If there are any nurses (or therapists) out there who have any personal knowledge about how the frequencies are determined by the physical and occupational therapies for Amedisys' Balanced for Life Program, the House Senate and Finance Committee is very interested in what you have to say. You may fax your responses to:
The Honorable Max Baucus
Committee on Finance
United States Senate
219 Dirksen Senate Office Building
Washington, D.C. 20510
The Honorable Chuck Grassley
Committee on Finance
United States Senate
219 Dirksen Senate Office Building
Washington, D.C. 20510
FAX: 202-228-0554.
They are very interested in what clinicians have to report about the Balanced for Life Program (e.g., how do the therapists determine how many visits the patient requires).
Believe me, they will get in touch with you if you have something pertinent to add to the ongoing investigation that is being conducted on over-utilization of therapy visits by the various companies under investigation.
Also, Gentiva has several class action lawsuits against them because their RN's have to do the Oasis SOC even if NO SNV is ordered, than they send a Therapist out to do a "Secondary eval." even if SN does not pick the pt up for skill the nurse is the Case Manager and ALL THIER STAFF spend hours upon end at night and weekends trying to get paperwork completed, UNPAID.
I have no interest in defending Gentiva, but the above situation is perfectly legit. Many agencies have RNs do all the OASIS assessments to standardize data validity. The PT doesn't do a "secondary eval," they are doing a Physical Therapy eval, which the RN is not qualified to do. Many agencies use RNs as case managers, even with therapy-only cases. If you don't understand this model, ask for training to be an effective case manager.
If staff are paid "per visit," as I believe they are, then the paperwork is considered part of the visit--it's the documentation portion. If you didn't document it, you didn't do it. And if you didn't do it, you don't get paid for it. And neither does the agency. If you are up all hours of the night and on weekends doing paperwork, you need to figure out why that is. If you're not doing the documentation in the patient's home, then where else do you expect to do it? The same is true of salaried employees.
We will just have to wait and see what the Department of Labor's viewpoint is on the matter of unpaid overtime. I believe any patient in the home would rather a nurse pay attention to them during the visit rather than trying to get documentation completed. It would be interesting to take a poll on here to see just how many field nurses are able to get all of their charting done in the home. Documentation is an administrative task--it is not direct patient care.
By the way, the exempt status for nurses getting paid overtime only applies to RN's. To all of you LPN's out there charting at home and not getting paid for it--you may want to look into why you are working for free. Look into the labor law pertaining to exempt status to clarify this for yourself. LPN's must get paid for all overtime--period. That is non-negotiable.
Here's the thing--if you choose to document at your home rather than the patient's, that's YOUR choice and your employer should not be penalized for it. You can sit in the driveway in your car if it makes you or your patient uncomfortable for you to be doing the "administrative" portion of your work--the documentation that proves your visit was done--in front of the patient. You are not "working for free." You are choosing to do the documentation outside of the visit. If you would rather not take work home with you, complete your documentation during the visit and be sure to capture the entire time in your visit notes.
If you were in the hospital, would you consider your charting to not be direct patient care? Would you go an entire shift without documenting on a single patient and then expect to be paid to take all the notes and charts home to do your documentation? Of course not! Document at the time you do your assessment and teaching and be done with it.
As I said previously . . . we will let the Department of Labor decide about that. As I recall--when I worked at the hospital, if I needed to spend extra time documenting after a crazy shift, I got paid for every minute of my shift. I did not clock out until I was completely finished. Seems to me there is some "gaming" going on with labor laws here. I don't think the Department of Labor is going to look lightly on agencies that were just found to have been "gaming" Medicare and taking advantage of senior citizens.
Let the chips fall where they may . . . However, if I was an LPN--I would be looking into just how many hours a week I was charting at home to get the documentation done.
Just for the record -- yes, it is feasible to complete your charting in the home or in your car. However, when the crappy charting does not meet Medicare guidelines for that visit to be considered "skilled"--that's when the importance of thorough charting becomes an issue. Before agencies start screeching about the quality of charting, just remember this . . . you get what you pay for. P.S. - when did paying someone for the work they produce become a "penalty". I thought it was considered "wages". Just my humble opinion.
Here's where I'm coming from: Average per visit pay in my area is $40 per visit. Most visits are between 30 minutes to an hour, giving an average per hour rate of $40-$80 an hour. If you're spending 30 minutes to see your patient and do your skilled visit, then choosing to go on to the next patient before completing your documentation and then catching up on "paperwork" at home, that is your choice--you've already been compensated for the visit, for your time. Why should you be paid an additional amount?
In home care, we don't have "crazy shifts." You go from one patient to the next. It's not a matter of having to run a code mid-shift and then having to go back and pick up the pieces. Sure, you may have times that you have to send patients out via rescue or a visit that takes longer than expected for whatever reason, but you still have the option of taking time in between patients to complete your charting. Better to take two to five minutes to complete it when it's fresh in your mind than to save it all for the end of the day when you may forget some details.
Now I will agree that many computer systems are unfriendly to the user and make documentation more difficult. That is something that can be taken up with administration of your agency to see if something different can be used. It is not difficult to write "skillable billable" documentation. It all depends on the wording you use and if you don't know what words to use to make good documentation--ask for help. If you don't like the documentation system you're using and the agency is not willing to change, vote with your feet. There are plenty of other agencies.
