RACs are contingency based, so, they are motivated to seek out variances.  They can audit 1% of the average monthly Medicare episodes of care (maximum 200) every 45 days per NPI.

Home Health agencies should anticipate to see audits of outlier payments for insulin injections. They should expect, based on coding algorithms to see records reviewed. Are you monitoring your coding and documentation closely? Expect audits.  Fiscal Intermediaries have identified reasons for claim denials and identified high risk areas for non-compliance. Those targeted areas include areas involving coding, homebound status, the documentation of the skilled services delivered, and the overall medical necessity of care administered.

Agencies should be cautious that the codes affixed are well supported by the documentation of the clinician. Too frequently, there has been partial denial of therapy resulting in medical review down-code. Too often and easily, FIs have found clinical documentation incongruent with OASIS M items. Too many times, the reviewers have found that the documentation does not support the focus of care, the sequence for coding, or the medical necessity of the skilled services billed.

In the RAC demonstration project, 35% of the findings pertained to coding. Expect Home Health coding to become one of the chief areas of focus. Remember, the RACs will be looking at variance which will allow them to view consistency of a client’s OASIS, coding, clinical documentation, and the plan of care.

The RAC attack: how to prepare and manage the audits

The Centers for Medicare and Medicaid  (CMS) has implemented, in home health, the  audit process that has proven successful in other areas of the health care industry.  The RAC auditors have been authorized to recover “improper payments “of preapproved areas of risk.  In the demonstration project, high areas of risk included incorrectly coded records, therapy appropriateness, and medically unnecessary services. The RACS use public information from the Office of Inspector General (OIG) and the General Accounting Office (GAO) to focus improper payment audits.

RACs have recovered over 96% of all audited claims resulting in high take-back dollars. Is it any wonder that the home health industry is concerned about their new focus?

RACs are contingency based, so, they are motivated to seek out variances.  They can audit 1% of the average monthly Medicare episodes of care (maximum 200) every 45 days per NPI.  The question is: what action should the home health agency consider now?

Choose a RAC Leader and RAC Response Team

First of all, agencies should appoint a RAC Team Leader who will identify the single point of contact and establish a RAC Response Team. This dynamic team should represent the components of the clinically driven revenue cycle management (RCM) process. Specifically, 1) physicians and clinicians;, nurses, therapists, social workers, 2) quality improvement and documentation specialists, 3) casemanagers, 4) coders, 5) HIM, 6) chargemaster/billing/RCM specialists, 7)  data analysts, Education/Training Specialists, 9) corporate compliance, 10) legal, 11) department heads, 12) mitigation sub-committee that will actually analyze and track each RAC record , and others will be called as needed.  This team will need to address both past and present tactical and oversight issues while prioritizing areas of risk. Additionally, they will review the agency’s ability to complete processes, including audits, and tracking the appeal response.

RAC audits represent significant risk to revenues, profit margins, and workflow stability.  The education of the RAC Response Team is vital in developing the most thorough, yet, efficient approach to establishing RAC risk review and protocol preparedness. Have the team ready.

Identify Vulnerabilities

RAC Response Team education should include lessons learned from the home health industry past: Operation Restore Trust (ORT), May 1995, a two year project in five states resulting in $187.5 million in fines, recoveries, and civil money penalties.  After four years, ORT was credited with a 45% decrease in improper payments, recovery of over $524 million in judgments and settlements and prevention of nearly $11 billion paid in inappropriate claims.

In general, ORT found issues with medical necessity, lack of homebound status, and lack of documentation to support care provided.  Sound familiar? ORT targeted agencies by volume of claims, frequency of medical review issues, LUPA episodes, outliers, therapy thresholds, as well as medical necessity determinations and coding errors.

The recent RAC demonstration results reflected similar focus areas. Agencies should heed those trends identified.

The RAC Response Team should become familiar with regulatory requirements and timeliness. Inservices as well as FAQ sheets with key regulatory highlights and a list of appropriate links to review could be provided. The leader should become familiar with the RAC website as well as monitor the CMS website, alerts, and transmittals.

The RAC Demonstration project showed a 7% payment recovery because of inadequate response to medical record requests so, a process will be needed, to mitigate information flow and manage RAC audit activities thus, create the RAC mitigation sub-committee. This committee or team should function as a subsection of the RAC Response Team, aiding the RAC Team Leader in tracking claims under review.

Identify the patient and document flow, identifying tasks and tools. Diagram patient care flow from intake > admission> medication profile review> discipline specific careplan development > coding >  plan of care development > RAP drop> discipline visits > outcome achievement> QA process review >to final claim submission and A/R management.

Retrospective chart audits as well as present processes and concurrent chart audits should be completed to identify risk. The RAC Response team may decide to contract with third party specialists for comprehensive consulting services to assist the team. The services can include:

• ICD-9-CM Coding Review (Soon to be ICD-10 CM)
• Documentation adequacy to substantiate the Plan of Care and the Codes
• Billing and Revenue Cycle Management (RCM) Review
• Process and Workflow Analysis
• Clinical and RCM Resource
• Presenting OASIS C and Evidenced-Based Practice correlations
• Conducting RAC training sessions to prepare identified personnel for audits

Comprehensive third party clinical/RCM review of care delivered can assign potential organization susceptibility.  The chart audits can distinguish:

• If the admission was medically necessary and the plan appropriate and covered all disciplines.
• If the clinical visits support the plan and the notes
• If the coding met convention and had adequate documented support
  • Focus on case mix diagnoses
  • Review diagnoses sequencing
• If therapy, treatment and procedures were appropriate
• If the reason qualifying homebound status was documented each visit and used objective measureable language
• Other criteria mutually identified by the RAC Response Team and the outside specialists

The RAC Team should consider reviewing the agency overall compliance process, keeping basic CMS regulations in mind.

