HH visits at ALF

[anticoagulationurse]

Does anybody else do admissions or visits at an assisted living facility that is staffed with NURSES?

This has always perplexed me and it makes me feel like I am "bending the rules" just to get a patient on the books when I am strongly encouraged to admit a patient at an ALF. 100% of the time it is for a wound, usually pressure or trauma in origin (which is the ALF's fault!). They have nurses on staff for med pass, treatments etc. But for whatever reason, they convince a doctor to order HH to come in to do the dressing changes? It doesn't sit right with me because I don't see the need for Medicare to pay HH when they are already paying a nurse at the facility. It seems we should not be going to these places at all, and if the wound care is so complex that the staff cannot handle it the patient needs to be living somewhere else for the time being. I wish I was allowed to just refuse the referral!

I document accordingly in my charting. Recording that Jenny, LPN was taught how to care for wound and also write this in the facility notes. I even put in the HH care plan: "HH nurse to teach skilled wound care to ALF nurses each visit until skill is achieved." I was asked later to change it from ALF nurses to ALF staff because "nurses" is a red flag to medicare. Um yeah, that's why I didn't want to do the admission in the first place!!!

Questions:

1) Do you think the ALF is trying to get outside nurses to care for the wound so that there is no real record of the wound on their forms? Thereby avoiding penalties on whatever reports they have to provide to Medicare?

2) Do you think they just order HH because the staff nurses "don't have time" to deal with the wound which they caused due to their negelct?

3) Is this habit reportable? To whom?

4) Should our HH agency even accept these cases from this referral source?

5) Am I held liable even though I attempt to decline the referral and document honestly, but am asked by supervisors to change it?

[KateRN1]

1) Do you think the ALF is trying to get outside nurses to care for the wound so that there is no real record of the wound on their forms? Thereby avoiding penalties on whatever reports they have to provide to Medicare?

*I'm not sure about that. Some of it depends on the licensing rules for ALF staff in your state. In FL, they must have a special certificate to provide wound care and we do admit patients for wound care at facilities that do not offer this. When it comes down to it, it all depends on what codes you're using for billing. If the ALF is not providing skilled care under Medicare, then it doesn't matter. If they are providing situational skilled care that they are billing under Medicare, then as long as you aren't billing the same codes it shouldn't be an issue, as far as I know. Remember, custodial care isn't covered by Medicare, so things like room & board and ADL assistance aren't covered.

2) Do you think they just order HH because the staff nurses "don't have time" to deal with the wound which they caused due to their negelct?

*ALFs are not skilled nursing facilities. They are there to assist patients with ADLs for the most part and not necessarily neglectful when patients develop wounds. If patients are routinely developing pressure ulcers, it's more a sign that the ALF isn't recommending a higher level of care as quickly as they should.

3) Is this habit reportable? To whom?

*I would start with your immediate supervisor and then, if deemed appropriate, the director or administrator of the ALF.

4) Should our HH agency even accept these cases from this referral source?

*I don't see any reason why not. The cases I question are the ones for diabetic ed for demetia patients who have their sugars, diet, and meds managed by the facility. If it makes you so uncomfortable, ask for clarification from your director of nursing.

5) Am I held liable even though I attempt to decline the referral and document honestly, but am asked by supervisors to change it?

*That depends on what you're documenting. First, you need to know whether it is within the ability of the ALF staff to provide wound care according to their license. And if you're documenting that you're teaching nurses, be sure that itis indeed licensed nurses you're teaching and not UAPs. Most of the ALFs that I'm familiar with use med techs, nurse techs, medical assistants, and the like for the majority of their staffing, with maybe an LPN as a team leader or supervisor.

[spejsa]

I have a similar situation... I received a referral from my office for the following:

A woman who was recently discharged from the hospital with a DX of possible cholecystitis. The MD wants labs (CBC, CMP, Amylase, Lipase) drawn prior to appt this Friday. She lives in an ALF and teh family says "all of her needs are met there. We don't think she needs a nurse on an ongoing basis." But, the office when I asked about it says we can't just go out for a blood draw but she is 80 and "Surely you can find reasons to go out". I went to see her and she has Alzheimers'. The staff was all in a meeting when I was there so I was not able to ask any questions about anything else and don't know what else I can do with her... I have been to this place in teh past and the staff did not want to be trained or taught anything. They are busy doing their jobs, etc... The LPN I work with told the agency that she went there in the past and did teaching, blah blah... I don't see a need for us to bill and really think the dr just sent us to do labs.. I could make something up but really... Should we just go out to chat with the pt and waste their time? Do we expect that the staff will learn? What to dO? I didn't get the blood draw so I will have to go back to get it so I guess I will find something I have to teach...

[KateRN1]

Not sure what state you're in, but at least in FL we are not allowed to teach/train the ALF staff as that is the responsibility of the facility.

ALFs are a tricky business, for sure.

[ProBeeRN, BSN, RN]

I was always told that assisted living facilities do not provide wound care, period, even with a nurse on staff. Has something to do with their certificates or license or something. So we do go out and go wound care for ALF patients. We also go to assisted livings and give injections. Again, I think it has to do with the facilities limitations.

[spejsa]

Well, this particular patient is not a wound care patient. She has a dx of cholecystitis (or possible, which they think was all better when she was DC'd from the hospital). I live in Arkansas and I am unsure about teaching the staff. My LPN said she taught staff there before and insists I need to go and told my nursing supervisor in the office. The nursing supervisor has never done home health (which is the reason I think I need to get out and will do so. I was going to see if they could work it out but I do not think that it will happen). And the woman has Alzheimer's and really no other chronic problems such as CHF, COPD, DM, PVD, HTN.... Otherwise, she is in pretty good health except the Dementia...

[KateRN1]

Have you asked your supervisor "What is the skilled need?" That's where I would start.

[spejsa]

She said we need to go out and see patients that the Dr. refers so we keep the relationship good...

[KateRN1]

"Keeping the doctor happy" is not a skilled need. Clearly she has no idea what she's doing with home health. Consider going somewhere else, when and if you can.

[spejsa]

KateRN1, I quit today. And, this time I am not changing my mind. This same nurse called me today on a patient that was admitted by another nurse a few weeks ago. It was for a patient that had a total knee arthroscopy. The nurse gave me report saying she didn't think I needed to schedule but the one visit to see the patient a few days after she admitted her. I went out and thought maybe I would keep seeing to teach, etc. but the patient and PTA (showed up while I was there) were like "oh, she said she would be DC'd this Saturday so she can go to outpatient therapy)." So, I talked to the PT that Friday and she said she would discharge. Now, it is end of month and this nurse at the office called and asked why I wasn't seeing the patient. That I needed to get the five visits in.. That i need to teach SOMETHING... I told her that the other nurse had told her I would not come but once and it made it difficult, plus the patient had been doing dressing changes 4-5 days at that point and really had no skilled need as far as I could see... So, she told me today "You have to go back out there and do more visits. We need 5 visits". I told her that I missed now cuz I never went last week. She said "just do a missed visit" and I said "no. I never called and what am I going to say?? YOu have to say you attempted the visit, which I did not"... Nevertheless, I quit last week and went back on it and I sent my resignation over to the boss tonight. My last day is next Friday.

[KateRN1]

I think you did the right thing. Want to move down to Florida and work with me? :-)

[spejsa]

I would love to... But, I live in Arkansas...