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HomeMy WebLinkAboutC93-036 Medicare MOU_Nursing Facilities Home Health Agencies14"%` `^ C93-36-22 SNF/HHA MOU APRIL 1, 1993 MEDICARE MEMORANDUM OF UNDERSTANDING PRO MEDICARE AGREEMENTS WITH SKILLED NURSING FACILITIES, HOME HEALTH AGENCIES THIS MEMORANDUM OF UNDERSTANDING is entered into this 1st day of 1993 by and between the COLORADO FOUNDATION FOR MEDICAL CARE, the Colorado Professional Review Organization, hereinafter referred to as the PRO, and EAGLE COUNTY NURSING SERVICE, to enumerate operational procedures that the above mentioned parties have agreed will be followed. In accordance with Section 9353(e) of the Budget Reconciliation Act of 1986, Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) are to maintain an agreement with the Professional Review Organization (PRO) regarding review of written beneficiary complaints regarding quality of care while the services were being reimbursed by Medicare, or for services which may otherwise be made under Title XVIII. The PRO will also review complaints received from and through the HCFA Region VIII office. Section 2030 of the PRO Manual requires that PROs review intervening care between readmissions that occur within thirty-one (31) days in PPS hospitals. Intervening care includes care provided to a Medicare beneficiary by a SNF or HHA. The care includes that for which payment may be made, whether or not it is actually paid for by Medicare. Health care facilities that submit claims for Medicare payment must cooperate in the conduct of PRO review. Facilities must: A. Assure that copies of the medical records are furnished to the PRO within thirty (30) days of the request. B. Provide patient care data and other pertinent data at the time the PRO is collecting information required to make its review determinations. For review of beneficiary complaints, all required information must be photocopied and delivered, without cost, to the PRO within thirty (30) days of the PRO's request. -1- EFF: 4/1/93 "Ofth", ,A� SNF/HHA NOU APRIL 1, 1993 C. Provide written notices to Medicare beneficiaries at the time the beneficiaries begin receiving care for which Medicare payment is sought; that this care is subject to PRO quality review; and indicate the potential outcomes of that review. (Attachment A) D. Provide photocopies of medical records to comply with the HCFA requirements for PRO re -review by an outside agency. The CFMC will contact the facility, in writing, to request the necessary records. III. REVIEW OF BENEFICIARY COMPLAINTS a. Determine the inquirer is a Medicare beneficiary or representative of a Medicare beneficiary. b. Determine that the services in question were provided in a Medicare certified facility even though the services may not be reimbursed by Medicare. c. The services in question are covered by Medicare regardless of whether they are covered for this particular beneficiary. d. Determine that the complaint is a quality of care issue. All non -quality concerns and complaints that do not meet items b and c above are forwarded to the HCFA Regional Office with a copy to the beneficiary. e. Acknowledge the beneficiary by letter that the complaint has been received and the PRO is reviewing. f . Request the medical record within fifteen (15 ) days of receipt of the complaint. The provider has thirty (30) days to provide the medical record. g. Review the record within fifteen (15) days and refer to a physician advisor, if necessary. If there is no quality problem, the PRO will respond in writing to the beneficiary within five days following the disclosure of information, rules in 42 CFR 476.1326 If there is a provider quality issue the PRO will continue with h. below. If there is a physician problem, the PRO will continue with i. below. If both physician and provider are identified as the source of the problem, both h. and i. will be followed. -2- EFF: 4/1/93 AI^N 14=&� SNF/HHA MOU APRIL 1, 1993 h. Potential provider quality issues will be referred to the provider with a thirty day response time. The response will be reviewed by the physician advisor and a determination made if there is or is not a confirmed quality issue. The beneficiary will be informed of the outcome of this review. The provider will be provided a copy of the letter to the beneficiary thirty days before the letter is sent to the beneficiary. A copy of the provider's comments will be attached to the PRO's response to the beneficiary. The PRO letter will indicate whether or not the care provided met professionally recognized standards of care. If the care did not meet these standards, the corrective action to be taken will be described in the letter to the beneficiary and to the provider. i . Potential physician quality issue will be referred to the responsible physician with a thirty day response time. The response will be reviewed by a physician advisor and a determination made if there is or is not a confirmed quality problem. The beneficiary will be notified that a thorough investigation of the complaint has been conducted and that corrective action will be taken if a problem is found. The physician will be sent a copy of the PRO response letter to the beneficiary thirty days prior to the letter being sent to the beneficiary. j. Corrective Action will be taken by the PRO when a confirmed physician and/or provider quality issue is identified. 