Blog and Helpful Articles

Top Home Health Agency Survey Deficiencies: Medication review

In Part 1 of this blog series on ACHC’s top home health agency survey deficiencies, we looked at the Plan of Care.  In the second installment of this weighty topic, let’s discuss medications.  CMS – and by extension, accrediting organizations – require a comprehensive assessment and regulations detail the aspects of this evaluation.  A review of medications is a critical component.  During the assessment and on a regular basis, agencies must review all of the medications, prescription and non-prescription, the patient is taking.  The review begins with making sure all the medications (as defined above) are listed on a medication profile, including the correct medication name, dose and frequency.  Next, the registered nurse must assess:

  • Potential adverse effects and drug reactions, including ineffective drug therapy;
  • Significant side effects;
  • Toxic effects;
  • Drug and/or food allergies, in addition to allergic reactions;
  • Immediate desired effects;
  • Unusual and unexpected effects including those which may rapidly endanger the patient’s life or well-being;
  • Significant drug interactions;
  • Duplicate drug therapy;
  • Noncompliance with drug therapy;
  • Changes in the patient’s condition that contraindicate continued administration of the medication.

For therapy-only cases, the therapist can compile a list all of the medications and forward the listing to the RN to review. As with all things medical, documentation is the key so the therapist must, of course, date the medication listing and sign it with his/her credentials and make a notation that the listing was forwarded to a named individual.  The reviewing nurse will do the same:  document the review and sign off as having reviewed the medications.

Medications that are taken PRN, or as needed, must include parameters or indications (e.g., for pain, when systolic pressure is > X). Additionally, oxygen must be listed on the medication profile, including method of administration (nasal cannula, mask), frequency, flow rate and parameters for its use.  Finally, the patient’s medical provider must be notified when there is a medication discrepancy, any side effect, problem or reaction to a prescribed medication.  All reported issues, conversations with and orders from the provider must be documented in the record. 

Because medications may change during the episode of care, make sure the medication profile is an important part of your agency’s quality assurance activities so you can minimize the likelihood for adverse patient care situations and survey deficiencies.

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HEDIS Reminder: Medication reconciliation

HEDIS, or the Healthcare Effectiveness Data and Information Set, is a collection of statistics that reflects health plan (and provider) performance in meeting specific quality metrics.  One important metric is the post discharge medication reconciliation (Category II code 1111F).  Obviously, it’s sound medical practice for a primary care provider (PCP) to review a patient’s medications at every visit to ensure they’re appropriate and effective, but more so, when the patient has been discharged from an inpatient stay.  Medications change while patients are institutionalized, and the hospital follow-up visit is an opportunity to assure the medication updates are reflected in the outpatient record.

There are two important words above; the first is inpatient.  Many providers believe the HEDIS medication reconciliation is for all hospital visits.  Not correct.  It’s a measure for reconciling meds post-discharge form an inpatient stay.  This means hospital and skilled nursing facility (SNF), primarily. Although a patient may visit an emergency department for an acute issue, and the practice would be correct to perform a follow-up visit, it is not appropriate to report 1111F after an ER visit. The medication recon must also occur within 30 days of the discharge.

The other important word is visit.  Many PCPs like to see their patient after an inpatient discharge – in a face-to-face appointment – but the medication reconciliation needn’t occur during a F2F visit.  It can be telephonic and should probably be done sooner than later so the provider is made aware quickly of medication changes.  In addition, the two services don’t need to occur simultaneously.  A qualified staff member can review the discharge medications and the PCP can conduct a F2F or telehealth visit after the reconciliation as long as there is documentation that the provider reviewed the medication changes.

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Recognized Diabetic Manifestations

Even people who know only the basics of risk adjusted payments know that there is a hierarchy in coding diabetes.  Diabetes with no complications contributes about two-thirds less in funding when compared to diabetes with a complication.  The unfortunate reality of diabetes mellitus (DM) is that sooner or later, patients often develop a complication. 

In the world of ICD-10 coding, though, the manifestation doesn’t necessarily need to have been caused by DM.  There are conditions that are coded as diabetic manifestations when they occur with DM, not due to, or secondary to, it.  In fact, the ICD-10-CM book lists the conditions that are supposed to be coded as diabetic manifestations.  These reflect coding rules and even if the conditions are not linked by the provider, proper coding requires coders to change ICD-10-CM codes prior to transmission of the claim or encounter.

