Archive for June, 2011

Missed and PRN Visits

Tuesday, June 28th, 2011

With the advent of the new Surveyor guidelines that went into effect May 1, 2011, the focus is data collection and outcome achievement moving away from the prior focus on process. Outcome achievement starts with a great assessment, careplan, and visit strategy that means adherence to physician frequency orders. What happens if the clinician misses a visit?

Missed Visit
In home health care under the CMS guidelines, a missed visit occurs when a scheduled RN, LVN/LPN, HHA, PT, PTA, OT, OTA, S/LP, or MSS does not keep an appointment with a patient.  Examples:  1) Because of an ice storm, a PT does not visit the patient as planned.  2) The RN wound care specialist does not visit the patient as she is detained with another patient.

If calls to the agency to apprize them of the situation and a call to the patient results in the rescheduling of the visit to maintain the physician-ordered frequency, then there is no missed visit.  The agency must communicate with the patient to ensure that his or her needs are met and there is no jeopardy.

Though the physician must be notified, there is no need to get an order.  The agency can notify the physician by phone, fax, e-mail, or mail. 

If no rescheduling within the physician prescribed frequency can be accomplished, then a call to the physician to apprize him/her of the missed visit is necessary and, in this case, a new order may be necessary.

Make certain documentation reflects the missed visit and is a part of the clinical record.

The Interpretive Guidelines for the Conditions of Participation, §484.18, discuss notification of the physician when a visit is missed.

PRN visit
A PRN visit is an additional visit or visits, ordered by the physician, that can be made when the  specifics of the identified care are warranted.

It must include a specified number of visits during a designated time (usually a certification period) and a specific reason or a delineated description of signs and symptoms necessitating the visit.  The reason for the visit must be anticipated and the frequency predicted based upon the assessment of the situation.  Reasons for a PRN visit might include the need to change a catheter, manage an IV, or reassess vitals if a B/P exceeds specific parameters.  Other situations might include a description of signs and symptoms that are linked to the patient’s specific medical condition, such as specific fluctuations in blood glucose readings. PRN orders can apply to any discipline if they are written specifically. Examples of complete, valid orders include:

2 wk 6 + 2 PRNs when blood sugar is over 280 then 1 w3 + 2 PRN visits when BS over 280 .

PRN visits can be denied if the order was found invalid/ lacking in specificity. Both the services and the number of PRN visits to be permitted for each type of service must be clearly identified as well as predictable.  CMS state that “Open-ended, unqualified PRN visits do not constitute physician orders since neither their nature nor their frequency is specified”.

CAHABA states,

PRN Orders

Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §30.2.2)

  • PRN orders are acceptable only when the orders are qualified for a specific potential need of the beneficiary and quantified to a specific number of visits to meet this need.
  • When a PRN visit is made, the date and reason for the visit should be explained in the medical record.
  • When an extra visit is billed and the plan of care contains open ended and/or unqualified PRN orders, an additional physician order must be obtained for the visit. If the agency does not have a signed interim order for the visit, the visit will be denied as in excess of orders.

Example 1: A beneficiary with a Foley catheter requires monthly catheter changes. The physician orders “Two (2) PRN visits per month for problems with the Foley catheter including blockage and/or leakage around the catheter.”  Visits are allowed because the physician specifically quantified the number of visits and qualified the visits to a specific need.

Example 2: A beneficiary with a Foley catheter requires monthly catheter changes. The physician orders include “PRN visits.” In this instance, since the orders are not quantified as to the number of visits or qualified as to a specific potential need of the beneficiary, no PRN visits are allowed.

Summary

Well written PRN orders and clear concise documentation supports patient need  The orders are acceptable (per CAHABA), if audited, when they are qualified for a specific potential need of the patient with a quantified  number of visits to meet this need. Make certain the physician is made aware of  PRN visit use, where appropriate. Also, be certain to inform the physician of trends in use of PRN visits which begin to identify a clear need for order frequency  modification.

