Home Health Denials


During January to March of this year, the top reasons for denial for Home Health Palmetto GBA claims were published on their website as listed below. They can be confusing in their meaning and so we have attempted to clarify as we understand them.  Without further ado:

56900—Medical Records not received
This has been the number one reason for denials for years. This occurs most often when an ADR is not seen in the system.  Alternatively, it is noticed too late to get records together and sent. To avoid this denial:

CGS encourages providers to use the Fiscal Intermediary Standard System (FISS) to check for MR ADRs at least once per week. To check for MR ADRs,
in the FISS system:

  1. Use Option 12
  2. Enter your NPI number and status/location of ‘S B60001’
  3. ADRs will appear as reason code 39700
  4. The ADR date is in the upper left corner.  45 days from the date of the ADR
    date the claim will auto cancel.

In addition to the above, we suggest:

  1. Uploading the documents when you are able.
  2. Mail the documents with proof of delivery requested.
  3. Track delivery.
  4. Retain copies of everything including the completed ADR.  If you sent by overnight mail five days before the due date and the records are not there two days later, you will have the opportunity to resend.
  5. Use the address and mail code on the ADR.  This is on the last page of the printed document and may differ from the return address on the first page.
  6. Print the ADR from the computer and include a copy with Your submitted documentation.

5FF2F Face to Face Requirements not Met

This should be easy by now but it’s still confusing. Our favorite cheat sheet is the PDF on CGS’s website. Additionally, we see denials that can be prevented by being mindful of the following:

  1. Regardless of the episode within the sequence of multiple episodes, the Face-to-Face document must be included even if it occurred six or more months ago.
  2.  The physician clinic visit or hospital documentation will be used to establish eligibility.
  3. If the information sent by the doctor does not clearly indicate that the patient is confined to the home or the need for skilled services, the agency can supplement the information.  Here’s how.  Send you Admission OASIS to the physician with a request to sign and date it, make a copy, file one in his records and return the copy to you.
  4. Teach everyone in the agency how to evaluate Face-to-Face documents.  You should never come into contact with one without reviewing it.

5F023 No Plan of Care

It is a rare event that an agency omits the plan of care from an ADR.  When an ADR is denied for not having the plan of care, agencies often assume that the mistake is on the part of the reviewer. Look again.  Often this means:

  1. The plan of care was not signed.
  2. The plan of care was signed by a Nurse Practitioner or Physician Assistant
  3. A different physician than the one listed on the plan of care signed it.
  4. The signature was not dated although there is a seperate code for this.
  5. The date of the signature was after the date of billing.

5CHG3 Partial Denial of Therapy

A reviewer will often deny visits based upon an arbitrary number of feet that a patient can walk or problems with individual notes. Because therapy adds significantly to the dollar amount of a claim, these services are an opportunity for Medicare contractors to save a few Medicare dollars at your expense. To avoid these denials:

  1. Document not only how far the patient ambulated but how they tolerated the ambulation.
  2. Take pre and post vital signs.  Document balance and gait disturbances.
  3. Always document pain and discomfort in quantitative measures.
  4. Document any complaints or new orders not related to therapy and report them to the case manager.  Follow up in writing.
  5. Most importantly, request a case conference and schedule discharge when the patient no longer needs therapy.

5FNOA – Appropriate OASIS not submitted

This code means that the OASIS was not found in the repository when the claim was billed.  Palmetto GBA explains this denial code as follows:

Under the HHPPS, an OASIS is a regulatory requirement. If the home health agency does not submit the OASIS, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for those services.

Since this list was generated from 2018 claims, it is unlikely that agencies would receive this denial code in response to an ADR because they are auto-rejected upon dropping the claim.  Yet, this reason for denial is ranked fifth.  If you have received a denial for reason code 5FNOA in response to records submitted in response to an ADR, please let us know.

5T072 – No physician Orders for Services

This denial refers to services provided in excess of what the MD ordered, or services provided before an order was obtained.  This is frequently seen when a physician orders PT to evaluate the patient but there are no subsequent orders. It may also be related to the date next to the nurse’s signature on the plan of care.  Nurses new to reviewing and signing plans of care will often date their signature with the date that the document was signed instead of the verbal SOC date.

To prevent this denial:

  1. If possible (and it should be possible), include therapy frequency on the plan of care.
  2. Consider amending your standard therapy contract to state that the agency will not pay for unauthorized visits.
  3. If the therapist includes the frequency and goals on the evaluation and that is signed by the MD, make a second copy to include with orders when an ADR is received.
  4. Educate and spot check the POCs of new case managers.  If a plan of care is not complete by the first day of the episode and the nurse contemporaneously dates his signature, all days prior to the date indicated are not billable as there are no signed orders.
  5. The same signature and dating rules apply to MD signatures on interim orders.
  6. The correct way to write an order that was received earlier is:
    1. Date the document on the day it was written
    2. Begin the order with, ‘Effective on (the date you received the order)
    3. Date your signature when you signed the document.

