Sticky situation.....please help!

SoCalRN1970 · Jul 9, 2011

MY BIG CONCERN.. was this patient you admitted "appropriate for hospice"?? I have worked at Vitas and a smaller but larger hospice doing admissions for a few years.

#1 Both agencies I worked for had often sent em out on the fly with no info except name address ect. A referral from the doctor is all it would take. I would assess thoroughly and get a history from patient or family best I could. I had about a 90% admit rate. ( Vitas tracks all stats ) But, often I would not bring someone on. Either they didn't' meet criteria or they were not ready. Admits happen at times with only a name.. but it's the nurse who is doing the admission to assess weather or not it's a clinically appropriate admission. Sista that is your license.

I was sent to do an "admission" with no consents signed and the dpoa was not available for a couple of days. My boss.. told me to "admit her" and send her home in an ambulance.. to her board and care. I told my boss, I can't legally touch her unless I know there is a consent. She said.. "oh he gave it to me..". YOU BET I INCLUDED THAT IN MY NOTES. VERBAL CONSENT OBTAINED BY XYZ MANAGER STATED ON THIS TIME THIS DATE...

I left that agency a week later. I was asked to document false happenings in order to bill for decline on patients I knew were not appropriate months ago. I was told.. be quiet or quit my job.. I quit.. I suggest if you feel uneasy about your office.. leave now. You don't like doing what your asked? Don't do it and leave.

The other compliance issues you speak of are vague. Are you out of compliance with certifications? Billing improperly? Not seeing patients on frequency stated? Not meeting COP's of medicare?

THere are alot of isssues with could of touched furhter in detail.. Being non compliant on visits but up to snuff on certs and medicare billing practice.. or non compliance on COPS?? Please clarify.

SoCalRN1970 · Jul 9, 2011

RNWithAHeart · Jul 10, 2011

Hi there,

Patient does not qualify based on evaluation, however, I am told that she has advanced ESRD....with labs to back it up that should qualify her. But, I am not seeing that picture just by the visit without any documentation.

Non compliant in many areas.......missed frequencies....non compliant with many of the COPs (one example....medical director not being present for IDG.......maybe over the phone and then somehow he is there to "sign" the paperwork without stepping foot in the building.

Patients are well cared for and the benefit portion of the COPs is followed well........most of these issues are with in the office with documentation, care plans, idg updates, etc.

I should be supervising these things, but spend the majority of my time out in the field seeing patients, doing admits. I am DCS, but have a patient caseload.....am on call 24/7....if not directly, always back up, but have been doing call about 20 days out of 30. Also working 60+ hours a week.

I just cant keep up.

Hospice Nurse LPN, BSN, RN · Jul 10, 2011

Hi there,
Patient does not qualify based on evaluation, however, I am told that she has advanced ESRD....with labs to back it up that should qualify her. But, I am not seeing that picture just by the visit without any documentation.
Non compliant in many areas.......missed frequencies....non compliant with many of the COPs (one example....medical director not being present for IDG.......maybe over the phone and then somehow he is there to "sign" the paperwork without stepping foot in the building.
Patients are well cared for and the benefit portion of the COPs is followed well........most of these issues are with in the office with documentation, care plans, idg updates, etc.
I should be supervising these things, but spend the majority of my time out in the field seeing patients, doing admits. I am DCS, but have a patient caseload.....am on call 24/7....if not directly, always back up, but have been doing call about 20 days out of 30. Also working 60+ hours a week.
I just cant keep up.

My goodness, girl! I think I would be finding another job and getting out of there ASAP. I work for a small, privately owned company (average census 15-20) and my DON does all the admits because she wants to see for herself that they are appropriate and also to meet the family. She only does visits in an emergency situation ie: both field nurses are in opposite areas. As far as all the compliance issues, there's going to be heck to pay when state comes a calling.

Do you have anyone doing QA? Our office manager checks notes against the time sheet to make sure they are correct and every Monday I check notes turned in against the schedule to make sure nothing is missing. If something is off, I need a missed visit form stating the reason the visit was missed. I always check all the POC before IDT is dismissed to make sure there are no missing signatures. If you doc isn't making IDT, maybe they need to find a new one.

Good luck to you and please keep us updated.

heron, ASN, RN · Jul 10, 2011

Not being a manager, I may be way off base here, but as DCS aren't you the primary responsible person for this stuff? Qualification for admission ... consents ... these are clinical issue and, it seems to me, that you should have the final decision.

It seems to me that they either need to hire an another nurse to take some of your field work or you need to mandate certain guidelines. If your boss won't go for it, then it's looking (to me) like you're being set up to take the fall if CMS comes calling.

Easy to say "find another job" but that's not so simple nowadays. You are in a classic double bind ... you have the final responsibility for clinical policies, including documentation, but are being treated like a gofer with no control over how things are done. What, exactly, does your job description say?

It's worrisome, because CMS can impose some pretty heavy sanctions up to and including fines and pulling the company's Medicare certification.

SoCalRN1970 · Jul 10, 2011

Dear RNWAH,

I need to say thank you for elaboration. So many regs and compliance issues are super simple to fix, but what you described is a HOT MESS!

All it would take is a disgruntled pateint or family to call your local state regulatory hot line and boom an audit. I will day would never happen the question is more like.... when??

I am concerned about what your roll is and what you are doing. What will happen.. and I have seen this happen. Smaller agencies or short staff agencies using internal management who are nurses to do the foot and field work. Charts are hurting and regs and COPS are not being met.

I don't want to sound like a negative nilly, but sorry, you are NOT providing good care to your patients. How can you? Missed visits? Missed reports to the MD, IDG issues. You company is NOT providing good care. It takes a good smart witted family member to call the state that is all.

Clean up your resume.. put it online monster career builder or whatnot. IF you are able to take another field job elsewhere ( you are already working as one anyway ) and leave on the fly. What will happen otherwise. An audit or survey. Plan of corrections and dificiences a mile long and MANAGEMENT will be to blame. You will more than likely be terminated by this non accountable company. I have seen this happen in the past. Pass the buck, fire your staff who has been working under horrific conditions and blame them.

I'd also contact CMS, the state and your other accreditation agencies in your state. AFTER you leave.

SoCalRN1970 · Jul 10, 2011

FYI for what it's worth. I worked at a small hospice ( it wasn't a small business it was affiliated with a huge medical center ) but we had like 20 = 30 patients at any given time. Our consents showed we provided actually 4 levels of care, routine, GIP, respite and CONTINUOUS CARE.

Truth is. We NEVER offered continuos care. We didn't have access to that kind of service, didn't contract with an agency and our own staff could not provide 24 hour coverage. To provide this is a COP at least for us at that time.

My administrator who worked in hospice for years.. said 'yes, we provide cc." " We are available 24 hours a day and we can do visits if need be."

I didn't complete a year at this agency as the hospital shut it down just as I was looking for placement elsewhere. HOWEVER. I did call the state and medicare to alert them of this practice. I did give my name... and hoped this kind of corruption would not happen again if that big major medical center opted to reopen it's hospice again.