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Posted in CMS, CMS Guidelines, Medicare, OASIS-C, PRN Visit, Surveys | 1 Comment »

Office of Civil Rights (OCR) and HIPAA

Friday, June 24th, 2011

At a recent HIPAA seminar, the Office of Civil Rights (OCR) identified that they are evaluating HIPAA audit models. The present model requests certain records, reviews, cites errors/omissions and calls for corrective action. Privacy and security of Protected Health Information (PHI) is of primary concern especially in light of social media and mandated Electronic Medical Record creation in healthcare.

Presently, organizations are reviewing their privacy and security programs. How compliant is your Compliance and HIPAA programs? Perhaps you should conduct a gap analysis.

Getting started

To conduct a review and analysis of your agency’s compliance program you must know if your program covers the required elements:

  • Complete written policies and procedures
  • Designation of a Corporate Compliance Officer
  • A training and education program regarding confidentiality, commitment to preventing fraud and abuse, and other elements of compliance
  • Communication lines to the Corporate Compliance Officer
  • Identification of compliance risk areas and a plan to mitigate risk
  • Responding to non-compliance issues
  • Policy of non-intimidation and non-retaliation against employees who identify non- compliance
  • Disciplinary policies regarding non-compliant behavior

Consider the re-signing of the organization privacy policies annually by employees. This act can become a reminder of the importance of privacy and confidentiality in the organization. Identify who will conduct regular internal audits. Conduct this present review and analysis as if it were a surveyor visit, only this time, you get to be the surveyor.

Audit the HIPAA Program

As part of the compliance audit process, be certain to evaluate the HIPAA program. Are there plan objectives? Is an audit and monitoring system in place? Who has the responsibility for completion?  Identify the audit checklist. Is it inclusive? Is there a documentation process to record findings?

Are there annual goals to improve on privacy and security in the organization? How are audit findings reviewed? How does follow up occur?

The Audit

The following checklist should be considered a guideline (not necessarily all inclusive) and would require agency individual application.

  • Is the Compliance plan, particularly the HIPAA portion, in compliance with the HIPAA Security Rule? Has an assessment been conducted regarding environmental/operational impact on PHI?
  • Can the organization identify how it protects access to information? Is there a policy re access to PHI and “need to know?”
  • Can patients obtain their information in a timely manner? Can information be provided in electronic format, as required by HITECH. Has a security risk analysis been conducted?
  • Have security measures been implemented to reduce the risk? What are those measures?
  • Have the Compliance, Privacy, and Security risk analysis available for an OCR audit or questions from an accrediting surveyor.
  • At the very least, for privacy, look at the following:
  • Can patients/guests view PHI? See computer screens? Is there any place on the premises that PHI is readily available?
  • Is PHI posted on wall boards where those who have “no need to know” have access to the info?
  • Is PHI left on desks? Are computer screens left on when the user steps away?
  • Are recycling bins used? Is there a BAA with that recycling vendor?
  • Are all BAAs in place with all vendors and in compliance with HIPAA HITECH?
  • Communication:
  • Is PHI faxed? Is there a confidentiality/disclosure statement on each fax coversheet?
  • Does the online system require level logins?
  • Are screen savers activated in a short period of time?
  • Are emails used with PHI? Are the emails encrypted?
  • Are phone calls used to give and receive PHI? How is the individuals receiving or giving info identified and confirmed?
  • Responsibility:
  • Can each employee identify when PHI enters their area of responsibility?
  • Who handles PHI? Where is it stored? What is the back up process? What is the length of storage? Is it secure? How do you know it is secure?
  • Have all employees been trained in privacy? Has security at the specific employee level been conducted? Is compliance training mandatory? Is it conducted annually?
  • Is there a protocol for new employees? Is there a protocol regarding confidentiality upon employee departure?
  • Are BAAs in place holding contractors accountable for PHI protection?  Have you seen their policies, procedures, and processes?
  • Reports:
  • Are reports created that have confidential information? Are they circulated to only those with “need to know” rights?
  • Have the reports been reviewed to reduce the amount of sensitive information, if possible? Could de-identified information be substituted?
  • Is transmission of report information secure?
  • Security:
  • Is there a written policy to protect PHI? Is there policies re computer screens in view with PHI? Are there policies re passwords?
  • Are there policies re storage of data and how backup tapes and storage devices are accounted for and monitored?
  • Has every station been evaluated as to protection of PHI and view and accessibility to information by those who do not have clearance to that station.
  • Technical Security:
  • Does the technical team periodically verify the technological security is in place and working appropriately? Can the technical team identify if an unauthorized user has accessed PHI? What safeguards are in place to protect against unauthorized access?
  • Is technology in place to verify identity of users?
  • Are passwords and IDs routinely changed per a schedule?