The most common diabetic manifestations are: chronic kidney disease, peripheral vascular disease, polyneuropathy and cataracts.  That’s right.  Cataracts.  Sometimes coding rules defy logic to a certain degree but we’re bound by them.  As you can see on this graphic by the National Institutes of Health, the prevalence of cataracts increases with age. In fact, the graphic defines a cataract as “a clouding of the lens in the eye that affects vision” and goes on to explain that, “Most cataracts are related to aging. Cataracts are very common in older people.”  In risk adjustment, the cataract would be linked to DM, coding-wise, regardless of its prevalence in all adults, diabetic or not.

In our MRA work, however, we see some unique pairings, such as habitually linking hyperlipidemia to DM.  This is one manifestation that should be rare but we routinely encounter practices for which this is the #1 complication among diabetic patients.  To be sure, this link must be made by the clinician, and not the coder. It shouldn’t even be suggested by the coder, in our opinion. Atherosclerosis is another one gaining popularity among some practices.  Coders will routinely link DM to atherosclerosis of the aorta, another commonly occurring condition.  This is not a recognized diabetic complication.

We understand the incentive to report at least one diabetic manifestation because of its effect on payments, but we must be careful to stay within the realm of medical and coding reality.  Request a FREE copy of the ICD-10-CM automatic diabetic manifestations and run a report of what’s being coded in your practice. And join us in the next installment of this blog series where we’ll go through the most common diabetic complications in a little more detail. 

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Florida Legislature Revises Assistance with Self-Administration of Medications Statute

The Florida Legislature recently revised Section 400.488, F.S which details what constitutes ‘Assistance with Self-Administration of Medications’ (ASAM) as it applies to home care organizations. The definition has expanded the tasks an unlicensed person in a home health setting may perform to assist a patient with the same kinds of self-administration of medication tasks that are allowed in an assisted living facility (ALF). The law became effective on July 1, 2022.

Prior to July 1, 2022, Section 400.488, F.S., allowed home health aides (HHAs) and certified nursing assistants (CNAs) to assist a patient with the self-administration of his or her medications, which included:

  • Taking the medication, in its previously dispensed, properly labeled container, from where it is stored and bringing it to the patient.
  • In the presence of the patient, confirming that the medication is intended for that patient, orally advising the patient of the medication name and purpose, opening the container, removing a prescribed amount of medication from the container, and closing the container.
  • Placing an oral dosage in the patient’s hand or placing the dosage in another container and helping the patient by lifting the container to his or her mouth.
  • Applying topical medications, including routine preventive skin care and applying and replacing bandages for minor cuts and abrasions as provided by the AHCA in rule.
  • Returning the medication container to proper storage.
  • For nebulizer treatments, assisting with setting up and cleaning the device in the presence of the patient, confirming that the medication is intended for that patient, orally advising the patient of the medication name and purpose, opening the container, removing the prescribed amount for a single treatment dose from a properly labeled container, and assisting the patient with placing the dose into the medicine receptacle or mouthpiece. (This paragraph was substantially modified and will be discussed below.)
  • Keeping a record of when a patient receives assistance with self-administration under this section.

The definition of ASAM remains substantially the same, but the revision adds new tasks with which an HHA or CNA may provide assistance in a home care setting, including:

  • Assisting with transdermal patches.
  • Using a glucometer to perform blood-glucose level checks.
  • Assisting with putting on and taking off antiembolism stockings.
  • Assisting with applying and removing an oxygen cannula but not with titrating the prescribed oxygen settings.
  • Assisting with the use of a continuous positive airway pressure (CPAP) device but not with titrating the prescribed setting of the device.
  • Assisting with measuring vital signs.
  • Assisting with colostomy bags.

The statute revised and simplified the manner in which ASAM via nebulizer may be performed in a home health setting to mirror how such assistance is provided in an ALF. Specifically, the revised statute says that assisting with the use of a nebulizer includes, “removing the cap of a nebulizer, opening the unit dose of nebulizer solutions, and pouring the prescribed premeasured dose of medication into the dispensing cup of the nebulizer.”

As before the amendment, Section 400.488, the ASAM by an HHA or CNA is conditioned upon a documented request by, and the written informed consent of, a patient or the patient’s surrogate, guardian, or attorney in fact.

Further, the requirement as set out in Rule 59A-8.0095, F.A.C., continues to require CNAs and HHAs to receive two hours of training prior to assisting with the self-administration of medication.

From an administrative standpoint, remember to update your agency’s ASAM policy & procedure to reflect the statutory changes, and for those licensees subject to staff member competency evaluation prior to the performance of a new task, remember to add the new duties to your competency verification program.

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Termination for Poor Performance is Often a Management Failure – Part 2

We started this two-part blog series about performance issues by looking at the aspects of work-life that perhaps make us too busy to devote the time to remediate staff behaviors that miss the mark. In this part, we’ll answer the question we posed last time, Once you transition tasks not worthy of a manager’s attention to other staff members, what will you do with the extra time? 

