Blog and Helpful Articles

Common and Avoidable Survey Issues – Independent Contractors

In this four-part series, so far, we’ve explored some of the most common and avoidable survey deficiencies:  illegible signatures and missing titles, expired documents and missing supervision, and failure to follow the plan of care.  Today we’ll cover certain aspects of independent contractors.

Rarely does an agency use only employees to provide care to patients.  Some clinicians are often independent contractors (I/Cs) or obtained by contract with another organization.  CMS specifically holds the home health agency accountable for anything done by a contractor.  It also has requirements for the relationship with the I/C and the monitoring of patient care.

To begin with, agencies must have a contract with the I/C that meets government requirements.  The contract should outline all aspects of the relationship and your expectations for performance.  Promptness of visits, documentation requirements, timely submission of notes, participation in case management and supervision of any assistants are just a few crucial items to include.

Keep in mind that I/C are considered part of your ‘staff’ or ‘personnel.’  So any regulations that address, for example, training requirements for personnel will require that your I/Cs be included.  When it comes to agency-specific information – like your compliance program or quality improvement program, for example – you must conduct the orientation and training to your agency’s specific policies and procedures.  While accepting proof of external education on topics such as OSHA and domestic violence is acceptable, your personnel need to understand the rules and operations of your organization.

Finally, the requirement for personnel files includes I/Cs regardless if they work for another company.  If they are providing care to your patients, you must have a file that contains the minimum hiring/contracting requirements, like background screening, health screenings, insurance, identification, etc.

Regulations create a level playing field for organizations, and they also protect us as patients from unprofessional or sloppy providers.  We understand that these guidelines can create a burden for healthcare providers, but knowledge and organization go a long way toward achieving compliance.

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Common and Avoidable Survey Issues – Failure to follow the Plan of Care

We’ve established that regulators are pretty narrow-minded when it comes to interpretation of the rules.  And they have to be.  Subjectivity contaminates the process and things fall through the cracks.  In this installment of our four-part series on Survey Issues, we will explore another common challenge for home health agencies: following the Plan of Care.

We all know that, in home health, the Plan of Care (POC) is sacrosanct.  This Constitution of Patient Care summarizes the plan and goals developed by licensed clinicians acting under the physician’s orders.  There can be no deviation from this document without cause and there’s a process for that eventuality.

Visit frequencies are one area where actions sometimes fail to meet the POC.  If the plan says you will provide nursing visits twice a week, make sure that occurs.  Nursing visits three times in one week is as bad a deviation from the plan as making only one visit.  Either way, it’s considered care that wasn’t in accordance with the orders.

When a patient receives Home Health Aide (HHA) services, the nurse must prepare a plan for the aide to follow.  This plan outlines the tasks the aide will perform and the frequency.  Nurses must use great care and attention when developing these plans.  If they require a task to be performed on a daily basis, and it isn’t, you’ve failed to follow the POC. An example of this is the patient who experiences frequent constipation.  The HHA care plan states that the aide will inquire on a daily basis if the patient had a bowel movement.  Some HHA visit notes don’t even have a space for this item, so if the aide doesn’t ask the patient and document it in the comments area, you just failed to follow the POC.  If you’re tempted to dilute the frequency to PRN, keep in mind that HHAs can’t be expected to assess the need for certain activities.  The RN must specify the frequency.

Be sure to pay attention to the patient’s educational requirements and ensure all clinicians are fully informed of the topics for patient education that are mentioned in the POC.  If the POC was prepared in a fairly rational manner, the education will follow the patient’s diagnoses and medications.  However, sometimes agencies get creative with their education and mention all kinds of topics.  Just make sure that there is documented proof of the education that was committed to (and ordered) on the POC.  Caveat:  you can’t just blindly check off boxes for education.  Each note brings with it a whole host of educational requirements.  Maybe the patient had a fall.  Was there re-education on safety?  If the patient was started on a new medication, did the nurse assess for drug interactions and educate the patient on side effects and what to do in the event of a reaction?  Those items aren’t on the POC, per se, but they are warranted based on the daily interaction with the patient.

