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If Operation Restore Trust (ORT) hasn’t hit your state by now, it’s likely just around the corner. Here are recommendations from Nancy Paulson, MSN, BSN, PHN, president of Home Care Consulting Services in Northridge, CA, on what you can do to limit the damage prior to ORT surveyors knocking on your doorstep:
1. Avoid the not us’ syndrome.
Paulson’s word to the wise is to take ORT very seriously, no matter how squeaky clean you think you may be.
"I’ve heard people say that if ORT came in and did a survey and found problems, there must have been something wrong, and that wouldn’t happen to them if they were surveyed," says Paulson. However, those agencies soon realized how serious ORT is when surveyors claimed to have found problems in their handling of Medicare patients.
2. Change your review patterns.
Most agencies first review records as part of their quarterly utilization review process. Although findings may identify opportunities for improvement and training needs, Paulson notes that such a process does not allow for ensuring current activities are meeting criteria. You need to implement an "upfront" concurrent review system.
Areas to pay close attention to include:
• Timely submission of paperwork. "If an employee is supposed to get something done today, such as patient documentation, and it isn’t done, home care people too often say Well, bring it in tomorrow,’" notes Paulson. But that can get you into real trouble. "They need to say It’s due today’ and enforce their policy."
• Documentation of coordination of care. The conditions of participation (COPs) require that the clinical records or minutes of case conferences establish that effective interchange, reporting, and coordination of patient care occurs, says Paulson.
She notes that in one instance, despite clear documentation by the case manager of calls to the physician to report laboratory findings and get the physician to call the prescriptions to the pharmacy, calls to the pharmacy to ensure the prescription was ready, and calls to the family to pick up the medication (which the family delayed), the agency was cited because it took four to five days before the patient started taking the medication.
"The surveyors said that regardless of the 17 calls, the interchange was not effective," says Paulson. "The surveyor’s attitude: If the outcome isn’t successful, the agency is at fault."
3. Be sure you can show how you’re meeting COPs.
Asking yourself if you’re meeting COPs isn’t enough.
"Go through the conditions of participation, and ask yourself how you are meeting them," says Paulson. "Ask yourself, What in our policies, procedures, and documentation show we’re doing that?’" If it’s not clear to you, it surely won’t be clear to a surveyor.
4. Look at homebound status.
Unfortunately, Paulson says home care providers may not be as observant of this requirement as they should be.
"Sometimes the patient really needs the care, and there’s nowhere else to get it, so they overlook the homebound status," notes Paulson. Do this, and you’re setting yourself up for denials and potential fines.
That’s why she recommends taking the time to read and digest the HCFA Pub. 11, Rev. 277 definition of homebound.
"If the patient doesn’t continually meet the homebound criteria, they don’t qualify for the Medicare Home Health Benefit," she says.
5. Discharge patients ASAP.
In working with those who have already undergone an ORT survey, Paulson notes that surveyors wanted to see patients discharged even when it wasn’t appropriate.
"They looked at insulin-dependent patients in many areas," she says. "It wasn’t a question of whether they were homebound or not but instead whether agencies’ attempts to teach the patient/ caregiver how to administer the insulin or find another caregiver was as timely as the surveyors thought it should be."
It is the family’s and patient’s right to refuse to provide their own care. And if the patient and family are slow in learning, it may take longer to discharge. ORTcited agencies in each of these scenarios anyway. Paulson’s suggestion: Some patients are going to take a long time to discharge, and "you need to document why."
She adds that it remains critical that goals for patient outcomes are clearly documented, that interventions are directed toward meeting those goals in a timely, realistic manner, and that documentation of ongoing care includes patient response/outcomes in relation to the goals. And once goals are met, the patient should be discharged.
6. Follow plan of care. Make sure staff are providing and documenting services as ordered on the plan of care and at the frequency ordered. For example, if the physician orders skilled nursing three times a week for nine weeks then lists all the interventions the nurse is to do, agencies are being cited if everything ordered is not provided three times a week.
"Make sure each person providing care knows what is on the plan of care and that the plan of care is updated when services are no longer needed and/or documentation clearly indicates that the goal is met and the intervention is no longer needed," says Paulson.