Documentation: Back to the Basics – Using the Nursing Process

Documentation: Back to the Basics – Using the Nursing Process
Problem Identification Documentation: Back to the Basics – Using the Nursing Process Presented by: Arlene Maxim, RN-President/Founder A.D. Maxim Consulting, LLC.

Objectives for session
Problem Identification Objectives for session Describe challenges and implications of documentation and how it impacts reimbursement and the survey process Discuss the use of the Nursing Process as a “Tool for Critical Thinking” Describe Components to assess related to Step 1 of Nursing Process: Start of Care OASIS Assessment Describe how to use the Nursing Diagnosis EFFECTIVELY as Step 2 of Nursing Process: Patient Problem Identification Describe how to determine patient-centered goals based on problems identified EFFICIENTLY as Step 3 of Nursing Process: Outcome Identification Illustrate how to prepare an outcome-driven plan (Plan of Care/485) as Step 4 in the Nursing Process Describe effective strategies for implementing the plan generated as Step 5 in the Nursing Process by writing notes that clearly demonstrate skilled care Describe how to evaluate the plan on an ongoing basis as Step 6 in the Nursing Process © 2014, A.D. Maxim Consulting, LLC

Problem Identification
Challenges and implications of documentation and how it impacts reimbursement and the survey process Let's talk about homecare documentation and what has happened in past years that has, in most cases, actually made documentation get WORSE!!! © 2014, A.D. Maxim Consulting, LLC

Florence Nightingale wrote of the need for clear documentation to be recorded.
The goal, she described, is “collecting, storing, and retrieving data to manage patient care intelligently” (Seymour, 1954, p. 32) © 2014, A.D. Maxim Consulting, LLC

Pre-OASIS Prior to OASIS (pre-2000) it was necessary for clinicians to complete an assessment on each patient in order to stay in compliance with the Federal Conditions of Participation This assessment was also used as a baseline of information for any medical review that might occur from a contractor Clinicians viewed their responsibility in documenting accurately and professionally as a vital part of professional practice © 2014, A.D. Maxim Consulting, LLC

THE GOOD (Pre-OASIS) Agencies had an opportunity to create their own system of documentation Agencies with good clinical staff created detailed assessment tools that allowed for good detail in each assessment Some assessment tools created were excellent Nursing Process was frequently used when creating such documents for assessment (as well as re-visit documentation) Clinicians took more time with patients in getting good assessment data Hospitals and inpatient facilities were willing to share information © 2014, A.D. Maxim Consulting, LLC

THE BAD (Pre-OASIS) Most Assessment Tools used in most agencies were unique to that agency Inconsistencies in tools Some Agencies copied tools from other providers with no understanding of how they worked. Often times these tools were copied so frequently that they were illegible There was no way to “measure quality” of care © 2014, A.D. Maxim Consulting, LLC

The GOOD (Post-OASIS) Data is streamlined
Data is used to collect patient outcomes Information is used to measure quality of care Information is consistent, making the jobs of surveyors and medical reviewers much easier © 2014, A.D. Maxim Consulting, LLC

The BAD (Post-OASIS) Clinicians rush through the assessment
Evaluations are frequently sketchy and/or incomplete Information is often the same for every patient Surveyors and Medical Reviewers on all levels can identify and isolate omissions and errors much more easily © 2014, A.D. Maxim Consulting, LLC

WHY DO WE NEED TO DOCUMENT? QUALITY VS QUANTITY
© 2014, A.D. Maxim Consulting, LLC

Other issues affecting documentation importance:
Consumer Awareness: There is an increase in consumer awareness We are all being given much more information as to what to expect from health care in general The public is much more aware than 10 to 20 years ago Home Health Compare provides a good snapshot of Agency performance © 2014, A.D. Maxim Consulting, LLC

Other issues affecting documentation importance (cont.):
Increased acuity of patients coming out of hospitals: DRGs made a bold statement in We could no longer be hospitalized for days (or weeks) on end. DRGs forced agencies to receive patients who were sicker when returning home. Patients have more complex needs. More drugs, more complex treatments, etc. © 2014, A.D. Maxim Consulting, LLC

Other issues affecting documentation importance (cont.):
Increased emphasis on outcomes: ALL healthcare providers are clearly focused on improving patient outcomes overall. All payers are looking to align with providers who have a proven track record of good-to-excellent outcomes. CASPER reports are a critical part of your responsibility in analyzing outcomes and determining just how they can be improved. © 2014, A.D. Maxim Consulting, LLC

We have a Professional Responsibility

We have a Professional Responsibility (cont.)
We are accountable for what we do; Remember, if it wasn’t written -- it wasn’t done!!! The information we include in our documentation provides for continuity in patient care as well as assisting in the coordination of ALL care provided toward positive patient outcomes. © 2014, A.D. Maxim Consulting, LLC

Homecare nurses must have critical thinking skills in order to make complex and sophisticated decisions regarding patient care issues. A nurse’s judgment can change a patient’s life forever; for better or for worse!! © 2014, A.D. Maxim Consulting, LLC

The clinician must document QUALITY -- not necessarily QUANTITY: Repetitive jargon does NOT support quality of care, medical necessity, nor care that is reimbursable – it is just JARGON A good patient evaluation must be clear and concise Evaluations, if done correctly, will easily identify patient problems and assist in establishing measureable and reasonable goals for the patient © 2014, A.D. Maxim Consulting, LLC

We need to achieve EXCELLENCE and we need to PUT IT IN WRITING!!!
We have a Professional Responsibility (cont.) Plans of Care must be to the point! “Fillers” are NOT acceptable! Surveyors will be looking for absolute compliance with the plan of care and all verbal orders. If it isn’t documented, it isn’t done! We need to achieve EXCELLENCE and we need to PUT IT IN WRITING!!! © 2014, A.D. Maxim Consulting, LLC

Legal Protection There is an increase in the number of negligence and malpractice cases against nurses and homecare clinicians in general EXCELLENT documentation could deter a person from filing suit against a provider or individual clinician © 2014, A.D. Maxim Consulting, LLC

Legal Protection (cont.)
If, on the other hand, a lawsuit should move forward, the clinician’s documentation will be used to “tell a story” in court Both attorneys and the jurors will view the documentation as the “truth” about the evidence presented and will decide cases accordingly “Timely, accurate, and complete charting helps the patient secure better care and protects the nurse from litigation.” - Iyer/Camp, 1995, pg. 2 © 2014, A.D. Maxim Consulting, LLC

“Negligence” Defined: “Negligence is the unintentional omission or commission of an act that a reasonably prudent person would or would not do under given circumstances. Negligence by a clinician in the performance of his/her duties is referred to as malpractice. It can occur when there is a failure to guard against a risk that should have been recognized, when a clinician engages in behavior expected to involve unreasonable danger to others, or when a clinician has considered the consequences of an act and exercised his/her best possible judgment.” © 2014, A.D. Maxim Consulting, LLC

Minimizing/Reducing Errors: Completing an accurate evaluation assessment Mitigating errors in medications -- RECONCILLIATION OF MEDICATIONS Communicating with other clinicians Assuring documentation is complete, thorough, accurate and completed timely! Legible documentation Write with clarity © 2014, A.D. Maxim Consulting, LLC

Write concisely Make corrections according to Agency policy – DO NOT USE WHITE OUT! – Document normal and abnormal findings Document patient complaints Make sure you have consents signed before providing ANY PATIENT CARE! © 2014, A.D. Maxim Consulting, LLC

Regulatory Reasons Federal Conditions of Participation and Medicare Policy REQUIRE that we document accurately and according to all regulatory requirements An Agency clinician MUST KNOW the Federal Conditions of Participation AND Medicare Policy before he/she embarks on the homecare journey! Survey Contractors © 2014, A.D. Maxim Consulting, LLC

Reimbursement Reasons
Medicare is the primary payer in most certified agencies. Therefore, in most agencies, documentation revolves around Medicare requirements. Contractors making payment to agencies for service have the responsibility to assure services rendered are based on policy. © 2014, A.D. Maxim Consulting, LLC

SURVEYORS Federal Conditions of Participation Measuring QUALITY

SURVEYORS Federal Conditions of Participation Measuring QUALITY
These Conditions were first introduced in 1965 when Lyndon Johnson signed the Social Security Act This was the first time folks who were aged and disabled had an opportunity to receive care in their own homes that would be paid for by the Federal Government © 2014, A.D. Maxim Consulting, LLC

SURVEYORS Federal Conditions of Participation Measuring QUALITY (cont
In order to assure QUALITY of care, each State was required to hire and train surveyors who would visit homecare agencies to review these conditions designed to assure quality of care © 2014, A.D. Maxim Consulting, LLC

There have been changes over the years. But in 2011 there was a significant change in how the surveys were conducted This revised process of completing the Survey (by all surveyors) was another attempt by the Federal Government to ensure quality of care for our senior citizens and those who are disabled and visited by Agency staff in the home © 2014, A.D. Maxim Consulting, LLC

Immediate Jeopardy Starting July 1, 2013, Surveyors began using the new survey protocol to identify patients who face Immediate Jeopardy situations as a result of Agency staff not adhering to the Federal Conditions of Participation as well as their own internal policies and procedures. © 2014, A.D. Maxim Consulting, LLC

Immediate Jeopardy (cont.)
This is yet another “arrow in its quiver” that you may not have heard about and it can clearly be a tremendous threat to your Agency CMS can use this as a reason for sanctioning the Agency whenever federal and state survey and certification personnel and complaint investigators identify a situation which "poses an immediate and serious threat to the health and safety of patients" © 2014, A.D. Maxim Consulting, LLC

Harm does NOT have to occur before considering Immediate Jeopardy. The surveyor must consider both potential and actual harm when reviewing the triggers in the table To avoid these Immediate Jeopardy issues we must be able to show quality of care and compliance through our documentation © 2014, A.D. Maxim Consulting, LLC

ACCURATE DOCUMENTATION

Accurate Documentation
Federal Conditions of Participation and Medicare Policy REQUIRES that we document accurately and according to all regulatory requirements An Agency clinician MUST KNOW the Federal Conditions of Participation AND Medicare Policy before they embark on the homecare journey! © 2014, A.D. Maxim Consulting, LLC

Orientation Orientation is a must and the key to success in any homecare operation. Without a proper orientation, clinicians become frustrated. Many times agencies loose really good staff because of the lack of education on the front end © 2014, A.D. Maxim Consulting, LLC

Let’s Take A Closer Look at COPs

Understanding COP Basics – It’s Important!
Many Agencies work day-to-day, not thinking about what it means to be “in compliance” By understanding COP’s and Medicare Policy, you can save yourself the loss of $10,000 per day! So how can you avoid this problem? By knowing and understanding issues under the Medicare COPs © 2014, A.D. Maxim Consulting, LLC