There have been no limits placed upon the number of sixty day episodes per beneficiary as long as they remain eligible for the home health benefit.  Payment is adjusted to the patient’s need. It becomes the home health agency’s responsibility to assess the patient accurately. Based upon answers to OASIS items describing the patient’s condition and projected therapy needs, a case-mix adjustment is determined. It is the agency’s responsibility to be certain the assessment is accurate, the care is appropriate, and expected outcomes are achieved. Congruency is a key.

Though no limits have been placed on the number of episodes, the Medicare home health benefit is intended to address short term medical needs designed to be met within 60 days. Ongoing recertification is meant to be the exception, not the norm. That recertification must be signed and dated and have backup support of clinical visit and progress notes, copies of summary reports sent to the physicians, and discharge planning. 42 C.F.R. 484.48.  Sometimes, agencies forget that recertification episodes must be clearly justified and are being reviewed carefully. The RAC Team may wish to call for an audit of patients with two episodes and higher.

Expect recertification assessments to become a focus of review.

Because, the RAC audits have focused on medical necessity, it is vital that the intake process and admission policies be reviewed to ensure compliance.  Involve case managers to discuss how they determine projected visit numbers as well as reconcile their careplan focused visits to the Plan of Care. That Plan of Care is the physician ordered medical certification substantiating the need for home health services. 42 C.F.R. 409.43(c) (3).

The coding processes have historically been one of the highest targeted areas of concern because of inaccurate coding in relation to the assessment and documentation submitted. Improper sequencing of codes with incongruence between assessment and plan of care create chart concerns. Chargemaster functions are to be reviewed to determine how identified problems are corrected. Consider third party coders or third party billing sources who know the rules and assist you to remain compliant.

Billing processes are diverse and should be order centric. A record and process review is necessary to map out areas of high risk, such as physician orders and signatures reconciled prior to final claims dropped. Timeliness requirements should be noted when the process is diagrammed.  Billing can become complex when changes and corrections must be made, so a clear tracking process must be maintained. Personnel must be kept current in billing code changes and CMS requirements.

Anytime adjustments or corrections must be made to the billing, there is a risk for duplicate billing. A strong, consistently reviewed process is needed to track beneficiary eligibility, routine billing requirements, billing adjustments, timeliness, and order centricity.  This review process will go a long way toward preventing automated audits. Remember, the automated audits are intended to locate the simple errors.

The Complex reviews are seeking errors that require more intense review; through medical record reviews.  If a RAC demand letter should arrive, the agency may wish to use that informal discussion period, to discuss the RAC’s reason for the repayment. The agency

You should discuss with the RAC auditor how they can submit supportive documentation. If the RAC agrees to see additional information, they can stop the recoupment process If they do not agree the agency can continue with the appeal process.

Providers/agencies have 120 days (from the date on the demand letter) to file an appeal.  This appeal can halt recoupment but, without a valid appeal, recoupment starts on day 41 per CMS.  Appeal prevention oriented agencies need strong process review and implementation. They need to start their own review now.

Coding and Documentation. Coding and Documentation. Coding and Documentation. They just keep becoming more and more important!

The new tiered system directs surveyors to focus on quality of care. A detailed list of surveyor probes are provided, outlining questions that may be asked throughout the survey process. Agencies should review the questions outlined for surveyors in order to prepare for the survey process. Preparation for this process will reinforce other patient focused processes. Are you ready? Visit www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter11_11.pdf to read more.

CMS stated surveyors would cite more deficiencies under the new process. After one year, it will be interesting to view the stats.

The Key Focus Areas

Patient Rights

Assessments

Plan of Care

Outcomes and Improvement

Infection Control

The survey process is guided by interpretive guidelines and survey protocols established to provide guidance for surveyors. The surveyor will review the assessment, the medication profile, and physician orders and then evaluate the established plan of care with review of that implementation of the plan of care. Patient and personnel interviews should support the findings of the clinical record.  Prepare personnel for survey interviews so they are familiar with terminology and types of questions they may be asked. Support the interviewees by having them understand that they are the experts in care delivery. They are merely verbalizing the assessment, the care, and the outcomes expected or achieved.

All surveyors are required, by CMS, to utilize these guidelines when evaluating an agency as to compliance with Federal regulation. Remember, the guidelines do not replace regulation and are not allowed to be the basis of any citation, but they provide guidance.  Violations are to be based upon clinical record reviews, interviews with patients, caregivers, and personnel, as well as the agency’s practices in relationship to regulation and agency policies.

“The survey and certification process provides a method for CMS to evaluate HHA compliance with the Conditions of Participation (CoPs), ensuring that patient services provided meet minimum health and safety standards and a basic level of quality. The HHA survey process incorporates an approach that is patient-focused, outcome-oriented and data-driven making it more efficient and effective in assessing, monitoring, and evaluating the quality of care delivered by an HHA…” (Appendix B, p.6).

The surveys are required to have at least one RN on the team.  Surveyors are required to attend the HHA Training Course prior to any survey. They are then required to be in an observational role as part of the training.

Preparing for the Survey

Appoint at least one person, in your agency, to become very familiar with the new survey process. You may want that person to be OASIS certified to readily discuss OASIS conventions. Develop a thorough process-oriented clinical orientation. Be certain all policies and procedures are current and personnel have had the appropriate inservices.

Have a third party or internal coding expert available to answer any questions regarding diagnoses coding conventions, manifestations, and sequencing. A coding audit by an external review agency may give you some peace of mind.

Be certain your clinical lead has reviewed and audited Starts of Care, Resumptions of Care, Recertifications, and Discharges. Be certain the assessments are well documented and the care plans adequately support that proposed Plan of Care.

Be certain the billing (revenue cycle management) audits include the compliance processes that prevent inappropriate billing without a physician order and evidence of all detailed and signed visit notes.

Types of Surveys

The survey process provides for a standard survey, a partial extended survey, and an extended survey. All HHAs must undergo a standard survey.

Initial Certification

The initial certification requires compliance with SS Act 1861(0) (4) as well as 2180 regarding licensing requirements. In addition, follow the guidelines of SS2008 “Early Surveys of New Providers and Suppliers”.

