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.

Elderly Abuse?


A colleague of mine got a couple of phone calls from patients terrified they were going to be admitted to a nursing home.  Two men had come by with a three page list of questions and started asking very personal questions about whether or not they can get in a car, if they can go out to eat and how often their nurse visits.

My colleague reports in his email to me:

“They are not leaving cards or anything. One savvy patient finally got all their information and called us with it.”

and

“One patient was not home when they stopped at his house so they talked with and asked his neighbor questions.”

The men in question were employed by Jackson Dunham Sato & Associates. If you glance through the bio’s on the left sidebar, you will see that essentially all of the managers, partners and associates mostly come from one of two federal governing bodies – the OIG, and CMS (Medicare).  In fact, if you go to the top bar and click on careers, you will find that they are not interested in you if you are not:

  • A current or former Office of Inspector General Auditor/Investigator with healthcare experience
  • A current or former CMS employee who has been involved in program compliance/integrity oversight

At least you don’t have to worry about them poaching your employees.

I realize and you probably do, too, that all of this information is second and third hand.  In order to be responsible, I emailed each of the three senior partners and have not received a response.  The questions asked of them were:

  1. Is this your usual policy regarding identification of your investigators on home visits?
  2. Would it be possible to have your folks dress down; perhaps wear scrubs?
  3. What explanation is given to the patients if they do not ask for identification?  Do the investigators allow them to make assumptions no matter how terrifying?
  4. Do you understand that a patient fearful of nursing home placement might exaggerate their functional abilities?
  5. Could you or do you leave some sort of documentation with the patients?  Patients are calling agencies who are unaware of your presence and cannot offer the patients any reassurance because they do not know who interrogated their patients.
  6. Do you ever send clinicians out to the home to verify medication use and evaluate gait and balance?
  7. Do you do a mental status exam on the patients?  Many patients with Alzheimer’s Dementia and other organic brain syndromes appear as right as rain the first couple of times you meet them.
  8. How do you choose the providers you will be investigating?   Are they assigned to you by Health Integrity?  Do you have access to databases that you can mine for data?
  9. How are you paid by Health Integrity?  Is your payment predicated in any way on recouped monies or arrests?

I have not gotten a response but Health Integrity, LLC confirms that Jackson Dunham, Sato and Associates are a ‘partner’ on their website.  Health Integrity, LLC is the Zone Program Integrity Contractor (ZPIC) for CMS Regions 2 and 4.  Combined, these two regions encompass  Alaska, Arizona, Colorado,  Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, New Mexico, Oklahoma,, North Dakota, Oregon, South Dakota, Texas, Utah, Washington, and Wyoming.

Regardless of an agency’s guilt or innocence, our elderly deserve to be treated with more respect than they have been shown by Jackson Dunham Sato and Associates.  I question the motives of a firm that resorts to intimidating elderly patients and possibly encouraging them to exaggerate their functional abilities in order to ‘prove’ that a patient is not homebound.  Are they genuinely concerned about the welfare of our elderly and protecting the trusts that fund Medicare or are they simply trying to satisfy a requirement for contract renewal, bonus pay or something else?

I can sit at my desk a thousand miles away from a patient and know whether or not their homebound status is questionable.  It is tedious to read every note, every MD clinic visit and OASIS assessment to look for discrepancies and the tell tale signs that the patient does not fit the description in the care plan and the visit notes.   It is not the most glamorous job in the world, I assure you but it can be done without instilling fear of unwanted nursing home placement in elderly people.  Even if a visit has to be made in order to make a final determination, it does not require rudeness or fear.  Even if the investigators are accompanied by a nurse from the agency, it is unlikely that a nurse would be able to influence the patient to lie.

The very best consultant and the very best lawyer cannot help you if you are determined to play outside of the conditions of participation and conditions for payment.  We’ll take you money and do our best. If it is a question of inadequate documentation versus fraud, we can generally help but there is not much we can do if you simply choose to sidestep the rules.