5F041-Information does not support medical necessity

This denial is listed twice with the same code.  It is also the easiest one to avoid when clinicians understand and appreciate the importance of their documentation. To avoid this denial:

  1. Read and distribute chapter 7 of the Medicare Beneficiary Coverage Manual.  Review specific topics at case conference.
  2. As much as possible document in the home.  Some patients complain that the nurse spends too much time focusing on the computer.  To prevent that, as you are finishing up, ask the patient if you can sit and document before you leave.  That way, you are not taking your attention away from the patient and if you forgot anything, you are still in the home.
  3. Display some clinical notes that are truly impressive as examples.
  4. Turn off the ability to cut and paste if duplicate notes by a nurse are found.
  5. Read The Z-Factor on the Haydel Consulting Services blog.
  6. If your job is to review notes, focus on what is important. Medicare does not pay for spelling and grammar and there is little virtue in embarrassing your nurses.  Focus on the contents of chapter 7.

Remember that the best reason to document is to communicate the condition of the patient to other clinicians.  You don’t have the luxury of shift change report.

5T070 – Visits/Supplies/DME Billed Not Documented/Not Documented As Used

Although this code includes visits, supplies and DME, Palmetto GBA’s explanation of this denial appears to be limited to visits.

The services(s) billed (was/were) not documented in the medical records submitted in response to the Additional Development Request (ADR). As a result, medical necessity for these services could not be determined.

It looks very similar to a denial for medical necessity.  Palmetto GBA advises:

To avoid unnecessary denials for this reason, the provider should ensure that adequate documentation is submitted to substantiate the medical necessity for all the services billed when responding to an ADR. The provider may submit discipline visit notes and/or a summary of the services rendered for the billing period. If a summary is submitted, it should include the following: (1) the information for the dates of service billed, (2) documentation of the services that “were rendered” by each discipline billed, (3) documentation of the patient’s condition, and (4) documentation of the patient’s progress/response to the treatments/services rendered.

This information appears to be outdated as visit notes are specified in the list of documentation required for ADRs. Our advice is to:

  1. Ensure that the recert and therapy evaluation are included if they were performed prior to the starting date of the episode.
  2. Include lab and other diagnostic tests that substantiate a diagnosis even if is not included in the episode.

5A301 Info Provided Does Not Support the M/N for Therapy Services

The same information that applied to the partial denial for therapy services also applies here so we won’t be redundant and repeat it here.

We hope you don’t need help with appealing denials but we are here for you if you do and to answer any questions about denials you might have received.  We would also appreciate any input if you have anything to add, especially about the denial for OASIS and the denial for Visits/Supplies/DME Billed Not Documented/Not Documented As Used.  Email us at TheCoders@hhcoding.com.

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Don’t Archive Your Agency


When the list of documentation required by AdvanceMed  for UPIC audits included a complete Medicare census, we were confused; or rather, we thought they were confused. Surely they can get their own lists based on any number of databases.
A report by the Office of the Inspector General reveals they are not confused. The OIG has noted that 9 of 28 agencies reviewed had discrepancies between Medicare data derived from claims and Casper and the list provided to surveyors at the time of state survey. It is this list that surveyors use to choose patient’s and they were not inclusive of all patients Medicare has on their lists.
Occasionally a difference of one or two patients can be explained. Many times a ‘missing’ patient is a typo -sloppy but not fraud. Changing out computer systems can be messy. Yet, when an agency presents a list to surveyors that is 150 patients light, equal to 90 percent of their patients, a very bad outcome is lurking on the horizon. Active patient lists that are incomplete ensure that absent patients are not visited by surveyors. In some cases, patients were omitted from the unduplicated census resulting in surveyors being unaware that the patient existed.
The OIG has arrived at the conclusion that while there are many possible reasons for these omissions, some agencies might be deliberately trying to avoid scrutiny for the omitted patients. Honestly, do you feel just a sorry for the OIG because they are only just now arriving at this conclusion?
The OIG also noted that patients were discharged from one agency on the day that the roster was requested by surveyors eliminating them from the ‘active patient’ list. These same patients were readmitted later in the year with no intervening events or claims from other providers such as hospitals, rehab facilities or other home health agencies. There are references a prior report that found frequent discharges and readmissions were often characteristic of fraudulent agencies.
The OIG suggests a couple of possible solutions to ensure that the list given surveyors has not been manipulated by the agency.
  • Instead of using an agency provided list, arm surveyors with a claims list provided by CMS
  • Spot check by asking an aide or a nurse about their patients and determine if all of those patients are on the agency provided lists.
  • Monitor the person in the agency who is running the list from the computer. Doesn’t this sound like fun for both the surveyor and the agency?
  • Conduct a retrospective review post survey using Medicare claims or Casper data.
Obviously you are not going to manipulate patient lists but it will instill confidence in surveyors if you are able to provide accurate information in a short period of time. Because surveys are unscheduled, multiple people should be trained to:
  • Run an active patient list
  • Run an unduplicated census (list of all patients regardless of the number of times they have been admitted. Each patient will be listed only once).
  • Run a duplicated census (the name of every admission regardless of whether the patient has been admitted more than once. This list is longer than the unduplicated census list.)
  • Speak intelligently about any potential flaws in your data and offer a work around. (Your biller should be able to provide a list of RAPs dropped or a referral log from the computer)
I know that agencies have rushed to ‘archive’ records of patients that who don’t have anything good to say about the agency and records that might be train wrecks due to documentation errors or poor care. Surveyors are very much aware that these patients exist. All agencies have at least one or two.
Unless care is egregious, state surveyors will allow the agency to provide a corrective action plan. If the deficiency is a repeat or widespread throughout the agency, you may be subject to financial sanctions and a hold on admissions until corrections are implemented and verified by the state agency.  It’s embarrassing to be certain but rarely fatal.
If you provide false information to the surveyors, you have crossed a line into a whole new level of non-compliance. Your Provider Agreement has been violated and you are at risk for losing your agency’s license or worse. And yes, there are consequences worse than being shut down because you have no license to operate.
Most agencies want to do the right thing. Knowing that the agency down the street with patients who do not need care or are not homebound and yet has a perfect survey while your agency has five or six deficiencies has been known to boil the blood of nurses but at least they know where to focus attention.
The agency that hides patients from surveyors now has a very real chance of being caught.  Depending on how patient lists are compared, it may take a while, too, contributing to insomnia.  If you have archived patients to avoid scrutiny, consider keeping a current passport handy. This could be fun.