The State Agency (SA) surveyor or the National Accrediting Organization (AO) inclusive of Joint Commission, CHAP, or ACHC with deeming authority conducts the initial certification. At the time of that survey, the HHA must

• Be operational and have completed the Medicare Enrollment 855A verified by the assigned MAC.
• Provide nursing and one other therapeutic service (42 CFR 484.14(a).
• Meet the new capitalization requirements and have completed an OASIS test submission.
• Have provided care to a minimum of 10 patients requiring SKILLED care.

Standard Survey

This survey is to be a review of the quality of care and services furnished by the HHA as measured by the medical, nursing, and rehabilitative care indicators. The new changes require this survey to review compliance with regulations most related to high-quality patient care. These highest priority standards (regulations) are called Level 1 standards addressing 9 of the 15 CoPs. The thinking is that if the agency is in compliance with these standards, it is in compliance with all CoPs.

Therefore,  “the surveyor can make a determination  that the HHA is in compliance with all CoPs when, after a review of the Level 1 standards, and after completing the required clinical record reviews, home visits, and interviews with patients and HHA staff, he/she does not discover any findings which would support a deficiency citation.”

Partial Extended Survey

This survey occurs when a standard level survey identifies a non compliant Level 1 standard and/or a deficiency practice may exist at a standard or conditional level not examined at the standard survey.  During this survey, the surveyor reviews at a minimum, the Level 2 standards under the same condition which are related to the non compliant Level 1 standards. See Table 1 Level 1 and Level 2 Standards.

Extended Survey

This survey includes a review of all conditions. It may be conducted at any time at the discretion of CMS and is required to be conducted when any conditional level deficiency is identified. The surveyor is required to review all agency policies, procedures, and practices related to the substandard care (one or more condition –level deficiencies).

Recertification Survey

All HHAs are mandated (SS1891) to have a recertification performed no later than 36 months from a previous recertification survey. These surveys are standard unless a Level 1 citation is leveled.

Now, you know the types of surveys. The following chart lists the standard and partially extended surveys with their related priority standards and G-tags. The more you know about the new process, the better prepared you will be for your next survey.

Level 1 and Level 2 Standards Appendix B

Table 1

Conditions                            Standard Survey                Partial Extended Survey

Level 1                                   Level 2

484.10

Patient Rights                          G107, G109                             G101, G108, G111, G114

484.12

Compliance with                     G121                                        G118

Federal, State, Local

Laws

484.14 Organization,               G123, G133, G143,                 G124, G125, G127, G138,

Services and                             G144                                       G139, G150

Administration

484.18 Acceptance                 G157, G158, G159                      G160, G162, G163

Of Patients, Plan of Care,       G164, G165, G166

Medical Supervision

484.30 Skilled                          G170, G172, G173,                     G169, G179

Nursing Services                     G174, G175, G176,

G177

484.32 Therapy                        G186, G187, G188                      G190, G193

484.36 Home Health Aide      G224, G229                               G212, G215, G225, G226, G230

Services                                                                                     G232

484.48 Clinical Records          G236                                        G239

484.55 Comprehensive          G331, G332, G334,                  G339, G341

Assessment of Patients          G445, G336, G337,

G338, G340

Some agencies treat these plans as necessary evils while others embrace the strength of the process and its ability to reduce risk. Recently, we have been asked about initiating a workable, useable, beneficial program.

The Purpose

The purpose of a Performance Improvement Program, Plan, or Process (PIP) is to outline a process that needs improvement. The team that will review the improvement process needs to baseline the present processes seeking efficiencies or other outcomes. This Performance Improvement Plan should support the organization Mission and its Corporate Plan.

Quality Concepts

·            The PIP is established to benefit the organization. It should address an issue or issues that require improvement.

·            The entire organizational team chosen for this Program should be actively included in all phases.

·            Focus on patient or operational outcomes, but try not to take on too many projects at once.

Suggested Patient Care Functions

·            Rights and Responsibilities

·            Ethics and Compliance

·            Assessment and OASIS

·            Adequate Documentation of Care

·            Patient Education and Re-Teaching

·            Continuum and Care Transitions

Agency/Organizational Operations

·            Leadership

·            Ethics and Corporate Compliance

·            HIPAA Privacy and Security

·            Management of Resources

·            Appropriate and Current Policies and Procedures

·            Infection Control

·            Supportive Environment Conducive to Optimum Employee Performance

·            Safety

·            Fiscal Soundness

Responsibility

The Board of Directors approves the Agency Administrator position and the Performance Improvement Program supports with adequate resources and financial support. The Agency Administrator oversees the program or appoints a delegate and assures the Program is continuous, is providing meaningful process monitoring and improvement. Annually, at minimum, results are reported to the BOD.

The Process and the Design

Processes should approach an issue that requires improvement. Processes are designed to be in alignment with the agency mission and strategic plan. They should also be based on evidenced based processes or best practices. They may be benchmarked against other organizations.

Measurement

There needs to be a sound way to collect data. The data will be collected, measured, and analyzed. The goal is to decide the statistical control methods, agree upon how the data will be collected, and determine how it will be measured. Is the agency seeking to evaluate a present process? Design a new process? Assess Performance? Identify areas of Improvement?

Over what period of time will you collect data? Will you evaluate your methods of collection and tools of measurement? Will you evaluate unusual occurrences? Will you keep drilling down until you locate the root cause of the issue?

Assess

The agency should be assessing for improved efficient processes. Will you analyze and discuss new processes so the best process is chosen. Who will be involved? How will they be involved? Will you reevaluate the new processes? When?

Improvement

Buy- in comes with improvement. Be certain that the new processes are truly an improvement. For each issue resolved or impacted, be certain there are clear recommended actions with a responsible party named who will monitor the new processes. Have a timeframe delineated for evaluation as well as evaluation of the “improvement.” Be certain everyone knows the expected outcome. Survey results and identify satisfaction levels.