Why, you will review the work you just delegated to make sure it’s being done correctly! You’ll also add to your day/week the time to review other people’s work.  Some examples include: spot-checking the appointment schedule to be sure slots are used correctly, not too many double-bookings, not too many new patients in a day, etc.  (Your practice has some scheduling parameters, right?); you could review some recent eligibility checks to be sure employees read them correctly and scheduled appropriately (with only providers who are credentialed by that plan, for example); it’s a good idea to look through new patient visits and make sure all paperwork is properly completed and filed in the chart, you have a copy of the patient’s ID and insurance card, photo in the EMR, access to portal granted, etc.  The list can be endless and you can pick one or two issues to review per week, making sure you touch every employee’s work.

Let’s talk for a minute abut interruptions.  While you’re tracking things, we hope you’re paying attention to the questions and issues employees bring you.  Does your staff have autonomy to resolve certain issues themselves, or do people have to come to you for everything?  Some managers don’t trust workers to function independently, while others like to feel important because “nobody can do anything without me.”  Both point to faulty leadership because eventually, your staff learns they don’t need to think, but will wait to be told – a death knell to any service business.   Your list of employee interruptions will point to training gaps that need filling, which is part of your managerial role.  If there is a seasoned junior person in the practice, perhaps he or she can become the first line of resolution and training so that you can focus on weightier matters.

This brings us back to the original issue of termination for poor performance.  Your to-do list should include time for counseling employees.  For the group that is meeting your expectations, a short convo to pat them on the back and praise a job well-done can go a long way.  You can also gauge where they see themselves, what new asks they’d like to learn, etc,, making them future delegees. (is that even a word?!) The group whose performance is missing the standard needs your time as well, giving them targeted feedback that helps meet expectations.

The hiring timeline is growing longer and in today’s (and well, any) economic climate, we need to retain the good staff we have and groom the not-yet-great into tomorrow’s stars. 

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Termination for Poor Performance is Often a Management Failure – Part 1

Supervising an employee’s work and coaching improvement are hard to accomplish on a consistent basis, but they’re critical to an organization’s operations and even its survival.  And frankly, we owe it to our staff members to periodically assess their work and provide feedback that lets them know how they’re doing and gives them an opportunity to finetune their performance.  The last place for an employee to learn of any deficiencies is on an annual evaluation or, perish the thought, at the point of termination.  That’s just poor management, in our opinion. 

While you may agree with this, you might be wondering how you can possibly add another – albeit important – task to your already full schedule. It may not be easy, but it does need to be a line item on your to-do list.  You might begin by analyzing your work day as a manager:  on what do you spend your time?  What interruptions occur? Do you ever encounter mistakes and just fix them because it’s easier than working with the employee who made the error?

When bogged down with periods of intense work but seemingly little accomplishment, our consultants will track their activities on a given day.  It’s tedious, for sure, and probably imperfect, but a few days of this will start to reveal patterns.  So, we suggest you start there. Once you can see the things that occupy your time, you can determine if these are tasks that you, personally, have to do.  While they may be “easy” and “don’t take a lot of time,” if they’re not managerial tasks, you’re squandering your brain-power and time.  We’ve also seen managers hide from facing big things because they’re busy on minutiae that other staff members can do. Make sure this isn’t you….but what if it is? 

If you find that you’re doing things others can do, develop a plan to transition those responsibilities to others.  Maybe you can split them up and redistribute one task to each of several people.  You’re not doing this to sit in your office and play video games, but to be more effective in your primary role as a manager and to develop others on your team.  And lest you think everyone else is “too busy” to take on one more thing, give it a try and let the worker come up with a plan to get things done.  The same way that paperwork expands to fill the empty parts of our desk (say it isn’t just me LOL), you may find that the amount of time it takes to complete work expands to fill the time allotted. Maybe others can learn to be more efficient in performing their tasks if you give them additional responsibilities.

What will you do with the extra time? 

Join us for the second half of this two-part series where we’ll answer that question and also tackle the topic of staff interruptions and remediation.

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Medical Records & MRA

Everyone involved in health care knows that having historical information on a patient is important, especially when the patient is relatively new to the provider.  The most meager of prior records still help to fill in the medical picture and offer background on what is – and isn’t – wrong with the individual.  In addition, old medical records are extremely important for the MRA chart reviewer, who often mines those records to identify incidental information that may result in risk adjusted conditions.

