. Likewise, there is a strong possibility that many people infected with Covid19 never have symptoms but have the capability to spread the virus. How fun is that? A stealth attack by a virus residing in an unknown host. Again, this supports the advice to stay at home. Teach patients that they could become infected by having visitors that look perfectly healthy. Set up FaceTime, Zoom, or similar software when smartphones or other technology is available.

Tell your patients on each and every visit to avoid the ER if possible. Give them specific criteria for an ER visit and make sure that the agency and physician numbers are in plain view. If your patient lives alone, make sure they have a panic alert button to summon Emergency Services. Be willing to head to a patient’s house with a syringe full of lasix or call a mobile X-ray company. Not only is the hospital a dangerous place but an ER visit will require use of hospital resources that are in short supply.

5. If you are a hospice nurse, be extremely cautious in. nursing homes. The true number of patients affected by Covid19 in nursing homes may be underreported. In Louisiana, the names of nursing homes that have clusters are no longer being reported.

To be brutally frank, death from Covid19 is worse than death from most other illnesses. The pain management for non-pulmonary patients may not be appropriate for Covid19 patients. It is not okay if a terminal patient contracts the virus. Do not be a vector!

6. There is no known cure or treatment for Covid19. However, we do not prescribe medication. If a patient is prescribed meds that have been re-purposed for Covid19, our job is to teach how to correct administration of meds and possible side effects. Answer questions as directly as possible without coloring them with opinions. If you share a negative opinion of Azithromycin and Plaquenil with patients, their trust in their physician may be damaged and that could cause more harm than the meds.

Covid19 will be an ongoing challenge at least until the end of the year and possibly longer. I expect we will all learn a lot by then.

Meanwhile, we would love to know what you are doing to prevent illness in your patients and staff. Are you able to get appropriate PPE? Are you providing masks for patients? What kind of questions are your patients asking? As an agency, has there been formal education?

We get our best stuff from you so bring it on! You can comment in the comments section or email us directly.

So Long, Therapists


For years we have been reading clinical records from many agencies. Therapy has been overutilized in some and underutilized in others but mostly, therapy use has been responsible.

Medpac and others advising the congress don’t believe that. They have been advising Medicare to do away with payment per visit for therapy for years.

These are mostly people who have never been in a home health agency. They are looking at claims data and OASIS. Their interest is in reducing healthcare costs.

Welcome to PDGM where therapy no longer results in an add-on payment. Medicare is expecting that therapy will be included in the payment rate for diagnoses and functional scores that were typically associated with therapy in PPS.

For example, we made up a patient falling into the rehab group (an ortho diagnosis) with a comorbidity of atrial fib which is a med management cardiac group. The actual diagnosis was a recurrent dislocated hip. Our made-up patient was given scores in the functional domain as follows:

Hospitalization: History of falls, five or more meds, two or more hospitalizations, reports exhaustion.

Grooming: Someone must assist

Dressing: Someone must assist dressing upper and lower body

Bathing: Unable to bathe and requires the assistance of another person to bathe

Toilet Transferring: Can use a bedside commode

Transferring: Able to bear weight but someone must transfer patient

Ambulation: Able to walk with the supervision of another person at all times

Our patient came from a hospital and this was the first admission (institutional; early)

Payment, per the CMS grouper, came to just under $2,700.00 for 30 days with a LUPA threshold of 6.

There are some other considerations but hopefully, this is close enough to convince you that you can afford therapy. In fact, because the patient required no surgery and was likely already knowledgeable about anticoagulation, it would be difficult to justify six nursing visits in the first 30 days.

This exercise in payment is probably pointless for the nurses and therapists read blogs about home health. It is rare for agencies to allow payment to determine clinical care. To be certain, we must all work within the confines of the payment system and it can be done. You will lose a few dollars on some patients and other patients will be more profitable.

Heaven help the patients of those agencies who are motivated solely by payment when a greed ridden owner figures out that payment will not change if they withhold therapy from their patients who need it. If there are enough of those agencies, Medicare will notice that therapy has been reduced and all agencies will suffer another payment reduction. Hopefully, Medicare will be analyzing claims data because outcomes will be slow to reflect changes.