 

Conditions of Participation 2018 Home Health Aide Requirements


The section of the 2018 Conditions of Participation pertaining to home health aides is lengthy and detailed and there are good reasons for that.  It is common to read reports of elderly patients who are victimized by their in-home caregivers.  Most of these reports concern Personal Care Services where an aide is in the home for hours each day.  In 2012 report, the Office of the Inspector General called for stringent background checks and greater oversight of these programs.  Since then, over 200 investigations have been opened to ferret out the fraudulent providers and their employees.

Expect that your home health aide services will be scrutinized during survey and should any irregularities be uncovered, it is not a stretch of the imagination to expect that other investigations may result if gross non-compliance or negligence is found.  So, the real question is how do you comply to the letter with the home health aide conditions of participation and the standards that support them?

Here is the Condition and the supporting standards.

Condition §484.80:

All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section.

  • 484.80(a) Standard: Home health aide qualifications.

(1) A qualified home health aide is a person who has successfully completed:

(i) A training and competency evaluation program as specified in paragraphs (b) and (c)    respectively of this section; or

(ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or

(iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or

(iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section.

So there are four ways that an aide can be recognized as competent.  Number 2, according to the Interpretative Guidelines ‘assumes that candidate has had training in the past that addresses all or some of the topics in paragraph (b) of this section. The competency test must address all requirements in 484.80 (c).

Be aware that some states have more stringent requirements for home health aide qualifications.  When comparing federal and state requirements, the most stringent regulation is the one to which agencies will be held accountable.

(2) A home health aide or nurse aide is not considered to have completed a program, as specified in paragraph (a)(1) of this section, if, since the individual’s most recent completion of the program(s), there has been a continuous period of 24 consecutive months during which none of the services furnished by the individual as described in §409.40 of this chapter were for compensation. If there has been a 24-month lapse in furnishing services for compensation, the individual must complete another program, as specified in paragraph (a)(1) of this section, before providing services.

  • 484.80(b) Standard: Content and duration of home health aide classroom and supervised practical training.

(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours.

(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours.

If you don’t provide a program for training, you will want something in writing that verifies that a training program followed these guidelines.

(3) A home health aide training program must address each of the following subject areas:

The following are paraphrased for brevity.  Please check the official guidance before making any changes to your policies and procedures.

  1. Communication skills including reading, writing and verbal skills
  2. Observation, reporting and documentation of patient condition and services provided
  3. Reading and recording temperature, pulse and respiration
  4. Infection prevention and control
  5. Elements of body functioning and changes that must be reported to the supervisor
  6. Maintenance of a clean, safe and healthy environment
  7. Recognition of emergencies and knowing emergency procedures and their application
  8. Understanding physical, emotional and developmental needs of patient population and how to work to address those needs including need for respect, patient privacy and patient property
  9. Appropriate, safe techniques in performing personal hygiene and grooming tasks including:
    1. Bed bath
    2. Sponge, tub, and shower bath
    3. Hair shampooing in sink, tub and bed
    4. Nail and skin care
    5. Oral hygiene
  10. Safe transfers and ambulation
  11. Normal range of motion and positioning
  12. Adequate nutrition and fluid intake
  13. Recognition and reporting of changes in skin condition, including pressure ulcers
  14. Any other task that the Home Health Agency assigns as permitted under state law
  15. The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section.

