11/25/2022
IS THE DEVIL HIDING IN PLAIN SIGHT?
I was recently asked to QA some Hospice plans of care after the claims had rejected in Medicare for incorrect diagnosis. I was amazed by what they found acceptable and began questioning thier processes.
The current staffing crisis in thier area had left them without an experienced Quality leader so they found someone within who was interested in the role! Thier administrator oversight is a non-clinician -the beginning of the devil in thier details!
Neither person was aware of the October ICD10 code changes. Their QA is an LPN who by nature of her license has never case managed or written a plan of care.
When auditing records everyone has their own process I prefer to start at the nurses admission summary to create a picture in my mind of the patient and what I should expect within the records being reviewed.
This summary was of an elderly lady with dementia and COPD, having also fallen recently and now needing hospice care due to weight loss, increased confusion, shortness of breath, agitation increased sleeping and difficulty swallowing. So there I have it a probable eligibility for hospice.
So now to the beginning with a picture in my mind. The nurse entered F02.80 Dementia without behaviours and I10 Essential hypertension as the comorbidity as the only diagnosis, patient is a full code, and the plan of care is to provide an aide for ADL support and environmental safety. Digging a little further and hoping for the Medicare compaince required personal plan of care I find the box version with no edits.
Education to this team began with thier processes and a fundamental review of the plan of care regulation from CMS https://ecfr.io/Title-42/Section-418.56 which states: All hospice care and services must follow an individualized written POC that meets the patient’s and their family’s needs with goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessment, providing all services necessary for the palliation and management of the terminal illness and related conditions of the individual and coordinated with the IDG.
So back to the beginning, as it is clear the plan is far from meeting the needs of this patient or meeting the needs of a CMS survey or claims review; now to correct the submitted plan of care a physicians order must be written to add diagnosis relevant to this patient, the plan of care must be updated to reflect the diagnosies submitted and their impacts on this patients needs and visit frequenccies created to manage the care delivered.
Education then followed to leadership on how to develop and manage a QAPI program within or via outsourcing.
Without a solid assessment, strong case management, IDG coordination and quality oversight this agency may go to ADR and then onto focused educated quality oversight. These issues are serious, they paint the picture to Medicare of an ineligible patient that they may have falsely paid claims for.
Today your focus must be more directly on the Quality team and what they are permitting to remain as the patients record. The Plan of Care remains a CMS top 10 survey deficiency.
Would your Plans of Care withstand Medicare scrutiny? Is your QAPI team equipped to meet the changing areas of concern? Are you seeing RTP errors on claims?
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