Understanding COP Basics – It’s Important! (cont.)
Alternative Sanctions began on July 1st, 2013 Entirely NEW challenge for Home Health Care Implemented after decades of procrastination by HCFA & CMS Sanctions Include: Temporary Managers Directed In-Service Training Directed Plan of Correction Termination from the Program ** Beginning July 1, 2014, we will see Civil Monetary Penalties up to $10K a day!!!** © 2014, A.D. Maxim Consulting, LLC

Understanding COP Basics – It’s Important! (cont.)
We will begin discussing the critical need for you and all staff (including contractors) to understand each COP The impact of misunderstanding the COPs Responsibilities for each Agency regarding compliance Documentation differences between COPs and Medicare Policy Examples of what you need to have for “Proper Documentation” for each COP © 2014, A.D. Maxim Consulting, LLC

Top G Tags Cited in 2012 G156 Acceptance of Patients, Plan of Care, and Medical Supervision G168 Skilled Nursing Services G122 Organization, Services, and Administration G202 Home Health Aide Services G242 Evaluation of the Agency’s Program G330 Comprehensive Assessment of Patients G151 Group of Professional Personnel G235 Clinical Records © 2014, A.D. Maxim Consulting, LLC

Top G Tags Cited in 2012 (cont.)
G320 Reporting OASIS Information G100 Patient Rights G184 Therapy Services G117 Compliance with Federal, State, and Local Laws G194 Medical Social Services G310 Release of Patient Identifiable Information © 2014, A.D. Maxim Consulting, LLC

3 Parts of COPs COPs are divided into 3 parts:
General Provisions – thru 484.4 Basis & Scope Definitions Personnel Qualifications Administration – thru Furnishing of Services – thru © 2014, A.D. Maxim Consulting, LLC

Level 1 & 2 Deficiencies 484.10 Patient Rights
Compliance with Federal, State & Local Laws Organization, Services & Administration Acceptance of Patients, POC, Medical Supervision Skilled Nursing Services Therapy Services Home Health Aide Services Clinical Records Comprehensive Assessment of Patients © 2014, A.D. Maxim Consulting, LLC

Conditions (Part B) Administration
Patient Rights Often taken for granted Not just in compliance if you give Patient a copy Example of a Condition Level Citation Condition of Participation: Patient Rights Agency Experience G100 – Example of Stated CONDITION LEVEL deficiency “This Condition is not met as evidenced by the Surveyor. Based on record review, review of the Agency’s Policies & Procedures, and interview, it was determined the Agency failed to ensure the Patient’s Rights by failing to confirm the Patient’s Authorized Representative (G104); failed to ensure that records are kept to document both the existence and resolution of complaints (G107); and failed to document the presence of a DNR order according to State Law….” © 2014, A.D. Maxim Consulting, LLC

So What Happened Next? The State Surveyor stated: “The cumulative effect of these systemic problems resulted in the Agency’s inability to ensure the provision of quality health care in a safe environment.” **OUCH!** © 2014, A.D. Maxim Consulting, LLC

Agency P&P review The Agency’s Admission Packet Policy stated that, “Prior to care being initiated, each Patient is given the Patient Information Packet. The clinician explains the important documents contained in the packet” The Agency’s Policy also stated regarding Patient Bill of Rights that “this document is carefully reviewed with each Patient prior to care” Medical Record #1: Survey Home Visit was conducted with a RN/Administrator for SOC. The RN/Administrator did not inform the Patient orally of Patient Rights Patient Info Packet was reviewed and the Bill of Rights and Patient Responsibilities were found on back of the Patient Consent Form. This was not noted to Patient © 2014, A.D. Maxim Consulting, LLC

Identifying and Following Up on Complaints
G 107 Level 1 Citation Agency failed to document existence/resolution of complaints and failed to inform Patient of complaint resolution process at SOC visit Findings Include: During a review of Agency’s P&Ps, Admission Packet Policy states that “prior to care being initiated, each Patient is given the Patient Information Packet. The admitting clinician explains the important documents in the packet.” This included the Client Concern Procedure Medical Record #1: During home survey visit with RN, it was noted that the RN did not inform the Patient of the Client Concern Procedure, including the existence of a State Hotline © 2014, A.D. Maxim Consulting, LLC

Documentation Issues This is why you must have an excellent understanding of your P&Ps! The Agency had a clear policy regarding how the Patient would be educated about Rights Nurse failed in following policy when verbally educating the Patient Then, during the interview, the Nurse could not verbalize the Agency policy © 2014, A.D. Maxim Consulting, LLC

Documentation Issues (cont.)
The RN failed to comply with the Agency’s Policy in the Admission Packet and did not inform the Patient of the Complaint Resolution Process Surveyor requested the Agency’s Complaint Documentation Administrator stated, “We never have any complaints. Sometimes the Patients just call because the nurse or therapist is not there, and I just handle it myself” When asked if the calls were documented, the Administrator asked, “Am I supposed to?” Surveyor reviewed Agency Complaint Policy with Administrator and it stated, “All concerns/complaints are logged on the Client Complaint Log” © 2014, A.D. Maxim Consulting, LLC

Once again, staff MUST know Agency Policy & abide by it! There was a clear lack of knowledge of Agency Policy in this case Lack of knowledge caused a Condition Level Citation (a) Standard: Notice of Rights G102, G103 Surveyor is looking for documentation in the clinical record that supports the Patient was given his/her Rights prior to care being initiated This is also the area that will determine if the Agency provided the OASIS Rights Statement in the same manner. They will look at P&Ps and for documentation statement that the SOC Clinician reviewed these items © 2014, A.D. Maxim Consulting, LLC

484.10(b) Standard: Exercise of Rights and Respect for Property and Person G104, G106, G105, G107 The Surveyor will be looking for compliance for these Standards primarily while in the home. Will be questioning the Patient about any complaints that have been filed, how they were handled and whether or not they know WHO to call in the event of a complaint The policies on complaints will be carefully reviewed and contents of the Agency Complaint Log could be a target for review © 2014, A.D. Maxim Consulting, LLC

484.10(c) Standard: Right to be Informed and to Participate in Planning Care and Treatment G108, G109, G110 In this area of the Condition, the Surveyor is most concerned about the Patient’s participation in care planning, being informed about the care plan and contributing in the care plan and whether or not the care plan is meeting the Patient’s needs 484.10(d) Standard: Confidentiality of Medical Records G111, G112 This entire section will investigate Patient confidentiality of OASIS data and is cross referenced to to follow. Pay close attention to how the staff instructs the Patient to keep the Home Record confidential © 2014, A.D. Maxim Consulting, LLC

484.10(e) Standard: Patient Liability for Payment G113, G114, G115 Liability for Payment Issues. The Patient will be interviewed regarding the status of payment for services and whether or not the clinical staff informed about the liability for payment. This is a complex and confusing issue for many Patients. Be sure there is a written statement in the record indicating the Patient/Caregiver being informed of issues related to payment. 484.10(f) Standard: Home Health Hotline G116 Assure that staff have made every effort to inform the Patient about the Hotline Number and when they should use it. Remember, this is not a number just for complaints that cannot be resolved by the Agency, but it can be used to ask questions about local homecare agencies and to file complaints concerning the implementation of Advanced Directives. © 2014, A.D. Maxim Consulting, LLC

484.11 COP – Release of Patient Identifiable OASIS Information
G310 – May ask to see the contract you have with a vendor used for transmission of OASIS data for the purposes of confirming confidentiality of the data Also may address OBQI/OBQM monitoring Surveyor will interview admin staff regarding processes in place to protect confidential information, assignment of passwords within the Agency and how OASIS data is kept confidential © 2014, A.D. Maxim Consulting, LLC

COP – Compliance with Fed, State, Local Laws; Disclosure; Ownership; Professional Standards & Principles 484.12(a) Standard: Compliance With Federal, State, and Local Laws and Regulations G118 Review may include, but not be limited to State licensure (if any). If the Agency has violated any State or Federal rules that are obvious, the Surveyor has the responsibility to contact the Regional Office with the information Under G118, the Surveyor will also determine just how staff that are “under arrangement” have current licensure and registrations checked © 2014, A.D. Maxim Consulting, LLC

COP (cont.) 484.12(b) Standard: Disclosure of Ownership and Management Information G119, G120 The Agency is expected to have Disclosure of Ownership statements for owners and management. This includes, but is not limited to, whether or not there is ownership in another Agency. Some of this information is disclosed on the CMS 855-A The Surveyor may review the most recent CMS 855-A for discrepancies with the organizational chart provided during the survey. © 2014, A.D. Maxim Consulting, LLC

COP (cont.) 484.12(c) Standard: Compliance With Accepted Professional Standards and Principles G121 Surveyor may compare practice by Agency Professionals with internal Policies & Procedures, ANA Standards, Best Practices, State Practice Acts, etc. He/she may review your clinical policies and/or reference materials used in providing Patient care Surveyor may look for competency of staff in areas such as wound care, wound assessment, or physical assessment © 2014, A.D. Maxim Consulting, LLC

484.14 Condition of Participation: Organization, Services, and Admin G122, G123, G124, G125, G126
For this Condition, the Surveyor will be asking about your organizational chart and will be looking for the chart to have clearly-defined delegation of responsibility down to the Patient care level 484.14(a) Standard: Services Furnished G127 The Surveyor may look at your contracts to identify how supervision is done and to assure that the Agency does not delegate supervisory authority to another outside Agency 484.14(b) Standard: Governing Body G128, G129, G130, G131, G132 The Governing Body assumes FULL legal responsibility for the Agency and assumes responsibility for the operation of the Agency – including Policies & Procedures, services, organization, and budget preparation. The Surveyor may review your budget © 2014, A.D. Maxim Consulting, LLC

COP (cont.) 484.14(c) Standard: Administrator G133,G134,G135,G136,G137 The Administrator will be assessed for qualifications related to directing day-to-day operations according to Policies & Procedures. There also must be someone delegated by the Board to act on behalf of the Administrator in his/her absence. 484.14(d) Standard: Supervising Physician or Registered Nurse G138, G139, G140 Qualifications of the Registered Nurse or Physician will be reviewed for his/her qualifications as the Supervising Nurse/Physician. 484.14(e) Standard: Personnel Policies G141 The Surveyor will be looking at personnel records, conducting interviews, observing staff in the home in an effort to assess qualifications of personnel to meet the needs of Patients admitted to the Agency. © 2014, A.D. Maxim Consulting, LLC