At the risk of being elemental, let’s go over the importance of past records.  First, every practice has – or should have – a process for requesting, and following up on, prior info.  This process begins at, or slightly before, the first visit and a valid medical records request should be directed to every provider the patient has seen in the last few years.  Not an easy task.  The main reason to blanket the provider landscape with requests is that a prior PCP may not release everything in the chart.  Since the provider – and not the patient – is the owner of the record, he or she can determine what will be released regardless of any stipulation of “all records” on the release form. 

Some providers release only the documents they created in their practice, namely visit notes and perhaps laboratory reports.  Others release visit notes and all imaging and lab info.  On the other side of the continuum is the practice that releases the whole record, fax cover sheets, hospital documents, everything.  We love those guys!

The receipt of records can take several requests and you definitely need a practice-wide policy for the process and its timeframes.  How often do you follow up?  How do you follow up on outstanding requests?  How many times do you fax a request before making a phone call (and maybe, a friend)?  If requests are taking a long time, or records are not forthcoming, you might re-revaluate what you’re asking for:  do you really need the whole record? If you’re requesting records from a specialist, the last visit note is usually sufficient.  Try asking for that, which may be easier for them to send quickly and just as useful for your purposes. if it’s an old PCP, maybe try limiting your request to the last two years.

Last thing is to make sure you update your records so you don’t re-request the same thing over and over again.  And while we’ve got our chart reviewer wish list out, how about filing the same document only one time as opposed to the three or four times we’ve found in many charts, AND titling the document with the specialty name and date of service. 

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What We’re Reading – As inflation hits 40-year high, how is it changing employer strategy?

We certainly don’t need to watch the news to know that inflation is ravaging our country’s economy.  The price of just about everything has risen and paychecks fall short.  As managers, what can we do when our company’s budget is not expanding to allow for higher wages and our employees are struggling?   Some outside-the-box thinking may be in order, as we add our ideas to this article from Healthcare Executive’s suggestions to lighten the stress and financial burden.

Benefits. In the area of employee benefits, the author suggests assistance with tuition or student loan repayment.  She also states that employers aren’t moving quickly enough to offer benefits that address pain points. As consultants who offer HR support, we’ve sometimes been called upon to conduct in-depth employee surveys, suitable for a deep dive on worker sentiment, but what about a quick survey aimed at these economic times?  Perhaps a short three-question anonymous check can give you targeted information to spur more timely and responsive solutions for the right now. Ask about main issues and then focus a small committee on quick-to-launch solutions.  

Healthcare costs.  While we can’t do anything about actual premiums, perhaps the company can: cover a higher percentage of the employee premium; or for larger employers, offer a wider selection of plans. For those who offer health savings accounts (HSAs), what percentage of the workforce uses them?  It may be a good idea to shows employees (again) what they can save by using an HSA. 

Remote work. Many organizations were rethinking remote work and attempting a return to the office employee wave.  However, consider that – if feasible for your industry – remote work can lower employee expense (think gas, clothing, lunches, time) and provide a mental health boost.  So too, moving to a four-day work-week – if possible – may balance your workforce’s stress even if you stagger the schedules to assure all-week coverage.  Commit your company’s resources in IT and HR to moving those who want this option to a successful, longer-term remote work environment.  

Retirement.  With workers trying to live through the here & now, talk of retirement can seem out of touch.  The article’s author suggested reminding your workforce to continue investing in their retirement.  But she also mentioned that some employers are making special contributions to employee retirement accounts.  While raises would be a boon, they may not be sufficient to balance out inflation’s bite, but the added 401(k) contribution may at least offer a small silver lining.

Compensation.  A recent employer survey noted that 2/3 of companies were planning to make compensation changes.  Every little bit helps, as they say, and any increase will surely be met with appreciation.  However, for companies that are financially strapped, some other ideas are:  short-term bonuses or gifts, which are helpful on the spot but don’t have to be long-term if the company’s finances can’t handle that; helping with gasoline costs, for example, with a gas card or subsidy; other gift cards, such as for food or sundries that convey concern and defray an expense or two.

Times are tough and sometimes, as managers, we’re overwhelmed with the desire to make sweeping gestures that often get bottlenecked in the system.  Smaller, more frequent tokens of help and concern may be easier to pull off quickly in almost any work environment. 