1) If the quality problem meets the definition of a gross and flagrant violation or a substantial violation in a substantial number of cases, the PRO Sanction Process will be initiated. (Refer to Section V). 2) If the quality problem has the potential to affect the care provided to other beneficiaries, the PRO will forward their findings to the HCFA Regional Office. k. Confirmed quality issues identified will be added to the PRO quality profile data. � 3 w EFF: 4/1/93 f SNF/HHA NOU APRIL 1, 1993 1. Pablem Identification The nonphysician reviewer screens the medical record for referral of questions about quality of care to a physician reviewer using discharge criteria, other local criteria, and SNF and HHA generic quality screens. (Attachment B) 2. Physician Review For cases which do not meet criteria or fail generic quality screens, the nonphysician reviewer will make a determination as to whether the case represents a potential quality concern. in cases which have been identified for further review, a Preliminary notice of Potential Quality Concern is sent to the physician and provider informing them of the opportunity for discussion. The provider/attending physician will be provided 30 days to respond to the Preliminary Notice of Potential Quality Concern. The response will be reviewed by a physician reviewer. The physician reviewer: reviews the medical record and any additional information or results of telephone/in-person discussions with the physician/provider; makes a final determination regarding the quality concern(s) and the source(s) of the quality concern(s). A Final Notice of Quality Concern is sent to the physician ( if any) whose care is at issue and the* provider for every case where a potential notice was issued. Cases with a final determination of no quality concern will be included in the quarterly profile. -4- EFF: 4/1/93 11� ram\ 3. Re-ReView SNF/HHA MOU APRIL 1, 1993 A physician or provider dissatisfied with a final quality concern determination is entitled to a review of that determination. The physician or provider does not need to submit new information to be entitled to a re -review. This re -review is an administrative, not a regulatory, process. No additional review or appeal beyond this re�review of the final quality concern is available. The re -review physician reviewer (an individual who was not involved in the initial determination): Reviews any additional information furnished by the physician or provider and re -reviews the final determination about the quality concern; Makes a final determination regarding the quality concern(s) and the source(s) of the quality concern(s). A Notice of Re -review of Quality Concern is sent to the physician and provider for every case where a re -review was requested. Cases with a final determination of no quality concern will be included in the quarterly profile. Physician profiles will include all PRO -reviewed cases in which they rendered care during a stay as an attending physician, surgeon, or anesthesiologist. The physician profiles will also include all PRO -reviewed cases in which the physician had one or more confirmed quality concerns and rendered care during the stay as a consultant. For each case reviewed, the PRO must identify each physician who provided care during the stay as an attending physician, and collect this information for profiling. -5- EFF: 4/1/93 14� ice\ SNF/HHA MOU APRIL 1, 1993 4. Profiling Profiles will be completed for each physician, each provider and Statewide. The profiles will include data for the most recent quarter and cumulative data up to one year prior to the current quarter. The CFMC will review the profiles and follow up on patterns of quality concerns by focused review, or feedback discussions with physicians/providers, as appropriate. Types of profiles will include profiles by State, physician and provider for: Type of variation in the quality of care; Adverse outcomes resulting from multiple systems failures; and Results of the application of weighing formulas (to be developed). At a minimum, profile reports are to be provided each quarter to: State medical and hospital associations on physicians and hospitals, aggregated to the State level (i.e., these reports should not identify individual providers or physicians); Each provider on data about services performed in that provider and Statewide data; and Each physician with a pattern of quality concerns. Physicians are to receive profiles of information about his/her services, data on providers at which he/she practices and Statewide data. In addition, at least once per year, every physician in the State is to be provided with profile information on the PRO review of the care he/she provided for the past year. This includes those physicians who do not have a pattern of quality concerns. EFF: 4/1/93 rma e460N' V . SAM19HS SNF/HHA MOU APRIL 1, 1993 Section 1154 of the Social Security Act (the Act) provides that health care practitioners and any other persons (including hospitals or other health care facilities, organizations or agencies) who furnish health care items or services for which payment may be made ( in whole or in part) by the