The new components are:

  1. Communication, including the ability to read and write
  2. Recognizing and reporting changes in skin condition
  3. Ensuring that the aide is trained before doing anything for which competency has not been assessed; example shaving a male patient (or even female)
  • 484.80(c) Standard: Competency evaluation.

An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section.

The competency consists of both oral and written examination.

  • 484.80(c)(1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (b)(3)(iii), (b)(3)(ix), (b)(3)(x), and (b)(3)(xi) of this section must be evaluated by observing an aide’s performance of the task with a patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient. The following skills must be evaluated by observing the aide’s performance while carrying out the task with a patient.

For your convenience, those tasks which must be observed directly during patient care (Subject areas specified under paragraphs (b)(3)(i), (b)(3)(iii), (b)(3)(ix), (b)(3)(x), and (b)(3)(xi)) are:

  • Communication skills including reading, writing and verbal skills
  • Reading and recording temperature, pulse and respiration
  • Appropriate and safe techniques in performing personal hygiene and grooming tasks that
  • include
    • (A) Bed bath;
    • (B) Sponge, tub, and shower bath;
    • (C) Hair shampooing in sink, tub, and bed;
    • (D) Nail and skin care;
    • (E) Oral hygiene;
    • (F) Toileting and elimination;
  • Safe transfer techniques and ambulation;
  • Normal range of motion and positioning

These tasks must be observed in their entirety to verify competency of the home health aide.  The use of mannequins or simulated activity is prohibited.

The Interpretative Guidelines state that the Competency for the remaining tasks may be demonstrated via written or verbal testing or during performance of the task.

(2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section.

To comply with this standard, you must also know what paragraph (f) says.  For your convenience, it is stated almost verbatim below:

 (f) Standard: Eligible training and competency evaluation organizations.

A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years:

(1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; (these are the standards and guidance about training, qualifications of the trainers and inservice training).

(2) Permitted an individual who does not meet the definition of a “qualified home health aide” as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or

(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or

(4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or

(5) Was found to have compliance deficiencies that endangered the health and safety of the HHA’s patients, and had temporary management appointed to oversee the management of the HHA; or

(6) Had all or part of its Medicare payments suspended; or

(7) Was found under any federal or state law to have:

  • Had its participation in the Medicare program terminated; or
  • (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or
  • (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or
  • (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA’s patients; or
  • (v) Been closed, or had its patients transferred by the state; or
  • (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program.

(3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate.

Although other professionals such as therapists may assist in the competency evaluation of an aide, the ultimate responsibility defaults to the Registered Nurse.

(4) A home health aide is not considered competent in any task for which he or she is evaluated as unsatisfactory. An aide must not perform that task without direct supervision by a registered nurse until after he or she has received training in the task for which he or she was evaluated as “unsatisfactory,” and has successfully completed a subsequent evaluation. A home health aide is not considered to have successfully passed a competency evaluation if the aide has an “unsatisfactory” rating in more than one of the required areas.

(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met.

According to the Interpretative guidelines, documentation would include:

  • A description of the competency evaluation program, including the qualifications of the instructors;
  • Documentation that confirms that competency was determined by direct observation and the results of those observations.
  • Documentation that distinguishes between skills evaluated during patient care, and those taught in a laboratory, i.e. using a volunteer or combination of evaluation techniques including direct observation of patient care, skills lab demonstration, written and oral examinations.
  • How additional skills (beyond the basic skills listed in the regulation) are taught and tested if the admission policies and case-mix of HHA patients require aides to assist medically complex patients.

Question:  How many agencies have a ‘competency evaluation program’?

(d) Standard: In-service training.

A home health aide must receive at least l2 hours of in-service training during each 12-month period. In service training may occur while an aide is furnishing care to a patient.  Notice that the standard does not mandate one hour each month.

(1) In-service training may be offered by any organization and must be supervised by a registered nurse.

According to the Interpretative Guidelines, RN supervision means RN approval of the content and attendance at the presentation to ensure that the material is appropriate and consistent with the agency’s policies and procedures.

(2) The HHA must maintain documentation that demonstrates the requirements of this

standard have been met.

(e) Standard: Qualifications for instructors conducting classroom and supervised practical training.

 Classroom and supervised practical training must be performed by a registered nurse who possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home health care, or by other individuals under the general supervision of the registered nurse. 

The Interpretative Guidelines list ‘others’ as follows:

  • Physical therapists;
  • Occupational therapists;
  • Speech and language pathologists;
  • Medical social workers,
  • LPN/LVNs; and
  • Nutritionists

 

The next standard is §484.80(f) Eligible training and competency evaluation organizations.  This standard was referenced above and the content was moved up so you wouldn’t be waiting with baited breath to find out who was and was not able to train and evaluate the competency of aides.

  • 484.80(g) Standard: Home health aide assignments and duties.

 (l) Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist).