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EEOC Makes COVID Policy Changes

In the last two years, COVID-19 has become a regular part of our lives, and perhaps, in order to re-establish some normalcy, we’ve accepted it and moved on.  The EEOC, however, has re-evaluated its COVID-19 testing stance for employers and made some recent changes.  For those workplaces that still require screening and testing, the EEOC update necessitates employers to justify that their testing practices are job related and consistent with business needs.  It’s no secret that we’re fans (and a client) of Fisher & Phillips, a law firm that specializes in employment law, and we follow their guidance on these subjects; their recent article that suggests the following:

  • Because COVID-19 testing is considered a medical examination, employers need to review their policies and assure, with objective evidence, that the employee’s ability to perform essential job functions will be impaired by the medical condition or that the employee will pose a risk of substantial harm to themselves or others.  The EEOC advised employers to consider:  community transmission levels, transmissibility of COVID variants, working conditions, etc.
  • Employers should review guidance from the CDC and other public health authorities and memorialize this process regardless of whether you maintain your current COVID policy or change it.
  • If you continue to require testing, ensure that you’re checking the result of a viral test that detects COVID-19 at that time, and not an antibody test, which may signal a past infection.
  • COVID screening questionnaires are still considered valid, and employers may continue to exclude employees with COVID symptoms from the workplace.  The F&P guidance reminds us that organizations cannot generally screen remote workers and those who do not otherwise have personal contact with coworkers, customers or other business partners.
  • An employer may ask a worker to provide a medical practitioner’s statement that he or she may safely return to work after a COVID infection, but companies are not required to do so. It may be more practical to include in your policy other ways of determining safety when allowing employees to return to work, especially if a medical practitioner is not able to provide the note.
  • A workplace may screen applicants and potential employees in the same manner that it screens anyone else.  Going beyond your regular screening may be considered engaging in a disability-elated inquiry or pre-hiring medical examination.
  • Make sure to review compliance with other employment laws if your workplace continues to test workers.

The bottom line is that just because COVID has perhaps faded into the woodwork of our day-to-day minds doesn’t mean that as employers, our policies can remain on auto-pilot.  Stay informed, dust off those P&P and review your protocols and of course, we always recommend F&P as a source of reliable information. 

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Fractures & Coding the 7th Character

ICD-10-CM turned coding on its head when implemented in October 2015.  The coding convention was so unlike the mostly numeric, five-character codes we were accustomed to in ICD-9.  Now I wonder how we ever got along without the coding upgrade! If anything, the number of potential codes is staggering, which can lead to errors if providers and coders don’t fully read and apply coding guidelines.  One area where we see mistakes is in orthopedic coding. 

To clarify, the majority of our clients are primary care providers who operate under risk adjusted payment paradigms.  Their ortho coding is mostly limited to back pain (and its more specific causation), arthritis and the occasional fracture.  Most ortho codes seen in primary care do not risk adjust, but some fractures do, such as pelvic and hip breaks.  We thought it prudent to review the seventh character in ortho ICD-10 codes to dispel any myths.

Here is the list of seventh characters for fracture of the femur, which coding guidelines say should be added to all codes from category S72:

  • A – initial encounter for closed fracture
  • B – initial encounter for open fracture type I or II, initial encounter for open fracture NOS
  • C – initial encounter for open fracture type IIIA, IIIB, or IIIC
  • D – subsequent encounter for closed fracture with routine healing
  • E – subsequent encounter for open fracture type I or II with routine healing
  • F – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
  • G – subsequent encounter for closed fracture with delayed healing
  • H – subsequent encounter for open fracture type I or II with delayed healing
  • J – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
  • K – subsequent encounter for closed fracture with nonunion
  • M – subsequent encounter for open fracture type I or II with nonunion
  • N – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
  • P – subsequent encounter for closed fracture with malunion
  • Q – subsequent encounter for open fracture type I or II with malunion
  • R – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
  • S – sequela

The most important for our conversation is the initial encounter.  We can all agree that a patient with a hip fracture is not generally seen in an outpatient setting for the initial encounter.  He or she is seen in follow up after the fracture is surgically repaired by whatever means.  The initial encounter character relates to the initial encounter for the condition, not the provider.  This means that the initial encounter occurs in an emergency room, for the most part. Yet time and again, we see PCPs coding initial encounters for these fractures because it’s the first time the PCP is seeing the patient for the condition.  Incorrect.

Moreover, only the initial encounter codes are risk adjusted, which means that PCPs who report this code during their visits are inflating their coding under the CMS-HCC model.  And finally, notice the wording: “for ___ fracture.”  Remember that providers report diagnoses they actually assess at the visit.  Is the PCP seeing the patient for a fracture?  Doubtful.  Coding a condition whose care is deferred to another provider, in this case the orthopedist, is not proper because the PCP isn’t treating it.  Using the M-E-A-T acronym as our documentation standard, the PCP can and should assess at the visit any other aspects of the fracture that persist beyond the initial encounter, such as pain, immobility, etc.  By that point, the fracture – to use some coding humor – is history.  Literally. (Z87.81)

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