Obviously, we could list other areas of the POC where agencies seem to drop the ball, but you get the idea.  In our last discussion, we will focus on the challenges of having independent contractors.  See you then!

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What We’re Reading: Five Key Benchmarks That Could Make or Break Your Practice – Part 2

In this last section of this article, the author asks: Is Your Practice Clinically Healthy? She urges practitioners to go beyond tracking solely financial metrics; the first benchmark of this section is tracking avoidable emergency room visits and hospital admissions.  Track a one-month sample and then assess monthly against that benchmark.  Patient outreach activities and perhaps a critical eye on the office telephones (Are they always busy? Can patients schedule urgent appointments?)  could minimize this issue.

Everyone believes they provide top-notch customer service, but would your patients recommend your practice to others?  Don’t assume they would. Ask.  And then listen. The author gives 90% affirmative answers as a reasonable target.

The end of the article provides a handy chart to help you in your benchmarking.  This article is a quick, must-read for every practitioner.

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Common and Avoidable Survey Issues – Expired documents & missing supervision

Last time, we started our series on some of the common survey deficiencies with a discussion of signatures.  This week, we’ll tackle another popular issue:  the myriad documents in a personnel file.

Bur first, a word about regulators…. They’re so narrow-minded, aren’t they??  Here you are giving superior care to your patients and the documentation in a personnel file of someone’s CPR certification, or car insurance, or nursing license has expired.  This should hardly be a big deal!  Well, it is.  It is your responsibility to make sure the individuals who render care as part of your organization meet regulatory guidelines.  One such standard is the presence of current documents. And verbal assurances from the staff member don’t count.  You need physical evidence, such as the renewed CPR card, new insurance card, etc.

Our blog entitled Tracking the Details provides some suggestions for developing a computerized or manual system to track these items.  Our blog on the QI process reinforces the role of auditing to spot these issues in time to correct them.

It can’t be over-emphasized that your actions require follow-through with regard to expired documents.  If you remind the staff member to produce a current piece of information by a certain date and the item is not received, remove the individual from active status.  This means transfer the patients to another staff member whose personnel file meets all regulatory guidelines.  I can guarantee that if you do this one time, word will spread throughout your organization that this is not an area where you can be flexible.

Supervisory visits are another needless deficiency during a survey.  The easiest way to avoid a problem in this area is to be organized and use technology to do your job.  The schedule for supervisory visits hasn’t changed since the beginning of time, it seems, yet agencies frequently run late in performing them.  Some companies forget them entirely.

Check out our blog entitled Tracking the Details for some tips to avoid this citation.  In a nutshell, success on this rule requires an organized system and holding one person accountable.  This individual must create a calendar and schedule the supervisory visits for every episode of care.  Some agency software programs allow you to do this in the system and generate a report.  Other companies that aren’t as technologically savvy use a calendar program.  Whatever you do, plan out the episode ahead of time and note the dates of the supervisory visits. Then issue a reminder to the clinician and make sure to follow up on the documentation.

Surveys are definitely stressful times, and we all have a tendency to watch the calendar and scramble as our imagined survey date approaches.  The key is obviously to be prepared for survey every single day and to make certain things so habitual that you automatically stay within the rules.  Join us next time as we explore the Plan of Care and some ways to avoid being cited.

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Common and Avoidable Survey Issues – Illegible signatures and missing titles

Most of us who’ve been around healthcare know that physician handwriting is hieroglyphic, at best.  However, nurses and other professionals aren’t far behind. Maybe it’s our keyboard-oriented world, but handwriting is getting worse every day.  Keeping in mind that medical records are legal documents that have patient care and payment implications, it behooves us to make sure the information is legible and identifiable.

