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.

Opioid Use in the Elderly


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A few years ago, I was reviewing the clinical record of a patient who had just been discharged from the hospital with a severe GI bleed. While he was hospitalized, a drug screen was run and it was determined that he had no opioids in his system despite the fact that he had Lortab ordered three or four times a day. Going back further, I read that while his wife was present during visits, she was often ‘napping’. I do not know how the physician knew to order the drug screen but it’s not a long leap to figure out why Adult Protective Services were called. As it was discovered, the patient’s wife was substituting two aspirin for the Lortab doses; hence the bleed.

Fast forward to a couple of months ago when I read a chart of a man who had chronic back pain. He had been taking oxycodone for years and had recently underwent surgery which mostly corrected the cause of his pain. He then fell and was admitted for pneumonia. The admitting physician said the patient asked for much more than his prescribed dose of pain medication. When he received it, he was somnolent and showed other signs of overdose.

Then there was a patient whose chart indicated that she had very severe 10/10 pain on each visit. The physician was not called. I called the agency on this during a meeting as multiple clinicians had seen the patient. They told me that what I didn’t see was the five o’clock news when the patient was arrested for selling her prescription medication.

Here are some facts.

  • Pain affects approximately 100 million American adults each year, resulting in a national cost of $635 billion annually in medical treatment and loss of productivity.
  • Medicare beneficiaries (aged and disabled) have among the highest and fastest-growing rates of diagnosed opioid use disorder at more than 6 of every 1,000 beneficiaries (CMS, January 2017).
  • In 2011, on an average day, 80 adults aged 65 and older visited the emergency department for problems with narcotic pain relievers and seven older adults’ visits (on an average day) involved heroin (Mattson et al., 2017)

Obviously, there is more information and statistics about Opioid use in the elderly. Half of the internet could be filled with the complex reasons of how the epidemic began but that is hardly useful information. The most useful intervention that a visiting clinician can employ is common sense which is exceedingly uncommon in healthcare. Consider the following:

  1. Blind adherence to CDC guidelines is causing some patients who have been on large doses of narcotics for years to have their doses abruptly dropped by a significant level. This Huffington Post Story tells the story of Jay Lawrence who had his pain medication reduced by 25%. Shortly before the next pain management visit, when he expected that his dosage would be reduced again, he committed suicide. If a visiting nurse or therapist had been in the home, they could have tried to intervene by documenting the patient’s history including prior and current abilities. Although awkward, the CDC guidelines should have been reviewed with the physician as he appeared to be following guidelines for patients new to narcotic pain relievers.
  2. Disabuse yourself of the notion that narcotics given for legitimate pain do not cause addiction. Many of you will be insulted by this tidbit of advice but this information was shared with healthcare providers for years by pharmaceutical sales people. In fact, there is no ICD-10 code for addiction – only for dependence which occurs after taking the medication for a prolonged period of time regardless of the reason.
  3. Do not hesitate to code an F11 code if you have physician documentation.
    Assess the patient completely for pain remembering that assessment is more than interview. For years, we were told by very respectable organizations that the patient’s pain was what the patient said it was. That’s not always true. A full assessment includes observation of the patient’s ability to participate in daily activities, assessing sleep patterns, appetite and nonverbal behaviors such as grimacing, inability to focus on what you are saying and guarding the area the area where the pain is. Ask family members when present during assessments if the patient shows signs of pain during the evening or in the mornings when getting out of bed.
  4. The blind adherence to CDC guidelines has physicians focusing on the amount of opioids ordered but they seem to be oblivious to the recommendation that they find treatment and/or support for patients who may have a serious problem. The physician is more likely to refer a patient for help if you have suggestions handy. Waiting for an order takes much longer than asking for an order for a referral to specific providers.
  5. If your patient has been abruptly cut off or has had a sharp reduction in pain medication, be aware that suicides increase dramatically after the cessation of opioids. Depression is part of the withdrawal process and can be intolerable for patients who have an existing diagnosis of depression.
  6. Include both long term and short term effects of opioid pain relief. This is especially valuable for patients who do not take opioids on a regular basis but are undergoing a procedure that will leave them with pain. Help them set realistic pain goals. Teach your patient that pain medications should reduce the pain to where it is tolerable but can cause falls, confusion and impaired judgement. Long term, speak to the idea of tolerance to the medication and dependence. Reassure them that problems do not occur if they take pain meds infrequently for a short period of time and return to tylenol or NSAIDs as soon as their physician allows. Teach caregivers to wait until the patient asks for the medication instead of giving it routinely.
  7. Visiting clinicians probably see diversion more than most other healthcare providers. If there is any suspicion of diversion, ask the pharmacy to dispense only a week at a time so that missing medications will become obvious sooner if that is allowed in your state. Alternatively, ask for two pill bottles and keep only seven days worth and (with the patient’s or trusted caregiver’s knowledge) hide the remainder. If you know with reasonable certainty that medications are being taken from a patient, call elderly protective services and allow them to investigate. If there is doubt about why pills are missing, call in the social worker.