COP (cont.) 484.14(f) Standard: Personnel Under Hourly/Per Visit Contracts G142 This is another instance in which contractual personnel will be scrutinized along with the Agency policies related to the use of contractual staff, how contractual staff assure Patient Rights, the type of orientation that is provided to contract staff, how contract staff are monitored by the Agency, etc. 484.14(g) Standard: Coordination of Patient Services G143, G144, G145 Frequent citations are issued. Surveyors will need to assure that health information regarding each Patients’ health status and the Plan of Care is communicated to ALL TEAM MEMBERS including physician, home health aide, contract staff, etc. Clinical Managers will be questioned about how information about the Patient is communicated with and among all team members. There should be written evidence that lab values, changes in medications, response to interventions, changes in the Plan of Care, etc. are communicated © 2014, A.D. Maxim Consulting, LLC

484.14 COP (cont.) 484.14(h) Standard: Services Under Arrangement G146
There must be information in the contract for all under-arrangement plans to indicate that the Patient must NOT be charged for homecare services by anyone other than the homecare Agency 484.14(i) Standard: Institutional Planning G147 The Agency has to assume responsibility under the BOD. It must have an overall plan and budget and a capital expenditure plan if there is an anticipated $600,000 or more that will be spent within that fiscal year 484.14(i)(1) Standard: Annual Operating Budget If asked, it will be necessary to provide a copy of the Annual Budget prepared by a budget committee and approved by the BOD 484.14(i)(2) Standard: Capital Expenditure Plan Again, if spending greater than $600,000 in one fiscal year, the surveyor may ask for the plan © 2014, A.D. Maxim Consulting, LLC

COP (cont.) 484.14(i)(3) Standard: Preparation of Plan and Budget G148 Must have a budget committee. This should be made up of representatives of the governing body, administrative staff, and the medical staff (if any) from the Agency 484.14(i)(4) Standard: Annual Review of Plan and Budget G149 This portion requires that the budget be reviewed at least annually under the direction of the BOD 484.14(j) Standard: Laboratory Services G150 The Surveyor may ask to see a copy of the CLIA Waiver Certificate. Make sure it is up to date. If you send labs out for testing, the Agency is responsible for retrieving a copy of the outside lab’s CLIA certificate and having it available if asked © 2014, A.D. Maxim Consulting, LLC

484.16 Condition of Participation: Group of Professional Personnel G151, G152, G153
484.16(a) Standard: Advisory and Evaluation Function G154, G155 Your Professional Advisory Group is a requirement. The Federal regulations only require it meet frequently enough to address issues within the Agency Be sure you have clearly-defined and documented minutes. The PAC must be made up of a representation of services provided in the Agency, so include someone from each of the following: Skilled Nursing Physical Therapy Occupational Therapy Speech Therapy, etc… © 2014, A.D. Maxim Consulting, LLC

Condition of Participation: Acceptance of Patients, Plan of Care, and Medical Supervision G156, G157, G158 The surveyor will assess whether or not you are accepting only clients for care that can have needs adequately met by Agency staff 484.18(a) Standard: Plan of Care G159, G160, G161, G162 This is the number one deficiency almost every year. There must be a Plan of Care for every Patient covered by Medicare. The surveyor will assess the frequency of visits, adequacy of the frequency, etc. Surveyor will determine if the Patients receive appropriate services BASED ON THE ASSESSMENT, and that all elements of the Plan are completed Surveyor will evaluate whether the POC and the coordination of services assist the Patient in reaching goals, how the Agency monitors contract staff in complying with the Plan, and if the frequency of visits adequately assures that Patient care is optimal © 2014, A.D. Maxim Consulting, LLC

POC (cont.) 484.18(b) Standard: Periodic Review of Plan of Care G163, G164 Focus on changes in the Patient status, including measurements of outside stated parameters, or any changes suggesting a need to alter the Plan of Care, notifying the physician of changes and notifying the physician of discharge when the goals and needs have been met. They will be looking for SCIC assessments here when there is a significant change in condition. 484.18(c) Standard: Conformance With Physician Orders G165, G166, G167 Assure that the Agency staff administer only medications and treatments as ordered by the physician. Orders are signed and dated with the date of receipt by the qualified clinician and all orders are signed as soon as possible by the primary physician. © 2014, A.D. Maxim Consulting, LLC

484.20 Condition of Participation: Reporting OASIS Information G320
484.20(a) Standard: Encoding OASIS Data G321 Surveyor will be determining if the encoding and transmission of OASIS data occurs within the 30-day time frame allotted following the completion of the assessment 484.20(b) Standard: Accuracy of Encoded OASIS Data G322 Surveyor will be looking for contradictory information from the Assessment reviewed compared to that transmitted. May ask to do a home visit with a clinician to observe OASIS data being collected Surveyor will observe and ask questions about the correction of OASIS policy used by the Agency © 2014, A.D. Maxim Consulting, LLC

POC (cont.) 484.20(c) Standard: Transmittal of OASIS Data G324, G325, G326, G328 This will be part of the pre-survey task for the Surveyor. They will look for timeliness of care among other data transmitted to the State. When on-site, they will review Policies & Procedures related to OASIS transmission. OASIS error analysis will be conducted 484.20(d) Standard: Data Format G327 If there are issues related to data transmission, the surveyor will determine what steps the Agency takes in resolving such issues © 2014, A.D. Maxim Consulting, LLC

484.30 COP: Skilled Nursing Services G168, G169, G170
Standard: Skilled Nursing Services The HHA furnishes Skilled Nursing Services by or under the supervision of an RN and in accordance with the Plan of Care It is a high priority that the care provided matches the Plan of Care 484.30(a) Standard: Duties of a Registered Nurse G171, G172 The RN makes the initial evaluation visit and regularly re-evaluates the Patient’s nursing needs at least every 60 days (or more often if the Patient’s condition or needs change) For Patients with co-morbidities, is there evidence that pertinent interrelated factors are addressed in managing Patient’s care (eg., addressing nutrition and skin care in a Patient with diabetes and a wound)? RN is expected to initiate the Plan of Care and any revisions to the POC when appropriate © 2014, A.D. Maxim Consulting, LLC

484.30(a) (cont.) Is there evidence of Patient’s medical, nursing and rehab needs that are not addressed in the POC or communicated to the physician? Are newly identified Patient’s medical, nursing and rehab needs addressed in updates to POC? Expected Outcomes G174 – Care is provided by qualified nurses who are capable and competent to provide care as ordered and needed (IV care, ostomy care, wound assessment and care) G175 – Patients receive appropriate preventive and rehabilitative nursing care as ordered on the POC © 2014, A.D. Maxim Consulting, LLC

484.30(a) (cont.) G176 – RN’s clinical & progress notes are complete & provide consistent (non-conflicting) data regarding Patient status and treatments/services provided. RN coordinates & communicates with other staff members & the MD about the Patient’s condition/needs G177 – RN provides or supervises the provision of care & teaching appropriate to each Patient’s needs G178 – How does the HHA confirm that services requiring specialized nursing skills are furnished by individuals with the appropriate qualifications? © 2014, A.D. Maxim Consulting, LLC

484.30(b) Standard: Duties of the Licensed Practical Nurse G179, G180, G181, G182, G183
LPN provides services in accordance with Agency policies, prepares clinical & progress notes, assists the physician and RN in performing specialized procedures, prepares equipment & materials for treatments using aseptic technique & assists the Patient in learning appropriate self-care techniques Surveyor will make same comparisons as he/she did when reviewing duties of the LPN Are services provided in accordance with the Agency’s professional practice standards and with guidance & supervision from RNs? © 2014, A.D. Maxim Consulting, LLC

484.32 COP: Therapy Services G184-9
Therapy Services offered by the Agency directly or under arrangement are given by a qualified therapist or therapy assistant under the supervision of a qualified therapist in accordance with the POC Therapist evaluates the Patient when ordered, and assists the physician in developing & revising a POC that addresses the Patient’s needs Therapist documents the Patient’s progress towards goals and outcomes appropriately Therapist communicates with Patient/family, physician & other disciplines regarding Patient’s progress towards goals & outcomes © 2014, A.D. Maxim Consulting, LLC

Probes How does the Agency assure that therapy offered by staff under arrangement/contract meets the requirements? Does the clinical record document the Patient responses to therapy? How does the Agency coordinate therapy with other skilled services to complete the POC & promote positive outcomes? Is therapy provided to each Patient as ordered? Is there evidence of Patient therapy/equipment needs that are not addressed in the POC or communicated to the Physician? Are therapy visits made in the frequency ordered? Are assessments & communication with other care providers documented? © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? Standard 484.32 not met
Example: The therapist failed to assist the physician in evaluating the Patient’s level of function and help develop the POC when the Patient had therapy ordered. Records were marked to indicate POC was reviewed with physician, but there was no date, time or indication of who the PT spoke with regarding reviewing the POC with the physician To avoid this error, proper documentation must contain names, dates and contact information of all informed regarding therapy on the POC © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? (cont.)
Example: Therapist failed to prepare complete & accurate clinical progress notes, including discharge summaries according to Agency policy resulting in late or missing documentation. Agency policy indicated documentation is due every two weeks with payroll. At the time of collection, there were late docs, Patient records missing task instructions, and additionally a Patient was discharged to hospice. SN services had a discharge summary on file, but PT did not. Another Patient’s discharge summary failed to discuss Patient progress toward goals & Patient condition at time of discharge

Additional Errors PT can document pain during visit, but if he does not document reporting to the RN regarding ongoing pain, there can be an issue Therapist can forget to communicate & document discharge from therapy to the RN In Patients where the RN and LPN have documented confusion and dementia, the PT should not solely document, “Patient was given written instructions to execute tasks.” If there are mental issues impacting competency to follow instruction, a family member or caregiver must be educated regarding the HEP. This individual should be documented © 2014, A.D. Maxim Consulting, LLC

484.32(a) Standard: Supervision of PTA’s and OTA’s G190-2
Specific instructions for assistants must be based on treatments prescribed in the POC, evals by the therapist, & accepted standards of professional practice. The therapist evaluates the effectiveness of services provided by the assistant Documentation should show that communication & supervision exist between the asst. and therapist about the Patient’s condition, response to services furnished by the asst., and the need to change the POC © 2014, A.D. Maxim Consulting, LLC