 Patients are assigned a specific home health aide by design by considers the skills of the aide and, when possible, the preferences of the patient.  A nurse generally identifies the need for home health need services, but a therapist may determine a need for home health aide services in therapy only cases.  In therapy-only cases the therapist may create the plan of care for the home health aide and perform the supervisory visits.

  (2) A home health aide provides services that are:

 (i) Ordered by the physician;

(ii) Included in the plan of care;

(iii) Permitted to be performed under state law; and

(iv) Consistent with the home health aide training.

(3) The duties of a home health aide include:

(i) The provision of hands on personal care;

(ii) The performance of simple procedures as an extension of therapy or nursing services;

(iii) Assistance in ambulation or exercises; and

(iv) Assistance in administering medications ordinarily self-administered

The Interpretative Guidelines state (at this time) that Assistance in administering medications in this requirement means that the HH Aide may take only a passive role in this activity. This assistance is limited to getting water or fluids for the patient to take their medication.

(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures.

 When an aide is assigned to a patient, it is likely they know a lot about the patient.  Much of this information is not written down due to the formatting of the home health aide documentation tools in your software or the hard copy notes.  Furthermore, home health aides may have limited ability to communicate in writing.  Although they must have the skills to document vital signs, etc., expressing a complex thought in writing is often difficult.  Nurses and therapists should speak often with the home health aides caring for their patients and encourage an open line of communication.  And, home health aides should always be present at team conferences.

  • 484.80(h) Standard: Supervision of home health aides. 
  • If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit.
  • If an area of concern in aide services is noted by the supervising registered nurse or other appropriate skilled professional, then the supervising individual must make an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he or she is performing care.
  • A registered nurse or other appropriate skilled professional must make an annual onsite visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care.

This is new.  It can be condensed as saying that if a problem is found during a supervisory visit, the supervising nurse must return when the aide is performing services to assess the situation.

In the absence of any problems where the supervising nurse accompanies the aide to the house, an onsite visit must be made annually.   Neither the CoP’s or the Interpretative Guidelines specify whether this is per patient or per home health aide.  An annual onsite visit with each aide is a good idea and can be combined with competency testing should you keep no patients on service longer than one year.

(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care.

(3) If a deficiency in aide services is verified by the registered nurse or other appropriate skilled professional during an on-site visit, then the agency must conduct, and the home health aide must complete a competency evaluation in accordance with paragraph (c) of this section.

(4) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements:

 Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional;

  • Maintaining an open communication process with the patient, representative (if any), caregivers, and family;
  • Demonstrating competency with assigned tasks;
  • Complying with infection prevention and control policies and procedures;
  • Reporting changes in the patient’s condition; and
  • Honoring patient rights.

This is considerably different from the check off boxes used in most forms that document that the aide is dressed appropriately and shows up on time.   The person making the supervisory visit is expected to document how these elements were evaluated.  During the routine supervisory visits without the aide present, the six factors listed above must be evaluated.  When the aide is present for the visit, only one through four are documented.

The Interpretative Guidelines further describe ‘maintaining an open communication’ process.  The aide should be able to explain what he or she is doing to the patient, ask the patient open ended questions, seek feedback from the patient and representative (if any), caregivers and family.

(5) If the home health agency chooses to provide home health aide services under arrangements, as defined in §1861(w)(1) of the Act, the HHA’s responsibilities also include, but are not limited to:

  • Ensuring the overall quality of care provided by an aide;
  • Supervising aide services as described in paragraphs (h)(l) and (2) of this section; and
  • Ensuring that home health aides who provide services under arrangement have met the training or competency evaluation requirements, or both, of this part.

This standard does not apply to most of you but if you only have sporadic needs for aide services, it might be a future consideration.  Alternatively, if you have a large agency, it may be an idea to offer aide services under arrangement to smaller agencies.

484.80(i) Standard: Individuals furnishing Medicaid personal care aide-only services under a Medicaid personal care benefit.

An individual may furnish personal care services, as defined in §440.167 of this chapter, on behalf of an HHA. Before the individual may furnish personal care services, the individual must meet all qualification standards established by the state. The individual only needs to demonstrate competency in the services the individual is required to furnish.

That’s it, folks and it is more than enough.  Medicare has raised the bar for home health aide services and your aide services will be at risk unless you raise the bar in your agency.

I wish the changes were not so lengthy and I wish they were more interesting, but they are important.  Read them.  Call us for help, if needed.  If you step up to the plate, your patient care will improve.

The Countdown Begins


Here’s a rundown of the first section of the new Home Health Conditions of Participation.  Check back for additional information.  We’ll be adding more later.  Let us know if you have anything to add.