The extremists on either side of the opioid crisis are costing money and in some cases, lives. Complications from opioid use have resulted in opportunities to create new laxatives specific to Opioid induced constipation that are priced upwards of 350.00 per month. The sexual performance pharmaceuticals are also benefiting as patients suffering Opioid induced sexual dysfunction need a little boost. Falls in the elderly taking opioids are common and should a hip be broken, there is a 25 percent chance that they will not be alive in six months.

And yet, there is no feeling more powerful than shooting some morphine into the veins of a patient suffering from kidney stones. Hospice patients have a better quality of life with opioids and they are very useful for fracture and burn patients. Make no mistake. Opioids have their place as do antihypertensives, diabetic medications, etc. but they need to stay in their place. Patients should be cautioned about taking opioids for chronic pain unless all other avenues of pain relief have been explored and nurses and therapists need to be honest and unreserved in their teaching of medication safety.

Ding!


A client just received their certification report and it was good but not deficiency free as they had been in the past.  The reason?  Although the risk factors for hospitalization were pulled from the OASIS assessment, they were not identified on the Plan of Care as risk factors for hospitalization.  The interventions were similarly not tied to the risk factors even though they did address them.  The DON reported that she talked to a friend at another agency and learned that the other agency had received the very same tag.  Coincidence or survey trend?  Time will tell.  For now, smart agencies will go with ‘survey trend’ as their final answer.

The Condition of Participation is §484.60(a)(2).  It reads:

(2) The individualized plan of care must include the following:

  1. All pertinent diagnoses;
  2. The patient’s mental, psychosocial, and cognitive status;
  3. The types of services, supplies, and equipment required;
  4. The frequency and duration of visits to be made;
  5. Prognosis;
  6. Rehabilitation potential;
  7. Functional limitations;
  8. Activities permitted;
  9. Nutritional requirements;
  10. All medications and treatments;
  11. Safety measures to protect against injury;
  12. A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
  13. Patient and caregiver education and training to facilitate timely discharge;
  14. Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
  15. Information related to any advanced directives; and
  16. Any additional items the HHA or physician may choose to include.

This is a new requirement included in the 2018 Conditions of Participation.  It’s something that (hopefully) has been done by agencies in the past but risk factors haven’t always been labeled.  The requirement is consistent with the CMS goal of avoiding unnecessary admissions.

There are no instructions on how to do this.  Prior to the final regulations, the proposed regs suggested stratifying patients as high, medium or low risk.  That was omitted from the final rule.  From the 2018 CoPs:

While there may be benefits to establishing more inter-HHA consistency in the application of this requirement, we do not believe that those benefits would outweigh the cost of reducing HHA flexibility and innovation to determine the best possible way to achieve the overall goal of reducing unnecessary emergent care visits and hospital admissions.

The OASIS question that examines risk factors for hospitalization is M1033 reads:

(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)

  •  History of falls (2 or more falls – or any fall with an injury – in the past 12 months)
  •  Unintentional weight loss of a total of 10 pounds or more in the past 12 months
  •  Multiple hospitalizations (2 or more) in the past 6 months
  •  Multiple emergency department visits (2 or more) in the past 6 months
  •  Decline in mental, emotional, or behavioral status in the past 3 months
  • Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months
  •  Currently taking 5 or more medications
  •  Currently reports exhaustion
  •  Other risk(s) not listed in 1–8
  •  None of the above

Additionally, M1036 looks at smoking, obesity, alcohol dependency and drug dependency.  There is a falls risk assessment which may score high in patients who have not fallen in the last 12 months such as those who had a recent hip replacement.  Depression is assessed and is known to impair recovery in most illnesses and conditions but is not included in the question specific for risk factors unless it has an onset within 3 months.

Some of the most dangerous risks to our patients are not captured by OASIS at all.

  • Elderly patients living alone in a rural area
  • Patients unable to afford or prepare food; may have frequent interruptions in utilities due to financial limitations.
  • Transportation or willing caregiver to pick up medications.
  • Functionally illiterate patients

It is possible that drawing in some information from OASIS might meet the condition, but it may not serve the patient.  On the other hand, it is highly unlikely that you would be hit with a survey deficiency if you included risk factors that were based on a full assessment even if they are not included in the OASIS assessment.