Buy- In

Buy- in can drive motivation and success. It is important that employees see results for the extra work of the PIP. This process can be applied after Organization Risk Assessments. It teaches problem resolution and hones skill sets. It encourages team building and drives results in an organized fashion. Organizational learning is essential for success. This is one simple way of achieving positive results while reinforcing respect and value for each employee.

Recently, I was speaking with an agency leader, whose firm is known for its Performance Improvement Projects. She has two teams. The key is fun as they attack real problems. Each team identifies projects that impact improved care, outcomes, impact employee morale, or directly impact costs. They present two projects each to the BOD or the Professional Advisory Committee. This allows many to be involved,

Each team defends their chosen project as to benefits derived. They defend the value of the project. Each year the BOD presents a cash bonus and dinner to the team with the best project over the past 12 months. The Leader stated employees via to be on the committees and the PIP are becoming more creative. They are “attacking real problems and finding real solutions we all can live with.” Employees see they are impacting positively on their agency; its care and reputation. They also see the value of group dynamics, peer pressure, and improved performance.

For 2012, the employees have proposed a third team. Leadership is thrilled at that proposal and the fact that she frequently hears, “That should be referred to the PIP, because we can do better.”

RACs, MACs, Z-PICs, Part II of IV

CERTS – (Comprehensive Error Rate Testing) To better calculate the performance of the FIs and MACs, as well as to look at the reasons for their errors, CMS decided to look at a number of additional rates. The additional rates include

—   provider compliance error (how well providers prepared claims for submission)

—   paid claims error rates (measures how accurately FIs and MACs make coverage, coding, and other claims payment decisions). CERTs randomly select a sample of about 100,000 claims each reporting period.

—  CERTs review the claims for proper Medicare coverage, coding, and billing rules, and if not in compliance, they assign an overall error rate.

CERTs also identify if providers received overpayment letters or notices of adjustments to be made for claims that were overpaid and underpaid. CERTs are considered the Quality Improvement specialists who track and trend the performance of fiscal intermediaries and Medicare Administrative Contractors.

Z-PICs – Zone Program Integrity Contractors will perform Medicare Program integrity functions for CMS. They will interact with each MAC to handle fraud and abuse issues within their jurisdictions. ZPICs are seen to consolidate the work of present CMS Program Safeguard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs) and are divided into 7 zones.

The Z-PICs act with the Department of Justice and FBI and act as the investigators when fraud is very strongly thought to have been found. The Z-PICs have the power to suspend claims for up to a year and the agency has no appeal recourse during that time.  That power can cripple or financially devastate an agency.

HEAT –This auditing body is considered the more aggressive investigator of essentially DME and Home Health.  There has been expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay and as recently as September, 2011, they have struck, arresting 91.

The HEAT is the technologically oriented auditing body using state of the art analytics to expand the CMS Medicaid provider audit program. This program leadership has meetings with top anti-fraud leaders in Congress/Law enforcement/Private sector.

CMS states that their mission includes, “providing additional resources to our civil enforcement efforts under the False Claims Act to increase dollars recovered; data sharing, including access to real time data; detect patterns of fraud through technology; strengthening partnerships among Federal agencies between public and the private sectors.”

Clearly, with all of the auditing bodies, CMS is making a bold statement; fraud and abuse will not be tolerated.. Unfortunately, in this kind of environment, innocent casualties can occur. Agencies need to take action now.

RACs, MACs, Z-PICs, Part I of IV

CMS has Unleashed the Auditors

Annually, CMS receives 1.2 billion claims. That breaks down to 4.3 million claims per work day, 574,000 claims per hour, and 9,579 claims per minute. Fraud and abuse are on the rise and the pressure is on.

CMS has unleashed the age of the auditor with the advent of the RACs, MACs, CERTs, MICs, Z-PICs, and now, the HEAT.

RACs- The contingency motivated Recovery Audit Contractors (retrospectively focused). The RAC Demonstration Project of 2005-2007 recovered over $1.3 billion, mostly due to medically unnecessary services (45%), incorrect coding (35%), and insufficient documentation (10%). With four RAC approved firms covering specific geographic regions, these auditors are expected to continue their positive recovery program. The RAC demonstration project yielded a cost of only 22 cents for every $1.00 recovered. They are now in place and ready to go at measure. Certain RACs have been held back until all MACs were in place. That is now completed.

MACs – Medicare Administrative Contractors have been transitioning in and replacing the Regional Home Health Intermediaries (RHHIs). There are 15 MACs with 4 focusing only on DME claims. Though providers fear the RACs, they are well aware of the power of the MAC. This auditing body can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for over payment estimation of claims (current and prospective focus). MACs have power and Congress is encouraging them to use it.

You are a leader or have interests in home healthcare and hospice, so you are aware of the challenges and opportunities presented in this electronic age.

Are you conducting your HIPAA Risk Analysis?

Do you have your Disaster Preparedness and Recovery Policies and Procedures current?

Do you have a policy regarding use of social media in the workplace?

Are you allowing nurses to take pictures of wounds with their personal cell phones?

Are you employing etechnology ethics ?

Technology and Change:

Today, we all use a GPS, an iPhone, a Droid or some brand of cell phone, and touched our iPad or other tablet,  powered up a laptop or computer to send email, or completed status updates to Facebook,  Linkedin, or Twitter or accessed the Internet for  patient information, financial or clinical reports and benchmarks, or budgets. Technology has not necessarily made life easier. It certainly has increased its constraints on time.

Technology has impacted how we do banking, make purchases, conduct transactions, complete travel reservations, attend conferences, provide healthcare schedules, teach patients and personnel, automate revenue cycle management, and generate personnel schedules and  agency reports.

The negative effects include:

5/19/11 57 hard drives from the servers at the Blue Cross Blue Shield Tennessee Call Center were stolen with 1 million individuals impacted.

9/29/11  4.9 million Tricare beneficiaries affected after data stolen.

