OASIS Alert

Evaluate legal risk, too.

Question: Many OASIS outcomes can be influenced by whether or not the patient complies with the plan of care. What do we do when we have a diabetic patient with uncontrolled blood sugar who refuses to follow her diabetic diet and eats whatever she wants? The physician wants to control the blood sugar with insulin adjustments only. Should we discharge this patient as noncompliant or continue seeing her to control the blood sugar just using insulin. What does CMS require? What other options do we have?

Answer: First, the Centers for Medicare & Medicaid Services provides several guidelines on whether skilled nursing services are medically reasonable and necessary in the CMS online manual #100, Chapter 7, says senior consultant Judy Adams with Charlotte, NC-based LarsonAllen Health Care Group. These include:

1. Services must be consistent with the nature and severity of the illness or injury. Here the patient has diabetes that cannot be regulated through dietary management alone. Insulin administered in response to blood sugars is another alternative for regulating this patient, Adams explains.

2. Look at the patient's unique medical condition and individual needs. In your case, there is considerable evidence that the patient is not compliant with dietary teaching and the only way to manage her diabetes is to use insulin, Adams says.

3. The physician must establish that the service is reasonable and necessary. This patient's doctor has ordered the management using insulin.

4. Services must be consistent with accepted standards of medical and nursing practice. Insulin using a sliding scale approach is an effective mechanism for controlling diabetes, Adams notes.

Determine whether the patient can be taught to administer her own insulin based on a sliding scale, Adams counsels. (Progress in this area can improve M0800 and your outcomes, too.)

If she can, Medicare will cover nursing visits to teach the patient how to do this, by using physician's orders and blood sugar results. Conduct very limited monitoring visits to see if the patient is complying with the plan.

Caution: Attempt to find options other than having the nurse administer the daily insulin. If you haven't already, you should work with the patient to try to teach her to administer her own insulin rather than just assuming the nurse would have to interpret the glucose meter readings and give the insulin, Adams says. And carefully document your efforts to manage this case.

If the patient is physically or mentally unable to self-administer the insulin -- and there is no willing and available caregiver -- the agency may provide daily visits to administer the insulin, Adams explains. Insulin-dependent diabetics will need insulin throughout their lives, so "this specific situation is waived from the intermittent criteria that limits daily services to a short period," she says.  "It is the only exception to the finite end point for daily services," she tells Eli.

Consider Legal Ramifications

Outcomes are certainly a consideration for agencies as the focus on them increases. But while you are evaluating your options, you also need to look at potential legal liability, says Burtonsville, MD health care attorney Elizabeth Hogue.

Hogue offers these action steps:

• Determine how serious the non-compliance is. Is there a high risk of injury to the patient? If non-compliance is serious enough to discontinue services, are there other actions you should take to protect the patient?

• Attempt to assist the patient to achieve compliance. Have you provided enough teaching? Has the patient demonstrated she understood the teaching?  Have you pointed out the non-compliance to the patient each time? Have you tried using a contract with the patient stating what she will do to have the services continue? Be sure to document everything.