You won’t find many interventions to address isolation, depression and lower socioeconomic status in care pathways for other conditions, but they are equally as important for some patients as falls precautions which are ordered for pretty much everyone.  It may cost a little more but in the long run, lower hospitalization rates will correspond with higher margins.

The CoP’s mandate that care plans include patient risks for hospitalizations and Emergency Room visits and corresponding interventions to mitigate the risks.  Since you must do it, make it meaningful.

Contact us if you need help setting up a system for this or if you would have us review your careplans for you.

Here We Go Again


A notification of the intent to re-implement the Pre-Claim Review process is being published today in the Federal Register.  The purpose, as stated in the notice, is to develop and improve methods to investigate and prosecute fraud in the home healthcare services.  In other words, Medicare wants you to send them evidence before you are even suspected of a crime. At its onset, agencies in Illinois, Ohio, Florida, North Carolina and Texas with the option to expand.

If there was even a chance that this burdensome, intrusive and expensive process would serve its stated process, my objections might not be so strong (but maybe they would).  Assuming that this process involves collecting the same information as the 2016/2017 demonstration, it is not likely identify or help in the prosecution of fraud. For those of you unfamiliar with the process, agencies had to gather and submit eligibility information for patients and submit it prior to billing the final claim.  (Palmetto GBA’s Guide to PCR submission) What’s even more amazing is that the United States Congress agrees with me.   

Here’s what they wrote in the Final Rule for the 2015 PPS update:

Each year, the CMS’ Office of Financial Management (OFM), under the Comprehensive Error Rate Testing (CERT) program, calculates the Medicare Fee-for-Service (FFS) improper payment rate. For the FY 2013 report period (reflecting claims processed between July 2011 and June 2012), the national Medicare FFS improper payment rate was calculated to be 10.1 percent.  For that same report period, the improper payment rate for home health services was 17.3 percent, representing a projected improper payment amount of approximately $3 billion.  The improper payments identified by the CERT program represent instances in which a health care provider fails to comply with the Medicare coverage and billing requirements and are not necessarily a result of fraudulent activity.

Worse than being ineffective, the proposed PCR project does not state goals of prevention of fraud, improvement of patient outcomes, or identification of opportunities for innovative approaches to home healthcare.   The process focuses on Face-to-Face information, documentation of homebound status, signatures and dates, and care plans. Nothing written here is meant to dismiss the importance of these statutory requirements but agencies who are fraudulently bent are coached by the CMS in how to get paid whether or not visits are being made or if the ordered care is given. Numerous checklists and examples could serve as a Fraud 101 primer.    It befuddles me that an undated signature may result in a denial or delay in payment but Medicare doesn’t understand that a fraudulent agency may document homebound status perfectly even when the details are contrary to reality.

But you do have a choice.  You can opt out of the PCR process.  It’s a condescending choice like when a toddler is told he can eat his vegetables or be sent to bed early with no dessert. Most kids will hold their nose and get the Broccoli down.  

Similarly, Medicare is giving agencies a choice to participate in PCR or suffer a 25 percent reduction in payment IF they are paid after a mandatory request for additional records (ADR).  So agencies will hold their nose and participate in PCR.

Agencies can also opt for a post payment review. In this scenario, you would submit information after being paid which means any errors found occurred prior to billing.  Undated signature? Denied. Then you will have an overpayment which will be recouped. There are few things worse than having money you already earned taken back. But agencies have a choice.

Agencies will be removed from PCR after they reach an unannounced target goal. If the purpose of PCR is accurately stated, how could the goal be less than 100 percent?  If a 90 percent target is set, that means that 10 percent of claims meet the categories of fraud, abuse or waste.  

What has never happened to the best of my knowledge is anyone being notified by the person reviewing a patient in the pre-claim review process of errors that might cost Medicare money. Just once I would like to see advice to an agency to include therapy because even though it was received in a prior admission, it’s worth another shot because the patient is having pain difficult to manage without opiates increasing the risk of falls and subsequent injury.  

Luckily, you don’t have to sit back and wait for the curtain to fall.  You have been invited to comment on the PCR process. Before you do, take a look at the document which was to have been included in today’s Federal Register.  As of now, it does not appear to be there.

Note that there are multiple ways to submit your comments.  Use them all. Tell your co-workers, bosses, employees and mother to read the memo and draw their own conclusions.  There is an ethical dilemma if you tell them how to feel about a political matter but providing a stamp won’t draw the attention of anyone.

Also note the title of the gentleman who signed the memo; Director, Paperwork Reduction Staff.  I couldn’t make that up if I tried.

The Coders will prepare comments for submission and share them with you. Please feel free to share your comments for or against the reimplementation of the Pre-Claims Review Demonstration.  And remember, you have options.

