? about SN frequency orders on 485

cjk02 · Apr 4, 2002

My goodness! From reading your posts I feel like I have it pretty easy (but don't tell my boss!). At my agency we are still writing frequencies in ranges (1-3/wkx3wks) and in decreasing order. For dailies we do not need to write ranges (7/wkx9wks). We base our frequencies on the patient's need at the time of admission and it frequently cahnges througout the course of their treatment, in which case we write a new order for the change in frequency and the reason why. In the case of prn visits, we write an "extra visit" order as needed to cover them. The whole system seems to work out well and nobody gets missed. When I first started in home health writing frequencies was pretty confusing but I guess I've worked for the same agency long enough that it actually makes sense to me!

cjk02 · Apr 4, 2002

BY the way, I explain to my patients at the start of care that the frequncy that I am suggesting to the MD is based on their current need and that if their needs change then the frequency will be changed accordingly. I have had no problems with patients wondering why they aren't getting a certain amount of visits, they are generally very understanding and reasonable about it.

juliesosarn · May 2, 2002

We don't write range visits (1-3, etc.). The regulations say that Medicare and surveyors will interpret the range as an order for the highest number in the range so you will be out of compliance if you only do 2 visits on a week with a 1-3 range. And each agency determines their own week. If your week is Sun-Sat, then an intermittent patient who starts on a Saturday could not possibly get 3 visits in, so why be confusing? It is much easier to track order compliance with specific frequency orders, like 1wk1, 3wk3, 2wk4, 1wk2, for example. The vast majority of our patients get full 60-day frequencies. We can always discharge early or adjust, but it's easier than writing new frequencies in the middle when you run out of orders.

hoolahan, ASN, RN · May 3, 2002

julie, I find that hard to believe. If you give a range, it is because the pt status may fluctuate, and if you order 1-3 or even 2-3 w4, and you do 2 visits x 4 weeks, you are still in compliance with the orders. If only 1 visit was made in the 2-3 week range, then you would be out of compliance. If you are getting cited for that, I would definitely appeal it!!

I think that since PPS came along, what they are lloking to detect is agencies that state 1-3 w 6 and only do 4 visits, changing them to a LUPA, even tho the agency may have been paid for an episode rate for the HHRG. My current agency does not worry about that too much, and I think they should. My former agency used to have us indicate up front if we thought the case would be a LUPA. My present agency backpedals the paperwork, which I think is a mistake, and will make them vulnerable to the scrutiny of surveyors, even tho I absolutely do not believe it is being done with intention of fraud or anything like that at all, just maybe out of ignorance.

I didn't know each agency determines their own week, I thought it was a Medicare guidelines that the week started on Sunday.

juliesosarn · May 3, 2002

hoolahan, it's in the regs. I will try to find it for you. It's not an issue so much for the state surveyors, but it is how Medicare can read the chart if you have to submit it for ADR review. We have never been cited for it because I have never, at any agency, written range visits. I never made a policy allowing it just because it is much harder to track compliance and missing notes, etc. if you don't have specific orders for all the weeks and supplemental orders adjusting those frequencies.

hoolahan, ASN, RN · May 4, 2002

Thanks Julie, that would be great if you could post the link, b/c I will forward it to my supervisors, b/c we've been doing it wrong for the last three years at least. I did try to find it last night, from the link Karen had posted above, but since HCFA changed their name to CMS, they re-did the website, and it looks like the HHM 11 is much shorter than it used to be, maybe it's my imagination. I couldn't find anything about the range vs specific visit orders, or the rule about an agency making it's work week whatever they want. Again, maybe I was looking in the wrong spot. There are so many components, it gets confusing.

Home Health Columnist / Guide · May 4, 2002

since i submit adr requests, i can state that ranges for visits are acceptable! this is not a reason visits are being denied, but rather that the documentation does not support homebound status or suggests that the patient is stable.

think agencies are placing tight visit patterns as means of controlling visits + staffing and controlling costs under bba. (i know that was one of the questions asked by mc on our eval last week-- how do we know how many total visits pts are to receive and how do we determine if agency has adequate staff to cover all visits.)

however, visit patterns are to be: what drs recommend for the patient with signed orders are documented on 485 pot.

problem with tight visit pattern is if you don't perform all visits requested in that week you are out of compliance. additionally, if a patient has unstable condition resulting in multiple additional visits, verbal order is required for every visit over that amount listed on pot.

agencies seem to have one or the other approach to visits.

copied tonight from cms website-- manual revised 2/01/02:

http://www.hcfa.gov/pubforms/11_hha/hh200.htm

12-01 coverage of services 204.2

204.2 services are provided under a plan of care established and approved by a physician.--

a. content of the plan of care.--the plan of care must contain all pertinent diagnoses, including the patient's mental status, the types of services, supplies, and equipment required, the frequency of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral, and any additional items the hha or physician choose to include.

note: this manual uses the term "plan of care" to refer to the medical treatment plan established by the treating physician with the assistance of the home health care nurse. although cms previously used the term "plan of treatment," the omnibus budget reconciliation act of 1987 replaced that term with "plan of care" without a change in definition. cms anticipates that a discipline-oriented plan of care will be established, where appropriate, by an hha nurse regarding nursing and home health aide services and by skilled therapists regarding specific therapy treatment. these care plans may be incorporated in the physician's plan of care or separately prepared.

specificity of orders.--the orders on the plan of care must specify the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services.

example: sn x 7/wk x 1 wk; 3/wk x 4 wk; 2/wk x 3 wk, (skilled nursing visits 7 times per week for 1 week; three times per week for 4 weeks; and two times per week for 3 weeks) for skilled observation and evaluation of the surgical site, for teaching sterile dressing changes and to perform sterile dressing changes. the sterile change consists of (detail of procedure).

orders for care may indicate a specific range in the frequency of visits to ensure that the most appropriate level of service is provided during the 60 day episode to home health patients. when a range of visits is ordered, the upper limit of the range is considered the specific frequency.

example: sn x 2-4/wk x 4 wk; 1-2/wk x 4 wk for skilled observation and evaluation of the surgical site. . . .

orders for services to be furnished "as needed" or "prn" must be accompanied by a description of the patient's medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician order would have to be obtained.

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that's all that's in the regs.

PattiRN · May 14, 2002

New Diabetic 1-3wk7

Old diabetic 2wk1,7wk7 - as a supervisor I would expect if there is no healing in a 2 wk period MD is contacted and wound care changed. We are using Saf-gel and duoderm Q3-7 D change to get away from expensive daily wound care under PPS.

CVA 1wk1, 1-3wk7