Medicare program have certain obligations. These obligations are to assure that the services or items: a. will be provided economically and only when, and to the extent they are medically necessary; b. will be of a quality which meets professionally recognized standards of health care; and c., will be supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by the CFMC in the exercise of its duties and responsibilities. In carrying out its Title XVIII duties and functions, the CFMC is to determine whether any person or practitioner may have violated Section 1154(a) Obligations. The feedback and/or cooperative improvement project process is used when a pattern of concerns or interests (e.g., best practices) is identified. Projects may be Statewide or may concentrate on groups of providers or practitioners or on individual providers or practitioners. Singular concerns will be addressed through the customary CFMC mechanisms (e.g., denials, DRG adjustments). The CFMC will use its data gathering and analysis capabilities to identify categories of outstanding performance in particular providers, or in the State, or areas of the State (e.g., very low rates of mortality and morbidity following CABGs, no or very few denied admissions). The CFMC will identify the categories of best practices, analyze the reason(s) for outstanding performance (this will include discussions with the outstanding facilities), and develop cooperative improvement projects to assist all facilities in improving quality of care, utilization, coding, and documentation practices. -7- EFF: 4/21/93 #01M%� &a SNF/HHA MOU APRIL 1, 1993 The CFMC will use its data gathering and analysis capabilities to identify categories of variation that may be of concern in particular providers, in the State, or in areas of the State (e.g. , poor outcomes following CABGs, sudden rise in denied admissions). The CFMC will identify the categories of greatest concern and develop projects to address them. The CFMC is to use all of the information which it has available to it through individual case review, focused sampling, profiling, and pattern analysis to determine where the feedback and/or cooperative improvement project process can be utilized most efficiently and effectively to improve overall performance. Under the educational feedback and cooperative improvement project process, the CFMC will develop and implement feedback and/or cooperative improvement projects using information gathered from pattern analysis activities that include: 1. The profiling of data used to assess quality of care concerns in case review; 2. The analysis of patterns of practice and outcome under each of the cooperative projects; 3. Systematic analysis of patterns of care based on analytic and bill files provided by HCFA; 4. The systematic analysis/profiling of denials, DRG changes, and documentation errors from case review. When a pattern of concerns is identified for physician or provider through individual case review pattern analysis, profiling, or focused review, the CFMC will work with involved physicians and providers to identify remediable problems that have given rise to these concerns. The CFMC must provide assistance to the provider in addressing the concern(s). The provider is expected to review the information provided by the CFMC to identify any underlying problems that are the source(s) of the identified pattern variations with emphasis on systemic problems which can be addressed. When these problems are identified, the physicians and providers must either provide convincing evidence that a plan is not needed, or develop an action plan to correct the problem. The definition of a pattern for individual case review is under development. -8- EFF: 4/1/93 00"%� EOM1 SNF/HHA MOU APRIL 1, 1993 The CFMC will work with both the administrative and the medical staffs of the facilities involved when providing individual feedback. Where the source of the quality, utilization, documentation, or DRG concern is a physician, the CFMC will notify the physician that the CFMC will work with the physician and the provider in a cooperative effort to improve performance. For all patterns of concern (except gross and flagrant situations for which the sanction process applies), regardless of the source of the concern, the provider is provided an opportunity to develop an action plan. In most cases.. HCFA expects a plan to be requested within 30 calendar days. The initial request for the action plan will include a summary of the findings which are the basis for the request and may include CFMC suggestions for corrective action. The notice gives the provider 30 calendar days to develop the plan and provide a contact person for discussion. The provider will be informed that the action plan must: 1. Describe the expected outcome (goals) of the actions. The stated outcome must be measurable; 2. State what the provider believes to be the underlying cause of the concern and how it identified the cause; 3. Describe the specific actions the provider will take to correct the underlying cause of the concern; 4. Provide a t.imeframe for initiating and completing the actions; 5. Where a physician is the source of the concern, the CFMC will obtain an acknowledgement by the physician that he/she will cooperate with