Agencies that have no plans to reduce needed therapy or skimp on care in any way should include advice to referral sources that therapy orders need to be reviewed. When they see no therapy or very little therapy for patients that would benefit, they need to take time out of their day and call or merely alter the care plan. If this becomes a pattern with an agency, the referral source should look for another agency.

We can’t do anything about how Medicare payment policies but we can give our patients everything that they need. There is always going to be a way to game the system but Medicare will catch on and until then, you fight as hard as you can on the front lines for your patients. Like you always do.

Call if you have questions. If you have any sage advice for us as your first claims are going out, we want to know. Leave your comments or email us. And remember, we are always willing and able to help you with your OASIS review and coding so that you get the maximum ethical payment.

Welcome Back, Mr. SCIC


The SCIC is Back

Nurses who did not enter home health until this decade may be familiar with SCIC’s. Maybe they read about them or they were briefly reviewed in orientation. In the early years of PPS, a SCIC or other follow-up assessment changed the payment of an episode. Then it didn’t. Soon it will again. So the Significant Change in Condition; or other follow-up is a thing and it’s about to be a bigger thing.

The Quarterly OASIS Q and A from Medicare state:

When diagnosis codes change between one 30-day claim and the next, there is no requirement for the HHA to complete an RFA 5- Other follow-up assessment to ensure that diagnosis coding on the claim matches to the OASIS assessment. The CoP 484.55(d) does require an RFA 05 when there has been a major improvement or decline in a patient’s condition that was not envisioned in the original Plan of Care. CMS expects agencies to have and follow agency policies that determine the criteria for when the Other Follow-up assessment is to be completed.

The OASIS User Manual defines ‘RFA-5 other follow-up’ as:

… comprehensive assessment is conducted due to a major decline or improvement in patient’s health status occurring at a time other than during the last five days of the episode. This assessment is done to re-evaluate the patient’s condition, allowing revision to the patient’s care plan as appropriate.

With 30-day claim periods and 60-day OASIS intervals, there may be changes in your patient’s condition causing your patient to need more care that are not reflected in payment. If this occurs during the first claim period, the SCIC assessment is a way to increase payment for the second 30-day claim period. The claim period will only be adjusted if the date of assessment occurs prior to the 30th day.

So, in crafting or revising your SCIC policy, a good place to start would be with the OASIS questions that will affect your outcomes and payment – particularly hospitalizations. Currently, you must collect information on hospitalization risk and it will affect payment. Why not include factors that might increase the patient’s risk for hospitalization?

  • One or more falls
  • Unintentional weight loss of a total of X pounds (contingent upon base weight of patient.)
  • Any hospitalization, ER visit or MD visit that results in a change in orders.
  • Persistent decline in mental, emotional, or behavioral status.
  • Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) that is not corrected within two weeks with patient and caregiver education.
  • New medications that require teaching
  • Exhaustion that was not present on admission and does not result from exertion such as family outing or holiday.

All of these criteria have the potential to change the case mix weight. And remember that the Conditions of Participation state that risks for hospitalization should be on the care plan along with interventions on how to mitigate those risks.

Crafting a policy around two mandates already in effect will result in a policy that doesn’t require a lot of extra work to teach or monitor.

Should you have any questions or comments, please email us or leave a comment. If you have a different idea, we are open to hearing it.

PDGM for Nurses


This brief overview is directed specifically to nurses and therapists who will be completing the OASIS assessments that will determine payment. This is not a complete guide to PDGM but it is important for the field clinicians.

You work hard. Get paid.

A PDGM Primer


It’s almost time for PDGM, the payment system that could dampen our holiday spirits if agencies are not ready. As you can see by the chart below, provided by our friends at CMS, the HIPPS code, which determines payment, will be calculated a little differently than the current PPS HIPPS code.

Position 1 will refer to a new 30 day billing cycle and only the first 30 day period of care will be considered ‘Early’.  Bring your billers Starbucks or Redbull.  They will need it as twice as many claims will be dropped.  And yet, OASIS will still be collected on the same 60 day cycle.

Look at next column. There are 12 different groups into which patients will fall according to their diagnosis codes. Most agencies have certified coders (presumably us) and the assessing clinician’s job is to provide accurate assessment information to assist The Coders in finding the correct codes and sequence. Many codes that are currently used will not be accepted as primary in PDGM and The Coders will be searching for clues to refine the diagnosis codes.