OCR Investigations and Review:

If you have a breach that triggers an investigation by OCR, be certain to promptly respond as to what happened, how it happened, what was done to mitigate outcomes, and what has been implemented to prevent a future occurrence.  Be certain to identify the fact you have a full Compliance Program in place. Identify that all employees have routine education re Compliance and HIPAA.

If documents are requested, your counsel may request confidentiality for those documents being sent to OCR. Create and maintain a log of events, complete with dates, times, and people involved throughout the entire investigation process. Save all electronic documents. Keep statements by all employees involved in the incident and the investigation. Obtain counsel’s advice as to phone conversations with OCR as written correspondence maintains an investigation trail.

Focus on internal compliance. If there is a HIPAA breach, there must be remediation/education regarding the process and the prevention of a reoccurrence.

Summary:

  • Keep your plan objectives current.
  • Identify who is responsible for the audits and establish times and how findings will be transmitted.
  • Have corrective action plans in place.
  • Include documentation of audits, results, and remediation/corrective action/education
  • Report findings to the BOD, leadership, and counsel.
  • If there is an OCR audit/investigation have a team established to quickly respond, pull data, analyze, and report.
  • Have an ongoing risk analysis performed as specified by policy. Be certain the risk analysis encompasses the technical requirements of the Security Rule.
  • Be certain the Risk Analysis is well documented. Be certain the plan for mitigation of any adverse findings is in place.

Like the clinical documentation rule, “if it wasn’t documented you did not do it,” so it is true here also. Document each step of the plan. If ever there is an audit, the fact a full compliance plan is in place in your agency including a HIPAA Privacy and Security review, can speak volumes about you and your organization.

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Posted in Compliance, HIPAA, Legislation | No Comments »

Evidence-based practice in Establishing Care Plans for the Home Health Patient: CHF

Friday, June 10th, 2011

Evidenced – based practice is considered the best available evidence derived from systematic research, clinical experience, and tested expertise to achieve expected and/or improved patient outcomes (Institute for Healthcare Improvement, 2008 ). The new protocols for surveyors have moved the focus to data – driven and outcome – oriented (CMS, 2011) and the need to establish a well defined plan of care foreshadows the need to follow evidence – based practices for specific diseases to achieve the expected outcomes (even though, at this time, CMS has not yet mandated their use). The following are evidenced based practice SmartCues to remind the clinician as to specific processes/interventions to be considered in planning care.

A Focus on CHF

To significantly improve care, impact the quality of life, and reduce emergent and inpatient admissions several diagnoses require aggressive attention.  That attention requires evidenced based interventions.

Congestive Heart Failure (CHF)

Chief symptoms of CHF are dyspnea and fatigue which limits tolerance to exercise and promotes fluid retention that leads to pulmonary congestion and dependent edema. Because volume overload is not always seen at the time of evaluation, sometimes the term heart failure is used instead of congestive heart failure.

CHF effects over 5.5 predominately elderly individuals with 660,000 new cases diagnosed annually. According to the Journal of the American Heart Association, CHF is the underlying cause for 12-15 million office visits and 6.5 million hospital days per year. It ranks as the primary and secondary diagnoses for all hospitalizations over the age of 65. The financial burden is in excess of $40 billion dollars annually (AHA, 2008, 2009).

