Can someone set me straight?

Specialties Home Health

Published

Specializes in Urgent Care, Hospice, Home Health.

I keep hearing "that's just how it is in home health", but I am not convinced that everything is on the up and up with this HHA. I have dealt with hospice and medicare for years and know the hospice regs up down and sideways. Home health seems to be a whole different animal.

For example:

1. Case Managers. What do HH case managers do? Is it normal for the DON (who is a family member of the owner) to be the Case Manager for every patient and never see patients? Is it normal for the LVN to be contacting the physician, obtaining orders from the physician, setting up appointments and labs and procedures (all case manager-ish type roles) for a patient?

2. Corrections. From what I understand it is standard for documentation to be returned for corrections, but returned repeatedly and told "we need to see more skilled nursing in your visit"? How much skilled nursing can you do with a patient who doesn't legitimately need skilled nursing? Also, paychecks are held until documentation is corrected to the DON's liking.(Totally illegal in our state, but that's neither here nor there.) It's like they are holding our money hostage until we legitimize visits that aren't legit.

3. "Homebound" status - Simply being without a car does not make a patient "homebound", does it? We are on Kinnser and homebound status is to be documented every visit. I have been told it is to be documented as stated on the 485, regardless of what is going on with the patient. Is that true? I have patients who "need assistance for all activities" who have part-time jobs outside of the home. That does not sound right to me at all.

4. Case Conference - Do LVN's typically write case conference reports? I am used to hospice where IDT is attended by case managers, social workers, and chaplains. LVNs and field staff do not present at case conference in hospice.

Is this just the nature of the beast with home health? A lot of this seems downright shady to me. I know the obvious solution is to find another job, but in the meantime, I smell a rat. This does not seem legit. I should also add that orientation consisted of, "This is Kinnser. Fill it out. If you have any questions, ask the DON."

Basically, are these true red flags or am I just out of my element?

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That's about par for the course.

The only thing I would maybe have a problem with is patients who work outside the home. If the person has medicare, or tricare, etc that could be a problem. V.A. patients dont have a lot of the restrictions that other insurances do. Many private insurances have rules that pt has to be homebound, some only require that they be in need of the services (same thing as medicaid in my state).

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I keep hearing "that's just how it is in home health", but I am not convinced that everything is on the up and up with this HHA. I have dealt with hospice and medicare for years and know the hospice regs up down and sideways. Home health seems to be a whole different animal.

For example:

1. Case Managers. What do HH case managers do? Is it normal for the DON (who is a family member of the owner) to be the Case Manager for every patient and never see patients? Is it normal for the LVN to be contacting the physician, obtaining orders from the physician, setting up appointments and labs and procedures (all case manager-ish type roles) for a patient?

2. Corrections. From what I understand it is standard for documentation to be returned for corrections, but returned repeatedly and told "we need to see more skilled nursing in your visit"? How much skilled nursing can you do with a patient who doesn't legitimately need skilled nursing? Also, paychecks are held until documentation is corrected to the DON's liking.(Totally illegal in our state, but that's neither here nor there.) It's like they are holding our money hostage until we legitimize visits that aren't legit.

3. "Homebound" status - Simply being without a car does not make a patient "homebound", does it? We are on Kinnser and homebound status is to be documented every visit. I have been told it is to be documented as stated on the 485, regardless of what is going on with the patient. Is that true? I have patients who "need assistance for all activities" who have part-time jobs outside of the home. That does not sound right to me at all.

4. Case Conference - Do LVN's typically write case conference reports? I am used to hospice where IDT is attended by case managers, social workers, and chaplains. LVNs and field staff do not present at case conference in hospice.

Is this just the nature of the beast with home health? A lot of this seems downright shady to me. I know the obvious solution is to find another job, but in the meantime, I smell a rat. This does not seem legit. I should also add that orientation consisted of, "This is Kinnser. Fill it out. If you have any questions, ask the DON."

Basically, are these true red flags or am I just out of my element?

1. DON should be doing DON duties, not case managing patients.

2. Our LPN's do none of that, but it would be nice if they did. RN must co-sign all MD orders for a LPN.

3. That's called Medicare fraud for unnecessary visits. No need for nursing, the pt should be discharged. Holding paycheck!! What the hell is that about. All notes should be handed in within a certain time frame, but if corrections are needed they can't withhold your pay check. I would contact human resources about that one

4. Your absolutely correct about home bound status. I could have no car, but if I'm going out to eat every day with my friends, I'm not home bound. OMG!! They have part time jobs?? That is Medicare fraud for sure. What's wrong with your company? Is it privately owned? Home bound status should be documented for that scheduled visit. Your home bound status can change with every visit. You shouldn't be writing what's on the 485.