484.32(a) Probes Surveyor will ask:
How does the therapist evaluate the Patient’s needs and response to services furnished by the therapy assistant to measure progress toward outcomes? What kinds of in-service programs have the therapist/assistant participated in during the past year? Who provides them? Were comprehensive assessments completed by the OTA or PTA? Only qualified clinicians (RN, PT, SLP/ST, or OT) may assess and complete the comprehensive assessment © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? Surveyor can find that the PTA was not appropriately supervised by the PT Example: Initial visit by PT created a care plan with HEP and various additional therapies. PTA documented 15 visits, but there was no documented evidence that the services provided by PTA were supervised by the PT. There was no documented communication between the PT and PTA regarding the POC for this Patient at the time that the PT turned over care to the PTA Also, TENS unit was requested, but there was no documentation regarding how long the PTA used the TENS on the patient, and there was no documentation of the PT supervising the PTA with using the TENS © 2014, A.D. Maxim Consulting, LLC

484.32(b) Standard: Supervision of Speech Therapy Services G193
How does the Agency confirm that Speech Therapy services provided under arrangement or contract meet the requirements of this condition? © 2014, A.D. Maxim Consulting, LLC

484.34 COP: Medical Social Services G196-201
If the Agency furnishes medical social services, those services are given by a qualified social worker or by a qualified social worker assistant under the supervision of a qualified social worker, and in accordance with the POC The social worker assists the physician and other team members in understanding the significant social and emotional factors related to the health problems, participates in the POC, prepares clinical progress notes, works with the family, uses appropriate community resources, participates in discharge planning and in-service programs and acts as a consultant to other Agency personnel © 2014, A.D. Maxim Consulting, LLC

What Does This Mean? Medical social services, when required by the POC, must be available on a visiting (not consultative) basis in a Patient’s home Either the Social Worker or the SWA may make the initial visit to the Patient. All information gained during home visit is reviewed by the Social Worker who communicates with the physician about the POC Social Worker may provide services or assign care to the assistant, providing the supervision is required Surveyor will ask how the Agency confirms that Patient’s social service needs are met, including services provided under arrangement or contract © 2014, A.D. Maxim Consulting, LLC

484.36 COP: Home Health Aide Services G202-3
Home Health Aides are selected on the basis of such factors as exhibiting a sympathetic attitude toward the care of the sick, ability to read, write and carry out directions, maturity and ability to deal effectively with the demands of the job Agency is responsible for assuring that Home Health Aides are trained and evaluated properly The FUNCTION of the Aide determines the need for training and competency evaluation © 2014, A.D. Maxim Consulting, LLC

484.36 Condition Level Citation
It was determined the Agency failed to ensure that written Patient care instructions for the Home Health Aide were prepared by the RN or other appropriate professional who is responsible for the supervision of the Aide, the home health aide care plan includes all necessary elements, and the home health aide performs services described on the care plan (G224) The Agency also failed to ensure that the RN makes an on-site visit to the Patient’s home to provide home health aide supervision no less than every 2 weeks (G229) This was determined to create an unsafe Patient environment © 2014, A.D. Maxim Consulting, LLC

484.36(a) Standard: Home Health Aide Training G204-6
Content & Duration of Training: Supervised practical training encompasses at least 75 hours, with at least 16 hours devoted to classroom training Home Health Aides are trained in the following areas: Communication Skills Observation, reporting and documentation of Patient status & the care or service furnished Reading/recording temp, pulse, resp Basic infection control Basic elements of body functioning and changes in body function that must be reported to the aide’s supervisor Maintenance of a clean, safe and healthy environment Recognizing emergencies and knowledge of emergency procedures Physical, emotional, developmental needs of and ways to work with the populations served by the Agency; respect for Patient, privacy and property © 2014, A.D. Maxim Consulting, LLC

484.36a-1 Home Health Aide Training (cont.)
Appropriate & safe techniques in personal hygiene/grooming that include: Bed bath Sponge, tub or shower bath Shampoo, sink, tub or bed Nail and skin care Oral hygiene Toileting and elimination Safe transfer techniques and ambulation Normal range of motion and positioning Adequate nutrition and fluid intake Any other tasks that the Agency may choose to have the Aides perform ** Training should be based on an instruction plan that includes learning objectives, clinical content, and minimum, acceptable performance standards that meet the requirements of the regulation.** © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? Upon review, an Agency was found to have an actively working Home Health Aide who was not documented to have completed the required 75 hours of training with at least 16 hours devoted to supervised practical training 12 hours of in-service (per year) is not documented © 2014, A.D. Maxim Consulting, LLC

484.36a-2 Standard: Conduct of Training G207
The Agency must not have had any Condition of Participation out of compliance within 24 months before it begins a training and competency evaluation or competency evaluation program Correction of a Condition Level Deficiency does not relieve the 2-year restriction © 2014, A.D. Maxim Consulting, LLC

484.46a-3 Standard: Documentation of Training G210
Agency must maintain documentation of compliance with this regulation for aides employed by or under contract with the Agency Alternate training organizations, training, instructors and documentation must meet the requirements of the regulation Documentation must include: Description of the training/competency eval program, including qualifications of the instructors Record distinguishing subjects taught at bedside vs. with mannequin and proof of skill competency How additional skills are taught if Agency case-mix requires aides to perform more complex procedures © 2014, A.D. Maxim Consulting, LLC

484.36b Standard: Comp. Eval. In-Service Training G211
1 – Applicability (G212) – The Agency is responsible for ensuring that aides meet competency evaluation requirements RN must evaluate the aide to assure skills learned/tested elsewhere transfer successfully to new patient in his/her place of residence. Review of skills can be done when RN installs aide into new Patient care situation, during supervisory visit or as part of annual performance review If the case-mix of the Agency demands more complex training for the Aide, the Agency must document how these additional skills are taught & tested © 2014, A.D. Maxim Consulting, LLC

484. 36b-2 Content & Freq. of Evals and Amt
484.36b-2 Content & Freq. of Evals and Amt. of In-Service Training G213-5 Agencies must do a performance review of each aide every 12 months Annual performance review may be completed during a 2-week supervisory visit in a Patient’s home or during installation of an aide in a new Patient care situation In-service training can occur as part of the 2-week supervisory visit, but must be documented as to the exact new skill or theory taught Aides may fulfill the annual 12-hour in-service training requirement on either a calendar-year basis or an employment anniversary basis © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? Aide certification can expire. If an aide was certified more than 24 months ago and has not been furnishing home health services, then the certification is null and void Skills can not just be discussed upon interview; they must be viewed as performed in a home care setting and the location of the evaluation must be clearly documented 12 hours of in-service must be clearly documented within a 12 month period of employment Filling out a self-evaluation is not adequate. RN must evaluate, and both parties must sign and date the documentation that will be kept on the employee’s file © 2014, A.D. Maxim Consulting, LLC

484.36b-3 Standard: Conduct of Evaluation and Training G216-18
Certain subject areas must be evaluated with tasks being performed on a pseudo-patient (another aide or volunteer) in the lab setting, while other tasks must not be simulated in any manner Surveyors will verify: How does the Agency ensure that aides perform only tasks for which they received satisfactory ratings on their competencies? If the skills needed are above the basic skills needed in the standard, how does the Agency train and test aides for competency? How does the Agency plan for extended training if it is unable to train its own aides? How does the Agency monitor the assignment of aides to match the skills needed for individual Patients? © 2014, A.D. Maxim Consulting, LLC

484.36b4 - Competency Determination G 219
A home health aide is not considered competent in any task for which he or she is evaluated as unsatisfactory The aide must not perform that task without direct supervision by a licensed nurse until after he or she receives training in the task for which he or she was evaluated as unsatisfactory and passes a subsequent evaluation with satisfactory © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? The surveyor may find an aide performing services during a home visit for which he/she is not properly trained

484.36b4(ii) Competency Determination G 220
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

G221 Documentation of Competency Determination §484.36(b)(5)
Standard: Documentation of Competency Evaluation. The HHA must maintain documentation which demonstrates that the requirements of this standard are met

G223 Documentation of Competency Determination
G223 §484.36(c) Standard: Assignment and Duties of the Home Health Aide (1)-The home health aide is assigned to a specific patient by the registered nurse G224 (Rev.) §484.36(c)(1) - Written patient care instructions for the home health aide must be prepared by the registered nurse or other appropriate professional who is responsible for the supervision of the home health aide under paragraph (d) of this section

G225-G227 §484.36(c)(2) Duties The home health aide provides services that are ordered by the physician in the plan of care and that the aide is permitted to perform under State law 226 §484.36(c)(2) - The duties of a home health aide include the provision of hands-on personal care, performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications that are ordinarily self-administered G227 §484.36(c)(2) - Any home health aide services offered by an HHA must be provided by a qualified home health aide

G228 §484.36(d) Supervision 1) - If the patient receives skilled nursing care, the registered nurse must perform the supervisory visit required by paragraph (d)(2) of this section. If the patient is not receiving skilled nursing care, but is receiving another skilled service (that is, physical therapy, occupational therapy, or speech-language pathology services), supervision may be provided by the appropriate therapist

Supervision G229 (Rev.) §484.36(d)(2) - The registered nurse (or an other professional described in paragraph (d)(1) of this section) must make an on-site visit to the patient’s home no less frequently than every 2 weeks. G230 §484.36(d)(3) - 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 a supervisory visit to the patient’s home no less frequently than every 60 days. In these cases, to ensure that the aide is properly caring for the patient, each supervisory visit must occur while the home health aide is providing patient care

Supervision G-231-G233 References Aides not directly employed by the Agency and Personal Care Attendants Refer to COPs

484.38 COP: Qualifying to Furnish Outpatient PT or SP Services
If an Agency provides outpatient therapy services on its premises, it must meet all specified Conditions of Participation Therapist may develop POC for outpatient PT and ST services. Medicare Patients need a POC and results of treatment must be reviewed by a physician. Non-Medicare Patients are not required to be under care of a physician, and so do not need a POC established by and reviewed by a physician. For non-Medicare Patients, the POC may be reviewed by the therapist or by the physician © 2014, A.D. Maxim Consulting, LLC

484.48 COP: Clinical Records G235-6
An organized, current, clear Clinical record with pertinent past & current findings is maintained for every Patient receiving home health services Filing of documents is current acc. to Agency/State policy Record contains: Identifying information Name of physician Drug, Dietary, Treatment & Activity Orders Signed/Dated clinical & progress notes Copies of reports sent to attending physician Discharge summary Correctly executed electronic signatures (if applicable) Agency must inform physician of the availability of a discharge summary © 2014, A.D. Maxim Consulting, LLC

Electronic Health Records
If the Agency uses and EHR, the Agency is expected to provide the surveyor: Tutorial on how to use the electronic system An individual who will, when requested by the surveyor, access the system, respond to any questions or assist the surveyor as needed in accessing the electronic information in a timely fashion Each surveyor will determine the EHR access method that best meets the need for that survey © 2014, A.D. Maxim Consulting, LLC