Patient Rights and Responsibilities

The Condition of Participation concerning patient rights and responsibilities will require that:

  1. The agency must provide information about rights and responsibilities verbally and in writing in a manner the patient can understand. There must be documentation that the agency has complied in the chart.
  2. There must be a complaint log that documents the existence and resolution of complaints about care furnished made by the patient or their representative and family.
  3. The agency must let the patient know in advance of the disciplines that will furnish care, the plan of care, the anticipated outcomes of care and changes in the care to be furnished.
  4. The agency must advise the patient of agency policies regarding disclosure of patient records.
  5. The agency must advise the patient of any financial liability.
  6. The agency must advise the patient of the home health hotline number and explain its purpose, hours of operation.
  7. The names and telephone numbers of specified state and federally funded entities. (See Below)
  8. The right to access auxiliary aids and language services and how to access these services.

Specified numbers

  1. Agency on Aging
  2. Center for Independent Living
  3. Protection and Advocacy Agency
  4. Agency and disability resource center
  5. Quality Improvement Organization

These new and revised rights are in addition to other patient rights that are currently being used so you will have to edit your current forms before January 1.  We expect that most forms will patient rights 2 taken from the regulations and edited slightly for clarity.

We suggest that when the forms are replaced that old forms be removed from the office and archived on your computers so they are not accidentally used in 2018.

Complaints

Another thing you can do immediately is prepare your complaint binder for 2018.  Remember that the complaints that you must record and address are those having to do with patient care and mistreatment, neglect, or verbal, mental, sexual and physical abuse including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the agency.

Anyone employed by the agency in any capacity who identifies, notices or recognizes anything suggestive of mistreatment, neglect, or verbal, mental, sexual and physical abuse including injuries of unknown source, MUST report the findings to the agency immediately and other appropriate authorities in accordance with state law.  Notice that it states the employee who identifies mistreatment must report it.  Be supportive of your staff but keep in mind that the person who suspects any neglect or abuse must report it.

Communication

Every agency who is Medicare Certified has completed a Section 504 packet for submission to the Office of Civil Rights.  The penalty for not doing so is having payment withheld so it’s a The Office of Civil Rights investigates claims of discrimination and assures that healthcare providers and others understand and attest to their non-discrimination policies.

Now the section on limited English proficiency has become a standard in the Conditions of Participation.

If your agency is very old, you may not be aware of what is in the packet but you can obtain sample policies and explanations on the Office of Civil Rights webpage.  If you scroll down to the third section  of the linked page, you can find the tools that The Office of Civil Rights has for Medicare Certified Healthcare Providers.

The available resources that you must plug in such as translators, etc. will vary according to your location.  Now is the time to task somebody with identifying these resources if you haven’t already.

So, here are three new requirements that your agency can address in a week.  Instead of being overwhelmed by all the changes, complete a few to the best of your ability and move on to the next.  Keep checking back for more advice on how to get in a position to be compliant by January and send to us any ideas that you have on how to best comply with the new Conditions of Participation.

Medicare’s Pre-Claim Review Demonstration Project


Imagine if every one of your Face-to-Face documents and plans of care were scrutinized prior to payment.  Would 90 percent of them be found compliant with existent rules?  If a non-clinical person determined that your documentation did not meet Medicare coverage guidelines, would you take their word over your nurses’?  How would you feel about submitting a perfectly valid claim for eligible services and being paid 25% less than your peers?

Agencies in Illinois do not have to use their imagination.  It is already happening through the Pre-Claim Review process.  This process involves submitting plans of care, face to face documents, physician and hospital notes and sometimes more to Palmetto prior to dropping a claim for ‘affirmation’.  Once affirmed, a secret code is given to the agency which is placed on the claim. Without the code, final claims are reduced by 25 percent.

And while Medicare is reporting a 90 percent ‘affirmation’ rate, it does not report that there were over 80,000 RAPs submitted compared to 23,000 final claims.  Agencies are apparently reluctant to submit their pre-claim review documentation.

Because a RaP will be taken back after 120 days if not answered by a final claim, I expect that many agencies are going to drop an enormous number of claims in the coming weeks which means the number of pre-claim reviews will far exceed that ever imagined by Palmetto, GBA.  Maybe Palmetto really can process an additional 60k reviews without any interruption in services to the rest of us.  Maybe; but I doubt it.

In April, Florida will come on board.  Texas, Michigan and Massachusetts will follow at undetermined dates.

Agencies in states other than Illinois might not be impressed with all this stuff and nothing.  They are busy with the changes to the OASIS data set, the impending Conditions of Participation and perhaps their own audits or surveys.  Hopefully they will take pause and consider the magnitude of this demonstration project to understand the egregious nature of this intrusive and burdensome little project taken on by Medicare.

The new conditions of participation expected in July of this year explain that the prior Conditions focused on identifying agencies with poor performance.  The updated Conditions of Participation take a much-needed step away from this punitive approach.  As written in the new regulations:

Ensuring quality through the enforcement of prescriptive health and safety standards, rather than improving the quality of care for all patients, has resulted in expending much of our resources on dealing with marginal providers, rather than on stimulating broad-based improvements in the quality of care delivered to all patients.  

There is nothing about the Pre-Claim Review process that stimulates broad-based improvements in healthcare.   How could the Pre-Claim Review Project be so far removed from the intent of the home health Conditions of Participation?