The source of the episode is not very flexible but agencies can change marketing strategies to try to increase the number of patients admitted post hospital. Understand that refusing community referrals that meet your admission criteria policy to improve your ‘numbers’ is highly unethical and possibly illegal. But, if you have a very high percentage of community admissions, there is nothing wrong with increasing marketing efforts to surgeons and other physicians who typically admit patients directly after a hospitalization.

elderly-folksThe admitting clinician’s largest contribution to payment is the functional domain which has been chronically under assessed and given the least attention of all payment elements. Many agencies will be leaving money on the table and risking denials for homebound status if nurses and therapists don’t know how to respond to the questions make up the functional status. There are eight OASIS questions used to in the PDGM calculations and seven of them are the functional domain questions.

The first place to start is teaching and reteaching the Conventions for completing OASIS. The can be found in Chapter 1 of the manual. They haven’t changed since the advent of OASIS but as new clinicians rotate in and out, they are often overlooked in orientation. The ones that are misunderstood are sandwiched between statements of common sense. Here are two that are frequently misunderstood (without wonder).

  1. Report what is true on the day of assessment unless a different time period has been indicated in the item or related guidance. Day of assessment is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home.
  2. If the patient’s ability or status varies on the day of the assessment, report the patient’s “usual status” or what is true greater than 50% of the assessment time frame, unless the item specifies differently.

These two conventions could mean that some of your patients who had a procedure the day before admission are being underscored.  Misunderstanding them  could also cause a nurse to underscore a patient if they simply record what is true at the time of the visit. (Read about a real life example from 2009 here.) Sundowning generally occurs after the nurse’s visit. Add a sleeping pill at ten PM and it could be true that the patient wasn’t safe to get to the restroom independently for over 12 hours of any given day. Agencies can improve OASIS scoring and ethically increase payment by understanding these two conventions.

Here are two more.

  1. Understand the definitions of words as used in the OASIS.
  2. When an OASIS item refers to assistance, this means assistance from another person. Assistance is not limited to physical contact and can include necessary verbal cues and/or supervision.

The definitions of words as used in OASIS often varies from normal everyday use. This is why seemingly intelligent employees sometimes answer OASIS questions incorrectly. Consider OASIS question m2020 that investigates the patient’s ability to take all oral medications but when you read the OASIS manual it instructs us to consider the medication for which the most assistance is needed when selecting a response.  (Why the bold, italicized font if the definition of ‘all’ wasn’t ‘all’)

If a family member must constantly remind your patient to use a cane, that is considered assistance. If someone must remind them to eat, they need assistance.

This information is from the official OASIS Guidance manual. It is not an invitation to upcode. Rather, it is a warning to not leave money on the table. Don’t wait until PDGM to teach and reteach these conventions. Start checking admission paperwork now and educating the nurses and therapists doing your admissions when you see contradictions between the chart and the OASIS. Good agencies work hard to provide care to patients and deserve to be paid. We have friends and colleagues working in the field and we see how tired they are at the end of the day.

If you have any questions, do not hesitate to contact us. We are always available to check your OASIS and ICD-10 coding but for now, pull ten charts and see if the functional domain questions are answered in accordance with these conventions.

Don’t worry.  We’re making this adventure with you and will post more information next week.

Predictive Analytics


I just saw an advertisement for a company offering predictive analytics so that within minutes after the clinician inputs data, predictions are made. It even tells you how many visits will result in a good outcome and what kind of visits those are. There’s another tech company that guides you to better allocate your resources (you are the resource, by the way).

Although I love computers, I wonder if we are trying too hard to substitute computer data for critical thinking. Using computer predictions to determine how much care should be delivered has too many opportunities to fail, and failure in nursing harms patients.

The algorithms in this and other programs are based on thousands of patient episodes. In theory this is good. Validation is achieved by the repetition of results across many occurences. TUG tests and PHQ depression assessments are validated but those results are not influenced to any great degree by data that we are unable to measure.

So, agency owners who are interested in these data crunching, predictive programs might want to ask what information goes into making these predictions and what variables can influence the data. OASIS and basic assessment data is readily available but OASIS does not ask about income or education level; both of which influence a patient’s response to care provided. Typical assessment data does not provide insight into family dynamics or how far it is to the nearest grocery store, hospital or their MD office.