the provider in the action plan; and 6. Describe the process the provider will use internally to ensure that the actions resolve the concern and correct any deficiencies. It is expected that provider action plans will often incorporate various actions that were formerly CFMC responsibilities (e.g., pre -admission review, establishing a preceptorship). -9- EFF: 4/1/93 ?00*%, QO C. SNF/HHA MOU APRIL 11 1993 If the action plan meets CFMC*s approval, the provider will be expected to implement the action plan according to the agreed upon timef rame . The CF4C has the authority/responsibility to determine that the provider plan is neither adequate nor appropriate and to work with the provider to modify the plan to meet CFMC expectations. It is expected that, in most instances, a satisfactory action plan will be developed by the provider, or by the provider with the CFMC's assistance, and that the action plan will correct the pattern of concerns. However, there will be instances when the provider is unwilling or unable to formulate a satisfactory action plan within the required timeframe, when an action plan cannot be satisfactorily modified, when a provider formulate a satisfactory action plan, but fails to adequately follow through on its implementation, or when a provider continues to be unsuccessful in resolving identified patterns of concerns. In these instances, the CFMC is required to institute corrective interventions. Actions the CFMC may take include: 1. Imposition of a CF4C directed action plan; 2. Direct negotiation of an action plan with a physician when a physician is the source of the pattern of concerns; 3. Referral to the HCFA Regional -Office (or to a State survey agency through the regional office) for a facility investigation for compliance with the hospitall's Medicare provider agreement; 4. Referral to the carrier for prepayment review ( for a physician with an identified pattern of utilization, medical necessity, or other problems as appropriate); and/or 5. Referral for possible sanction action. Periodic ,Statewide Feedback On a semi-annual calendar basis, the CFMC will furnish to the medical community (e.g., individual facilities, the State Hospital Association, the State medical societies, and relevant specialty societies) and appropriate State agencies, (e.g., State Licensing Boards, State Health Departments, State Insurance Commissions) in its State reports of: 1. The prevalence of significant quality of care variations as demonstrated by the analysis of State quality of care profiles; -10- EFF: 4/1/93 SNF/HHA MOU APRIL 1, 1993 Quality of care concerns which are identified at one or more facilities but are determined to have significance to other facilities/physicians; 3. Quality of care variations/issues identified through pattern analysis; 4. The prevalence of significant utilization, DRG/coding, and documentation variations; 5. Utilization, DRG/coding, and documentation concerns which are identified at one or more facilities but are determined to have significance to other facilities/physicians; and Patterns of utilization and DRG rates, with appropriate adjustments (e.g., number of inpatient admissions billed for the treatment of pneumonia in rural hospitals of 50 beds or less, number of DRG 468s billed by urban hospitals of 300-400 beds), of interest to the medical community (e.g., high volume DRGs, shifts in admission/DRG patterns). THIS MEMORANDUM OF UNDERSTANDING between the Colorado Foundation for Medical Care and the aforementioned facility shall be effective April 1. 1993 through March 31, 1996. IN WITNESS WHEREOF, the foregoing has been duly executed the day and year indicated above. COLORADO F DATION FO MEDICAL CARE /yi By: President / / Date • �J V- EAGLE COUNTY NURSING SERVICE SKILLED NURSING FACILITY/HOME HEALTH AGENCY -11- EFF: 4/l/93 ATTACHMENT A Colorado Foundation for Medical Care 1260.S. Parker Rudd Denver. CO 80231-2179 Alailbig Address: R O. &zc 17100 Delver. CO 80217-0300 (303) 695-3300 • FAJI (303) 695-3350 AN IMPORTANT MESSAGE TO MEDICARE BENEFICIARIES The Omnibus Reconciliation Act (OBRA) Sections 9353 (c and e) requires a review of all written complaints from Medicare beneficiaries about the quality of care they have received. These complaints about the quality of care can be in hospitals, skilled nursing facilities, hospital outpatient departments, ambulatory surgery centers or home health agencies. This review is to be carried out by Peer Review Organizations. Peer Review Organizations ( PROs ) are groups of doctors who are paid by the Federal Government. Peer Review Organizations will respond to your request and inform you of the outcome of that review and any corrective action taken. If you have a complaint about the quality of care you have received as a Medicare beneficiary, place your complaint in writing and sent to: COLORADO FOUNDATION FOR MEDICAL CARE ATTENTION: SPECIAL REVIEW PROGRAMS P.O. BOX 17300 DENVER, COLORADO 80217 If you have questions regarding payment of your bill, charges on your bill, or questions about whether services are paid by Medicare, they should be directed to: ELEMENTS EXCLUSIONS err s-a (Coax.) Hong suss Acs = CMWaC QU=Tsr SCRMMS OnrnMMMs DATA SOURCES 1. AdeSuaa of Intake Evaluation a. A d e q u a t e None HHA admission assessment