It is reported by CMS that “inadequate treatment, discharge planning, and follow-up, many patients with CHF are caught in a ‘revolving door’ process” leading to rehospitalization (Jencks, S, CMS, 2005).

Home health care plan intervention per HHQI, the American Heart Association, and the National Heart, Lung, and Blood Institute would include the following SmartCues. (However, all plans of care should be approved by the patient’s physician):

Symptom: Assess for shortness of breath (dyspnea).

Instruct patient to identify its triggers.

Clinician should reassess each visit.

  • Symptom: Assess activity tolerance.

Instruct patient to identify activity daily and/or number of feet walked before dyspnea occurs. Consider Physical Therapy referral for muscle strengthening exercises for legs and upper arms. Teach exercise safety. Teach energy conservation when appropriate.

Clinician should note baseline and assess activity levels and dyspnea changes each visit.

  • Symptom: Assess for increased weakness and fatigue

Instruct patient in energy conservation to achieve ADLs life quality.

Clinician should note baseline and progress each visit.

  • Symptom: Assess for signs of orthopnea

Instruct patient to identify any change in number of propped pillows needed to breathe comfortably when lying down.

Clinician should note baseline and changes each visit.

  • Symptom: Assess for paroxysmal nocturnal dyspnea (feeling of smothering or fullness in the chest when lying down and resolves when standing up)

Instruct patient how to identify changes in symptamotology.

Clinician should assess each visit and note progress each visit. This symptom as well as increased orthopnea is usually an intermediate sign of fluid retention and per HHQI, “intervention at this point could still prevent rehospitalization.”

  • Symptom: Assess for symptoms of chest pain or heaviness

Instruct patient when to contact clinician or physician. Instruct as to utilization of and safety aspects of O2, if ordered by physician.

Clinician should verify any occurrence each visit and identify S3 and S4. Assess for any new or recurrent dysrhythmias or murmurs. Per HHQI, “changes in heart rhythm can lead to poor cardiac output and worsening heart failure. Note: Extra sounds can be a warning of impending heart failure exacerbation.” Clinician to also assess lung sounds to identify any changes or note wheezes, crackles, rhonchi, or diminished breath sounds.

Clinician should discuss with physician; pneumococcal vaccination and influenza immunization.

  • Symptom: Assess for changes in B/P especially elevated B/P

Instruct patient re proper technique to obtain B/P and heart rate (pulse).

Clinician should obtain B/P sitting/standing, Heart Rate (HR), Respiratory Rate (RR), and Jugular Venous distension each visit.

  • Symptom: Assess for edema of feet, ankles, hands, abdomen, or sacrum (anasaca).

Instruct patient re how to assess every day.

Clinician to obtain baseline and assess fluid retention (focus on feet/ankles, hands, sacrum, scrotal area, and abdomen) each visit.

  • Symptom: Assess for increase in weight of 2-3 pounds in 24 hours or 3 pounds in one week.

Instruct patient to weigh self daily and when to alert home health agency.

Clinician should weigh patient and measure abdominal girth each visit.

  • Symptom: Assess for diminished urinary output.

Instruct patient to report decreased urinary output.

Clinician to monitor at each visit as this is a signal of potential impending renal failure, or heart failure decomposition, or the body’s attempt to increase blood pressure.

  • Symptom: Assess for appetite changes especially decreased appetite.

Instruct patient on physician ordered low-fat, low-sodium diet and to record days of lowered appetite, as well as when to contact the clinician.

Clinician should assess patient appetite each visit and if diminished appetite is reported, verify if there is abdominal fluid retention which could cause feelings of fullness and satiety.

  • Symptom: Assess for depression or lack of interest in surroundings and difficulty with focus.

Instruct patient as to psychosocial coping skills to maintain optimum self care-management.

Clinician should assess for symptoms of depression on each visit as well as assess family and support systems.

  • Symptom: Assess for smoking

Instruct patient as to negative effects on health. Encourage regular exercise as tolerated and commensurate with stamina and endurance.

Clinician should ask re smoking and discourage both first and second-hand smoke.

