Transcript Skilled Management and Evaluation of a Care Plan Presented by

Documentation: Back to the Basics –
Using the Nursing Process
Presented by: Arlene Maxim, RN-President/Founder
A.D. Maxim Consulting, LLC.
1
© 2014, A.D. Maxim Consulting, LLC
Objectives for session
1. Describe challenges and implications of documentation and how it impacts
reimbursement and the survey process
2. Discuss the use of the Nursing Process as a “Tool for Critical Thinking”
3. Describe Components to assess related to Step 1 of Nursing Process: Start of Care
OASIS Assessment
4. Describe how to use the Nursing Diagnosis EFFECTIVELY as Step 2 of Nursing Process:
Patient Problem Identification
5. Describe how to determine patient-centered goals based on problems identified
EFFICIENTLY as Step 3 of Nursing Process: Outcome Identification
6. Illustrate how to prepare an outcome-driven plan (Plan of Care/485) as Step 4 in the
Nursing Process
7. Describe effective strategies for implementing the plan generated as Step 5 in the
Nursing Process by writing notes that clearly demonstrate skilled care
8. Describe how to evaluate the plan on an ongoing basis as Step 6 in the Nursing
Process
2
© 2014, A.D. Maxim Consulting, LLC
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!!!
3
© 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)
4
© 2014, A.D. Maxim Consulting, LLC
Prior to Y2K
Pre-OASIS
5
© 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
6
© 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
7
© 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
8
© 2014, A.D. Maxim Consulting, LLC
OASIS
Year 2000
and beyond
9
© 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
10
© 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
11
© 2014, A.D. Maxim Consulting, LLC
WHY DO WE NEED TO
DOCUMENT?
QUALITY
VS
QUANTITY
12
© 2014, A.D. Maxim Consulting, LLC
4 Primary Reasons:
 Professional Responsibility
 Legal Liability
 Regulatory Reasons
 Reimbursement Reasons
13
© 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
14
© 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 1983. 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.
15
© 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.
16
© 2014, A.D. Maxim Consulting, LLC
We have a
Professional
Responsibility
17
© 2014, A.D. Maxim Consulting, LLC
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.
18
© 2014, A.D. Maxim Consulting, LLC
We have a Professional
Responsibility (cont.)
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!!
19
© 2014, A.D. Maxim Consulting, LLC
We have a Professional
Responsibility (cont.)
Documentation MUST clearly reflect and
communicate JUDGEMENT and
EVALUATION!!
20
© 2014, A.D. Maxim Consulting, LLC
We have a Professional
Responsibility (cont.)
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
21
© 2014, A.D. Maxim Consulting, LLC
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!!!
22
© 2014, A.D. Maxim Consulting, LLC
LEGAL
Protection
23
© 2014, A.D. Maxim Consulting, LLC
Legal Protection
o There is an increase in the number of negligence
and malpractice cases against nurses and
homecare clinicians in general
o EXCELLENT documentation could deter a person
from filing suit against a provider or individual
clinician
24
© 2014, A.D. Maxim Consulting, LLC
Legal Protection (cont.)
o If, on the other hand, a lawsuit should move forward, the
clinician’s documentation will be used to “tell a story” in
court
o 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
25
© 2014, A.D. Maxim Consulting, LLC
Legal Protection (cont.)
“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.”
26
© 2014, A.D. Maxim Consulting, LLC
Legal Protection (cont.)
Minimizing/Reducing Errors:
o Completing an accurate evaluation assessment
o Mitigating errors in medications -- RECONCILLIATION OF
MEDICATIONS
o Communicating with other clinicians
o Assuring documentation is complete, thorough, accurate
and completed timely!
o Legible documentation
o Write with clarity
27
© 2014, A.D. Maxim Consulting, LLC
Legal Protection (cont.)
o Write concisely
o Make corrections according to Agency policy
– DO NOT USE WHITE OUT! –
o Document normal and abnormal findings
o Document patient complaints
o Make sure you have consents signed before providing ANY
PATIENT CARE!
28
© 2014, A.D. Maxim Consulting, LLC
29
© 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
30
© 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.
31
© 2014, A.D. Maxim Consulting, LLC
SURVEYORS
Federal Conditions of Participation
Measuring QUALITY
32
© 2014, A.D. Maxim Consulting, LLC
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
33
© 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
34
© 2014, A.D. Maxim Consulting, LLC
SURVEYORS
Federal Conditions of Participation
Measuring QUALITY (cont.)