10/11 McAfee demonstrated how they could hack into a Medtronic Insulin Pump and could have lethally increased the dose.

2010 File boxes of patient records found in two major cities.

The world is changing. The workforce is changing. Remote workers need special policies re PHI and protection of patient data. Be certain they attend sessions regarding HIPAA HITECH, privacy, and security. You may have a policy that addresses ‘view only’ access to data with no printing of data.

HIPAA HITECH

The American Recovery and Reinvestment Act of 2009 (ARRA) was signed into law on February 17, 2009.  Title XIII of ARRA is the Health Information Technology for Economic and Clinical Health Act (HITECH Act). HITECH legislation is meant to affect health care delivery

• One way to affect change is to provide financial stimulation to create and have physicians and hospitals adopt electronic health records (EHR)

The Federal operating plan can be found at http://www.hhs.gov/recovery/reports/plans/onc_hit.pdf

This act includes $20 billion in funding for health information technology projects.

These projects include reimbursement incentives for health care providers to acquire electronic health record technology.  Hospitals are being encouraged to move toward becoming paperless.

HITECH has TEETH

The HITECH Act has given the HIPAA Privacy and Security Rules real teeth by strengthening business associates agreements.  One of the major goals of the HIPAA  Privacy Act was and is  “to assure that individuals’ health information is properly protected  while allowing the flow of health information  needed to provide and promote high quality health care and to protect the public’s health and well being.” HIPAA ensures that personal health information  given to covered entities is protected, even information shared with home health agencies, physicians, hospitals, third party billing providers, coding specialists, and others who provide or pay for healthcare services. But Business Associates were not held to the same standards as covered entities. HIPAA HITECH moved to correct this weakness.

BUSINESS ASSOCIATES

• The BAA states that the Business Associate is obligated to:
  Use/disclose PHI only as permitted or required by the agreement and by law.
  Use appropriate safeguards to prevent use or disclosure of PHI other than as permitted by the BAA.
• Report to the healthcare entity any use or disclosure of PHI not permitted. Require all subcontractors and agents that create, receive, use, disclose, or have access to PHI to agree, in writing tobe held to the same restrictions and conditions on use or disclosure of PHI.

HIPAA HITECH imposed breach notifications on both covered entities and business associates and increased individual rights with respect to PHI maintained in EHRs. In addition, there is increased enforcement of, and penalties for HIPAA violations..

The Department of Health and Human Services (HHS) has published a notice of proposed rulemaking that would modify the HIPAA Privacy, Security, and Enforcement Rules. The Proposed Rule implements the requirements of the HITECH Act as well as expands upon the statutory provisions of the HITECH Act.  On March 15, 2010 HHS stated that other than the security breach notification rule and new penalty levels, the new regulation would be enforced. The compliance date for all provisions of the Proposed Rule is 180 days after publication of the Final Rule. HHS accepted comments on the Proposed Rule through September 13, 2010. As of January, 2012, the final rule has not yet arrived, but is expected soon.

Prior to the HITECH Act, a Business Associate (BA) was not directly subject to HIPAA privacy and security requirements.  The BA obligations were to the CE under the terms of the agreement. The BA was subject to contractual remedies only for any breach of the business associate agreement (BAA).

• Prior to ARRA, HITECH Business Associates were not required to meet the obligations for Administrative, Physical, and Technical safeguards, and Procedure and Documentation Requirements.
• NOW the BAA must clearly require the BA to comply with HIPAA regulations just as the CE.

Penalties for the BA are the same as the CE. That is a huge responsibility for the BA and the CE.

The HITECH Act and the Proposed Rule require business associates to comply with the requirements of the HIPAA Security Rule and implement policies and procedures in the same manner as the CE. Also, subcontractors to business associates must develop Security Rule compliance programs. Rules to be followed include:

Security and Incident response policies

• Breach Log
• Every employee must understand they have personal responsibility for intentional breaches
• Email with PHI is to be encrypted

Breach:

A breach is an unauthorized acquisition, access, use, or disclosure of protected health information relating to failure to comply with organizational security or privacy policies, or violation of federal or state privacy and security regulations. Accessing information by an employee of a covered entity, in good faith, is not considered a breach.

However, HITECH strengthens the specifics of privacy and security, significantly increasing penalties, establishing a heightened enforcement scheme giving state attorneys general enforcement authority. Individuals may now be held accountable for wrongful disclosure (HITECH Act section 13409).

Under the new law, when a breach is learned, a covered entity (CE) should notify each individual whose unsecured PHI has been, or believed to have been, accessed or disclosed.  Business associates must notify the CE of the breach.  Note the understanding that the breach has been evaluated to have caused harm to the individual.  CE and BAs must notify individuals about a breach as soon as possible but, no later than 60 days following discovery of the breach.

If a breach involves 500 or more individuals, the department of Health and Human services should be immediately notified. They will post the covered entity on their website. DHHS began posting names on March 1, 2010. Breaches of below 500 must be recorded on a log and annually sent to DHHS.

UCLA Medical Center recently was fined $865,000 and required to submit(and have approved) a corrective action plan after allowing workers to access records who should have had more  limited access and a higher level authorization. This is an organization with a sophisticated compliance plan and still had this breach.

The EHR

The Privacy Rule gives individuals the right to obtain copies of their paper PHI from a CE. The HITECH Act expanded those access rights to PHI maintained in an EHR.

ARRA prepares for the government goal of establishing electronic health records for all Americans by 2014

• to accomplish this goal, privacy rules have been strengthened and the requirements for breach notification and responsibilities of business associates have been greatly increased.

CEs must prepare processes in response to the requirements and have updates to the BAA.

At Select Data,

• We believe in Corporate Compliance
• We have a strong HIPAA Awareness and Corporate Compliance Plan which assertively strives to protect PHI.
• We notify the Corporate Compliance Officer of suspected or actual incidents of PHI disclosure

We want to comply with the regulations and we want to protect health information because, not only is it the law, but, it is the right thing to do.