  • Symptom: Assess for medication understanding and medication compliance.

Instruct patient on medication management. Meds may include an Angiotension Converting Enzyme (ACE) Inhibitor, a beta blocker, diuretic if needed, digoxin, and an anticoagulant.

Clinician will monitor medication safety and compliance and should seek blood chemistry results and INR (as ordered by physician) and obtain heart rate, B/P, and clinical status with each dosage change.

Sources:

CMS Appendix B Guidelines for Surveyors

www.homehealthquality.org

HHQI Best Practice Intervention Practice, 8SOW-PA-HHQ07 467 App, 1/2008

www.qualitynet.org

http://mhcc.maryland.gov/consumerinfo/hospitalguide/hospital_leaders/best_practices/hf..h

www.chronicconditions.org/ClearingHouse/cat/Heart%20Failure,61.aspx

Heart and Ling Sounds by 3M

http://solutions.3M.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds

Decision Support Tool: Heart Failure Publication # 8SOW-PA-HH05.187

Posted in Best Practice Intervention Practice, CHF | No Comments »

Evidence-based practice in Establishing Care Plans for the Home Health Patient: COPD

Wednesday, June 1st, 2011

Evidenced – based practice is considered the best available evidence derived from systematic research, clinical experience, and tested expertise to achieve expected and/or improved patient outcomes (Institute for Healthcare Improvement, 2008 ). The new protocols for surveyors have moved the focus to data – driven and outcome – oriented (CMS, 2011) and the need to establish a well defined plan of care foreshadows the need to follow evidence – based practices for specific diseases to achieve the expected outcomes (even though, at this time, CMS has not yet mandated their use). The following is an evidenced based process for COPD using SmartCues as reminders for clinicians.

A Focus on Chronic Obstructive Pulmonary Disease (COPD)

COPD is a progressive airway disorder associated with abnormal inflammatory response of the lungs to noxious gas and/or particles. It is primarily manifested as two related diseases: chronic bronchitis with the presence of cough and sputum production for at least three months and emphysema.

COPD and exacerbation is the fourth leading cause of death in US and causes about 500,000 hospitalizations annually. It is expected to move up to the third leading cause of death in the US by 2020 (Crawford & Harris, 2008). Anthonisen defines COPD exacerbation as requiring the presence of at least one or more of the following: increased sputum purulence, increased sputum volume, and worsening of dyspnea. COPD decompensation is seen 1-3 times per year when care is not managed. Exacerbation etiology is usually infection driven. Other triggers include heart failure, pulmonary emboli, and non pulmonary infections.

Though COPD is progressive, literature states, COPD can be managed better to produce improved outcomes. The Home Health Nurse should follow agency protocol, physician orders, and professional nurse evidence-based practice when assessing and planning care with the patient diagnoses with COPD. Consider the following when establishing care:

  • Symptom: Assess for signs and symptoms of infection (especially pneumonia)

Instruct patient to note change in sputum quantity, volume, and consistency. Patients should also note temperature with any other sign of infection and not increased temperature > than 100 degrees lasting longer than 72 hours (unless different physician guidelines)

Clinician should reassess each visit.

  • Symptom: Assess for hypoxia and dyspnea

Instruct patient to utilize airway tolerance techniques (cough and deep breathing exercises that may include incentive spirometry. Instruct patient when to call home health agency, physician, or to seek emergency care (severe SOB, severe wheezing, or uncontrollable coughing). If Oxygen is used, instruct in importance, in safety and appropriate use of flow rates.

Clinician should assess VS (TPR and B/P), pulse oximetry, and evidence of accessory muscle use.

Clinician should assess for jugular vein distension, peripheral edema, and peripheral edema.

Clinician should assess for anxiety and restlessness

  • Symptom: Smoking

Instruct patient and family in need to cease smoking. First hand and second hand smoke is contraindicated with the patient with COPD.

Clinician must assess each visit.

  • Symptom: Assess for signs of orthopnea

Instruct patient to identify any change in number of propped pillows needed to breathe comfortably when lying down.

