Medicare Requirements

  1. Does anyone know if Medicare requires compliance on the part of residents/patients in their care & treatment in order to receive Medicare benefits?

    In our nursing home we have several Medicare residents who do not comply with physician orders and it has created a big problem in one instance. There is a resident who consisitently refuses his BID wound treatments . . . he lets only two nurses perform them and one is on indefinite medical leave. These wounds are massive in the groin and abdominal region and because they are being treated only once or twice a week, the odor is like nothing you have ever smelled. Think of dead, rotting meat & fish with a lot of poop thrown in (the man has a colostomy). Needless to say, the smell permeates the entire wing.

    Our social services department, DON & Administrator all agree that it is very offensive & something needs to be done about it, but they spew out the "residents rights" issue. What about the other residents, family members & staff who seem to have lost their rights in this issue?

    I will be checking with Medicare but I thought someone out there might have some insight into this kind of dilemma.

  2. Visit ohlpn profile page

    About ohlpn

    Joined: Aug '01; Posts: 57; Likes: 14
    Specialty: 16 year(s) of experience in Assisted Living


  3. by   Talino
    Medicare covers for services provided to a qualified client. If care or task is not rendered then it would be fraudulent to claim for services. Besides, when you accurately complete an MDS for PPS, the CMI (RUGs Score) will fall below Medicare reimbursed services.

    Residents have rights to refuse treatment. Residents also have rights to be afforded a quality of life (one is be free from obnoxious odors). Although industrial deodorizers can relieve the problem, that is not the answer.

    Staff's attitude towards a resident often dictate compliance. Displaying acceptance and a matter-of-fact demeanor towards a resident's behavior can play a major difference.

    How do the "favored nurses" treat this difficult resident? Maybe the other staff members need to do the same thing, too.

    What I would do....

    1. When the "favored nurse" (let's call her Nurse A) is in to do the dressing, have another staff member (let's call her Nurse B) accompany her.

    2. Have Nurse A introduce Nurse B to the resident. Nurse A informs resident that "Nurse B is interested to learn how I do the dressing so she can do it in when I am not in."

    3. Let Nurse B accompany Nurse A during these procedures at least twice. On 3rd time, let Nurse B do the dressing while Nurse A watches (as if she really need to). Repeat at least 2 more times.

    Although not all problems can be corrected, document all the interventions you have done to resolve it and their outcomes. Show emphasis on infringement on other residents' well-being. If you can prove you have exhausted all means available in your facility, you may be able recommend resident's transfer to another facility.

  4. by   aimeee
    What is the qualifying skill here? Is it the wound care? If that's what is qualifying him, and he is refusing the dressing changes, then Medicare isn't going to continue paying for a skilled bed when he isn't getting the skilled services.

    Can you get your medical director to speak to the patient about compliance? In the LTC I worked at we had a resident who was refusing all his showers--would only take them from male CENA's and even though only sporadically. He was so rank he was ruining the appetites of the other diners. The medical director spoke with him and got him to agree to one shower a week given by a male CENA. He would still try to weasel out of it, but once reminded of his contract with the medical director he would relent and cooperate.
  5. by   AGI
    You have a tough issue, first, if wound care is keeping him skilled, it best be done qd like it is suppose to be. Second, this gentleman is Medicare but gone on LOA? We are looking at some fradulent issues. The family, the resident needs to be talked to and informed about skilled criteria and meeting it daily. Is he capable of living @ home, maybe he needs home health care. If he isn't cooperative with the plan of care, he may need to leave. I hope your administration would be supporting the nurses in this. Also, does the resident realize that footing the bill will be his problem if Medicare benefits seize, however, if he is Medicaid, he isn't going to care. Tough situation. One of the responses to have favored nurse A, showed less-favored nurse B the scoop, was excellent.!!
  6. by   AGI
    Also, make sure their is detailed documentation as to this residents cooperation, make sure documentation shows teaching,
    and anything pertinent. Keep administration informed, document that also, not only that they are informed but what you have informed them of.
  7. by   CoachCathy
    Unfortunately, even if the dressing is only changed once a week per the resident request, he could still qualify for Medicare. The MDS doesn't address the frequency of the dressing changes, only that there is an order for it. The MDS will also address the stage of the wound, etc. There is also an area on the MDS for 'refusing care', that MUST be addressed to cover you with the state. We had a resident at our facility who refused showers. The smell was intense. We got social work involved and the responsible party involved - explained to them that, yes, the patient had the right to refuse showers (or dressing changes as the case may be), but that the rights of the other residents on the hall were equally important. Basically, it ended up coming down to a threat of a 30-day notice (which we could do, citing the rights of the other residents) to encourage the resident to comply. Good luck!!
  8. by   ohlpn
    I have been following all of the responses to my initial post and I'm overwhelmed by the thoughtfulness & practical information provided. I have presented much of the information & solutions to my DON & Social Service Director with surprisingly positive results. Medicare will be taking away his special bed due to the non-compliance of his TX's. He complains that his TX's are quite painful (he wears a Duragesic 75mcg patch) and has prn Ultram which he takes q4hrs. He was just given a new order for Tylenol #3 to be given prior to TX's, which he always declines. I might mention that the man is under 50 years old & has major psych & depression problems. He has 2 fistula's in his groin & 1 fistula in his shoulder region which are secondary to Crohn's Disease. He has been at our facility over 5 years & seems to be very comfortable lying around in his bed all day, watching basketball games on tv, & having the aides fetch him cans of Pepsi from the pop-machines. He is able to ambulate unassisted yet refuses because he is "too depressed." One final note; his favorite nurse has been on medical leave for brain surgery for the last two months & will not be returning for 6 more months. The relief nurse is the only other nurse he will let shower him & render his TX's & she is in only 2 days a week, so he is being treated less often than previously. I will keep anyone who is interested, posted on this ongoing story. It is probably one of our more challenging cases in this 150 bed facility.
  9. by   Catsrule16
    Whatever happened to the resident's resposibilities? Along with rights come responsibilities... to follow the plan of care and plan of treatment. If the resident won't let you provide the care he needs then doesn't that warrant the possibility for discharge? I think a surveyor would question the lack of aggressively seeking a solution to this problem. Is this a person who is alert and oriented? Is he able to understand the consequenses of his actions? Read the Regulations for Tag F201... Futhermore, the interpretive guidelines for the tag. I know we are hammered daily with resident's rights. When does the overall health and well being overstep the rights issue? Do we just sit back and let residents like this rot before our eyes??? If after a reasonable attempt to get him to comply with treatment, I say start looking to find more appropriate placement. Good Luck!