I agree fully with your last comment--if we are dealing only with skilled nursing visits. I would have NEVER left home health nursing if all I had to do each day was skilled nurse visits. However, home health agencies have drifted towards a nurse care delivery plan that involves RN's doing only the OASIS assessments, while LPN's do the skilled nurse visits. Depending upon what type of computer system is being used, I can most assuredly state that there is no way that a nurse could complete their documentation on an OASIS visit while at the patient's home. Now, couple 3-4 SOC, ROC, Recert visits each day (with no easy peasy skilled nurse visits to chart on) and it is really easy to see how RN's are taking hours of charting at home. Moreover, a lot of HHA have some kind of a turn around time on their OASIS visits (faster they are locked in to Medicare's system, the faster the HHA gets reimbursed). Also, I would like to point out that in Louisiana, RN's get $26.00 per skilled nurse visit and between $35.00 and $55.00 for OASIS visits. Now, let's say you have to drive 30 to 40 minutes between SNV (Louisiana is very rural), you spend 45 minutes to 1.0 hour with your patient (non-compliance is rampant in Louisiana--therefore, there are NEVER 30-minute visits) and you can see how your hourly wage goes way down. By the way, I don't understand how you came to your $40 - $80 hourly rate. Could you please explain? The only conclusion I came to is you have two SNV in one hour; do you not have to drive? If you are documenting your note in that timeframe, just how much actual "hands-on" nursing care can you provide if you claim you can do two SNV in one hour? Are we talking about "drive-by nursing"?
We have a huge 6 county area to cover, so we have a mix of urban and rural. It is possible to do 2 visits in an hour if it is not complicated. We also sometimes have married couples on service and boy if that isn't a jackpot! If the nurse doesn't have to travel more than a couple of miles between visits and has good time management skills and uses excellent teaching aids, it's possible to get 2 visits in an hour. But I do see a lot of "drive-by nursing," that's for sure. I've never done visits in less than an hour, so I'm not one of those who can make that great rate.
I agree about the OASIS assessments taking longer and not always able to be completed in the home. Still, I've been known to sit in a driveway to complete the forms so that I wouldn't have it hanging over my head later. It's possible.
I will have to save your last message for when my nurses start to complain about pay, working conditions, etc. They think they are so overworked here with 30 units in a week and each SOC counts as 3 units! They can realistically do 2 admits a day each day of the week and not have to do any more. Anything over 30 units and they get the perdiem rate. Lucky buggers
I agree fully with your last comment--if we are dealing only with skilled nursing visits. I would have NEVER left home health nursing if all I had to do each day was skilled nurse visits. However, home health agencies have drifted towards a nurse care delivery plan that involves RN's doing only the OASIS assessments, while LPN's do the skilled nurse visits. Depending upon what type of computer system is being used, I can most assuredly state that there is no way that a nurse could complete their documentation on an OASIS visit while at the patient's home. Now, couple 3-4 SOC, ROC, Recert visits each day (with no easy peasy skilled nurse visits to chart on) and it is really easy to see how RN's are taking hours of charting at home. Moreover, a lot of HHA have some kind of a turn around time on their OASIS visits (faster they are locked in to Medicare's system, the faster the HHA gets reimbursed). Also, I would like to point out that in Louisiana, RN's get $26.00 per skilled nurse visit and between $35.00 and $55.00 for OASIS visits. Now, let's say you have to drive 30 to 40 minutes between SNV (Louisiana is very rural), you spend 45 minutes to 1.0 hour with your patient (non-compliance is rampant in Louisiana--therefore, there are NEVER 30-minute visits) and you can see how your hourly wage goes way down. By the way, I don't understand how you came to your $40 - $80 hourly rate. Could you please explain? The only conclusion I came to is you have two SNV in one hour; do you not have to drive? If you are documenting your note in that timeframe, just how much actual "hands-on" nursing care can you provide if you claim you can do two SNV in one hour? Are we talking about "drive-by nursing"?
With good software it is completely possible to finish the OASIS assessment in the home while interviewing and assessing the patient. I prefer to do it this way. In a previous job I was usually able to completed an SOC visit, 90% of the documentation in the home in 60-90 minutes. THis does not include travel time, or pre-visit review or intake papers time. With my new job the software is so laborious all I can manage to complete in the home is the OASIS, and I've been saving the other crap for later, unfortunately.
We have started to use Home Care Home Based on a Droid. What a joy. No paper! No ink pens! I think I could easily do 3 - 4 admits a day on this system and be done by 5pm. Just not having to sort through all the forms and not having to write the patient's name umpteenth times is such a time saver. Only wish we had started this earlier, since now I am semi-retired and only see a small number of patients a week.
KateRN1
1,191 Posts
I have no interest in defending Gentiva, but the above situation is perfectly legit. Many agencies have RNs do all the OASIS assessments to standardize data validity. The PT doesn't do a "secondary eval," they are doing a Physical Therapy eval, which the RN is not qualified to do. Many agencies use RNs as case managers, even with therapy-only cases. If you don't understand this model, ask for training to be an effective case manager.
If staff are paid "per visit," as I believe they are, then the paperwork is considered part of the visit--it's the documentation portion. If you didn't document it, you didn't do it. And if you didn't do it, you don't get paid for it. And neither does the agency. If you are up all hours of the night and on weekends doing paperwork, you need to figure out why that is. If you're not doing the documentation in the patient's home, then where else do you expect to do it? The same is true of salaried employees.