Clinician should note baseline and changes each visit.

  • Symptom: Increased wheezing (prolonged expiration)

Instruct patient to identify and eliminate triggers.

Instruct patient on stress reduction and stress management techniques such as guided imagery with simple exercises that can be utilized quickly.

Instruct patient in use of music therapy and choose a piece of music that is associated with calm and piece.

Instruct on airway clearance techniques that may include coughing and deep breathing exercises. Coughing is a general manifestation of COPD and may be worse in the morning. Patient should pace activities.

Instruct patient when to contact home health agency, contact physician, or to seek emergency care especially if there is severe SOB that is uncontrollable.

Clinician should assess incidences upon each visit and effect of instruction.

Clinician should inquire if “tripod” position has been necessary (patient leans forward with head tilted and arms resting on legs or table). Note visible use of accessory muscles in neck, abdomen, and chest. Teach patient to take slow deep breaths through pursed lips. (“This will help him relax and inhale oxygen and exhale carbon dioxide at a slower pace, decreasing the respiratory rate and preventing alveolar collapse” Crawford & Harris, 2008).

Clinician should assess lung sounds and listen for not only wheezes but crackles and may also note diminished breath sounds.

  • Symptom: Assess activity tolerance

Instruct patient to identify activity daily and/or number of feet walked before dyspnea occurs. Wheezing can worsen with activity so a strong assessment and measured activity schedule is necessary.

Consider Physical Therapy referral for muscle strengthening exercises for legs and upper arms. Teach exercise safety. Teach energy conservation when appropriate. Conditioning exercises aid to strengthen the muscles used in breathing.

Clinician should note baseline and assess activity levels and evidence of dyspnea changes each visit.

  • Symptom: Assess for increased weakness and fatigue
  • Instruct patient in energy conservation to achieve ADLs life quality. Patient should note when the symptoms occur.
  • Clinician should note baseline and progress each visit.
  • Symptom: Assess nutrition and hydration status (may have low levels of serum protein)

Instruct in high protein foods that do not require significant energy for preparation. Maintenance of adequate caloric intake should be taught. Nutritional supplements should be considered.

Clinician should assess nutritional status at each visit.

  • Symptom: Medication compliance

Instruct patient as to medication actions, side effects, contraindications, when and how to take, and how to store meds. Likely medications may include bronchodilators, steroids, antibiotics, mucolytics, antivirals, and antipyretics.

Clinician to assess medication changes as well as  patient use of meds such as metered-dose inhaler; exhale completely, take a slow deep breath when inhaling, and holding breath for 5-10 seconds. Verify directions re use on each med.

Patients should have pneumonia and flu vaccine if agreed to by physician.

  • Symptom: Assess for depression or lack of interest in surroundings and difficulty with focus.

Instruct patient as to psychosocial coping skills to maintain optimum self care-management.

Clinician should assess for symptoms of depression on each visit as well as assess family and support systems.

Caring for COPD can present a challenge for home health nurses, but proper patient education, using a variety of techniques, while gaining family and friends’ support can assist to motivate patients to strive for optimal outcomes.

Sources:

CMS Appendix B Guidelines for Surveyors

Crawford, A & Harris, H (2008) COPD Help your patients breathe easier. AHC Media. www.modernmedicine.com/modernmedicine/CE+Library/COPD-Help-your-patients

www.homehealthquality.org

HHQI Best Practice Intervention Practice, 8SOW-PA-HHQ07 467 App, 1/2008

www.qualitynet.org

http://mhcc.maryland.gov/consumerinfo/hospitalguide/hospital_leaders/best_practices/hf..h

www.chronicconditions.org/ClearingHouse/cat/Heart%20Failure,61.aspx

Heart and Ling Sounds by 3M

http://solutions.3M.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds

Decision Support Tool: Heart Failure Publication # 8SOW-PA-HH05.187

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Posted in Best Practice Intervention Practice, COPD, Home Health, Teaching/Education | No Comments »