A common deficiency surfacing these days has to do with signatures.  More often than not, signatures are illegible and may not even contain a professional designation.  Urge your staff to make sure to sign legibly and if this is a recurring difficulty, consider investing in stamps that bear the person’s name.  If you’re a clinician and you know your signature looks like chicken scratch, it might be a good idea to have your own handy stamp.  Please note that the stamp does not take the place of the signature. It just translates it to the rest of the world.

Missing professional designations is inexcusable, really.  No ifs, ands or buts:  no matter where you sign your name in a chart, it MUST contain the initials that go with your profession.  In the world of deficiencies, this one is needless, and easy to fix.  Just think of your student loans every time you sign your name. If that doesn’t remind you to add your title, we don’t know what else to say.

Final note:  a Master List of Signatures should be a requirement in your organization.  This document can be a single page per employee or a running log.  The idea is to have every individual who documents in your patient files to give a sample of his/her best signature and initials.  Store this document separately from the employee file and keep it indefinitely.  Imagine ‘participating’ in a lawsuit where you need to identify someone’s chicken scratch in one of your agency’s records… and the person’s employee file has been destroyed.  I rest my case! (pun intended)

In the next installment of this series, we will discuss expired documents.  Be sure to check out our blog (Tracking the Details) for some tips to avoid breaking this rule.

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Common and Avoidable Survey Issues – A four-part series

Complying with rules and guidelines is a way of life for healthcare administrators.  We know that our field is rife with regulations and oversight so we’re accustomed to scrutinizing our operations to find areas needing improvement.  It’s also common sense to want to identify those weaknesses and correct them before a survey team points them out.  In this blog series, we will explore the most common deficiencies we see during home health agency pre-survey reviews and accrediting organization surveys.  We encourage you to make an objective assessment of your organization to make sure you’re not making the same mistakes.  In this first installment of our four-part series, we’ll discuss illegible signatures and missing titles.

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What We’re Reading: Five Key Benchmarks That Could Make or Break Your Practice – Part 1

This is the first article in a series that we read about ensuring a financially vibrant medical practice.  In this installment, the author starts by suggesting a revenue analysis in several parts.  First, is to assess the practice net collection rate, which is recommended to be 97%.  If your practice varies greatly from the benchmark, the culprits could be ineffective billing practices or a specific payor.  The second part of the revenue equation is to scrutinize your overhead.  The writer emphasizes that the MGMA produces cost estimates for various practices, by specialty, so a little research will help you spot areas where your expenses exceed your peers’.

The next major are discussed in this article is measuring productivity, which is done by analyzing the different CPT codes billed and benchmarking against peers.  If you’re like me, your eyes are glazing over from all the math.  But frankly, this is an easy statistic to measure and even delegate to your practice manager who can summarize the bottom line for you. And we can’t underestimate the importance of working smarter, not harder.

In part two of the author’s series, she discusses your practice’s clinical health.  Stay tuned.

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Lawful and Unlawful Interview Questions- Avoid costly litigation

Many employers walk a fine line during the interview process, asking questions that could land them in court for discrimination.  Unfortunately, many candidates feel compelled to answer these questions out of ignorance or fear of appearing “uncooperative,” the kiss of death in the job quest.  The cost of an employer defending itself against a discrimination case lodged by a savvy prospective employee can hit the six-figure mark.  It is consequently even more critical to conduct lawful employment interviews to avoid employer liability and to protect the individual’s rights.

The guiding principle behind any question to an applicant should be, ‘Is the question relevant and a job-related necessity?’  During an investigation by the Equal Employment Opportunity Commission (EEOC), the intent behind the question will be examined to determine if any discrimination has occurred. Questions asked must be job-related and the interviewer should ensure that all questions asked are absolutely necessary in order to judge the qualifications, level of skill and overall competence of the job applicant.