Nobody who works for Medicare or is contracted or subcontracted by Medicare seems to understand that good providers have even less tolerance for the fraudulent providers than they do.  If they would make just the tiniest effort to work with the majority of providers who are good, they might learn a thing or two and then it wouldn’t take years and hundreds of millions of Medicare dollars gone before they caught up with the truly bad players.  At that point, they could offer more frequent education to those providers who take compliance seriously.

If your patients have had visitors or if you have had experience with Jackson Dunham, Sato and Associates, please email me privately and let me know.  As always your comments are welcome below and if I get a response from Jackson Dunham, Sato and Associates, I will be sure to let you know.

One last thing….. if I ever hear of you intimidating a patient, watch out.  I am not nice when I hear of an elderly person treated with anything less than respect.

THE Hospice Quiz


If you own or work at a hospice, there has never been a better time to make sure that you understand the rules and regulations just like Medicare intended.  The quiz below is a very basic quiz designed for you and your staff or co-workers to take to ensure that you are not denied payment or worse,  step on a regulatory landmine.

10 Common Documentation Flaws


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Stop and use caution before documenting your visit!

 

If you are not concerned about poor to mediocre patient care, getting paid or your license, read no further.  If any or all of these issues are of concern to you, keep reading.  Below are ten of the most frequent flaws in nursing documentation reviewed by the coders.  We know that these oversights and omissions are most often the result of a busy schedule or inattention to documentation because we know our clients.  State surveyors, Medicare contractors and agencies named with 3 letters and an Eagle (OIG, FBI, DHS, CMS, etc.) do not express any great interest in the underlying causes of poor documentation.

1.  No MD Contact Documented when appropriate

Many times, the MD is not called at the house due to time constraints or other issues.  When orders are received, they do not tie back to any communication in the chart.  Documentation of two way communication is critical to both sound clinical practice and payment.

2.  Contradictory Information

The 486 summary indicates that the patient lives with a daughter but the OASIS states the patient lives alone.  The OASIS data states that the patient becomes short of breath with minimal activity but the plan of care does not include shortness of breath in the functional limitation.

3.  Blind Adherence to Rules of Thumb

Somewhere along the way, nurses were told that they must always document on the primary diagnosis on every visit and follow the clinical pathway written by someone who has never visited the patient.  This has led to visit notes that read like, “Pt found on floor with scalp wound bleeding profusely.  Reports she fell yesterday and wasn’t wearing life alert button.  Taught to avoid soda and other concentrated sweets to manage blood sugar.”

4. Failure to Document Sensitive Information

A chart found in one the best agencies I know of had multiple notes reading that the patient complained of extreme pain.  The physician was notified after every visit with a fax and a copy of the med list.  No new orders were received.  The Director of Nursing explained that the patient had recently been the subject of an evening news story involving the sale of her pain meds to supplement her Social Security check. 

5. Missing the Little Stuff

When little things like vital signs, weights, and blood sugars are omitted from the clinical record, it causes problems.  A weight gain of ten pounds after two weeks of forgetting to weigh the patient is negligent but not as bad as forgetting the third week when the patient is hospitalized.  Most nurses take vital signs.  I spend many nights staring at the ceiling wondering why they aren’t on the chart.  Then I remember that I tend to write them on my arms and if I bathe before I chart, they are lost to the water supply.  What’s your reason?

6.  Missing the Big Stuff

Missing new orders, teaching on medications that have been discontinued and not notifying the MD for problems is more common than you think.  It is what feeds many malpractice attorneys.  It is why state surveyors might not trust anything you say during survey.  It is why nurses find themselves answering very difficult questions to the state board of nursing.  If you do not have a current care plan, refuse to see the patient until you have a verbal report.  Document the verbal report.  If you see a patient without looking at prior orders, shame on you.  If the prior orders taken by another nurse are not written and as a result you teach a patient to take a med that has been discontinued, write an incident report.  This is stuff that kills patients.

7.  Lack of Follow-Up

Lack of follow leaves gaping holes in the chart, and often, results in missed opportunities to provide better care to patients.  Consider a clinical record where you read one week that the patient has a doctor’s appointment the following day and that’s the last time it is mentioned.  Did anyone call to see if there was lab or new meds ordered?  It’s hard to believe but sometimes patients don’t tell you these things. 