57 million US consumers have accessed their medical information. Another 40 million want to do so states Cyber Citizen Health US, 2011 survey.

DISASTER PREPAREDNESS

The Security Plan: Each CE must plan and document how they will operate during a disaster and how ePHI will be secured. HIPAA 2005 required a Data Backup Plan. That plan requires the backup plan for accessing protected data in case the original data has been destroyed.

The Plan must show regular duplication of patient files that are stored in a secure location. The Plan also required an inventory of software and hardware used so key systems can be restored quickly, if a disaster occurs. It is not acceptable to merely store information on a cell or smartphone. Have a clear concise, complete backup plan.

The Security Plan is expected to show ways of protection from access to the premises by employees. It also requires records and how each employee can access data. In addition, levels of access are to be delineated.  There should be power on authentications and auto-locks. CEs are expected to test and revise their contingency plans taking steps to identify and mitigate areas of weakness.

Employees should be aware that not just patient names are identifiers. PHI also includes addresses, phone numbers, drivers license numbers, medical record numbers, policy and account numbers, VIN numbers, health plan numbers, and relative name and identifiers.

Lastly, the HIPAA Security Plan must be in writing and the industry standard is an annual review (though there is no frequency statute). The Plan should have detailed policies and procedures with all incidents recorded, identifying a Disaster Plan with contingencies and technological interventions planned.

To read more about HITECH, please refer to Federal Register/Vol 75, No. 134/Wednesday, July 14, 2010/Proposed Rules

Department of Health and Human Services, Office of the Secretary

45 CFR Parts 160 and 164

Modifications to the HIPAA Privacy, Security, and Enforcement Rules Under the Health Information Technology for Economic and Clinical Health Act

Agency: Office for Civil Rights

Social and Professional Media

Social media is one of the most dangerous of risks. What an interesting dichotomy: on one hand we, in health care, are operating under increasing rigid privacy restrictions and on the other, individuals are posting the most intimate or the most mundane information about themselves and others on the internet for the world to read and see forever.

Agencies that allow clinicians to use their personal smart phones to take pictures of wounds and upload them to a patient record may need to be concerned about patient information stored on a personal cell phone. Who owns the data? Who will protect the data? Is texting a safe way to transport patient data? Experts say, “No.”

Should clinicians worry that their party and beer drinking pictures could be used against them if they are involved in a med error or a law suit?

At the VA, a new social media directive covers the use of Facebook pages, Twitter feeds, blogs, and YouTube channels. They use examples of these sites to educate personnel re personal and professional responsibilities.

100% of the Top 100 firms employ personnel to monitor social media. Every person interviewed has their social media investigated. Hiring is dependent upon the findings. Law firms, banks, accounting firms use social media investigators. Garner Consulting and TechCrunch Blog state “the new social media customer relationship management market (CRM) is expected to reach over $1 billion in revenue by the end of 2012, up from approximately $625 million in 2010. World-wide social CRM is projected to total $820 million in 2011.”

What are the ethics of making negative comments about a present or prior employer? Many organizations, especially banks, hospitals, and academic institutions are monitoring what is said about them and their clients or patients. They have clear policies reflecting training as to HIPAA. If an employee or former employee breaches a confidence, they may be sanctioned or sued.

WHAT Can You Do?

Encrypt email with patient or other sensitive data!

Be certain your organization has a strong corporate compliance plan in place. Have a strong Corporate Compliance Officer who reports to the CEO and Board of Directors. Consider the CCO having direct access to corporate counsel.

Have compliance policies and procedures that also address disaster preparedness, social media, data protection and backup. Annually, minimally, review the Corporate Compliance Plan. Keep a copy of the presentation with an attendance sheet to demonstrate corporate wide support of the plan. Be clear as to internal audits conducted as well as a corporate wide risk analysis conducted annually.

Review the American Nurses Association’s Principles for Nurses re Social Media and Social Networking. Draw from the ANA’s Code of Medical Ethics. Review the American Physical Therapy Association Code of Ethics. Many clinical associations can provide ethical guidelines that can assist with policy development.

Mayo Clinic has refined policies on social media well worth reading. Protect your agency. Be certain your employees know your agency’s ethical stance. Review regulations frequently:

http://www.govinfosecurity.com

http://www.mobilhealthnews.com

http://www.hhs.cms.gov

http://www.healthdatamanagement.com

Expect clinicians to adhere to their Standards of Practice. Expect everyone to adhere to the best practices in ethical protection of patient data.  Password  protect and change them frequently.

Be serious and state your ethical beliefs, in front of employees, frequently. Encourage employees that when in doubt…don’t. Don’t send data that causes them to hesitate. Encourage them to double check what is being sent to whom.

Ethics and Compliance have become the watchwords for a safer healthcare environment. Remember agencies with similar beliefs seek each other out. The ethical industry leader wants to work with other industry organizations that share the concern to protect, care, and achieve expected patient outcomes in a compliant ethical manner. Have a great 2012.

The Federal Register published Nov. 4, 2011 provided the final rule that updates the home health prospective payment system (PPS) rates for 2012.

The notice identifies changes to the national standardized 60-day episode rates and per visit LUPA rates based on the market basket update and the case-mix creep adjustment. Additionally, this rule includes notable changes to the HH PPS case-mix system

As mandated by the Patient Protection and Affordable Care Act, the payment updates for 2012 include a 1.4 percent update factor to the episode rates, which reflects a 1 percent reduction applied to the 2.4 percent market basket update factor,

Average Episode Payment Rate Timeline

These episodes will then be reduced by 3.79 percent for case mix creep, resulting in an overall episode and per visit reduction of 2.39 percent. An additional 3 percent will be applied to payments for services to patients in rural areas based on the Congress-approved rural add-on. Be aware that agencies failing to submit required quality date will be subject to a reduction of 2 percent to their episodes and per visit payments.