Although this is a subject that is detailed and, at times, complex, let us briefly discuss the main areas that affect discrimination cases in this area of employment law:

  • Disparate Impact – The EEOC’s focus is protected groups and ensuring that interview questions do not yield information that can have a discriminatory effect by screening out certain groups of individuals, such as the aged, minorities, etc.
  • Pre-Employment Inquiries – State and federal equal opportunity laws prohibit the use of pre-employment inquiries that are not justified by some business purpose. Questions must be solely aimed at determining the applicant’s qualifications. Some questions that would be illegal include inquiries about the applicant’s year of graduation from school, country of origin or what child care arrangements the applicant has in place.
  • Race – Unless the information is legitimately needed for affirmative action data, as seen on most applications, a prospective employer should not ask candidates any questions regarding race, gender, religion or national origin.
  • Military Discharge – Military discharge inquiries are not illegal but are not recommended as the answer is not usually relevant to general business necessities.
  • Educational Requirements – Certain jobs require applicants to meet specific educational requirements. However, employers should ensure that the educational requirements listed for the job do not exceed what is needed to successfully perform the duties of the job. In many cases, these requirements can violate Title Vll (see anti discrimination blog) anti-discriminatory laws if they disproportionately exclude certain racial groups.
  • Arrest and Conviction Records – These records should not be used to exclude applicants from being hired unless the conviction applies to the nature of the job.  This practice could again disproportionately exclude certain racial groups. Companies should make sure that when they administer background checks, they are in compliance with EEO laws. ( see administering background checks blog).  On April 25, 2012 the US EEOC issued guidance on employer use of criminal background checks. It is the EEOC’s stance that this guidance does not prohibit employers from using criminal information in their hiring practices, but the employer must take steps to avoid violating discrimination laws under the Title Vll of the civil rights act of 1964. To access the guidance document please use this link: http://www.eeoc.gov/laws/guidance/arrest_conviction.cfm
  • Application Forms – Application forms must be used with caution and it is a good idea to have legal counsel review these forms prior to their use.  As discussed above, the use of certain questions, such as religion, arrest record and year of graduation, could be questionable. Employers should also avoid asking for social security numbers on applications. The applicant’s social security number should only be used in conjunction with completing I9 forms, W4 forms or to administer a background screening.

Finally, it is recommended that employers and HR personnel always refer to the appropriate state employment laws for guidance as these can sometimes differ from federal EEO laws. While federal EEO law may not prohibit certain hiring practices, those same practices may be prohibited on a state level. In addition, we are all advised to tread lightly as the EEOC has its own guidelines for protecting individuals from discrimination.

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QI, PI, QA – Making Sense of Alphabet Soup (Part 4)

In this last section of our four-part series entitled QI, PI, QA – Making Sense of Alphabet Soup, we will discuss the last very important component of the QI process: documentation.  We all know that in health care, if it isn’t documented, it didn’t happen.  The same is true in QI.  Your documentation doesn’t need to be fancy; it just has to reflect what occurred.  Here is an example:

On 4-3-12, Sally (Admin), Henry (DON), Rosario (QI Manager) and Mavis (RPT) discussed the results of the QI audit on supervisory visits.  Of the three charts reviewed, only one showed timely supervisory visits; the majority of the missed visits were for LPN supervision, which is the responsibility of Henry (DON).  The team reviewed the agency policy and confirmed that the guidelines are clear.  They checked training documents and noted that all supervisors were trained on the supervisory visit schedule.  In addition, the agency’s tracking system is being used and timely reminders to the clinical professionals were documented by Maria, the Administrative Assistant.  Henry stated that with the new baby, he and his wife don’t get much sleep these days.  He is having difficulty with time management and organization.  Mavis (RPT) stated that she got her days mixed up and was one day late in performing the supervisory visit on her PTA. The team discussed some solutions:  temporarily assigning nursing supervisory visits to another RN; having Maria issue another reminder on the morning of the scheduled supervisory visit; having Maria confirming that the supervisory visit was conducted on the same day, and alerting Sally (Admin) immediately of any problem.  The group selected all the alternative solutions and agreed to a weekly monitoring schedule for the next two months.