8.  No Ongoing Medication Reviews

One of the easiest way to prevent re-hospitalizations, adverse reactions, and non-compliance with medication is to simply review all medications against the med list on each and every visit.  Every time a med is missing, a new med appears, or there seems to be confusion in dosing, there lies an opportunity to improve the care of a patient and to increase your level of skill ensuring payment. 

9.  Taking the patient’s word at face value

If a patient tells you they had a lab or diagnostic test and the results were fine, by all means document it.  Also call the physician who ordered the test and get the scoop.  The physician may have told the patient it was ‘fine’ or ‘no change since the last MRI’ but in the context of the specific patient, that same test could show degenerative disease, a low hematocrit or some other information important to support eligibility for your patient.  If possible, always get copies of the final reports for lab and diagnostic tests.

10.  Evidence of Ignorance

This sounds harsh but it is evident en masse in the clinical records reviewed by The Coders.  A new medication will be ordered specific to a disease that is not documented anywhere.  Eye drops for glaucoma, Zemplar for hyperparathyroidism secondary to renal disease, Invokana for Type II diabetes are all medications seen within the last week that have no corresponding diagnosis.  These meds both have serious side effects and teaching to ‘take medications as ordered’ will not help the patient avoid untoward adverse reactions or recognize side effects. 

All of these shortfalls in clinical documentation can be avoided by simply reviewing the charts.  The average time for a skilled nursing visit is 30 minutes and the average payment is equal or more to what nurses would make in the hospital.  This means that nurses have the time to review the clinical records, go to case conference meetings and call physicians.  If a nurse has ten fingers and a keyboard or two thumbs and a smart phone, enough information regarding medications is available around the clock.  Medscape has a great completely free app for mobile phones that has data that can be stored on your phone when you are away from Internet connectivity.

We all want to get paid.  If agencies don’t get paid, they have no money to pay consultants and coders and that reason to document well falls second only to improving patient care.

Hospice Coverage


 

What exactly does the hospice benefit cover?  When is it appropriate to treat an illness or condition for a hospice patient?  There are multiple shades of grey in these questions.  If a patient has a bladder infection, antibiotics will not only cure the infection but bring enormous relief to a patient.  A patient with Alzheimer’s Disease will not improve if their hypertension is treated but is it the responsibility of the hospice to pay for those medications?  On the other hand, withholding treatment for hypertension may put the patient on a fast track for a stroke hastening death (and lowering costs).  Medicare has addressed some of these questions directly and alluded to new adaptations of existing rules indirectly.  Brian Daucher, a lawyer who has championed the cause of hospice to the extent that he went up against Medicare won a huge battle concerning caps validity, has weighed in on Medicare’s new approach to hospice payments. 

When Mr. Daucher speaks, we should listen.  Graciously, he has agreed to allow us to reprint his article from December 19. 

Hospice to Provide “Virtually All” Care – First Up, Prescription Drugs

By Brian Daucher on December 19, 2013 Posted in Other

A hospice patient waives the right to receive other Medicare benefits “related” to the terminal illness.  In turn, the hospice must provide any care necessary for “pain or symptom relief.”  Focusing upon this waiver/assumption of liability, CMS is now redefining the scope of a hospice’s duty, requiring hospices to pay for “virtually all” prescription drugs and other care given to hospice patients.

In early 2013, CMS revisited hospice reporting requirements on billing.  CMS issued a reminder of the requirement that a hospice must code for all co-morbidities and also announced the phase-out of failure to thrive and debility as primary diagnoses.  Both instructions ensure that a hospice’s responsibility for any admitted patient will be broad, the first by broad listing of any co-morbidities, the second by requiring more concrete primary terminal diagnoses.  These reporting requirements help set up review of the hospice’s duty to cover any “related” care.

In guidance issued in October and December,[1] CMS explores a hospice’s dual obligation to cover any medical care (including drugs) for any related condition but to limit such care to pain or symptom relief.

CMS concedes that historically it has viewed the hospice “related care” question as one to be addressed on a “case-by-case basis” considering the “wide variation of patient circumstances.”  To date, CMS has shown deference to providers on this question.

