Home Health Providers and rehab clinicians have certainly garnered the focus of CMS contractors currently auditing for qualified and skilled care content in homecare episodes, and the level of specificity of the audits reveals an entirely new standard for qualified care in these areas of our programs. In addition, the expectations for therapy service delivery under the Part A Home Health benefit may be significantly different from what many Providers have produced over the PPS era. This level of audit focus may also mirror the expectations that CMS has for this aspect of our care programs; the proposed Med Pac changes for therapy identify care and quality controls that address how therapy is produced, delivered and managed for the Home Health patient.
Today, we review audit content seen over the last three months to identify expectations for covered care.
Our first example reflects the need for frequency maintenance and plan of care specificity:
Example #1: The plan of care ordered physical therapy services to be provided 2 times per week for 6 weeks. At the time of the post-discharge record review, it was noted that physical therapy services were provided one time per week during weeks 3, 4 and 5. During an interview at the time of the review, the Director of Nursing stated the agency had no additional clinical record documents for this record. The plan of care also included orders for “Therapeutic massage to bilateral ankle for 15 minutes.” During the review of the physical therapy visit notes the following deviations from the plan of care orders were noted: On two consecutive visits, therapeutic massage was provided to bilateral knees and ankles for 20 minutes; on two additional separate visits no therapeutic massage was provided; and on two other separate visits, therapeutic massage was provided to bilateral knees.
Further scrutiny of frequency maintenance of rehab care:
Example #2: The plan of care ordered physical therapy services to be provided 2 times per week for 8 weeks. At the time of the post-discharge record review, it was noted that physical therapy services were provided one time during week 1, no physical therapy visits were provided week 3, one visit during week 4, and one visit during week 8. During an interview at the time of the review, the Director of Nursing stated the agency had no additional clinical record documents for this record.
Incomplete service delivery as per Plan of Care orders:
Example #3: The plan of care, for the period of 4-2-12 to 5-31-12, included orders for physical therapy and occupational therapy to evaluate and treat the patient. At the time of the 5-16-12 record review there was no evidence that the agency had provided any physical therapy services, and it was also noted that there were no occupational therapy services provided until 5-1-12. The plan of care also included orders for nursing services to be provided 1 time per week for 9 weeks. There were no nursing visits documented on week 2, and no nursing visits documented after 4-25-12. During an interview at the time of the review, the Director of Nursing stated the agency had no additional clinical record documents for this record.
Incomplete services that extend beyond a single certification period:
Example #4: The plan of care, dated 11/16/11, included orders for physical therapy and occupational therapy to evaluate and treat the patient. At the time of the 5/16/12 record review there was no evidence that the agency had provided any occupational therapy services throughout the duration of the certification period. Additionally, the physical therapist did not document an evaluation visit until 1/14/12, which was the day the certification period ended.
This patient was recertified for a second period of care. A physician’s order, dated 1/13/12, specified “Recertify home care services…. skilled nursing, physical therapy, occupational therapy.” At the time of the 5/16/12 record review there was no evidence that the agency had provided any occupational therapy services throughout this second certification period either. During an interview at the time of the review, the Director of Nursing confirmed the agency had no additional clinical record documents available for review for the above identified records.
Lack of reportable vital signs or incomplete therapy Plan of Care information:
Example #5: The physical therapy plan of care did not include the frequency of visits for the physical therapy services the patient was to receive. In addition, the plans of care for all records failed to include reportable vital sign, blood sugar and weight parameters that were applicable to each patient.
Incomplete MD communication regarding ordered rehab services:
Example #6: This patients SOC date was 8/26/11 and the patient was receiving services that included PT. According to the PT POC, the PT visit frequency was “1×1, 2×4”. During record review, it was noted that the PT completed a “Missed Visit Note” dated 9/8/11. The PT documented the reason for the missed visit as “Patient went out of town”. Under the “Physician Notification” section, the PT documented the physician’s name, but failed to indicate (by checking the box) how the physician was notified (by phone or fax). The PT also failed to specify the date and time that the physician was notified of the missed visit.
Failure to follow Plan of Care modifications:
Example #7: This patient’s POC ordered PT services 2 x week x 4 weeks for a total of 8 visits. Upon review of the medical record, a telephone order for Week 5 was found to increase the visits “1×1 week”. The total number of visits found in the record was 8 visits as ordered on the original POC, there were no additional visits documented on Week 5 or subsequent weeks. The agency failed to follow the increased frequency of visits as ordered by the physician.
Failure to individualize Plan of Care to patient:
Example #8: According to the SOC POC dated 3/29/12, the patient was receiving SN, PT, and speech therapy (ST) for diagnoses that included muscle weakness and acute URI (upper respiratory infection). A Medicare survey home visit was conducted with this patient and the Speech Therapist on 4/25/12. During the Medicare survey home visit, it was noted that this patient was oriented to name only, was confused and uncooperative throughout the visit, and had the assistance of a caregiver who administered the patient’s medications. When the Speech Therapist was questioned about the patient’s mental status, they stated, “This is not that unusual for him.” During record review, it was noted that the SOC POC included SN orders to “require repeat demonstrations or explanations about medications that will be taken at home” and “Have the patient repeat back the information provided or show that they have mastered drug administration techniques such as measuring liquid medications”. It was determined that the patient did not have the ability to administer his own medications. Also, the SOC POC did not include liquid medications. The agency failed to ensure that the SN orders were individualized for the patient.
Most of these case denials revolve around issues that exist in nearly all agencies in some shape or form. Providers preparing for future success would be wise to assertively address lapses involving rehab service delivery in these areas described above. Now is the time to act to shore up your agency’s performance in these areas of your episodes; the future is here now.