The Centers for Medicare and Medicaid Services (CMS) will apply the CY 2012 HH PPS payment rates for episodes with claim statement “through” dates on or after Jan. 1, 2012, and on or before Dec. 31, 2012.

The 2012 national standardized episode payment will be $2,138.52, prior to case-mix and wage adjustments, as compared to 2011’s $2,192.07.

The table below gives a more detailed comparison:

Case-Mix System Changes

The case mix system 2012 changes identify removal of two hypertension codes – 401.1 benign essential hypertension, and 401.9 unspecified essential. Coders will need to be very careful that clinician written “renal failure” or “renal insufficiency” in a record for a hypertensive patient requires a query to the physician to be certain the insufficiency/failure is chronic as that is the only way they will garner their HTN points in 2012.

Policy changes in the CY 2012 HH PPS final rule related to the case-mix system will be effective beginning with episodes with OASIS M0090 dates of Jan. 1, 2012.

Therapy

Because of the presenting patterns of therapy utilization over the past few years, payments impacted by therapy have been revised by CMS. Lower therapy cases seem to be encouraged. Payment for higher-therapy episodes is reduced, while payment for lower-therapy episodes is increased.

The case-mix model has five steps:

• Step 1: First and second episodes, 0-13 therapy visits
• Step 2: First and second episodes, 14-19 therapy visits
• Step 3: Third episodes and beyond, 14-19 therapy visits
• Step 4: Third episodes and beyond, 0-13 therapy visits
• Step 5: All episodes with 20+ therapy visits

The revision seems to be indicating that the industry may have been providing more therapy than was expected by CMS. The changes also parallel payment with costs and redistribute dollars from high therapy payment groups to other case-mix groups.

Prepare Now

Change in regulation means a need for updated policies and procedures. Do not forget to alter your casemix list for coders. Be certain everyone understands the changes in therapy reimbursement. Therapy visit numbers should correlate to the OASIS integrated assessment identification for need.

Remember, CMS expects the changes to this rule to decrease payments to agencies by over $425 million dollars. It is essential that agencies are very efficient in assessment, care, and documentation.

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Some of the new initiatives include the Transitions of Care movement, the Accountable Care Organization, as well as the Patient-Centered Medical Home Model. In future issues, we will deal more with these alterations and potential impacts to the health delivery system. Know that PPACA and ARRA are designed to fundamentally expand access to health care for all US residents. They are meant to look at new ways to deliver safe, quality, and economically affordable care.

In doing so Congress has stated the new delivery models will require rapid engineering of the health care delivery system to consistently provide high quality care at an overall lower cost.

The new delivery systems essentially require ready access of information across the care continuum to empower individuals to use and manage their own care. PPACA identifies one way of “improving health and health care for all Americans is through the use of information and technology.” But, in order to expand use of the information from one care provider to the other requires ready access, and ready access requires the ability to protect individual rights.

At a time when rapid sharing of data is essential for improved quality health care, the government learned the confidence in the protection of health data was low. The Federal Health Information Technology Strategic Plan 2011-2015 was established to “Inspire consumer confidence and trust in health IT.”

The Federal Health IT Vision and Mission

Vision: “A health system that uses information to empower individuals and to improve the health of the population.”

Mission: “To improve health and health care for all Americans through the use of information and technology.”

To do so, the Office of the National Coordinator for Health Information Technology (ONC) published the plan, opened it for public comment, and finalized the Plan in October, 2011 after incorporating over 200 public comments.

Privacy and Security were key concerns. Though individuals rely on HIPAA to assist in guarding how data is transmitted, maintained, and received, the HITECH regulations provide more control of that data by Covered Entities as well as Business Associates. There are stronger provisions for sanctions and significantly higher fines. In addition, the Office of Health and Human Services has commissioned a “principal-level, inter-division workgroup to develop an updated approach to privacy and security policies.” That workgroup will make recommendations to the HIT policy Committee as well as to the HIT Standards Committee.

The Federal Health IT Principles support the government in its desire to “put individuals and their interests first” (Overview Federal Health IT Strategic Plan 2011, p2).

Goal 1: Achieve Adoption and Information Exchange through Meaningful Use of Health IT

The new Federal Health Information Technology Strategic Plan (FHITSP) will be a living document that will be responsive not only to those committees, but also to the public, and other organizations, including Congress. The ONC, responsible for the Plan, already has proposed an extension of Meaningful Use, Stage 1, by a year (to 2014), to allow time to incentivize more providers in the use of Electronic Health Records (EHRs). Giving another year would allow providers and vendors more time to develop functionality for the EHR. CMS has requested more improvement of data portability.

One goal of improved data accessibility is to, per Congress, “engage patients and families in their health care.” To accomplish this goal, patients are to have an electronic copy of their health information; test results, medications, problem lists, procedures, and instructions, upon request. Providers are to be able to easily exchange data, including information that may have been patient-authored. When the patient is transferred from one setting to another, a patient transfer summary of care should be available for each transition of care or referral. You will see the use of the word discharge begin to fade away. The belief is the patient is not discharged, merely transitioned to the more appropriate level of care; thus a transition summary, not a discharge summary will be written.

Meaningful Use- Stage 1 Objectives include protection of health information created and /or maintained by the Electronic Health Record technology through the “implementation of appropriate technical capabilities.”

Meaningful Use- Stage 1 Measures include conducting a security risk analysis and implementation of updates as necessary with identified security deficiencies identified as part of the risk management process. (45 CFR 164.308 (a)(1).

The belief is that to ensure mass acceptance, privacy and security must be the solid foundation. Patients, families, and providers must feel confident that laws, regulations, and procedures are in place to keep health information safe and they must be able to access care from one level to the next.

Goal II: Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT

Exploring the use of new health care delivery models is being encouraged. From Care Transition programs to Accountable Care Organizations, CMS is seeking new ways to treat populations. The year 2012 brings in the CMS regulations regarding ACOs:

On October 20, 2011 the US Department of Health and Human Services released the final rule implementing the ACO Shared Savings Program and the complementary regulations and guidance from CMS/OIG as well as the DOJ/FTC. It should be noted that the final rules are materially different from the proposed rules of March, 2010.