5. It should be the case managers decision if they want the LPN to write or put their input on the case conference sheet

6. Get out of there!!! That's not only shady their not following Medicare guidelines for home health care... I would report them to the state after you quit!! Good Luck!!!

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I keep hearing "that's just how it is in home health", but I am not convinced that everything is on the up and up with this HHA. I have dealt with hospice and medicare for years and know the hospice regs up down and sideways. Home health seems to be a whole different animal.

For example:

1. Case Managers. What do HH case managers do? Is it normal for the DON (who is a family member of the owner) to be the Case Manager for every patient and never see patients? Is it normal for the LVN to be contacting the physician, obtaining orders from the physician, setting up appointments and labs and procedures (all case manager-ish type roles) for a patient?

I am a case manager. I have a team of patients and I see patients daily. Usually only one Oasis pt and one SN visit or if I don't have an Oasis that day, I will do 3-4 SN visits and a few calls. The DON can get referrals on patients and set up the SOC and they guide us and learn the patients by our reports and by talking with them or seeing them when they are on call. It is okay for the LVN to be in contact with a patient... after all she IS a nurse correct? My LVNs will write a fax to the MD concerning the pt and I will sign off on it when I read it. They also make appointments for patients. Why not? Cant you make an appointment for your mother, brother sister, grandpa? It isn't illegal for them to make appointments for patients. They see a patient in need of a visit and they are proactive and use their NURSING judgment to make an appointment and then they report it to me, and I appreciate it and have never been upset with an LVN for making one of my patients an appointment. We are a team.

2. Corrections. From what I understand it is standard for documentation to be returned for corrections, but returned repeatedly and told "we need to see more skilled nursing in your visit"? How much skilled nursing can you do with a patient who doesn't legitimately need skilled nursing? Also, paychecks are held until documentation is corrected to the DON's liking.(Totally illegal in our state, but that's neither here nor there.) It's like they are holding our money hostage until we legitimize visits that aren't legit.

I don't know what to tell you on this. I would never fake document home bound status, but just because someone can leave their home doesn't mean its SAFE to leave the home. Sometimes nursing documentation is lacking. Did you do an assessment as you should? If so there should be plenty of documentation. Enough to explain why they are home bound and why YOU as a nurse are there. I mean if there isn't, either you aren't doing enough with the patient or they are not in need of services and I have never known a reputable company to keep a patient on for no reason. Medicare will cap you for that.

3. "Homebound" status - Simply being without a car does not make a patient "homebound", does it? We are on Kinnser and homebound status is to be documented every visit. I have been told it is to be documented as stated on the 485, regardless of what is going on with the patient. Is that true? I have patients who "need assistance for all activities" who have part-time jobs outside of the home. That does not sound right to me at all.

Well, on the 485 are they listed as SOB with exertion? Likely if they were, they will continue to be. Do they have poor endurance with an unsteady gait and despite the fact they can go to town, would you be surprised if they fell or had a spell in the grocery store or had to sit and rest before they needed to come home? 9xs out of 10 an elderly person will not be hard to legally document home bound status if they have a disease fitting (COPD, CHF, OA, Dementia, L/E CVA with general weakness). I mean if an elderly person had a stroke in the past and has some weakness, just because you see them driving a car doesn't mean it is SAFE to.

4. Case Conference - Do LVN's typically write case conference reports? I am used to hospice where IDT is attended by case managers, social workers, and chaplains. LVNs and field staff do not present at case conference in hospice.

Why do LVNs and field staff not participate in case conference? They are an important part of the team of individuals who care for the patient. They know their patients and have a valid contribution.

Is this just the nature of the beast with home health? A lot of this seems downright shady to me. I know the obvious solution is to find another job, but in the meantime, I smell a rat. This does not seem legit. I should also add that orientation consisted of, "This is Kinnser. Fill it out. If you have any questions, ask the DON."

Basically, are these true red flags or am I just out of my element?

Yes your orientation does seem that it is lacking for sure, but your other concerns seem nit-picky and almost as if you are cutting short the huge impact LVNs and DONs and HHAs have in case coordination. I don't know what to tell you about corrections, but unless they are telling you to flat out lie, then document accordingly. You shouldn't ever have to lie or falsify to justify your patient qualifying for care.

Good luck in your search!

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Specializes in Pediatrics, Emergency, Trauma.
I keep hearing "that's just how it is in home health", but I am not convinced that everything is on the up and up with this HHA. I have dealt with hospice and medicare for years and know the hospice regs up down and sideways. Home health seems to be a whole different animal.

For example:

1. Case Managers. What do HH case managers do? Is it normal for the DON (who is a family member of the owner) to be the Case Manager for every patient and never see patients? Is it normal for the LVN to be contacting the physician, obtaining orders from the physician, setting up appointments and labs and procedures (all case manager-ish type roles) for a patient?