484.48 Probes Are there patterns in the records that are of concern?
Do the records document Patient progress and outcomes based on changes in the Patient’s condition? How does the Agency inform the physician about the discharge summary? How does the Agency ensure that the discharge summary gets sent to the physician upon request? © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? Signed and dated clinical notes and discharge summaries must be provided, including names of who reported to physician and date information was sent Discharge summary should not just say “goals achieved” without explanation of summary of care; should include progress toward goals and Patient’s medical and health status at discharge Nursing notes must be submitted in a timely fashion. A delay of 6 weeks is not acceptable and will be found deficient. RN can not possibly recall detailed PHI for that many weeks © 2014, A.D. Maxim Consulting, LLC

484.48a,b Standards: Retention & Protection of Records G237-41
Clinical records are kept for 5 years after the cost report to which they apply is filed with the intermediary, unless State law is different If a Patient is transferred to another health facility, a copy of the record is sent with the Patient Records may be stored electronically, including OASIS information. All material must be available for review during the retention period and for unannounced surveys OASIS and OBQI/M reports should be retained for 12 months until the new annual reports are received. Information must be safe from unauthorized use and safe from destruction Written Policies & Procedures govern use, removal and release of clinical records Can those furnishing services access the records easily? © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? Example: Agency cited for lack of safeguards against loss or unauthorized use for all records, resulting in potential for loss or unauthorized use of PHI for all Patients served by the Agency. Findings… Patient referral information was not kept in Patients’ clinical records, rather, it was kept in a binder under the FAX machine. The binder contained Patient information and was not secured, as it was in a hallway with no potential of being locked. © 2014, A.D. Maxim Consulting, LLC

484.52 COP: Evaluation of the Agency’s Program G242-47
Agency evaluations are not required to be completed all at the same time, or by the same evaluators Patient care services should be evaluated by providers and consumers The evaluation should address the entire program, including: Services furnished to Patients Administration/management of the Agency Policies & Procedures Contract Management Personnel Management Clinical Record Review Patient Care Goals & Objectives being met Results of the annual evaluation must be available upon request of the surveyor © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? If an Agency does not perform an annual review at all, they will be cited If an Agency does not provide documentation of a review that has found that the Agency program is appropriate, adequate, effective and efficient, or however they choose to state it in their Policies & Procedures, they will be cited. The overall findings should be clearly stated on the final page of the review documentation Administrative records of the annual evaluation should be kept where staff can access them readily upon request of the evaluator © 2014, A.D. Maxim Consulting, LLC

484.55 COP: Comprehensive Assessment of Patients G330-342
OASIS data must be collected by a qualified clinician Each patient must have a comprehensive assessment, regardless of payment source, within the required timeframe Plan of care must be developed based upon the assessment and reviewed at least every 60 days OASIS does not apply to the following Patients, but it can still be collected if the Agency chooses: Under age 18 Maternity services Housekeeping/chore services only Personal care services only Non-Medicare/Medicaid insurance Patients Medicare eligibility must be included, along with homebound status © 2014, A.D. Maxim Consulting, LLC

Requirements for Homebound Status
Patient is confined to home Services are provided under POC established and approved by physician Patient is under care of a physician Patient needs skilled nursing care on an intermittent basis or PT or ST or has continued need for OT © 2014, A.D. Maxim Consulting, LLC

What Can Go Wrong? An Agency can fail to complete initial assessments with accuracy and within 48 hours of the referral Medication review must be performed, and if it is not, then a condition level deficiency will result The comprehensive assessment needs to be updated and revised at discharge. Discharge documentation must be completed or a condition level deficiency can result. © 2014, A.D. Maxim Consulting, LLC

484.55a Standard: Initial Assessment Visit
RN completes the initial assessment and the comprehensive assessment when skilled nursing is ordered Initial assessment must occur within 48 hours of referral If the visit happens after the 48-hour window, Patient request for a more convenient time must be documented in the record, and physician must be notified of Patient’s request for a delayed start of care If the physician ordered the later start of care, is there an order in the chart specifying the delayed start of care date? © 2014, A.D. Maxim Consulting, LLC

484.55b G334-G335 Standard: Completion of Comprehensive Assessment
The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. © 2014, A.D. Maxim Consulting, LLC

G336 Completion of Comprehensive Assessment
When physical therapy, speech-language pathology, or occupational therapy is the only service ordered by the physician, a physical therapist, speech-language pathologist or occupational therapist may complete the comprehensive assessment, and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. The occupational therapist may complete the comprehensive assessment if the need for occupational therapy establishes program eligibility. © 2014, A.D. Maxim Consulting, LLC

484.55c Standard: Drug Regimen Review
The comprehensive assessment must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. © 2014, A.D. Maxim Consulting, LLC

484.55d Standard: Update of the Comprehensive Assessment
The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status The term “major decline or improvement in the patient’s health status” is the impetus for collecting and reporting OASIS data in the following situations: As defined by the HHA (reason for assessment 5, other follow-up); To assess a patient on return from an inpatient facility, other than a hospital, if the patient was not discharged upon transfer (resumption of care); and As determined by CMS © 2014, A.D. Maxim Consulting, LLC

Medicare Benefit Policy Manual
Chapter 7 Home Health Services (Rev. 144, ) © 2014, A.D. Maxim Consulting, LLC

Assess for qualifying criteria from Medicare Benefit Policy Manual
30 - Conditions Patient Must Meet to Qualify for Coverage of Home Health Services To qualify for the Medicare home health benefit, under §§1814(a)(2)(C) and 1835(a)(2)(A) of the Act, a Medicare beneficiary must meet the following requirements: Be confined to the home; Under the care of a physician; Receiving services under a plan of care established and periodically reviewed by a physician; Have Current Face to Face Documentation; Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy. © 2014, A.D. Maxim Consulting, LLC

Patient must be homebound

If not homebound, do not admit to home health!
Add the physical conditions, mental impairments or physician restrictions that are causing the patient to be homebound Examples: pain, dyspnea, dementia, confusion or wandering, post-op restrictions after THA, no driving r/t epilepsy Patient may be physically able to leave, but would not be safe -- describe unsafe conditions specifically Patient can make infrequent trips of short duration and still be homebound (MD appt, church, bank, lunch w/CG, chemo) © 2014, A.D. Maxim Consulting, LLC

Under Care of Physician

It is a requirement to contact the physician to confirm the plan of care for every Start of Care and Resumption of Care assessment Document clearly on assessments which physician was notified/who took your call or confirmation of fax and that plan of care was confirmed Without a physician approving plan of care and signing home care orders, the patient cannot receive services If no physician will sign orders, agency will not receive payment for care © 2014, A.D. Maxim Consulting, LLC

Reasonable and Necessary SN Services

Reasonable and Necessary SN/Therapy Services Include:
Whatever you are doing in the home MUST TAKE THE SKILLS OF A REGISTERED NURSE/LICENSED THERAPIST TO PERFORM!!! © 2014, A.D. Maxim Consulting, LLC

Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status Observation and assessment of the patient's condition by a nurse are reasonable and necessary skilled services where there is a reasonable potential for change in a patient's condition that requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment or initiation of additional medical procedures until the patient's treatment regimen is essentially stabilized. © 2014, A.D. Maxim Consulting, LLC

Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status (cont.) In the case where a patient was admitted to home health care for skilled observation because there was a reasonable potential of a complication or further acute episode, but did not develop a further acute episode or complication, the skilled observation services are still covered for 3 weeks or so long as there remains a reasonable potential for such a complication or further acute episode. © 2014, A.D. Maxim Consulting, LLC

Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status (cont.) Information from the patient's medical history may support whether there is a reasonable potential for a future complication or acute episode and, therefore, may justify the need for continued skilled observation and assessment beyond the 3-week period. © 2014, A.D. Maxim Consulting, LLC

Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status (cont.) Moreover, such indications as abnormal/fluctuating vital signs, weight changes, edema, symptoms of drug toxicity, abnormal/fluctuating lab values, and respiratory changes on auscultation may justify skilled observation and assessment. Where these indications are such that there is a reasonable potential that skilled observation and assessment by a licensed nurse will result in changes to the treatment of the patient, then the services would be covered. © 2014, A.D. Maxim Consulting, LLC

Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status (cont.) There are cases where patients whose condition may appear to be stable continue to require skilled observation and assessment (see examples below). However, observation and assessment by a nurse is not reasonable and necessary to the treatment of the illness or injury where these indications are part of a longstanding pattern of the patient's condition which itself does not require skilled services and there is no attempt to change the treatment to resolve them. © 2014, A.D. Maxim Consulting, LLC

EXAMPLE 1: A patient with atherosclerotic heart disease with congestive heart failure requires observation by skilled nursing personnel for signs of decompensation or adverse effects resulting from prescribed medication. Skilled observation is needed to determine whether the drug regimen should be modified or whether other therapeutic measures should be considered until the patient's treatment regimen is essentially stabilized. © 2014, A.D. Maxim Consulting, LLC

40.1.2.2 - Management and Evaluation of a Patient Care Plan
HHA B.2 Skilled nursing visits for management and evaluation of the patient's care plan are also reasonable and necessary where underlying conditions or complications require that only a registered nurse can ensure that essential non-skilled care is achieving its purpose. © 2014, A.D. Maxim Consulting, LLC

40.1.2.2 - Management and Evaluation of a Patient Care Plan
For skilled nursing care to be reasonable and necessary for management and evaluation of the patient's plan of care, the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of skilled nursing personnel to promote the patient's recovery and medical safety in view of the patient's overall condition. © 2014, A.D. Maxim Consulting, LLC

40.1.2.3 - Teaching and Training Activities
Teaching and training activities that require skilled nursing personnel to teach a patient, the patient's family, or caregivers how to manage the treatment regimen would constitute skilled nursing services. Where the teaching or training is reasonable and necessary to the treatment of the illness or injury, skilled nursing visits for teaching would be covered. © 2014, A.D. Maxim Consulting, LLC

40.1.2.3 - Teaching and Training Activities (cont.)
The test of whether a nursing service is skilled relates to the skill required to teach and not to the nature of what is being taught. Therefore, where skilled nursing services are necessary to teach an unskilled service, the teaching may be covered. Skilled nursing visits for teaching and training activities are reasonable and necessary where the teaching or training is appropriate to the patient's functional loss, illness, or injury. © 2014, A.D. Maxim Consulting, LLC

Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. © 2014, A.D. Maxim Consulting, LLC

The reason why the training was unsuccessful should be documented in the record. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient's illness, functional loss, or injury. © 2014, A.D. Maxim Consulting, LLC