form/ assessment of intake evaluation, nurses' notes, HHA's capacity of provide t h e physician's orders, plan of care, services required hospital or SNP transfer information, social service for recovery or notes. m a x i m u m restoration of function. b. A d e q u a t e None. assessment of HHA admission assessment form, p h y s i c a l nurses' notes, intake evaluation. environment and capability of caregiver to provide care in the home. C. A d e q u a t e None. HHA admission assessment form, assessment of nurses' notes, intake evaluation, patient before hospital or SNP discharge record, or, at time of admission, and physician's orders, plan of care. source of referral to HHA. 2. A ro riate and Timel Interventions EXPLANATORY NOTES Review for appropriateness of level of care (i.e., is the HHA capable of providing the car required for this patient? Di he/she require a higher level of care?) . Review home environment to determine if any changes were required. (Examples: open stairway, exposed electrical cords.) Were solutions to the problem identified, discussed and appropriate resolutions agreed upon? Was an adequate assessment of the patient done so that the HHA was aware of all the patient's needs? The assessment should include mental status (e.g., depression, orientation). Did the patient have to be referred by a family member as opposed to the medical community? Latitude is permitted for the nurse reviewer to use his/her judgment when there is a physician's order which covers the situation identified by the element. co J ' i �IBIT 5-4 (CONT. ) am m3ALTH AGMicr GHMIc Q=&= SCRMWS I MIZELMS ELEMENTS EXCLUSIONS DATA SOURCES a. Presence o f None Nurses* notes, vital sign flow temperature sheet, physical contact report, elevation of aide notes. 100OF oral (rectal 101'F), or presence of hypothermia, without physician notification within 4 hours from the time detected. b. Presence of B.P. None Nurses' notes, vital sign flow reading < 85 or sheet, physician contact report, >18 50osystoli'loQOr hospital or SNP discharge record, aide notes. diastolic without physician notification within 4 hours from the time detected. c. Presence of pulse None Nurse's notes, vital sign flow <50 (45 if the sheet, physician contact report, patient is on a aide notes. beta blocker) or >120 without p h y s i c i a n notification within 4 hours from the time detected. d. Presence of other None Nurses' notes, physician contact significant report, physician's orders. changes in signs and symptoms without physician notification within 4 hours from time detected. EXPLANATORY NOTES If the BHA identifies a temperature elevation, 'physician notification" is satisfied by the agency's attempt to notify the physician within 4 hours. NOTE: Hypothermia, as well a hyperthermia may be a probler Therefore, a -2' from patient', normal temperature requires intervention. Any patient being treated for hypertension would fail the screen if B.P.s were not recorded. Any patient receiving digoxin or an anti -arrhythmic drug would fail the screen if pulse was not recorded. If the patient has a pacemaker, physician contact is expected if the pulse is less than the ordered parameter. Look at visits where significant adverse changes occurred in signs or symptoms in any body systems or function without physician notification. f MMXBrT s—S (CONT.) u(SM =MTN AGEFICz ELEMENTS GMMRXC QmLrs SCRMS WWRLrNss EXCLUSIONS DATA SOURCES EXPLANATORY NOTES e. Appropriate diagnostic None. Physician's orders, nurses' This element applies to elements services provided notes. 2.a. through 2.d. on physician's orders. f. Abnormal results None Nurses' notes, physician's of diagnostic orders, laboratory reports, x—ray s e r v i c e s reports. addressed and resolved or the record explains why they are unresolved. q. Appropriate None Nurses' notes, social service intervention if notes, physician contact report, significant aide notes. change in social support system, i n c l u d i n g environment. h. nr i a to f o None Nurses' notes, social service re porting P g notes, physician contact report, abuse/neglect. aide notes. i. Timely reporting None Nurses' notes, social service A benchmark of three consecutive, to physician of lack of family notes, physician contact report, P professional visits where and/or patient aide notes, P.T. notes. noncompliance is noted without compliance. physician contact is sufficient to fail this screen. Noncompliance is defined as a refusal rather than an inability to comply. 3. Adequacy of Restorative 'Restorative Care" is intended in Care the broadest sense here as opposed to a more narrow sense. The specialty therapies include physical, speech and occupational. a. Specialty therapies. Those not requiring specialty therapy. MUM T 5-4 (CONT. ) HONE HBAMB AGMICr GEMWC QUALITY SCEUMS GUIDBLI 3 ELEMENTS EXCLUSIONS DATA SOURCES EXPLANATORY NOTES 1. Restorative need As in 3.a. identified and addressed through assessment, plan implementation and evaluation. 2. Presence of As in 3.a. therapy plan of c a r e a n d documentation of therapist's compliance with plan. 3. Presence of As in 3.a. p a t i e n t education. b. N u r s i n g Those not receiving nursing instructions services. 