Watch your own pot as other home care providers boil

Charges against Olsten involve some common documentation problems

Melville, NY-based Olsten Health Services is in some hot water, as you’ve probably read. Finding 56 examples of care delivery and coordination problems related to 32 patients, the Washington state Department of Health could revoke the Seattle branch office’s home health license.

The Department of Health, based in Seattle, has filed charges against the home health provider for neglecting to carry out prescribed treatment plans, often failing to provide skilled nursing as frequently as physicians’ orders indicated.

That could never happen to your agency, right?

But did you know that, according to Olsten’s written request for a meeting with state officials and an administrative hearing to answer charges, "many of the alleged deficiencies result from the fact that, at the time the surveyors made their visits, not all applicable paperwork had yet been placed in the patient files"? Other deficiencies resulted from errors in documentation.

"It’s not performance improvement," says Cathy Nielsen, RN, CPHQ, vice president of clinical services for In-Home Health in Minnetonka, MN. "It’s all quality assurance — making sure you’re meeting the standards."

Consider:

• Several physical therapy, aide, and nursing visit notes were not in patient files when surveyors arrived.

• Staff accidentally misdated some documentation of visits.

• The weekend schedule did not match the master schedule in a few instances, and did not show some visits that were in fact made according to physician’s orders.

Olsten Health says it is taking the charges seriously and has taken steps to correct the problems, such as firing the branch director, sending corporate quality management support to the site and keeping them there until the survey concerns have been resolved, beginning multiple staff inservices, and improving the scheduling process.

Many respondents to Homecare Quality Management’s 1997 reader survey stated that documentation and keeping clinical records were a big concern. But what can you do before federal or state surveyors turn up the heat under your agency and you lose your job? One Florida agency found a way to improve its nurses’ documentation skills by turning its field nurses into case managers and reducing bad documentation habits.

The agency’s nurses thought they were doing a good job of documenting cases. But the QI manager saw some holes in their case files.

"Every nurse is supposed to update the care plan as the patient’s condition changes," says Mary Lastinger, RN, QI coordinator for Community Home Health Care of St. Augustine, FL. "But it’s always been a problem area; it’s always been what people tend to let go," she adds.

A hospital-based agency with about 3,500 visits a month, Community Home Health Care may have contributed to the formerly lax attitude toward documentation by not requiring nurses to fill out their own Health Care Financing Administra tion (HCFA) 485 plan of care forms for Medicare. The agency was so small when it was founded in 1976 that it was easier to have the clinical coordinator fill out everyone’s HCFA 485 forms. Even when nurses began filling out their own Medicare forms on a computer system, they still needed help.

Lastinger’s solution was to create a case management program in which all field nurses were responsible for every facet of case documentation. They received scores, just like school grades, for how well they completed their case files.

She picked up the idea from a QI peer group meeting in Florida. (See news brief item on QI peer group, p. 143.) "One agency shared a tool they’d used for case management, and they said it helped improve documentation."

Since the case management program started last year, the agency’s documentation has improved. So far the agency has three quarters of data, and Lastinger is seeing individual scores climb each quarter.

"I just had a meeting with a nurse last week," Lastinger says. "She was very anxious to come in and get her results for this quarter because she had a few significant problem areas."

The nurse’s average score climbed from an 80% to 91% in one quarter. Six different case charts were averaged together to come up with the score.

The program also has given nurses a more focused review of their work. And a surveyor from the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, complimented the program during a survey earlier this year, says Betty Poyner, RN, MBA, director of Community Home Health Care/Care Tenders.

"I think that was one big area we improved on," Poyner adds. "It makes your documentation more uniform."

Here’s how Community Home Health Care set up the program:

1. Create tools and outline.

Lastinger outlined the old tool’s problems and goals of a new system, including details she could use later in developing the case management tool. (See story on developing case management tool, p. 136.)

The outline’s chief components were:

• identifying problems with old tool;

• selecting goals;

• developing new tool;

• selecting criteria for review;

• reporting under new system;

• planning next steps;

• meeting with case managers face-to-face. (See outline of case management review tool, inserted in this issue.)

