Home Health & Hospice Week

Make sure your RNs document visits the right way.

With the OIG throwing its spotlight on missing and insufficiently documented supervisory aide visits, hospices can expect tougher enforcement of the requirement going forward.

In a new report, the HHS Office of Inspector General estimates that more than half of “high-risk” RN visit pairs it audited showed that nurses failed to make the required visits, or documented them too poorly to comply with the Medicare condition of participation requiring them. In the report, the Centers for Medicare & Medicaid Services agrees to increase awareness of the requirement to surveyors (see story, p. 344).

That means you can expect surveyors to focus on this topic in more detail than ever before, experts warn. Smart hospices will consider these steps to make sure they are complying with the requirement — and heading off any related survey citations:

1. Ensure the visits happen. CoP §418.76(h) requires an RN to make a supervisory visit “no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide,” notes the National Association for Home Care & Hospice. Step one is to make sure those visits occur as required, says NAHC’s Katie Wehri.

Tip: You may want to use your electronic health record (EHR) system’s scheduling feature to make sure the visits occur, Wehri suggests. Otherwise, just create your own.

Set up systems to remind the RN when the visit is scheduled, Wehri adds.

Double-check: Some electronic medical record (EMR) systems contain an option that alerts the supervisor if an RN fails to make the scheduled supervisory visit every 14 days, notes Carrie Cooley with Weatherbee Resources. Using that feature can help the supervisor address any potential noncom­pliance.

2. Document the visit sufficiently. CMS requirements for aide supervision are pretty rudimentary. “There is no format requirement for documenting supervisory visits,” notes attorney Brian Nowicki with Reinhart Boerner Van Deuren in Madison, Wisconsin.

But while the CoP doesn’t address documen­tation, the Interpretive Guidelines at Tag L633 do say “documentation of RN supervision should include, but not be limited to, if the aide is following the plan of care, is competent in performing required tasks and is satisfactory to the patient/family,” Nowicki points out.

That means documentation should go beyond a bare-bones entry that says “Supervisory visit on mm/dd/yyyy,” advises attorney Robert Markette Jr. with Hall Render in Indianapolis.

Wehri suggests agencies should address the three items mentioned in the IGs, as well as two more topics that the CoPs reference for aide assessment: Complying with infection control policies and procedures (if aide is present and this can be observed or by asking the patient/caregiver) and reporting changes in the patient’s condition.

Plus: “The list of data points identified in the regulation is not exhaustive,” Nowicki points out. “It is ‘not limited to’ the enumerated items.” Those are just the starting point.

You don’t want to overcorrect, either, causing needless burden. While a simple checkmark indicating an RN made a supervisory visit, without any detail, “is not sufficient,” your clinicians shouldn’t need to go into multiple pages of narrative detail for the visit either, Markette judges (see related story on using checkboxes, this page).

3. Remember the audience. “There needs to be some detail,” Markette urges. “If we have a survey issue, complaint, or, worst case, a lawsuit, documentation showing not just that the supervisory visit occurred as scheduled, but what was noted, etc., can be useful,” Markette says. “I want the records to paint a clear picture for the surveyor.”

4. Educate your RNs. It’s not enough to draft a new policy outlining what you require in aide supervisory visit documentation. You need to train your relevant staff to make sure the message is received.

You should educate (or re-educate) RNs on both the CoP requirement and your own policy addressing it, Cooley advises.

5. Audit. After developing a new policy (if necessary) and training staff on it, audit records to make sure RNs are adhering to the policy — and warding off potential survey citations. An audit should check that the visit was performed as scheduled and documentation of the supervisory visit is in the medical record and contains the necessary components, Wehri recommends.

6. Engage QAPI. If your internal auditors find noncompliance, “use the hospice’s Quality Assurance Performance Improvement (QAPI) program to monitor and improve compliance,” Cooley recommends.

7. Check state regs. Don’t forget, “the hospice regulations for several states require more stringent supervision of hospice aides” than the Medicare CoPs, Cooley notes. Make sure you are complying with whichever regulation is more stringent.

8. Expect more data mining. “Now that hospice providers report every interdisciplinary group members’ visits on each monthly hospice claim, these types of untimely RN visits … can be easily identified by CMS,” Cooley cautions. Currently, “there are no payment-related consequences for untimely RN visits; however, this OIG report, along with other recent publications, may result in payment changes going forward.”