ACOs were created by the Affordable Care Act (ACA) signed into law March 2010. The dual purpose of this network provider model is to reduce the increasing cost of healthcare and to include incentives to create this new way of providing care for individuals. Coupled with the ACO rules, CMS had unveiled the Shared Savings Program (SSP), a program created by Congress to allow the ACOs to share in the savings and potentially share the costs of care to Medicare beneficiaries.

The final regulations were released. The proposed rules did not stimulate the interest expected. CMS has since changed the final rule to focus on the themes of flexibility, accountability, and innovation. It also provides clear guidance aimed at encouraging the development of the ACO participation in the Shared Savings Program. The purpose of ACOs is to realize savings and quality care through the coordination of services among the various providers, including hospitals, individual physicians, group practices, hospitals, home health agencies, and community health centers, or any combination of the above. Applications for the implementation of ACOs are currently being accepted through January 1, 2012, and the first ACOs will begin April, 2012.

The three goals of the ACOs stressed under the Shared Savings program will be to promote: 1) effective, patient-centered care for individuals; 2) preventive oriented and education oriented care for specific populations; and 3) cost savings (and profit) for the ACOs and CMS in general as well as decreasing waste in the system.

To be eligible to participate in the Shared Savings Program, ACOs must be accountable for at least 5000 beneficiaries a year for each of the three years of the agreement. To be eligible to share the savings, ACOs will be required to report on four quality measure domains.

It is apparent that this new healthcare model will be very patient-centered, not only addressing the medical needs of its participants, but also the social, nutritional and community needs as well. The cost sharing for the ACOs is determined by not-yet established benchmarks for 33 quality measures (QMs) broken down into the four domains:

• Care Coordination/Patient Safety (6 measures)
• Preventive Health (8 measures)
• At-Risk Populations/Frail Elderly Health (12 measures)
• Patient/Caregiver Quality Standards (7 measures).

The QMs include population focused areas that are approached in a patient-centered manner. These indicators include timeliness of physician appointments, effective communication, tobacco use, diabetes and other comorbidity control, as well as preventive screenings. Depending on the success of the outcome-driven education and approach to the care as well as patient ratings and surveys, specific provider scores could garner up to 60% of the savings realized by the organization. It is anticipated that the new system will save over $960 million over the next three years for the Medicare program, per CMS.

This new form of healthcare organization will utilize technology to link providers. “An ACO will be rewarded for providing better care and investing in the health and lives of patients,” said Donald M. Berwick, M.D., CMS Administrator. “ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”

Goal III: Inspire Confidence and Trust in Health IT and

Goal IV: Empower Individuals with Health IT to Improve their Health and the Health Care System

Regulations are Stronger because Risks are Higher. Recent breach statistics show the cause of consumer concern. On 5/19/11, 1 million people were impacted by the theft of 517 unencrypted hard drives from servers at BCBS Tennessee Call Center.   (www.healthcareinformationsecurity.com)

On 9/9/11 Microsoft Cloud Evaporates Leaving 365 Million Users without access for hours.     (http://techcrunch.com)

The Federal list of major health information breaches since September 2009 includes 345 incidents affecting 18.5 million people as of 10/24/11. Breaches affecting 500 or more individuals 9/09- 8/11 included 328 breach incidents affecting 11, 819, 283 individual records.

Security

In a 2010 survey, the Office of Health Information Management saw that 74% of providers surveyed offer patient access to the website or portal through the use of a unique log-in identifier. Believe it or not, 17% of those surveyed had no controls in place and were in violation of several regulations.

In the HIPAA final Security Rule (2006) personnel must be responsible for security, sharing of data safely must be provided in an electronic format, and there must be a patient identity validation.

Per the Federal HIT committees, the only secured data is data that has been destroyed or encrypted. Your IT provider should have Patient Privacy and Security Safeguards in place. Those will include an Assessment of Risk, IT Policies and Procedures with ongoing evaluations, Data Integrity Lifecycle Management, Audits, Storage and Data Retention Safeguards, with Disaster Recovery and data replication capability.

Goal V: Achieve Rapid Learning and Technological Advancement

Usability of EHR:

The ONC is looking at ways to improve the ability of providers to be more responsive to user need and improve data portability. CMS is monitoring the Medicare and Medicaid EHR incentive programs. Expect to see another collective ONC, Office of Civil Rights (responsible for HIPAA), and CMS national campaign to increase consumer awareness in the areas of:

• A National Transition to Electronic Health IT
• The Benefits of Managing Health IT Tools to Improve Health Care Management
• The Fact that this Move to EHIT Helps Keep the Consumer Empowered
• Health Information Privacy and Security

The campaign slogan chosen is to be “Putting the I in Health IT” which will encourage patients, families, and providers to share how IT can and has improved health care.

For more information and to read the Federal Health IT Strategic Plan visit http://healthit.hhs.gov/StrategicPlan

Clinical Compliance Role Of Verbal Orders CY 2011

Susan Carmichael, Chief Compliance Officer at Select Data answers a very import question regarding CMS changes for Cy2011 regarding the role of verbal orders.  Susan will answer more questions you have.  Fill out your question in the comment box below.  To find out more about Compliance for CY2011 or  watch more Educational Videos click here.

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

Analyze                    Appraise

Cues/Cued                Compromise              Corrected             Customize

Calculate                  Compare                   Contrast               Construct

Compose                  Choose                      Categorize            Collect

Directed                   Develop                      Distinguish          Define

Demonstrate                      Dramatize                  Diagram

Evaluate                   Exercised                            Elevate                Express

Explain                     Examine

Facilitate

Illustrate                   Identify                     Interact                Instruct

Modify                 Measure

Progressed           Practiced                   Proposed

Revised

Stimulated            Scheduled

Updated

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 13^th and 19^th 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:

http://www.asha.org/assessments.aspx

¡  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.