Consider that the demonstration project is resulting in difficulty meeting the educational demands in Illinois and that resources have already been relocated from Florida to Illinois.  Do agencies in other states have the same access to education as the agencies under pre-pay review?

According to the Medicare Pre-Claim Review Q & A:

The demonstration establishes a pre-claim review process for home health services to assist in developing improved procedures for the investigation and prosecution of Medicare fraud occurring among Home Health Agencies providing services to Medicare beneficiaries.

Nobody can deny that a small number of agencies operate without any regard to Medicare rules and only a passing acquaintance with ethics.  This inconvenient acknowledgment of fraud amongst the ranks does not justify excessive scrutiny on 100 percent of providers.  Somehow it does not seem fair to involve home care agencies in a demonstration project designed to enhance their prosecution.

And yet, agencies who fail to submit documentation for a Pre-Claim Review are put on a 100 percent review – a level of scrutiny previously reserved for agencies operating far outside of Medicare rules for an extended period.

The documentation required for a pre-claim review is reviewed for clerical errors and dare I say, elements that cannot be established with limited documentation by reviewers who are not nurses.  The reason for denial given most often per Palmetto GBA is lack of medical necessity.  We see care plans daily that are very poorly crafted supported by excellent nursing and therapy notes.  Conversely, we see plans of care worthy of a Pulitzer prize supported by 9 visit notes at weekly intervals documenting that a skilled nurse taught meds – presumably meds ordered for the patient but who knows?  Nobody asked us if it was possible to determine Medical Necessity without a complete review of the chart.

In the same vein, we see homebound status documented on visit notes that is contradictory to plans of care.  In one recent chart, we found that a patient was shopping weekly.  On another, a therapist documented the patient was driving.  Sufficient documentation on a plan of care that a patient meets the homebound criteria does not make it so.

But, the reviewers are also quick to note when a signature is not dated or the date of encounter is omitted from the Face-to-Face encounter document.  I agree that dates are an important step towards compliance but lack of a date is often nothing more than an oversight; not a tell-tale sign of fraud on behalf of the agency, especially since it is the physician who responsible for the dates.  If this keeps up, the federal prisons will be filled with healthcare providers who forgot to date a couple of documents.

The burden to the agency is extensive.  On a recent CMS conference call, many agencies reported that the PCR process was costing them $25,000.00 per month.  Another agency stated it was taking them about an hour per claim.  Even if these estimates are overstated, they are still far above Medicare’s estimation that it would take minimal time and expense to get the pre-claim reviews submitted.

If Tom Price is confirmed as the new secretary of HHS, there may be some relief but the Georgia representative will oversee 13 different agencies including CMS, the CDC, the FDA, National Institutes of Health and more.  While he has been outspoken against the Pre-Claim Review Process as a senator it is hard to imagine that the Pre-Claim Review process will find its way to the top of his priority list upon confirmation.

So, who benefits from this circus?  Is Palmetto being honest when they say the project is going well?  Are our patients happier and healthier because of frantic efforts to assemble and transmit paperwork?  Could the resources being consumed by The Pre-Claim Review project be put to better use?  What can you do?

I can only provide an answer for the last question.  The first thing you should do is to contact your elected officials in Washington.  After that, get your care plans and Face-to-Face documents in order because there is now an abundance of reviewers at Palmetto who are fluent at reviewing (and finding cause to deny) them.  If you are in Illinois and have claims that you believe are non-affirmed due to incompetent reviewers at Palmetto, contact NAHC.  Under no circumstances do we recommend ignoring the Pre-Claim Review Process because your state is not in the demonstration project.

Many Thanks to Tim Rowan, founder of the Home Care Technology Report. who has extensively and  investigated the Pre-Claim Review process and its effect on providers.  His articles are linked within the content of this post and you can find additional information on his website.

And of course we want your comments and questions.  You can leave a comment here or email us with questions.  We particularly want to hear from Illinois agencies (after you contact your elected officials).

Survey Readiness


Because you are bright and shiny home health employees with enthusiasm to spare, it goes without saying that you are ready for survey all day, every day.  But just in case you fell behind, here’s a few tips on being ready when those cheerful surveyors come calling.