The new tool had twice the indicators (16 total) and is more detailed than the tool the agency previously had used. (See Case Management Review, inserted in this issue.) The Joint Commission surveyor liked the tool, Lastinger notes.

2. Get buy-in from nurses.

Supervisors met with field nurses at group and individual meetings to convince them they are the pivotal people in each case.

"They determine if an aide is needed or if a social worker needs to be involved; they report to the doctor and touch base with everyone else involved in the case," Lastinger says.

The prevailing attitude was that they didn’t see themselves as people who have authority. "They saw themselves as a nurse who goes out to do wound care," Lastinger says.

Poyner, Lastinger, and other administrators discussed how home care is changing because of the national focus on outcomes, and the strong possibility of Medicare switching to a prospective payment system.

They told the nurses they had to focus on the Medicare 485 form and make patient teaching a priority so they could get more done in a shorter time.

Slowly the old attitude changed, and nurses, who now were expected to handle a great deal more paperwork, began to see how important their jobs were.

3. Set up a scoring/rating system.

This was crucial to the case management program’s success because it gave Lastinger and supervisors a more objective way to compare nurses’ documentation.

She broke the documentation criteria into two components:

• The assessments were made that were appropriate to the diagnosis.

• The teaching was directed toward the diagnosis.

Each quarter, Lastinger reviews about 30% of each nurse’s case management charts. These charts include the care plans, physician’s orders, case updates, medication sheets and updates, assessments, and every other documentation in a patient’s file. A thin chart might have 25 pages, and the more complex ones could be several inches thick.

However, Lastinger says she mostly reviewed new charts and information collected over three to 10 weeks. (See story on creating a rating system, p. 137.)

4. Use scoring tool in evaluations.

Lastinger soon found patterns in each nurse’s scoring.

"Generally what happens is if you read five charts for a particular nurse, weaknesses show up in the same areas," she says. "It shows their strengths, as well as the areas where they need to put a little more effort and pay more attention."

Each nurse is given a copy of the forms and scores, which are kept in a QI book. Each quarter, Lastinger distributes a quarterly report that compares their scoring averages by listing the individual scores anonymously. The scores are on a scale from 0% to 100%.

The nursing supervisors also are given copies they can use in evaluating nurses’ performance.

In preparation for the Joint Commission survey, supervisors met individually with nurses to go over their findings of the charts they had reviewed. Nurses responded well to the face-to-face meetings, so Lastinger hopes to continue these.

Documentation has improved all around, and Lastinger surmises that’s partly due to the competitive effect. The nurses know what their scores are, and then they see that someone else has scored higher. Even if they don’t know who had that high score, it makes the nurse want to try harder.

5. Identify nurses’ problem areas.

Lastinger and the supervisors used the review tool to identify the weak spots and to compliment nurses who were doing well.

Procrastination and time management were problems initially. "They would get wrapped up in a busy day and not make it a priority to highlight the chart and update care plans."

The QI manager or supervisor would go over mistakes in meetings with the staff nurses/case managers.

"I’d say, ‘We ran into a problem here because I couldn’t figure out who’s doing the wound care now that you’re not seeing the patient daily,’" Lastinger says as an example. "It could be that they trained the wife, but didn’t spell that out in the notes."

Or maybe a nurse gave an order to have a lab test drawn up, but it isn’t documented on the chart that the test was done.

"Some people forget to go into the computer and document it," she adds.

Sometimes computer problems would crop up. Unlike paper documentation, the computers didn’t allow a flowing narrative. Nurses occasionally had trouble finding the right computer screen to record the information. When this happened, a supervisor could see that the nurse received extra computer help.

If a nurse has had many problems with documentation, Lastinger will pull more charts for review.

It’s been a difficult transition, but Lastinger says the staff seems to appreciate what they’ve learned from the process.

"They’re getting better since we started doing the case management," Lastinger says. "Patients are sicker now, and the nurses’ jobs are very stressful, and we understand that. But at the same time you can’t let the documentation go just because you’ve had a hard day."