• 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
35
© 2014, A.D. Maxim Consulting, LLC
SURVEYORS
Federal Conditions of Participation
Measuring QUALITY (cont.)
• Many of you who have had Surveys over the past
couple of years have likely noticed a difference in
just how the survey is conducted
36
© 2014, A.D. Maxim Consulting, LLC
IMMEDIATE
JEOPARDY
37
© 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.
38
© 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"
39
© 2014, A.D. Maxim Consulting, LLC
Immediate Jeopardy
(cont.)
• You will find Immediate Jeopardy situations and
examples in Appendix Q of the State Operations
Manual at: www.cms.gov
40
© 2014, A.D. Maxim Consulting, LLC
Immediate Jeopardy
(cont.)
• 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
41
© 2014, A.D. Maxim Consulting, LLC
ACCURATE
DOCUMENTATION
42
© 2014, A.D. Maxim Consulting, LLC
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!
43
© 2014, A.D. Maxim Consulting, LLC
ORIENTATION
44
© 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
45
© 2014, A.D. Maxim Consulting, LLC
Let’s Take A Closer Look
at COPs
46
© 2014, A.D. Maxim Consulting, LLC
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
47
© 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!!!**
48
© 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
49
© 2014, A.D. Maxim Consulting, LLC
TOP G TAGS CITED
IN 2012
50
© 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
51
© 2014, A.D. Maxim Consulting, LLC
Top G Tags Cited in 2012
•
•
•
•
•
•
G320
G100
G184
G117
G194
G310
(cont.)
Reporting OASIS Information
Patient Rights
Therapy Services
Compliance with Federal, State, and Local Laws
Medical Social Services
Release of Patient Identifiable Information
52
© 2014, A.D. Maxim Consulting, LLC
3 Parts of COPs
COPs are divided into 3 parts:
 General Provisions – 484.1 thru 484.4
• Basis & Scope
• Definitions
• Personnel Qualifications
 Administration – 484.10 thru 484.20
 Furnishing of Services – 484.30 thru 484.55
53
© 2014, A.D. Maxim Consulting, LLC
Level 1 & 2
Deficiencies
54
© 2014, A.D. Maxim Consulting, LLC
Level 1 & 2 Deficiencies
•
•
•
•
•
•
•
•
•
484.10
484.12
484.14
484.18
484.30
484.32
484.36
484.48
484.55
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
55
© 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
• 484.10 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….”
56
© 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!**
57
© 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
58
© 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
59
© 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
60
© 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”
61
© 2014, A.D. Maxim Consulting, LLC
Documentation Issues
(cont.)
• 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
• 484.10 (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
62
© 2014, A.D. Maxim Consulting, LLC
Documentation Issues
(cont.)
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
63
© 2014, A.D. Maxim Consulting, LLC
Documentation Issues
(cont.)
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 484.11 to follow. Pay close
attention to how the staff instructs the Patient to keep the Home
Record confidential
64
© 2014, A.D. Maxim Consulting, LLC
Documentation Issues
(cont.)
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.
65
© 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
66
© 2014, A.D. Maxim Consulting, LLC
484.12 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
67
© 2014, A.D. Maxim Consulting, LLC
484.12 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.
68
© 2014, A.D. Maxim Consulting, LLC
484.12 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
69
© 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
70
© 2014, A.D. Maxim Consulting, LLC
484.14 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.
71
© 2014, A.D. Maxim Consulting, LLC
484.14 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
72
© 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
73
© 2014, A.D. Maxim Consulting, LLC
484.14 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
74
© 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…
75
© 2014, A.D. Maxim Consulting, LLC
484.18 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
76
© 2014, A.D. Maxim Consulting, LLC
484.18 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.
77
© 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
78
© 2014, A.D. Maxim Consulting, LLC
484.20 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
79
© 2014, A.D. Maxim Consulting, LLC
484.30 COP: Skilled Nursing Services
G168, G169, G170
484.30 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
80
© 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
81
© 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?
82
© 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 selfcare 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?
83
© 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
84
© 2014, A.D. Maxim Consulting, LLC
484.32 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?
85
© 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
86
© 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
87
© 2014, A.D. Maxim Consulting, LLC
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
88
© 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
89
© 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
90
© 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
91
© 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?