Teaching and training activities that require the skills of a licensed nurse include, but are not limited to, the following: Teaching the self-administration of injectable medications, or a complex range of medications; Teaching a newly diagnosed diabetic or caregiver all aspects of diabetes management, including how to prepare and to administer insulin injections, to prepare and follow a diabetic diet, to observe foot-care precautions, and to observe for and understand signs of hyperglycemia and hypoglycemia; Teaching self-administration of medical gases; Teaching wound care where the complexity of the wound, the overall condition of the patient or the ability of the caregiver makes teaching necessary; © 2014, A.D. Maxim Consulting, LLC

Teaching and training activities that require the skills of a licensed nurse include, but are not limited to, the following: (cont.) Teaching care for a recent ostomy or where reinforcement of ostomy care is needed; Teaching self-catheterization; Teaching self-administration of gastrostomy or enteral feedings; Teaching care for and maintenance of peripheral and central venous lines and administration of intravenous medications through such lines; Teaching bowel or bladder training when bowel or bladder dysfunction exists; © 2014, A.D. Maxim Consulting, LLC

Teaching and training activities that require the skills of a licensed nurse include, but are not limited to, the following: (cont.) Teaching how to perform the activities of daily living when the patient or caregiver must use special techniques and adaptive devices due to a loss of function; Teaching transfer techniques, e.g., from bed to chair, that are needed for safe transfer; Teaching proper body alignment and positioning, and timing techniques of a bed-bound patient; Teaching ambulation with prescribed assistive devices (such as crutches, walker, cane, etc.) that are needed due to a recent functional loss; Teaching prosthesis care and gait training; © 2014, A.D. Maxim Consulting, LLC

Teaching and training activities that require the skills of a licensed nurse include, but are not limited to, the following: (cont.) Teaching the use and care of braces, splints and orthotics and associated skin care; Teaching the preparation and maintenance of a therapeutic diet; and Teaching proper administration of oral medication, including signs of side-effects and avoidance of interaction with other medications and food Teaching the proper care and application of any special dressings or skin treatments, (for example, dressings or treatments needed by patients with severe or widespread fungal infections, active and severe psoriasis or eczema, or due to skin deterioration due to radiation treatments) © 2014, A.D. Maxim Consulting, LLC

40.1.2.4 - Administration of Medications
Although drugs and biologicals are specifically excluded from coverage by the statute (§1861(m)(5) of the Act, the services of a nurse that are required to administer the medications safely and effectively may be covered if they are reasonable and necessary to the treatment of the illness or injury. © 2014, A.D. Maxim Consulting, LLC

A. Injections The medication being administered must be accepted as safe and effective treatment of the patient's illness or injury, and there must be a medical reason that the medication cannot be taken orally The frequency and duration of the administration of the medication must be within accepted standards of medical practice, or there must be a valid explanation regarding the extenuating circumstances to justify the need for the additional injections © 2014, A.D. Maxim Consulting, LLC

1. Vitamin B-12 injections are considered specific therapy only for the following conditions:
Specified anemias: pernicious anemia, megaloblastic anemias, macrocytic anemias, fish tapeworm anemia Specified gastrointestinal disorders: gastrectomy, malabsorption syndromes such as sprue and idiopathic steatorrhea, surgical and mechanical disorders such as resection of the small intestine, strictures, anastomosis and blind loop syndrome © 2014, A.D. Maxim Consulting, LLC

2. Insulin Injections Insulin is customarily self-injected by patients or is injected by their families However, where a patient is either physically or mentally unable to self-inject insulin and there is no other person who is able and willing to inject the patient the injections would be considered a reasonable and necessary skilled nursing service © 2014, A.D. Maxim Consulting, LLC

EXAMPLE: A patient who requires an injection of insulin once per day for treatment of diabetes mellitus, also has multiple sclerosis with loss of muscle control in the arms and hands, occasional tremors, and vision loss that causes inability to fill syringes or self-inject insulin. If there weren't an able and willing caregiver to inject her insulin, skilled nursing care would be reasonable and necessary for the injection of the insulin. © 2014, A.D. Maxim Consulting, LLC

B. Oral Medications The administration of oral medications by a nurse is not reasonable and necessary skilled nursing care except in the specific situation in which the complexity of the patient's condition, the nature of the drugs prescribed, and the number of drugs prescribed require the skills of a licensed nurse to detect and evaluate side effects or reactions The medical record must document the specific circumstances that cause administration of an oral medication to require skilled observation and assessment © 2014, A.D. Maxim Consulting, LLC

C. Eye Drops and Topical Ointments
The administration of eye drops and topical ointments does not require the skills of a nurse. Therefore, even if the administration of eye drops or ointments is necessary to the treatment of an illness or injury and the patient cannot self-administer the drops, and there is no one available to administer them, the visits cannot be covered as a skilled nursing service. This section does not eliminate coverage for skilled nursing visits for observation and assessment of the patient's condition. © 2014, A.D. Maxim Consulting, LLC

Tube Feedings Nasogastric tube, tube feedings (including gastrostomy tubes), and replacement, adjustment, stabilization. and suctioning of the tubes are skilled nursing services If the feedings are required to treat the patient's illness or injury, the feedings and replacement or adjustment of the tubes would be covered as skilled nursing services © 2014, A.D. Maxim Consulting, LLC

40.1.2.6 - Nasopharyngeal and Tracheostomy Aspiration
Nasopharyngeal and tracheostomy aspiration are skilled nursing services and, if required to treat the patient's illness or injury, would be covered as skilled nursing services © 2014, A.D. Maxim Consulting, LLC

Catheters Insertion and sterile irrigation and replacement of catheters, care of a suprapubic catheter, and in selected patients, urethral catheters, are considered to be skilled nursing services Where the catheter is necessitated by a permanent or temporary loss of bladder control, skilled nursing services that are provided at a frequency appropriate to the type of catheter in use would be considered reasonable and necessary © 2014, A.D. Maxim Consulting, LLC

Wound Care Care of wounds, (including, but not limited to, ulcers, burns, pressure sores, open surgical sites, fistulas, tube sites, and tumor erosion sites) when the skills of a licensed nurse are needed to provide safely and effectively the services necessary to treat the illness or injury, is considered to be a skilled nursing service © 2014, A.D. Maxim Consulting, LLC

Wound Care (cont.) For skilled nursing care to be reasonable and necessary to treat a wound, the size, depth, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the skin surrounding the wound must be documented in the clinical findings so that an assessment of the need for skilled nursing care can be made Coverage or denial of skilled nursing visits for wound care may not be based solely on the stage classification of the wound, but rather must be based on all of the documented clinical findings © 2014, A.D. Maxim Consulting, LLC

Wound Care (cont.) The plan of care must contain the specific instructions for the treatment of the wound NOTE: Wounds or ulcers that show redness, edema, and induration at times with epidermal blistering or desquamation do not ordinarily require skilled nursing care © 2014, A.D. Maxim Consulting, LLC

Wound Care (cont.) Where the physician has ordered appropriate active treatment (e.g., sterile or complex dressings, administration of prescription medications, etc.) of wounds with the following characteristics, the skills of a licensed nurse are usually reasonable and necessary: Open wounds which are draining purulent or colored exudate or have a foul odor present or for which the patient is receiving antibiotic therapy Wounds with a drain or T-tube with requires shortening or movement of such drains

Wound Care (cont.) Wounds which require irrigation or instillation of a sterile cleansing or medicated solution into several layers of tissue and skin and/or packing with sterile gauze Recently debrided ulcers Pressure sores (decubitus ulcers) with the following characteristics: There is partial tissue loss with signs of infection such as foul odor or purulent drainage; or There is full thickness tissue loss that involves exposure of fat or invasion of other tissue such as muscle or bone © 2014, A.D. Maxim Consulting, LLC

Wound Care (cont.) Wounds with exposed internal vessels or a mass that may have a proclivity for hemorrhage when a dressing is changed (e.g., post radical neck surgery, cancer of the vulva) Open wounds or widespread skin complications following radiation therapy, or which result from immune deficiencies or vascular insufficiencies Post-operative wounds where there are complications such as infection or allergic reaction or where there is an underlying disease that has a reasonable potential to adversely affect healing (e.g., diabetes) © 2014, A.D. Maxim Consulting, LLC

Wound Care (cont.) Third degree burns, and second degree burns where the size of the burn or presence of complications causes skilled nursing care to be needed Skin conditions that require application of nitrogen mustard or other chemotherapeutic medication that present a significant risk to the patient Other open or complex wounds that require treatment that can only be provided safely and effectively by a licensed nurse © 2014, A.D. Maxim Consulting, LLC

Ostomy Care Ostomy care during the post-operative period AND in the presence of associated complications where the need for skilled nursing care is clearly documented is a skilled nursing service Teaching ostomy care remains skilled nursing care regardless of the presence of complications. © 2014, A.D. Maxim Consulting, LLC

Heat Treatments Heat treatments that have been specifically ordered by a physician as part of active treatment of an illness or injury and require observation by a licensed nurse to adequately evaluate the patient's progress would be considered a skilled nursing service © 2014, A.D. Maxim Consulting, LLC

Medical Gases Initial phases of a regimen involving the administration of medical gases that are necessary to the treatment of the patient's illness or injury, would require skilled nursing care for skilled observation and evaluation of the patient's reaction to the gases, and to teach the patient and family when and how to properly manage the administration of the gases © 2014, A.D. Maxim Consulting, LLC

40.1.2.12 - Rehabilitation Nursing
Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing that are part of active treatment (e.g., the institution and supervision of bowel and bladder training programs) would constitute skilled nursing services © 2014, A.D. Maxim Consulting, LLC

Venipuncture Effective February 5, 1998, venipuncture for the purposes of obtaining a blood sample can no longer be the sole reason for Medicare home health eligibility Sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act specifically exclude venipuncture, as a basis for qualifying for Medicare home health services if this is the sole skilled service the beneficiary requires © 2014, A.D. Maxim Consulting, LLC

– Venipuncture (cont.) However, if a beneficiary qualifies for home health eligibility based on a skilled need other than solely venipuncture (e.g., eligibility based on the skilled nursing service of wound care and meets all other Medicare home health eligibility criteria), medically reasonable and necessary venipuncture coverage may continue during the 60-day episode under a home health plan of care

– Venipuncture (cont.) The Medicare home health benefit will continue to pay for a blood draw if the beneficiary has a need for another qualified skilled service and meets all home health eligibility criteria. This specific requirement applies to home health services furnished on or after February 5, 1998 © 2014, A.D. Maxim Consulting, LLC