  1. Make sure your annual advisory meeting is held timely. There is nothing you can do when it’s time survey and your PAC meeting is six months late.
  2. Get your CLIA waiver updated if it within three months of expiration. If it is current, put the expiration date on your calendar with a reminder three months from the date.
  3. Plans of care for all patients should be current and updated and reflect the actual needs of your patients – not just what the computer thinks.
  4. Medication lists should be current. Obviously, you and your colleagues are checking meds on every visit but just in case it never hurts for the DON or QA nurse to spend an afternoon doing supervisory visits and checking medications.  If meds are okay, relax.  If you find errors, implement an agency wide plan to have the meds of all patients reconciled within a week.   After the initial medication campaign, follow up.
  5. Do the QA thing. At a recent Home Care of Louisiana meeting, the state agency responsible for whipping home health agencies in line gave a presentation about what they were finding on surveys.  Although tags were not frequently issued for Quality Assurance plans, almost every other tag could have been prevented by reading notes as they came into the agency against the plan of care.  Consider the difference between seeing a missed visit cross your desk compared to a chart with numerous missed visits.  You must read your charts if you want to know what is in them.
  6. Most importantly, call the physician.   Almost every survey with deficiencies includes at least one tag resulting from a change in the patient’s condition that was not communicated to the physician.  I have spoken with nurses who are unwilling to call physicians because they have been chastised in the past for ‘bothering’ physicians.  Communication is not the same as harassment.  If you reserve phone calls for emergent situations and fax or secured email for updates, everyone can be on the same page without overwhelming the physician.
  7. Consider a coding company. Although the primary purpose of The Coders is to ensure correct ICD-10 codes and OASIS responses, a registered nurse reviews the clinical records to determine what those codes and responses should be.  So, while we don’t specifically look for QA indicators, we notice the more serious omissions and make note of them for the agency.  Another side effect of a Coders contract is that our coders notice when assessments are incomplete or late.  Getting caught up can make an enormous difference for agencies with a backlog.

Notice what is not on the list.  There is no minimum standard for face-to-face encounters.  Surveyors may comment about excessive lengths of stay but rarely is a tag issued for redundant teaching or failure to provide reasonable and necessary services.  The state agencies do not pay your bills.  The hoops you must jump through for payment are in addition to the minimum standards for your state.

Some of you may know some people at an agency that is utterly unprepared for state survey.  If this is a long-standing problem, there is probably not much they can do in a short period.  On the upside, in the absence of patient harm and extreme irresponsibility on the part of the agency, the state will allow for an opportunity to clean up any messes in the form of an action plan.  Or they can pay a consultant to come in and have them write an action plan.  We prefer the latter but you won’t receive an invoice from the state surveyors.  Just saying.

Here’s what you don’t do.  Don’t call a consultant in the weeks before survey is due and expect them to make the changes required for a flawless survey.

The OASIS Day


Friday, we posted a quiz about OASIS.  In the next week or so, we will publish the answers to all questions but one question is being answered incorrectly so consistently that we feel obligated to explain the answer as it is likely costing you money and lowering your outcomes.

56 percent of you missed this question.

Upon admit, Mr. Jones states he is feeling better after a trip to the MD this afternoon. He denies dizziness and is able to walk unassisted with a walker, get in and out of his chair and use the restroom independently. According to his wife, he suffered severe vertigo and vomiting most of last night until he was finally seen late this afternoon. On admission you document:

His ability to transfer based on your observation of Mr. Jones independently getting in and out of the chair.  (50% of you chose this answer)

His inability to walk or transfer, get to the toilet, or bathe based upon his severe vertigo last night and this morning.   (42% of you chose this response)

His wife’s assessment of what he can usually do . (8% of you put your faith in his wife)

He is not homebound because he was able to get to and from the MD.  (Nobody questioned homebound status)

In order to arrive at the correct answer, you must know two things.  For functional limitations such as walking, ambulating, transferring, etc., your response must be based on what is true on the day of the assessment and….

You must know what is meant by a ‘day’.

So, how did 58 percent of you answer this question incorrectly?  Maybe because you are unfamiliar with an OASIS day which is quite different the usual day.  We couldn’t possibly make this stuff up so we are going to cut and paste from the OASIS Guidance Manual, Chapter 1, page 6.  We made the text bold – don’t give CMS credit for that:

Understand the time period under consideration for each item. 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.

In the scenario mentioned, the patient had been violently ill all night and most of the day until he went to the MD in the afternoon.  The same manual (OASIS Guidance Manual) on the same page (chapter 1; page 6), states:

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.

Without counting minutes and seconds, this means that if Mr. Jones spent 12 of the 24 hours in question unable to walk, transfer, get to the restroom, etc. safely, his OASIS assessment should reflect it.  Assuming his night began as late as Midnight and he continued to be violently ill until the afternoon when he saw the MD, the time span covered more than 12 hours.

Your answer, therefore should reflect his epic vomiting and vertigo.

Here’s another explanation of how to assess the intoxicated patient which should be considered in Louisiana as Mardi Gras gets under full swing.

Why This Matters

If this was a rare and unusual situation, it would not matter very much but it is not – especially on admission.  Anesthesia, pain meds following a procedure, reactions to medications all have the potential for taking a patient out of commission for a day or so, prompting a physician to order services to monitor and treat the patient.

With only 42% of you answering this correctly, it didn’t seem right to wait until we publish the rest of the answers to prevent further damage to your published outcomes or payment.  Congratulations to everyone who got this question right, including Lori Hopwood of Lane Home Health – a 4.5 Star agency right here is South Louisiana.  Laissez bon temps rouler in Cajun Country.