But CMS now states that separate Medicare coverage will only be available to hospice patients for conditions “completely unrelated,” noting for the first time that hospices are required to provide “virtually all care” needed by terminally ill patients and that unrelated care would be “extremely rare.”  CMS notes that many illnesses are “brought on by the underlying condition of the patient.”  These appear to be new standards that will require broad assumption of liability by hospices.

Less conspicuously, CMS tackles the question whether there are certain drugs that are inappropriate for hospice patients.  CMS notes that the hospice benefit only provides coverage for drugs “used primarily for the relief of pain and symptom control.”  CMS notes correctly that by electing hospice, patients are moving from a “curative model of care” to a “palliative model.”  But, because drugs provided by hospice are covered by the per diem and not separately paid by Medicare, CMS’ interest here appears to be to restrict access to certain drugs and treatments that might extend a patient’s life.  CMS has not yet defined any category of drugs as improper (i.e., antibiotics, chemotherapy).

Initially (October 30), with respect to what a hospice must cover, CMS took the initial step of indicating that it would view any analgesics (pain medication) as necessarily related to the terminal illness.  (October 30.)

In December, CMS expanded its analysis to apply to almost any conceivable medication, stating that “only very rarely” will a beneficiary take drugs not covered by the hospice.  (December 6.)

In these publications, CMS advises drug plan sponsors to track hospice patients and limit approvals of medications for them; and, if medications are given, sponsors may in some cases look to hospices for reimbursement.  In turn, CMS notes that hospices may refuse certain medications to patients; in turn, patients have appeal rights.  To mediate all of this, CMS will establish an independent reviewer.  According to a new Part D webinar, hospices will soon be “presumed responsible” for any medications given to a hospice patient.

Hospices should anticipate claims for payment where its patients receive drugs through Part D from any other providers.

To show the extent of this new thinking, consider CMS Change Request 8098 (September 30, 2013).  Although CMS has now indicated its intent to rescind this CR, the CR is still instructive on the thinking within CMS.  In this CR, CMS imposed a pre-payment edit to preclude payment to non-hospice providers for vaccinations of hospice patients (i.e., flu, PPV, Hepatitis B).

Although vaccines typically protect against diseases not then present in a person, CMS provided that the hospice alone should decide if a terminally ill patient would get such vaccines; and, if a hospice determined to vaccinate a patient, the hospice would then bill for such vaccines (presumably as unrelated care).  Of all treatment, it seems that vaccines might arguably be the least directly related to a terminal illness, as they are not present at the time of vaccination.  And yet, before rescinding this CR in response to questions, CMS tried to cabin vaccination decisions at the hospice level, showing the extent of CMS’ view that “virtually all care” should be through the hospice.

More than anything else, these recent changes seem to reflect CMS’ core desire to contain cost, both by ensuring that hospices pay “virtually all” costs associated with medical care (including drugs) of terminally ill patients and also, where possible, to limit the lives of such hospice patients (and thereby limit the cost of such lives).

CMS has not yet imposed a broader rule precluding any type of care to hospice patients by other providers, but these pronouncements could be early steps toward such a rule.

After years of slogging with modest success through hospice medical necessity audits, perhaps CMS has altered is strategic approach to cost containment.  The relatedness doctrine, now finding application in the prescription drug context, will likely find broader application.

[1] Clarification of Recovery of Part D Payment for Pain Medications for Beneficiaries Enrolled in Hospice, October 30, 2013 (published to Part D Plan Sponsors by Medicare Program Integrity Group and Medicare Drug Benefit and C&D Data Group); and Part D Payment for Drugs for Beneficiaries Enrolled in Hospice – Request for Comments, December 6, 2013 (published by Medicare Program Integrity Group, Medicare Drug Benefit and C&D Data Group, and Chronic Care Policy Group).

Weights


The Oxford English Dictionary defines weight as a body’s relative mass or the quantity of matter contained by it, giving rise to a downward force; the heaviness of a person or thing.

What the OED fails to mention is that weights are a critical measurement of overall health.  Symptoms of many diseases cause a person to shed weight.  Other diseases cause people to add body mass or weight.  It is a good thing to know what your patient weighs but more important to know how their weight changes over time.