– Venipuncture (cont.) FOR VENIPUNCTURE TO BE REASONABLE AND NECESSARY: The physician order for the venipuncture for a laboratory test should be associated with a specific symptom or diagnosis, OR the documentation should clarify the need for the test when it is not diagnosis/illness specific. In addition, the treatment must be recognized (in the Physician's Desk Reference, or other authoritative source) as being reasonable and necessary to the treatment of the illness or injury for venipuncture and monitoring the treatment must also be reasonable and necessary. © 2014, A.D. Maxim Consulting, LLC

– Venipuncture (cont.) The frequency of testing should be consistent with accepted standards of medical practice for continued monitoring of a diagnosis, medical problem, or treatment regimen. Even where the laboratory results are consistently stable, periodic venipuncture may be reasonable and necessary because of the nature of the treatment. © 2014, A.D. Maxim Consulting, LLC

– Venipuncture (cont.) Examples of reasonable and necessary venipuncture for stabilized patients include, but are not limited to those described below. Captopril may cause side effects such as leukopenia and agranulocytosis and it is standard medical practice to monitor the white blood cell count and differential count on a routine basis (every three months) when the results are stable and the patient is asymptomatic In monitoring Dilantin administration, the difference between a therapeutic and a toxic level of phenytoin in the blood is very slight and it is therefore appropriate to monitor the level on a routine basis (every three months) when the results are stable and the patient is asymptomatic © 2014, A.D. Maxim Consulting, LLC

– Venipuncture (cont.) Venipuncture for fasting blood sugar (FBS) An unstable insulin dependent or noninsulin dependent diabetic would require FBS more frequently than once per month if ordered by the physician Where there is a new diagnosis or where there has been a recent exacerbation, but the patient is not unstable, monitoring once per month would be reasonable and necessary A stable insulin or noninsulin dependent diabetic would require monitoring every 2-3 months © 2014, A.D. Maxim Consulting, LLC

40.1.2.13 – Venipuncture (cont.) Venipuncture for PT/INR re: Coumadin
Where the documentation shows that the dosage is being adjusted, monitoring would be reasonable and necessary as ordered by the physician Where the results are stable within the therapeutic ranges, monthly monitoring would be reasonable and necessary Where the results are stable within nontherapeutic ranges, there must be documentation of other factors which would indicate why continued monitoring is reasonable and necessary © 2014, A.D. Maxim Consulting, LLC

EXAMPLE: A patient with coronary artery disease was hospitalized with atrial fibrillation and subsequently discharged to the HHA with orders for anticoagulation therapy Monthly venipuncture as indicated are necessary to report protime levels to the physician, notwithstanding that the patient's protime tests indicate essential stability © 2014, A.D. Maxim Consulting, LLC

Student Nurse Visits Visits made by a student nurse may be covered as skilled nursing care when the HHA participates in training programs that utilize student nurses enrolled in a school of nursing to perform skilled nursing services in a home setting To be covered, the services must be reasonable and necessary skilled nursing care and must be performed under the general supervision of a registered or licensed nurse The supervising nurse need not accompany the student nurse on each visit © 2014, A.D. Maxim Consulting, LLC

40.1.2.15 - Psychiatric Evaluation, Therapy, and Teaching
The evaluation, psychotherapy, and teaching needed by a patient suffering from a diagnosed psychiatric disorder that requires active treatment by a psychiatrically trained nurse and the costs of the psychiatric nurse's services may be covered as a skilled nursing service Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse The services of the psychiatric nurse are to be provided under a plan of care established and reviewed by a physician © 2014, A.D. Maxim Consulting, LLC

40.1.2.15 - Psychiatric Evaluation, Therapy, and Teaching
Services of a psychiatric nurse would not be considered reasonable and necessary to assess or monitor use of psychoactive drugs that are being used for non-psychiatric diagnoses or to monitor the condition of a patient with a known psychiatric illness who is on treatment but is considered stable A person on treatment would be considered stable if their symptoms were absent or minimal or if symptoms were present but were relatively stable and did not create a significant disruption in the patient's normal living situation © 2014, A.D. Maxim Consulting, LLC

Getting Back to Basics Documentation Using the Nursing Process

The Nursing Process as a “Tool for Critical Thinking”
Critical thinking skills are essential in nursing because they are the basis for learning to prioritize and make decisions 5 steps to using thinking that is “purposeful”: What are you trying to figure out? What do you think can be accomplished? What is known about the problem? What are the concepts, ideas, and theories that we use in finding a solution to the problem? What are the consequences for our actions?

The Nursing Process as a “Tool for Critical Thinking” (cont.)
To become a professional nurse requires that you learn to think “like a nurse” To “think like a nurse” requires that we learn ideas, concepts, and theories that allow us to develop intellectual capacities and skills so that we become disciplined and self-directed Critical thinkers are clear, accurate, precise, and logical © 2014, A.D. Maxim Consulting, LLC

Skills of Critical Thinking
The skills that are needed include: Interpretation – The ability to understand and explain the meaning of information or an event Analysis – The investigation of a course of action based on objective and subjective data Evaluation – The process of assessing the value of the information obtained. Is it credible, reliable, and relevant? This skill is also applied in determining if desired outcomes have been reached

Skills of Critical Thinking
Explanation – The ability to clearly and concisely explain one’s conclusions The nurse should be able to provide sound rationale for his/her answers. Self-regulation – Involves monitoring one’s own thinking This means reflecting on the process leading to the conclusions. The individual should self-correct the thinking process as needed, being alert for biases and incorrect assumptions.

Considerations for Critical Thinking in the Uncontrolled Home Environment

Bias Everyone has biases Biases can interfere with patient care
Critical thinkers examine their biases and do not allow them to compromise the integrity of their thinking processes Biases can interfere with patient care For example, the Nurse believes patients with alcoholism are manipulative When the patient complains of anxiety, she ignores the complaint and could easily miss the signs of delirium tremens (DT’s) © 2014, A.D. Maxim Consulting, LLC

Closed-Mindedness The close-minded individual ignores alternative points of view Input from experts, patients, and significant others is ignored This results in limited options and the decreased use of innovative ideas © 2014, A.D. Maxim Consulting, LLC

USING THE NURSING PROCESS APPROACH

Step 1 of the Nursing Process: Assessment

Many components to assess:
Criteria to qualify for home care; The patient’s ability to improve with home care-????? Patient history, medication regimen changes, and prior level of function Physical assessment Functional assessment – including OASIS-C for safety Assessment of active problems requiring home care Need for additional disciplines – PT, OT and others © 2014, A.D. Maxim Consulting, LLC

Components to consider when completing the Assessment:
Patient history Prior level of function Psychological and social issues Complete physical examination © 2014, A.D. Maxim Consulting, LLC

Q: When should physical assessment begin for a new patient?

A: As early as the first phone call to arrange visit
A: As early as the first phone call to arrange visit! Pay attention to all cues – Hard of hearing? The patient needs instructions repeated? Out of breath from walking to answer phone? Once in the home, observe walking from door back to chair. Is the patient unsteady? Not using walker or using incorrectly (ex: picking up and carrying)? Pay attention to all cues, and never take the patient’s word when they say “I’m fine….” Use your clinical judgment Inspect all areas! The patient may protest at a full skin assessment or not want to walk to the bathroom. Remember this is your one chance to capture all issues you will be dealing with over the next nine weeks © 2014, A.D. Maxim Consulting, LLC

Step 2 of the Nursing Process: Patient Problem Identification

Patient Problem Identification
Using non-judgmental approach regarding patient/caregiver issues found in identifying ACTUAL problems Potential problems affecting outcomes will be addressed (in home health) WHEN the problem actually becomes a problem Using assessment data in identifying a problem at the time of the assessment (and during each visit) Identify risk factors related to present spell of illness © 2014, A.D. Maxim Consulting, LLC

Step 3 of the Nursing Process: Establishing Goals

Establishing Goals Identify patient-centered goals based on problems isolated during the assessment Identify individual patient goals - i.e., what does the patient expect to happen? Goals/outcomes must be MEASUREABLE LIMIT GOALS TO 7-8!!!!!!!! (Identifying signs and symptoms that may indicate need for referrals to other disciplines) © 2014, A.D. Maxim Consulting, LLC

Step 4 of the Nursing Process: Planning

PLANNING Implications of the Plan of Care developed
Using/tracking Process Measures identified Consider teaching strategies (learners ability to comprehend) Establishing frequencies of disciplines Establishing PRN visits Establishing Parameters for vital signs, weights, SaO2, etc. Documenting direct care © 2014, A.D. Maxim Consulting, LLC

Step 5 of the Nursing Process: Implementation

IMPLEMENTATION Writing a “skilled note”
The difference between teaching, direct care and observation Documenting “WNL” Coordinating Services Reporting to physicians Each Visit must contain information from the 485/plan of care! You CANNOT PERFORM CARE THAT IS NOT ORDERED! © 2014, A.D. Maxim Consulting, LLC

IMPLEMENTATION Should also include: Set of Vital Signs
Head to toe assessment - LOOK FOR CHANGES! Documentation of Homebound Status Documentation of pain level (if any) Teaching - only when teaching is ordered Direct Care - only when ordered © 2014, A.D. Maxim Consulting, LLC

IMPLEMENTATION ALWAYS keep a list of interventions and goals/copy of 485 (Plan of Care) When new issues arise, address immediately and contact the physician and document any new orders received Record progress (or CHANGE) at every single visit Identify goals addressed and/or met at each visit Document discharge planning with patient/CG throughout episode Coordinate Services when other disciplines are involved! © 2014, A.D. Maxim Consulting, LLC

IMPLEMENTATION – Writing a Nursing Note
Be realistic with the interventions you document each visit (for instance: do not document “taught uses and side effects of all medications”) Evaluate response to all teaching/instruction and treatments EVERY VISIT! Evaluate retention and use of information taught on visits Evaluate progress towards goals every visit © 2014, A.D. Maxim Consulting, LLC

Consider your Learner: Be aware of how much your patient/caregiver can learn in one home care visit Check boxes ARE NOT ENOUGH! INTEGRATE! Summarize teaching provided every visit, no need to rewrite all teaching content Example: instructed on diabetic diet – sources of carbohydrates If information is not being retained, may need to teach again and involve other caregivers © 2014, A.D. Maxim Consulting, LLC

ALL documentation must have: Legible Signature Date of Signature Late entries must be properly entered and dated with date of entry Corrections should be one line through error, date, initials and correction documented

Step 6 of the Nursing Process: Evaluation

EVALUATION Determining Recertification needs
Determining need for discharge Writing 60 day and discharge summaries © 2014, A.D. Maxim Consulting, LLC

EVALUATION – Is the Plan Working?
When approaching week 6, evaluate progress through episode and anticipated end of episode recertification vs discharge? Evaluate (re-assess) the patient and caregiver’s progress toward established goals compared to your initial plan As you go through the episode, determine if adjustments need to be made in the care plan If a particular goal is met, that part of the care plan is then discontinued and priorities need to be re-defined © 2014, A.D. Maxim Consulting, LLC