92
© 2014, A.D. Maxim Consulting, LLC
484.34 COP: Medical Social Services G196201
• 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
93
© 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
94
© 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
95
© 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
96
© 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
97
© 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.**
98
© 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
99
© 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
100
© 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
101
© 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
102
© 2014, A.D. Maxim Consulting, LLC
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 2week 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
103
© 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
104
© 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?
105
© 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
106
© 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
107
© 2014, A.D. Maxim Consulting, LLC
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
108
© 2014, A.D. Maxim Consulting, LLC
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
109
© 2014, A.D. Maxim Consulting, LLC
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
110
© 2014, A.D. Maxim Consulting, LLC
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
111
© 2014, A.D. Maxim Consulting, LLC
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
112
© 2014, A.D. Maxim Consulting, LLC
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
113
© 2014, A.D. Maxim Consulting, LLC
Supervision G-231-G233
• References Aides not directly employed by the Agency and
Personal Care Attendants
• Refer to COPs
114
© 2014, A.D. Maxim Consulting, LLC
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
115
© 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
116
© 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
117
© 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?
118
© 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
119
© 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?
120
© 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.
121
© 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
122
© 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
123
© 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
124
© 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
125
© 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.
126
© 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?
127
© 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.
128
© 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.
129
© 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.
130
© 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
131
© 2014, A.D. Maxim Consulting, LLC
Medicare Benefit
Policy Manual
Chapter 7
Home Health Services
(Rev. 144, 05-06-11)
132
© 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.
133
© 2014, A.D. Maxim Consulting, LLC
Patient must be homebound
134
© 2014, A.D. Maxim Consulting, LLC
• 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)
135
© 2014, A.D. Maxim Consulting, LLC
Under Care of Physician
136
© 2014, A.D. Maxim Consulting, LLC
• 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
137
© 2014, A.D. Maxim Consulting, LLC
Reasonable and
Necessary SN Services
138
© 2014, A.D. Maxim Consulting, LLC
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!!!
139
© 2014, A.D. Maxim Consulting, LLC
40.1.2.1 - 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.
140
© 2014, A.D. Maxim Consulting, LLC
40.1.2.1 - 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.
141
© 2014, A.D. Maxim Consulting, LLC
40.1.2.1 - 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.
142
© 2014, A.D. Maxim Consulting, LLC
40.1.2.1 - 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.
143
© 2014, A.D. Maxim Consulting, LLC
40.1.2.1 - 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.
144
© 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.
145
© 2014, A.D. Maxim Consulting, LLC
40.1.2.2 - Management and Evaluation of a
Patient Care Plan
• HHA-205.1.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.
146
© 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.
147
© 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.
148
© 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.
149
© 2014, A.D. Maxim Consulting, LLC
40.1.2.3 - Teaching and Training
Activities (cont.)
• 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.
150
© 2014, A.D. Maxim Consulting, LLC
40.1.2.3 - Teaching and Training
Activities (cont.)
• 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.
151
© 2014, A.D. Maxim Consulting, LLC
40.1.2.3 - Teaching and Training
Activities (cont.)
NOTE: There is no requirement that the
patient, family or other caregiver be taught
to provide a service if they cannot or
choose not to provide the care.
152
© 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:
1. Teaching the self-administration of injectable medications,
or a complex range of medications;
2. 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;
3. Teaching self-administration of medical gases;
4. Teaching wound care where the complexity of the wound,
the overall condition of the patient or the ability of the
caregiver makes teaching necessary;
153
© 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.)
5. Teaching care for a recent ostomy or where reinforcement of
ostomy care is needed;
6. Teaching self-catheterization;
7. Teaching self-administration of gastrostomy or enteral feedings;
8. Teaching care for and maintenance of peripheral and central
venous lines and administration of intravenous medications
through such lines;
9. Teaching bowel or bladder training when bowel or bladder
dysfunction exists;
154
© 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.)
10. 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;
11. Teaching transfer techniques, e.g., from bed to chair, that are
needed for safe transfer;
12. Teaching proper body alignment and positioning, and timing
techniques of a bed-bound patient;
13. Teaching ambulation with prescribed assistive devices (such as
crutches, walker, cane, etc.) that are needed due to a recent
functional loss;
14. Teaching prosthesis care and gait training;
155
© 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.)
15. Teaching the use and care of braces, splints and orthotics and
associated skin care;
16. Teaching the preparation and maintenance of a therapeutic diet;
and
17. Teaching proper administration of oral medication, including signs
of side-effects and avoidance of interaction with other
medications and food
18. 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)
156
© 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.