Nobody gets concerned about weight loss of a pound or two.  Some of us are even thrilled when we notice the needle on the scale drift downwards a bit.  What we occasionally see when I look at episodes in their entirety is significant weight loss over the period of 60 days that is unexplained by diet or increased activity.  Nurses in the field sometimes fail to realize that the pound or two here and there over several weeks could point to an unresolved health issue.

It seems almost pointless to tell nurses to weigh their patients with congestive heart failure and yet over the week, we have reviewed numerous charts from different agencies where no weights were recorded.  This lack of attention to a basic measurement of congestive heart failure can and does lead to unnecessary hospitalizations. 

Sometimes, it seems that orders are written to prevent that burdensome task of notifying a physician of a decline in a patient’s condition.  A frail elderly woman weighing 103 pounds should not have to gain five pounds before the physician is called for orders.

What you may not know is how much this is costing you in terms of denials.  If you are a manager or administrator responsible for ensuring compliance to Medicare coverage rules, pay close attention.  

Observation and assessment is only a skill for three weeks unless there are credible findings that a patient is at risk for exacerbation.  For our purposes, an exacerbation is a worsening of a condition that involves changing the care plan.  In order to change the plan of care, the physician must be involved and new orders received.  Not every order must be for medications so be prepared to ask the physician if he needs lab or if you can make an extra skilled visit to check on the patient.

Each order you receive is like a ticket to ride the episode train a little longer.  Skills are provided and they are reasonable and necessary because there is documented information upon which decisions regarding care are made.

Without a documented information, the same skills may very well be provided without meeting the reasonable and necessary criteria.  Or, the weight gain may not be noticed especially if a different nurse sees a patient. 

None of this is anything that can’t be handled but the first step is to take it seriously.  The easiest way to do this is to begin weighing all patients.  Reserve written orders only for those patients with diagnoses or conditions that require weights to prevent unnecessary tags on survey in the event one is overlooked.  Habits are powerful things.  You will know the habit is real when you just don’t feel comfortable until a weight is documented.

Every patient should have a scale in their home.  No home health agency has ever filed for bankruptcy because scales were purchased for patient care.  It doesn’t even have to be a good scale.  It just needs to be the same scale in the same place at the same time each day. 

If you want to provide telemedicine but don’t have the resources, you can get the patients to call their weights into the voicemail of an unused line at your office by three o’clock every day.  Those patients who have not called can then be contacted by a part time student.  Imagine the delight of a surveyor when they see pretty little spreadsheets with weights on them and orders in the chart corresponding with increases or decreases.  Better yet, imagine the horror of the MAC reviewer who desperately wants to deny your claims because care was not reasonable and necessary and sees the very same thing. 

This low-tech telemedicine program also allows you to be more conservative with visits so you can attack weight changes like a SWAT team.  Go ahead and make daily visits for two to four days and cut out some of those visits where the patient is taught that one side effect of Lasix is frequent urination as if they didn’t know after taking it for a year or more.  The worst that could happen by scheduling conservatively while following weights telephonically is that patients will develop the habit of weighing themselves and become more compliant with meds and diet.  Then you actually save money by making fewer visits.  How cool is that?

Don’t stop with failure patients.  The sad fact is that some people don’t have enough to eat.  Your patients are confined to the home and may be too embarrassed to tell you that they do not have enough money for food.  Other elderly people seem to lose their desire for food and still more have side effects from medications that cause increased or decreased appetite.   Whatever the underlying reason, it can only be addressed if you know about it.  Assuming your patients are not wearing tight yoga pants and a sports bra during nurse visits, the easiest way to determine weight changes before harm comes to the patient is by weighing them.

You are nurses.  You can do this.  I promise. If you are one of those nurses who habitually forgets to weigh your patients, think of us for a change.  It will be so much easier to code charts if there are orders and exacerbations.  We’re not asking you to cause an exacerbation by slipping some salt in their tea or moving the needle of the scale up a few pounds.  We just want you find out about an exacerbation and get some orders while the problem is manageable and get paid well for taking good care of patients.