EVALUATION – Is the Plan Working?
DISCHARGE? Are they ahead of plan? May need to discharge early, would need to discuss and provide discharge notices and notify the physician RECERTIFICATION? Are they making slow progress? Document barriers to progress – education level or low literacy, poor coping skills, multiple caregivers involved, changes in medication or treatment

Evaluation - Is the Plan Working? DISCHARGE

Deciding to Discharge Document discharge planning EVERY VISIT with patient/CG in revisit notes Develop plans for care after home health ends – follow-up lab draws, physician appointments Summarize episode and notify physician of anticipated discharge – see sample discharge summary Document all teaching at discharge visit including safety recommendations, physician follow up, ER plan © 2014, A.D. Maxim Consulting, LLC

Sample Discharge Summary
Deciding to Discharge Sample Discharge Summary List all original goals Document interventions performed Document status (met or unmet) Summarize entire episode, all disciplines involved Send to physician – office can mail or fax © 2014, A.D. Maxim Consulting, LLC

Evaluation-Is the Plan Working? Deciding to RECERTIFY

Evaluation - Is the Plan Working? RECERTIFICATION

Deciding to Recertify Document lack of progress and barriers in visits and notes Determine which goals are met and which are new or remain to achieve Summarize episode of care and send to physician – see sample 60 day summary Obtain order for recertification from physician Perform recertification and document physical and functional status, active problems that you will address in next episode © 2014, A.D. Maxim Consulting, LLC

Sample 60 day summary List all original goals
Document interventions performed Document status (goals met and goals requiring more time to achieve) List any new issues that developed during episode and status Summarize entire episode, all disciplines involved State which active problems require care in the next 60 days Send to physician – office can mail or fax © 2014, A.D. Maxim Consulting, LLC

Hospital/Nursing Home Style Charting

Home Care Documentation is a Revenue Generator
In the hospital, payment is for services provided by the physician, surgeon, diagnostic testing, etc. Hospital charting is focused on making progress toward discharge For home health, the comprehensive assessment by the nurse or therapist decides how much payment is received for care OASIS-C scores, coding, additional disciplines Your charting should describe all of the risks and problems home health services will work to improve problems or risks show a need for you to return… © 2014, A.D. Maxim Consulting, LLC

Do NOT Document Stable Reviewed Discussed Improved Observed

DO Document Beginning to respond Instructed/Evaluated
Taught-Requires Continued Instruction Observed/Assessed Confined to Bed Continues to progress Instructed Evaluated © 2014, A.D. Maxim Consulting, LLC

Protect your revenue and outcomes

Protect your revenue and outcomes
Failing to score OASIS-C based on safety will cost your agency revenue – scores compile to determine RAP Being overly optimistic at SOC/ROC will harm your agency’s outcomes Document WHAY what the patient can do SAFELY rather than what they SAY they can do © 2014, A.D. Maxim Consulting, LLC

Protect your revenue and outcomes (cont.)
When a surveyor, medical reviewer or RAC contractor is assessing your documentation, don’t make them dig for information! Completing a summary provides quick answers to reviewers Don’t leave them guessing what is going on and why your agency should be paid for care © 2014, A.D. Maxim Consulting, LLC

Developing a Plan of Care

Determining Diagnosis
What is your “Focus of Care?” Consider all of the information and use good clinical judgment to decide patient priorities and needs Decide which problems will be the focus of your care Coding must be based on descriptions within your assessment If it is not described or documented in the assessment it cannot be coded © 2014, A.D. Maxim Consulting, LLC

Inpatient Diagnoses: The Info May Help - but it May Not
Identify where they were admitted, diagnoses confirmed, procedures and treatments performed - this MAY help determine homecare diagnoses, but NOT necessarily Why did they go in and what conditions were treated in the facility? © 2014, A.D. Maxim Consulting, LLC

What’s new or different?
Look for problems/changes – Remember, CHANGE IS YOUR FRIEND! For patients referred from physician: you must find what’s worsened or changed – call office or CG © 2014, A.D. Maxim Consulting, LLC

Co-morbidities – add complexity
Certain conditions (Co-morbidities) will affect the patient’s plan of care and progress even if they are well managed, such as: CHF Hypertension Diabetes Neoplasms Amputations, etc. © 2014, A.D. Maxim Consulting, LLC

Coding to Support Therapy Needs
When a patient needs therapy services, diagnoses to support therapy are required Therapy diagnoses can be complicated (may also be primary if Therapy only cases) © 2014, A.D. Maxim Consulting, LLC

Medications Review and record ALL medications patient is taking;
Identify if New (N) or Changed (c); Include Herbs and Vitamins; Reconcilliation with the physician © 2014, A.D. Maxim Consulting, LLC

Orders for Care: Establishing Frequencies
PRN orders - MUST BE SPECIFIC Using visit “ranges” Do NOT use 1x week x 9 weeks - a good reason for denial Surveyors will look to see if frequencies ordered are reasonable and necessary - too many or too few Must be based on patient need Front Loading Visits as a “Best Practice” Using “phone visits” as a supplement - DO NOT BILL! © 2014, A.D. Maxim Consulting, LLC

Orders for Care: Establishing Frequencies
Be sure to include all disciplines ordered on referral! Be sure to document if the patient refuses a discipline that was ordered and that the physician was notified!

Orders for Care: Establishing Frequencies (cont.)
Therapy/Social Worker POC/Order Recommendation: KNOW YOUR POLICY!!!! Patient admitted on 7/5/2013 primarily with skilled nursing needs. Transfer and ambulation is a problem identified. “Physical Therapy to evaluate by 7/10/2013 re: gait disturbance”. “Social Worker to assess patient for community services available by 7/15/2013.” © 2014, A.D. Maxim Consulting, LLC

Orders for Care: Establishing Frequencies (cont.)
Ordering Aide Services: Must be reasonable and necessary Must include specific orders for care Must be supervised at least every 14 days RECOMMENDED EXAMPLE: “HHA 3x week x 2; then 2x week x 7 for personal care and assist with exercises prescribed.”

KEEP IT SIMPLE - Establishing Goals
Problem Identification KEEP IT SIMPLE - Establishing Goals Goals provide direction for individualized nursing intervention Goals set standards of determining the effectiveness of interventions established Serve as guideposts when selecting nursing interventions that will make up the “plan of care” Determine WHAT the patient needs to achieve within WHAT timeframe © 2014, A.D. Maxim Consulting, LLC

KEEP IT SIMPLE - Establishing Goals (cont.)
PUTTING GOALS FIRST Rules for GOAL Setting: Be Realistic Base each goal on CURRENT PROBLEMS identified during assessment Make sure each goal is measureable Be sure each goal is clearly articulated REMEMBER: Interventions are selected ONLY after goals and predicted patient outcomes are determined!!!

Problem Identification KEEP IT SIMPLE - Establishing Goals (cont.) Make a LIST!!!!! Keep orders to a minimum-based on goals established Orders must be related to diagnosis codes established Include Process Measures (OASIS Synopsis Items ) when applicable. Orders should be your ROADMAP to positive patient outcomes

List specific orders: Observation and Assessment (remember the 3 week time frame) Teaching: WHO will be taught? WHAT will be taught? Direct Care: Wound care - include specific treatments, frequency of treatment, identify who will PERFORM treatments, frequency of nurse evaluation of wound (if caregiver/patient will do the routine wound care), specific supplies to be used, etc. Infusion, lab draws, blood glucose monitoring, patient weights Notifying Physician of Parameters © 2014, A.D. Maxim Consulting, LLC

KEEP IT SIMPLE - Establishing Goals (cont.) Parameters should be specific to the patients condition! For Example: Patient admitted to Agency new to insulin-BS running Nurse orders parameters for notifying physician: Notify phys. BS <70 or >200 How often will you be calling Doctor???? Use good clinical judgment when establishing parameters!

KEEP IT SIMPLE - Establishing Goals (P.S.)
Be SURE the Clinician taking verbal orders for the start of care SIGNS AND DATES Box 23 on the 485/plan of care Make SURE the Physician signs and dates the plan of care - the Agency may NO LONGER date the date of receipt as a replacement for the physician’s failure to date orders!!

INTERVENTION PLANNING MISTAKES

Top Intervention Planning Mistake
Primary and Secondary Diagnoses are not considered when designing plan Goals are established AFTER documenting interventions Synopsis Interventions are scored on OASIS M2250 for diabetic foot care, fall risk reduction, etc., but they are not on Plan of Care/485 The patient is NOT INVOLVED in developing plan OR establishing goals © 2014, A.D. Maxim Consulting, LLC

Other Documentation Issues 1. Medication documentation - identify new and changed meds Update as frequently as necessary Be sure to have correct dates re: Start and Discontinuing meds If paper documentation - PRINT medications Highlight discontinued medications using yellow highlighter Antibiotics require start and end date on the order and on med profile! Keep LOGS for multiple changing meds - i.e., Insulin, Coumadin, etc. Be sure to have procedure for reconciliation of medications when disciplines other than nurse is performing SOC assessment

Other Documentation Issues (cont.)
Coordination of Services - write a policy Plan coordination of services with all disciplines on a regular basis Patient Recovery in home health care is a TEAM effort! Include what you discussed (should be problem/goal driven); and who provided input

Record Keeping Principles Medicare Benefit Integrity Manual
Pub Transmittal 442 (January 8, 2013) “Regardless of whether a documentation, submission originates from a paper record or an electronic health record, documents submitted to (medical reviewers) containing amendments corrections or addenda must: Clearly and permanently identify an amendment, correction or delayed entry as such, and; Clearly indicate the date and author of any amendment, correction or delayed entry, and; Not delete but instead clearly identify all original content.”

References and Resources
Medicare Benefit Policy Manual Conditions of Participation and Interpretive Guidelines State Operations Manual OASIS-C Guidance (Chapter 3, Best Practices Manual, Quarterly Q&As) Accrediting Body Manual (The Joint Commission, CHAP, etc.) Agency Policy and Procedure Manual © 2014, A.D. Maxim Consulting, LLC

Summary Using the nursing process approach to complete and careful documentation can help your agency achieve many goals: Improve outcomes Maximize reimbursement Withstand review from surveyors, ADRs and RAC reviews. Integrate the nursing process into each area of your documentation: Assess, Diagnose, Plan, Implement, Evaluate © 2014, A.D. Maxim Consulting, LLC

Documentation: Back to the Basics – Using the Nursing Process

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Documentation: Back to the Basics – Using the Nursing Process

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