 

Conditions of Participation… Professional Requirements


This week’s Condition of Participation involves Professional Services.  These are common practice and similar to what is in place in your agency anyway.   There are new requirements for the Administrator and a new position called ‘Clinical Manager’.  The requirements are linked in the post.  Adjust your job descriptions and a review of the Medicare Benefit Policy Manual, chapter 7 would be a good idea.

The Condition is pasted below followed by the standards that will be surveyed to verify compliance.

484.75 Condition of Participation: Skilled professional services.

Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician and medical social work services as specified in §409.45 of this chapter.

Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care.

This Condition is written as though you know all about subsections 409.44 and 409.45 but in case you do not, you can click the links.

Not to be confused with official guidance from Medicare, here’s an abbreviated summary of what you already know:

Skilled nursing services are those skills which can only be performed by a nurse.  Coverage is determined by the complexity of the skill as well as the condition of the patient.  If the skill could be performed by the average Joe, it would not be considered skilled.  The Medicare Benefit Policy Manual is our favorite source for researching skilled nursing services.

Physical Therapy skills must be of a nature that they can only be performed safely by a skilled therapist.  In determining if therapy is skilled, determine if the Jimmo ruling of 2013 applies.

Medical Social Workers provide services ordered by the physician to address emotional and social needs that may interfere with the patient’s ability to respond to the plan of care or the agency’s ability to carry out the plan of care.  According to the Interpretative Guidelines, they are furnished ‘on a short-term basis and it can be demonstrated that the service is necessary to resolve a clear and direct impediment to the effective treatment of the beneficiary’s medical condition or to his or her rate of recovery’.

The standards that demonstrate compliance should be familiar to you even if you did not know they were a part of the Conditions of Participations.

The first standard reads:

484.75(a) Standard: Provision of services by skilled professionals.

Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures.

The appropriate qualifications are in another section, so we made a quick cheat sheet.  The information is straight forward except for physical and occupational therapists.  Each of these therapists have provisions for states that do not have licensing laws.  A quick search of the web revealed that all states require licensing so if you stick with licensed therapists in your state, you should be okay.

There is also a provision in this condition that professional services are provided according to the agency’s policies and procedures.  This includes contracted therapists so be sure to share relevant policies with contractors and include them in compliance training.

484.75(b) Standard: Responsibilities of skilled professionals.

Skilled professionals must assume responsibility for, but not be restricted to, the following:

  1. Ongoing interdisciplinary assessment of the patient;

The interpretative guidelines define ‘interdisciplinary’ as an approach to healthcare that includes a range of health service workers, both professionals and non-professionals, with the majority being from professional groups. Ongoing interdisciplinary assessment is the continual involvement of all skilled professional staff involved in the plan of care from the initial assessment through discharge and periodic interactive, discussions regarding the status and recommendations for the plan of care. The interdisciplinary approach recognizes the contributions of the disciplines (MDs, RNs, LPN/LVN, PT, OT, SLP, MSW, HH aides) and their interactions with each other to meet the patient’s needs.

The Coders recommend weekly or bi-weekly case conferences where patients approaching the end of their episodes are discussed in a meaningful way by all involved disciplines.  Any patients who have significant changes in their condition or treatment plans can be added to the list.  It also means documentation of any casual discussions you may have with other agency employees or physicians.

  1. Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); 
  1. Providing services that are ordered by the physician as indicated in the plan of care; 
  1. Patient, caregiver, and family counseling; 
  1. Patient and caregiver education; 
  1. Preparing clinical notes;
  1. Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; 
  1. Participation in the HHA’s QAPI program; 
  1. Participation in HHA-sponsored in-service training 

Some of these criteria will be discussed in subsequent parts of the Conditions of Participation so don’t worry if one or more confuses you.

Supervision

Supervision is the focus of the next standard supporting the condition involving Skilled Services.  There are numerous references made to §484.115; our little cheat sheet referenced above with personnel qualifications. 

484.75(c) Standard: Supervision of skilled professional assistants

This is a generic supervision standard that applies to therapy assistants, LPN, etc.  As such, it does not include a time frame or the criteria for supervision.  Oversight is usually guided by the practice standards for each discipline.  Additionally, there must be written instructions for these assistants and you can expect that they will be surveyed.

484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k).

484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(e, f) or (g, h), respectively. 

Please note that therapists can only supervise assistants within their disciplines.  Occupational Therapy must supervise Occupational Therapy assistants, etc.

484.75(c)(3) Medical social services are provided under the supervision of a social worker that meets the requirements of §484.115(m).

Home Health Aide services, training and competency are soon to follow.  Meanwhile if you have any problems with the Professional Services information, feel free to drop us a line.