I am a case manager. I have a team of patients and I see patients daily. Usually only one Oasis pt and one SN visit or if I don't have an Oasis that day, I will do 3-4 SN visits and a few calls. The DON can get referrals on patients and set up the SOC and they guide us and learn the patients by our reports and by talking with them or seeing them when they are on call. It is okay for the LVN to be in contact with a patient... after all she IS a nurse correct? My LVNs will write a fax to the MD concerning the pt and I will sign off on it when I read it. They also make appointments for patients. Why not? Cant you make an appointment for your mother, brother sister, grandpa? It isn't illegal for them to make appointments for patients. They see a patient in need of a visit and they are proactive and use their NURSING judgment to make an appointment and then they report it to me, and I appreciate it and have never been upset with an LVN for making one of my patients an appointment. We are a team.

2. Corrections. From what I understand it is standard for documentation to be returned for corrections, but returned repeatedly and told "we need to see more skilled nursing in your visit"? How much skilled nursing can you do with a patient who doesn't legitimately need skilled nursing? Also, paychecks are held until documentation is corrected to the DON's liking.(Totally illegal in our state, but that's neither here nor there.) It's like they are holding our money hostage until we legitimize visits that aren't legit.

I don't know what to tell you on this. I would never fake document home bound status, but just because someone can leave their home doesn't mean its SAFE to leave the home. Sometimes nursing documentation is lacking. Did you do an assessment as you should? If so there should be plenty of documentation. Enough to explain why they are home bound and why YOU as a nurse are there. I mean if there isn't, either you aren't doing enough with the patient or they are not in need of services and I have never known a reputable company to keep a patient on for no reason. Medicare will cap you for that.

3. "Homebound" status - Simply being without a car does not make a patient "homebound", does it? We are on Kinnser and homebound status is to be documented every visit. I have been told it is to be documented as stated on the 485, regardless of what is going on with the patient. Is that true? I have patients who "need assistance for all activities" who have part-time jobs outside of the home. That does not sound right to me at all.

Well, on the 485 are they listed as SOB with exertion? Likely if they were, they will continue to be. Do they have poor endurance with an unsteady gait and despite the fact they can go to town, would you be surprised if they fell or had a spell in the grocery store or had to sit and rest before they needed to come home? 9xs out of 10 an elderly person will not be hard to legally document home bound status if they have a disease fitting (COPD, CHF, OA, Dementia, L/E CVA with general weakness). I mean if an elderly person had a stroke in the past and has some weakness, just because you see them driving a car doesn't mean it is SAFE to.

4. Case Conference - Do LVN's typically write case conference reports? I am used to hospice where IDT is attended by case managers, social workers, and chaplains. LVNs and field staff do not present at case conference in hospice.

Why do LVNs and field staff not participate in case conference? They are an important part of the team of individuals who care for the patient. They know their patients and have a valid contribution.

Is this just the nature of the beast with home health? A lot of this seems downright shady to me. I know the obvious solution is to find another job, but in the meantime, I smell a rat. This does not seem legit. I should also add that orientation consisted of, "This is Kinnser. Fill it out. If you have any questions, ask the DON."

Basically, are these true red flags or am I just out of my element?

Yes your orientation does seem that it is lacking for sure, but your other concerns seem nit-picky and almost as if you are cutting short the huge impact LVNs and DONs and HHAs have in case coordination. I don't know what to tell you about corrections, but unless they are telling you to flat out lie, then document accordingly. You shouldn't ever have to lie or falsify to justify your patient qualifying for care.

Good luck in your search!

^THIS. :yes:

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nursekiddo, I read one of your earlier posts that you work for a hh where half the patients were referred by mobile doctors, the ones who got in trouble for referring non homebound pts. if this is so, you may have a problem.

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I have worked twice in HH, once as the admin and once as ADON, and spent all of my time seeing patients because neither agency could attract or retain nurses.

That's just the way it is.

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Specializes in Urgent Care, Hospice, Home Health.

Don't get me wrong, I am not saying I have a problem with assessments and seeing patients. That is what I am there to do. I am not saying that setting up appointments is a "legal" issue. It just seems odd that the patients don't really have a case manager. It just doesn't seem legit to have LVN's coordinating ALL of the patient's care. As I said, the DON is the ONLY case manager we have. The LVN's manage everything for the patient. It seemed unusual, especially after coming from hospice. Same with case conference.

This is a small, private agency and is my first taste of home health. I am not a new nurse and I have done LTC, hospice, and clinic. I did not expect HH to be so vastly different from everything. The work itself is not a problem and is nothing new, aside from all the extra time I put in that I am not paid for and the withholding of paychecks. It's all of the background stuff and the management of HH that has totally shocked me. The majority of what I have seen since starting with this agency seems totally backwards and foreign. Maybe it is just this particular agency. I have nothing to compare it to because I have never worked for another agency.

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