OASIS Alert

Look back to find recert details.

Completing assessments on time isn’t the only hurdle your agency faces with recertifications. You also need to be sure to maintain quality documentation.

Why? When you recertify a patient, you need documented clinical evidence that supports the patient’s need for home care — and that proof must stand up in the event that the chart is audited. Poor documentation won’t show an auditor why your agency should continue to provide care for a patient.

“Recert documentation must be better in quality and content than even the start of care,” says Pam Warmack, RN-BC, HCS-D, COS-C, a consultant with Clinic Connections in Ruston, La. “The clinician must again prove the patient is eligible for care (remains homebound and needs care) and that there is justification for yet another episode of care.”

“Generally speaking, some agencies have a tendency to hold onto their patients too long,” cautions Rose Kimball, a consultant with Dallas-based Med-Care Administrative Services. “I see recerts when there isn’t a reasonable need for the patient to stay on service.” But good documentation illustrates the patient’s need for home health services.

To combat the inclination to keep patients too long, during the case conference you should review patient data to make sure it’s appropriate to keep the patient on service, Kimball says.

Start by reviewing a summary of the past 60 days, suggests Warmack. “What has occurred in the previous 60 days that has caused the patient to need a continuation of home care? New medications? Hospitalizations? Changes in treatment? New illnesses or exacerbations? Injuries?”

Review the goals for the preceding episode and discuss why they were not accomplished to help steer your thinking process and decide whether recertification is appropriate, Warmack says. “Is there potential for this patient to benefit significantly from home care services? A good team conference conversation can be so helpful to the clinicians in making these determinations.”