While there is much focus on PT and OT, know that documentation will be scrutinized regarding Speech/Language Pathology also. Most clinicians have a good understanding of how PT and OT intervenes with the clients but many clinicians may admit, that other than help with dysphagia, they are uncertain what other care the S/LP can provide?
S/LPs are subject to the same documentation goals under the CoPs:
¡ Provide evidence that the care given meets clinical standards
¡ Justify reimbursement for the payor
¡ Provide protection from liability
¡ Means of communication among individuals providing services
Provide accurate data regarding care for specific patient and diagnostic populations.
S/LPs must meet the same legal requirement to communicate:
¡ Record must be accurate in all respects
¡ Content of the record should contain measurable and objective data
¡ Interventions must be specifically documented and be relational to the POC
¡ Document what was taught and to whom
¡ Document what was learned and by whom
¡ Legal signature includes: Full Name, Full credentials and be legible
S/LPs must have the patient meet the Home Health eligibility per the CoPs:
¡ Homebound Status
CMS expects that the patient’s physical condition and/or physical limitations are such that it would be a considerable and taxing effort for the patient to leave home.
NOTE: Refer to CMS Benefit Policy Manual, (Pub 100-02), Chapter 7, 30.1
¡ Under the Care of MD, DO, DPM
“A medical treatment plan of care or the optional Form 485, must be established by the attending physician, or, where appropriate, in conjunction with a home health agency nurse, regarding nursing and home health services, and/or by skilled therapists regarding specific therapy treatments”
See 42 CFR Part484, Conditions of Participation, Subpart A General Provisions and 484.18 Plan of Care.
¡ Medical Necessity and Skilled Need
CMS states that medical necessity is defined as a “reasonable and necessary need for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member.”
S/LPs must document specific care to justify Medical Necessity
¡ Is there a feeding and swallowing problem?
The S/LP will routinely perform an oral/motor examination. They will evaluate swallowing, coughing, and the size of bolus.
The S/LP can develop a plan to mitigate risk of aspiration such as bolus control.
The S/LP can assist with the plan to maintain adequate hydration and nutrition through body positioning and maneuvers to improve safety.
They will assist in evaluating the independence factors in compliance with the overall plan.
¡ Is there a problem with language (verbal expression, comprehension, reading)
The S/LP can assist to minimize safety risks by finding tools and devices to aid in communication of safety needs to family and other caregivers.
¡ Is there a cognition issue?
The S/LP can assist with strategies to improve attention and attending cues, as well as memory cues.
The S/LP can identify strategies and tactics that can aid problem solving skills. This too can impact safety and independence.
¡ Does the patient require intervention with Voice?
The S/LP can identify strategies to impact on verbal expression, relieving vocal symptoms and, improving their functional voice. The S/LP will identify ways to increase voice loudness and decrease hypernasality.
The clinician should assess this need for S/LP under the Safety evaluation.
¡ Is the patient struggling with fluency and difficult sound production? Do they have an impairment of the tongue? Do they have a lower neuron disease or cerebellar lesion? Does the patient suffer from TBI or had a stroke, or MS?
The S/LP can provide assessment of and interventions for the patients suffering from receptive language deficits; the need to improve understanding of spoken language and can assist with expressive language needs also. It can be frustrating to a patient who cannot state needs or answer questions. Acting out behavior is frequently found to be due to fear, sadness, and frustration.
Depending upon the condition teaching and reteaching occurs.
¡ Three Types of Teaching:
¡ Initial Teaching of a patient requires instruction on a new order, new medication, new diagnosis
¡ Reinforced Teaching requires teaching/instruction on something the patient and/or caregiver may be knowledgeable of, but needs additional teaching
¡ Re-teaching involves evaluation and reinstruction on a medication, diagnosis, treatment, etc that the patient has had prior instruction
The S/LP has expertise in learning principles and teaching techniques.
Using Descriptive Verbiage in Documentation
Expect to see documentation descriptors that create a visual image in the mind of the reader. They should demonstrate the skill of the therapist, the value of the care as well as progress of the patient toward their goals:
Accessed Assessed Assisted Adaptive
Altered Accurate Automatic Applied
Cues/Cued Compromise Corrected Customize
Calculate Compare Contrast Construct
Compose Choose Categorize Collect
Directed Develop Distinguish Define
Demonstrate Dramatize Diagram
Evaluate Exercised Elevate Express
Illustrate Identify Interact Instruct
Progressed Practiced Proposed
The S/LP should document prior functioning in comparison to current. They should clearly document care coordination.
Choosing the Assessment Instruments and Tools
The home health agency, in conjunction with the therapist, should determine what tests will be approved by the agency, so there is continuity among all therapists. Be certain each therapist is knowledgeable with the tools chosen so inter-rater reliability issues are minimized. Also, much like PT consistency; will a TUG or Tinetti be used, S/LP must consider test and re-test reliability.
Consider time for the administration of the assessment. Nurses have seen assessment tools come and go. I can recall a fabulously thorough clinical assessment tool to be used on an inpatient unit. It soon lost favor when its lack of practicality surfaced. Are you seeking comprehensive tools? Be certain they are standardized so that reliability and validity issues do not surface.
Look at the OASIS functional items and look to well thought of commercially acceptable outcome measurements such as the NOMS. The National Outcome Measurement System can be used as an objective measurement tool for the CMS 13th and 19th visit per the American Speech-Language-Hearing Association.
Eight of the fifteen Functional Communication Measures (FCM) from the Adult NOMs were submitted to the National Quality Forum (NQF) for review and were endorsed and became a part of the public domain. The FCM is but one component of the overall NOMS, the national data base of treatment outcomes and customized data reports.
Other Common Tools Used by the S/LP
The Aphasia Language Performance Scale (ALPS)
The EFA-3, Examining for Aphasia
Boston Diagnostic Aphasia Exam
Cognitive Linguistic Quick Test (CLQT)
CADL, Communication of Activities of Daily Living
For a more complete list of Standardized Assessment Instruments, go to:
¡ Documentation to substantiate coding and care have become critical to agency providers.
¡ Documentation has become the key communication tool for care.
¡ Documentation has become the first and last line of defense with the scrutiny of the industry auditors.
Documentation provides the demonstration of the skills of the clinician and justifies the retention of the agency payment received.
Quick tip: Recently, a colleague shared with me that on their psych team, besides the psych nurse and the occupational therapist, they have added a S/LP in certain circumstances, especially with patients with challenged cognition. With patients who are acting out and have recently suffered a stroke or have exacerbated MS, the S/LP has much to add to the Home Health Team in assisting to decrease frustration and anxiety. Speech and Language Pathologists (therapist) add depth to the total team.