157
© 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
158
© 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
159
© 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
160
© 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.
161
© 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
162
© 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 selfadminister 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.
163
© 2014, A.D. Maxim Consulting, LLC
40.1.2.5 - 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
164
© 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
165
© 2014, A.D. Maxim Consulting, LLC
40.1.2.7 - 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
166
© 2014, A.D. Maxim Consulting, LLC
40.1.2.8 -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
167
© 2014, A.D. Maxim Consulting, LLC
40.1.2.8 -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
168
© 2014, A.D. Maxim Consulting, LLC
40.1.2.8 -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
169
© 2014, A.D. Maxim Consulting, LLC
40.1.2.8 -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
170
© 2014, A.D. Maxim Consulting, LLC
40.1.2.8 -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
171
© 2014, A.D. Maxim Consulting, LLC
40.1.2.8 -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)
172
© 2014, A.D. Maxim Consulting, LLC
40.1.2.8 -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
173
© 2014, A.D. Maxim Consulting, LLC
40.1.2.9 - 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.
174
© 2014, A.D. Maxim Consulting, LLC
40.1.2.10 - 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
175
© 2014, A.D. Maxim Consulting, LLC
40.1.2.11 - 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
176
© 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
177
© 2014, A.D. Maxim Consulting, LLC
Venipuncture
178
© 2014, A.D. Maxim Consulting, LLC
40.1.2.13 - 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
179
© 2014, A.D. Maxim Consulting, LLC
40.1.2.13 – 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
180
© 2014, A.D. Maxim Consulting, LLC
40.1.2.13 – 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
181
© 2014, A.D. Maxim Consulting, LLC
40.1.2.13 – Venipuncture
(cont.)
FOR VENIPUNCTURE TO BE REASONABLE AND NECESSARY:
1. 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.
182
© 2014, A.D. Maxim Consulting, LLC
40.1.2.13 – Venipuncture
(cont.)
2. 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.
183
© 2014, A.D. Maxim Consulting, LLC
40.1.2.13 – Venipuncture
(cont.)
Examples of reasonable and necessary venipuncture for stabilized patients
include, but are not limited to those described below.
a.
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
b.
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
184
© 2014, A.D. Maxim Consulting, LLC
40.1.2.13 – Venipuncture
(cont.)
c. 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
185
© 2014, A.D. Maxim Consulting, LLC
40.1.2.13 – Venipuncture
(cont.)
d. 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
186
© 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
187
© 2014, A.D. Maxim Consulting, LLC
40.1.2.14 - 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
188
© 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
189
© 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
190
© 2014, A.D. Maxim Consulting, LLC
Getting Back to Basics
Documentation Using
the Nursing Process
191
© 2014, A.D. Maxim Consulting, LLC
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”:
1.
2.
3.
4.
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?
5. What are the consequences for our actions?
192
© 2014, A.D. Maxim Consulting, LLC
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
193
© 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
194
© 2014, A.D. Maxim Consulting, LLC
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.
195
© 2014, A.D. Maxim Consulting, LLC
Considerations for Critical
Thinking in the Uncontrolled
Home Environment
196
© 2014, A.D. Maxim Consulting, LLC
Bias
1. Everyone has biases
• Critical thinkers examine their biases and do not allow them to
compromise the integrity of their thinking processes
2. 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)
197
© 2014, A.D. Maxim Consulting, LLC
Closed-Mindedness
1. The close-minded individual ignores alternative
points of view
2. Input from experts, patients, and significant others is
ignored
3. This results in limited options and the decreased use
of innovative ideas
198
© 2014, A.D. Maxim Consulting, LLC
USING THE
NURSING
PROCESS
APPROACH
199
© 2014, A.D. Maxim Consulting, LLC
Step 1 of the Nursing Process:
Assessment
200
© 2014, A.D. Maxim Consulting, LLC
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
201
© 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
202
© 2014, A.D. Maxim Consulting, LLC
Physical Assessment
203
© 2014, A.D. Maxim Consulting, LLC
Q: When should physical assessment
begin for a new patient?
