recerting too many times

[cny4rn]

Do any of you feel that patients are kept on and recerted when actually they should be discharged?

I have worked for two different agengies in the last six years and it seems management wants you to find a reason to recert for as long as possible. I am feeling disillusioned with home health for that reason. It seems there is a fine line there where it is almost fraudulent.

Do any of you feel this way?

[DutchgirlRN, ASN, RN]

My HH agency does not recert unless there is a real need to continue HH. They have no problem DC'ing patients when they are ready. They say it's the only honest way to run an agency.

[cny4rn]

I am glad there are agencies out there that are discharging as they should. Unfortunately I don't work for one. But I have been more vocal about it and the other case manager and I have been discharging more.

I think I am going to make a change in my life and do something different than nursing. I am just kind of burned out.

[colleennurse, ASN, RN]

I work in a mental health residence where 90% of my case load is medicaid. The other day at a weekly meeting with my supervisor, the marketing rep from my agency and the case managers at the building, I told them that I wanted to DC a patient that has refused the aide service since he was admitted and I am not really doing anything except taking his vitals. The manager of the building wants me to keep him on service adn I was like there is no skilled need for nursing. The marketing person said in front of everyone, yiou dont need a skilled need for medicaid. I am not sure what the regs are for medicaid exactly. But I was sooooo mad that they (my manager and marketing person) left me hanging there and did not back up my opinion to DC this patient. I felt like an idiot. But it just makes me wonder, there has to be some rules for medicaid????

[BabaLouRN]

can someone tell me where I can find in the CMS Medicare guidelines how they frown on too many recerts. I have recently worked for a small agency that sounds like they went to the same class as these others. No skilled need and the same ole same ole every day. When I went ahead and dc'd a pt (even the pt said he was ready) My NON NURSE boss threw an absolute temper tantrum about how he cannot run a business if I keep discharging the patient. The company I worked for in Oklahoma was VERY skilled need only, get in, get out and get on with it. This company does not have marketers who keep referrals coming in, if they did they would not be so freaked all the time. I wish I could show them as clear as ice where Medicare frowns on too many recerts...

[NRSKarenRN, BSN, RN]

eligibility for home care certification what clinicians should know

know the rules when it comes to medicare patient recertification

what the surveyors are looking for:

http://www.cms.hhs.gov/guidanceforla...07ap_b_hha.pdf

info from power point i developed for my staff gleemed from 25yrs in homecare. patients may to be recerted under "skilled management and eval" when the following conditions are met

medicare guidelines & considerations to recertify patient’s plan of care

cms definition:

[color=#3333cc]nthe registered nurse assesses the beneficiary's conditions (physical, mental, nutritional, emotional, social, environmental, or financial)

[color=#3333cc]nand support systems,

[color=#3333cc]nand manages the unskilled services needed to provide the appropriate interventions that impact the conditions and promote medical safety and/or recovery.

[color=#3333cc]nthe care plan must be so complex that only a registered nurse can appropriately manage the interventions and evaluate the results of the interventions.

[color=#3333cc]nonce the recovery is complete and/or medical safety is achieved (i.e., the beneficiary's care plan is unchanging), management and evaluation of the care plan is no longer reasonable and necessary.

https://www.cahabagba.com/part_a/education_and_outreach/eduaational_materials/hh_coverage.pdf pg. 47; viewed 7/14/06

[color=#333399]skilled management and evaluation [color=#333399]case checklist includes:

[color=#333399][color=#3333cc]nmultiple medical problems

[color=#333399][color=#3333cc]nmultiple medications: abuse or non-compliant

[color=#333399][color=#3333cc]nmultiple or restrictive functional limitations

[color=#333399][color=#3333cc]nadl deficits due to physical, mental, emotional problems

[color=#333399][color=#3333cc]ndeficits in thought processes

[color=#333399]

[color=#3333cc]nemotional problems

[color=#3333cc]nnutritional and/or hydration problems

[color=#3333cc]nhealth risking behaviors: chemically dependent, non-compliant

[color=#3333cc]ndeficits in support system: abuse, unsafe environment, etc.

[color=#3333cc]nmultiple community resources needed

[color=#3333cc]ndifficulty obtaining community resources

[color=#3333cc]nhistory of frequent hospitalizations or emergency room visits related to functional deficits (e.g., falls, dehydration, malnutrition, decubitus ulcer)

[color=#3333cc]nlong-term medical problems (e.g., aids, cancer, transplants, chf, copd)

management and evaluation is not

[color=#333399][color=#3333cc]nsupervising a home health aide

[color=#3333cc]nprefilling medication planners

[color=#3333cc]nhealth maintenance services

[color=#3333cc]nhealth promotion services

[color=#3333cc]nongoing supervision of a chronic, non-compliant beneficiary

three strikes and your out!

[color=#333399][color=#333399]include in plan of treatment language:

[color=#333399]"s[color=#333399]killed case management of the care plan"

[color=#333399]frequency of visit e.g. 1x/wk, q2weeks, 2-3x month for following problems

list problems like:

• medication management
  
• bowel elimination
  
• ostomy/catheter management
  

[color=#3333cc]•multiple unskilled caregivers

[color=#3333cc]•patient has more than one problem to manage e.g. chf with diabetes

[color=#3333cc]•caregiver fails to refill meds on timely basis increasing risk hospitalization

[color=#3333cc]•nutrition at risk: lack of adequate food intake, weight loss, constipating meds

[color=#3333cc]•slow healing wounds that required change treatment

[color=#3333cc]• unskilled caregiver needs supervision to ensure care consistently done (missed doctor appointments)

documentation for each visit:

[color=#3333cc]ø must address progress or lack thereof for each goal

[color=#3333cc]øinclude what is done to move the patient/ caregiver to achieve the goal.

management and evaluation ends when:

[color=#3333cc]nspecific, attainable goals are met and recovery complete

[color=#3333cc]nmedically stable: beneficiary's care plan is unchanging

[color=#3333cc]nmanagement and evaluation of the care plan is no longer reasonable and necessary, e.g. non-compliant patient

[twinpumpkin]

NRSKarenRN...Thank you for posting this information! :)

[erroridiot]

Inappropriate recertification is a huge problem in medicare home care agencies.

That is why RAC auditors are coming to take the money back.

The agency can keep on doing inappropriate recerts, but at some point in the future, they will give the money back to Medicare.

Many agencies will not be able to hear or see the truth until it is too late.

If you work for an agency doing the inappropriate, you may want to look for an agency that is "compliant".

[Lacie, BSN, RN]

Our nurses are required to review with the CLM prior to each proposed recert to discuss changes, non-compliance (must have appropriate documentation), if PT/OT goals were met or not met, etc. I have the hardest time getting through to the field staff that just filling the med box, doing PT/INR's or other labs is doesnt fit the "skilled need". I have a harder time getting my nurses to "let go" of the pt they have very frequently gotten attached to or I get "it will **** off the doctor if we d/c". Well the doctor isnt going to be the one charged with fraud or the fines lol. I review goals with my staff in case conference on a weekly basis - if non-compliant pts and we have done all we can then we d/c asap. Then deal with the doc lol.