If nurses surrender their own critical thinking to these programs, they are primed to violate the most fundamental of nursing standards by not individualizing care for the patient. Only the assessing clinician can do that. If non-clinical managers use these programs to determine the value of a nurse, he or she may end up on the radar simply for providing the patient what is needed.

I have never seen a computer program brought before the board of nursing or any of the therapy boards. If the computer advised the nurse to insert a knife into the eye of the patient, the computer would not be held accountable for the resulting loss of vision. The nurse is and always will be ultimately responsible for the nursing care rendered to the patient.

The legal implications are enough to make me glad I am not a lawyer and cannot give legal advice. That’s not to say you won’t wish you had called a lawyer before you allowed a computer to make clinical decisions for you.

I am an information junkie. If I had access to one of these programs, I would play with it the way Sheldon and Leonard played Halo on Wednesday nights. But I don’t think that is how this predictive technology will be used. My fear is that clinicians will be judged on how many visits they provide and whether the number falls within the computer generated parameters. I am afraid that careplans will be altered to accommodate an algorithm, and the patient will receive care they do not need or not receive care they do need.

There are no recipes for patient care – add five visits and a teaching guide for diabetes; stir well and season to taste with footcare. The best software helps clinicians care for patients. A good system frees up time by handling non-clinical tasks and minimizes the work of complete and accurate documentation . (No routine visit nursing note should require 20+ pages when printed.) Documentation in the home during a visit is ideal but not if it puts the computer between the patient and the clinician. Making information available when needed is much different than a Where’s Waldo game to locate vital signs in a sea of useless information.

Most State Boards of Nursing have a statement similar to the below taken from the Louisiana State Practice Act:

The standards are based on the premise that the registered nurse is responsible for and accountable to the individual for the quality of nursing care he or she receives. Documentation must reflect the quality of care.

If you are unable to find a similar statement in your state’s practice act, look for one that says:

Computer directed nursing is acceptable should the nurse not feel up to thinking critically.

You probably won’t find anything like that. Registered Nurses are able to delegate tasks but never responsibility.

If you have a different opinion, we’d like to hear it. Please email or leave a comment. And remember, we are information junkies and do not want to go into flagrant withdrawals but we also think you can do a better job of caring for patients than any software, anywhere, anytime.

And we can help. We have coding and OASIS certified nurses ready to review your admissions and give you the information you need to craft a care plan.

Happy New Year!


Welcome 2019! If you have performed or reviewed any OASIS assessments since the beginning of the year, you may have been taken aback by the number of changes in the dataset. While its true that more than twice as many questions have been removed than have been added, the questions added have multiple parts and are quite different from the traditional OASIS C questions.

After being immersed in OASIS-D for a couple of weeks, I decided to rest my weary mind today and look at a chart created for a patient who broke her hip. She was admitted to the hospital where she had an ORIF followed by a rehab and then SNF stay. Guess what I found? All the OASIS questions that are new to Home Health Care. This proves to illustrate the ultimate goal of standardization across post acute care providers described in the IMPACT Act. Very simple math will let payor sources know which providers are making patients better. And of course, they already know how much providers are paid. This could be a true advantage to home health. If we can achieve results that are equal to or better than other providers, Medicare will favor home health as providers because we cost less.

The good news is that therapists should be easy to train. In fact, CMS invites a multidisciplinary approach to the OASIS-D assessment and therapists might be the key to getting it right the first time.

The new questions are not difficult but they will require time and thought in order to arrive at the correct answer. There’s a new type of fall to be counted; the intercepted fall where a patient is caught by another before they hit the ground. Witnessed and unwitnessed falls will be documented so like most good agencies, falls will be assessed on each visit. Hopefully, reports will be engineered by software vendors so that you can run reports from your software. OASIS data will tell you how many falls were experienced, what kind of falls they were, and if there was an associated injury. QA will be easy although it is possible that an initial uptick in the number of falls will be the result of constantly assessing. Be sure to count each fall only once.

Mobility has subsections A through S. That’s almost an entire alphabet. The questions are interrelated but each one needs an answer. Only one goal is needed.

The Coders has education available for your agency. Contact us and we will find a day we can spend with your staff educating them about the magical powers of OASIS-D.

To find out if you need additional training, take our OASIS-D Quiz.

And until you are confident that your agency is proficient in the OASIS-D updates, we are always available for OASIS review and/or coding.

Good luck. More later.