Organization of QI records is paramount to tracking your progress and meeting a surveyor’s inquiry.  A QI calendar of activities for the year keeps you on track and provides a scheduling system so audits aren’t due at one time.  Here is an example that shows part of the year: (click here).

It’s a good idea to keep your QI materials in one or several binders, depending on your program.  For example, we advise clients to create a Patient Records Audit binder for each calendar year.  Because this particular client performs these reviews every 60 days, six tabs for the year will help organize their audits.  Under the January tab, we suggested they keep the individual audit forms and a summary of the results.  Any Corrective Action Plans for the Patient Records Audit can be filed in the same binder.

We hope this blog series has been helpful in minimizing your dread of QI activities.  Even though it is mandatory for Medicare providers, monitoring quality ensures that you can back up your claim of quality patient care by studying critical areas and harnessing the diversity and knowledge of your team to drive the improvement process.

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QI, PI, QA – Making Sense of Alphabet Soup (Part 3)

In the first two installments of this four-part series on QI, PI, QA – Making Sense of Alphabet Soup, we discussed the basics of QI and how to create a Quality Study.  This blog takes you to the next step in the process:  now that you have some data, what do you do with it?

If you recall, our audit on supervisory visits yielded some interesting results.  We audited three charts and the scores were 100%, 33% and 50%.  If the goal – as imposed by CMS – is 100% compliance, this agency obviously has a problem performing supervisory visits on time.  One hundred percent compliance means that CMS expects that supervisory visits will occur as mandated every single time for every single patient.  They don’t allow any flexibility on that guideline; that’s why our target is 100%.  For patient satisfaction, your ideal goal might be 100%, meaning you want every single patient to be thrilled with your agency’s service, but how realistic is that?  Aren’t there always patients who aren’t satisfied no matter what you do?  If there is no external requirement for 100% compliance, give yourself some leeway and start with a lower number, say, 85%.  You can raise the bar every year so you and your staff can meet the challenge.

Ok, so now that we have audit results, the next step is to ‘drill down’ to find the root cause.  It’s important to resist generating solutions ‘on the fly.’  Sometimes what we believe is the problem isn’t really the problem.  Assemble your QI committee (which should represent your major service lines) and discuss the results of your audit.  Here are some questions your team might consider:

  • Was all the filing current when the audit was performed?  (If not, that brings up a different issue, especially if the supervisory visits were done, but the notes were not filed.)
  • What does your agency policy state?
  • Who are your supervisory staff members?  Have they been trained on the requirement of supervisory visits?
  • How are the visits tracked by the agency?  Is there a mechanism to prompt a reminder so the clinical professional can be reminded?

Obviously these are just a few questions, and your team is bound to consider many other aspects.  The result of this exercise will lead you closer to generating alternative solutions.  If the supervisory visit policy isn’t understood by the staff, additional training may be required.  If your agency doesn’t have a good system for tracking when visits are due, you will need to establish a process.  There is no one-size-fits-all solution to this problem, as its source will vary with each agency.  The important thing is to spot the issue, discuss it with other knowledgeable professionals, dig into the possible causes, generate solutions, educate staff, and then monitor.

Once you’ve generated some solutions, select the ones to implement and create a Corrective Action Plan.  In a nutshell, write down what was discussed (bullet points are fine), the different alternatives, what you selected and why, and how you will implement the solution(s).  Also, state when you will check again to make sure the solutions fixed the problem.  With something as critical as supervisory visits, you might consider checking them on a weekly basis so that you can catch issues early.  Once you have observed (this means measured) compliance for a prolonged period of time, say one quarter of weekly reviews, you can scale back your audit schedule to monthly.  The idea is to make sure your solutions have truly fixed the problem before you relax your vigilance.  If you find that the problem persists, re-do the exercise of investigation/solutions/monitoring.

Next time, we will wrap up our four-part series on Quality Improvement by discussing documentation and how to file your QI materials for easy retrieval.

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