204
© 2014, A.D. Maxim Consulting, LLC
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
205
© 2014, A.D. Maxim Consulting, LLC
Step 2 of the Nursing Process:
Patient Problem
Identification
206
© 2014, A.D. Maxim Consulting, LLC
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
207
© 2014, A.D. Maxim Consulting, LLC
Step 3 of the Nursing Process:
Establishing Goals
208
© 2014, A.D. Maxim Consulting, LLC
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)
209
© 2014, A.D. Maxim Consulting, LLC
Step 4 of the Nursing Process:
Planning
210
© 2014, A.D. Maxim Consulting, LLC
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
211
© 2014, A.D. Maxim Consulting, LLC
Step 5 of the Nursing Process:
Implementation
212
© 2014, A.D. Maxim Consulting, LLC
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!
213
© 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
214
© 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!
215
© 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
216
© 2014, A.D. Maxim Consulting, LLC
IMPLEMENTATION – Writing a Nursing Note
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
217
© 2014, A.D. Maxim Consulting, LLC
IMPLEMENTATION – Writing a Nursing Note
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
218
© 2014, A.D. Maxim Consulting, LLC
Step 6 of the Nursing Process:
Evaluation
219
© 2014, A.D. Maxim Consulting, LLC
EVALUATION
• Determining Recertification needs
• Determining need for discharge
• Writing 60 day and discharge summaries
220
© 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
221
© 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
222
© 2014, A.D. Maxim Consulting, LLC
Evaluation - Is the
Plan Working?
DISCHARGE
223
© 2014, A.D. Maxim Consulting, LLC
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
224
© 2014, A.D. Maxim Consulting, LLC
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
225
© 2014, A.D. Maxim Consulting, LLC
Evaluation-Is the Plan
Working?
Deciding to RECERTIFY
226
© 2014, A.D. Maxim Consulting, LLC
Evaluation - Is the
Plan Working?
RECERTIFICATION
227
© 2014, A.D. Maxim Consulting, LLC
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
228
© 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
229
© 2014, A.D. Maxim Consulting, LLC
Hospital/Nursing Home
Style Charting
230
© 2014, A.D. Maxim Consulting, LLC
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…
231
© 2014, A.D. Maxim Consulting, LLC
Some Dos and
Don’ts
232
© 2014, A.D. Maxim Consulting, LLC
Do NOT Document
•
•
•
•
•
Stable
Reviewed
Discussed
Improved
Observed
233
© 2014, A.D. Maxim Consulting, LLC
DO Document
•
•
•
•
•
•
•
•
Beginning to respond
Instructed/Evaluated
Taught-Requires Continued Instruction
Observed/Assessed
Confined to Bed
Continues to progress
Instructed
Evaluated
234
© 2014, A.D. Maxim Consulting, LLC
Protect your revenue
and outcomes
235
© 2014, A.D. Maxim Consulting, LLC
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
236
© 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
237
© 2014, A.D. Maxim Consulting, LLC
Developing a Plan of Care
238
© 2014, A.D. Maxim Consulting, LLC
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
239
© 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?
240
© 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
241
© 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.
242
© 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)
243
© 2014, A.D. Maxim Consulting, LLC
Medications
244
© 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
245
© 2014, A.D. Maxim Consulting, LLC
Orders for Care
246
© 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!
247
© 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!
248
© 2014, A.D. Maxim Consulting, LLC
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.”
249
© 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.”
250
© 2014, A.D. Maxim Consulting, LLC
KEEP IT SIMPLE
251
© 2014, A.D. Maxim Consulting, LLC
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
252
© 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!!!
253
© 2014, A.D. Maxim Consulting, LLC
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
254
© 2014, A.D. Maxim Consulting, LLC
KEEP IT SIMPLE - Establishing Goals (cont.)
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
255
© 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 250-400
• 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!
256
© 2014, A.D. Maxim Consulting, LLC
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!!
257
© 2014, A.D. Maxim Consulting, LLC
INTERVENTION
PLANNING
MISTAKES
258
© 2014, A.D. Maxim Consulting, LLC
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
259
© 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
260
© 2014, A.D. Maxim Consulting, LLC
Other Documentation Issues
(cont.)
2. 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
261
© 2014, A.D. Maxim Consulting, LLC
Record Keeping Principles
Medicare Benefit Integrity Manual
Pub. 100-08 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.”
262
© 2014, A.D. Maxim Consulting, LLC
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
263
© 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
264
© 2014, A.D. Maxim Consulting, LLC
Questions?
Comments?
265
© 2014, A.D. Maxim Consulting, LLC