1. Presence of As in 3.b. patient education p l a n a n d documentation of n u r s i n g compliance with the plan. 2. Documentation in As in 3.b. the nursing care p l a n o f coordination of s e r v i c e s (interdiscipli— nary followup and reinforcement. Nurses• notes physician's orders therapy notes, specialty evaluation(s), plan of care. Look at the interaction/ coordinated effort of care as well as the documented evidence that the plan has been reviewed periodically and that there was adherence to it. Documentatio► must be present which addresse the unique needs, circumstances, and plan for each patient individually, with modification of the plan as conditions indicate. Therapy notes, aide notes, Patient education involves nurses' notes. teaching the patient how to do required exercises. It also involves supervision and return demonstration. Nurses' notes, physician's orders, aide notes, treatment plan, plan of care. Nurses' notes, physician contact report, plan of care, therapy notes, aide notes. Review for documentation that the patient was taught, and patient's response to taking his own pulse, diabetic therapy, or exercises as his condition warrants. This screen looks at the coordination of all disciplines required to carry out the care plan for this patient. ELEMENTS EXCLUSIONS GSN�tIC QQaT.ITZ BCRSBNB OVIOSI.IA89 DATA SOURCES EXPLANATORY NOTES 3. C o n t i n u a l As in 3.b. Nurses' notes, physician contact reassessment of patient's needs report, therapy notes, aide with referrals to notes, plan of care* other disciplines as necessary. 4. Deaths Within 48 hours of None. Trans Entire Home Health record. The purpose of this screen is t. er to Hospital as Ascertained rom the identify those cases where an Hospital Recor . untimely transfer to a higher level of care resulted in death. *5. Possible Indications of secondary Infections. a. Temperature None Nurses' notes, vital sign flow elevation > 2 chart, aide notes. degrees after 72 hours of start of care. b. Indication of an None i n f e c t i o n Nurses' notes, vital sign flow Look for linkage between the following an chart, laboratory reports, culture reports. procedure and the infection. Examples of invasive procedures i n v a a i v e procedure. are: catheterization; suctioning; tube feeding; intravenous feeding; hyperalimentation. *6. Issues Related to Patient Care After the Home Wealth Start of Care a. Presence of None Nurses' notes, physician contact Injury or untoward effect incident with resultant injury report, therapy notes, aide includes, but is not limited to: or untoward notes. fracture, dislocation, effect. concussion, or laceration. An incident that takes place when the HHA is not present in the home Would cause a screen failure only if the HHA was remiss in providing education which could have prevented the incident. * Prior to the 3.75 SOW, you are to record the failure of the screen, but need not refer potential Severity Level I quality problems to a physician reviewer until a pattern emerges. CIS 5--4 (CONT.) am SRAM AGMIcr GMWIC QULISZ BaR=NS GOID11=2 ELEMENTS EXCLUSIONS DATA SOURCES EXPLANATORY NOTES b. Presence of None. decubitus ulcer. C. Presence of life- None threatening complications d. Adverse drug None. reaction or medication error. e. Evidence of None. inappropriate planning and administration of patient care. Nurses' notes, therapy records, Decubitus ulcer is defined as a initial nursing assessment, break in the skin not present on physieian'e orders, aide notes. admission, regardless of the size and depth. If a previous decubitus ulcer becomes wors., while the patient is under th care of the HHA, it would also result in failure of this screen. Nurses' notes, physician contact report, therapy notes, aide notes. Nurses' notes, physician contact report, aide notes, therapy notes. Nurses' notes, physician contact report, treatment plan, plan of care. Use professional judgment on a case -by -case basis in determining whether an action or lack of action resulted in the life - threatening complication. An error or reaction that takes place when HHA is not present in the home would cause a screen failure only if - the RUA was remiss in providing education which could have prevented the incident. Review for physician error in prescribing drugs. This screen looks at the planning for the delivery of services. Examples would be: scheduling a physical therapy, speech therapy, skilled nursing, and aide visit all on the same day; planning one visit per week at the start of care for a patient who needs intensive teaching (diabetic care, colostomy care). f. Responsibility None Entire Home Health record. The purpose of this screen is to for termination identify premature discharge from of care only when the HHA. services are no longer required. ME SEA= act GSHSRIC QU TAM &CTS Go 0 TIMZLn= ELEMENTS EXCLUSIONS DATA SOURCES 7. Documented plan for Death. appropriate followup care and discharge summary to physician(s) of record. S. In the judgment of the None, professional reviewer, are there any other events/patterns of care that resulted in adverse outcomes that should be evaluated? No Ye Explain Nurses* notes, discharge summary, treatment plan. Entire Home Health record. EXPLANATORY NOTES Discharge planning is appropriate for all patients. Documentation must be present which addresses the unique needs, circumstances and plan for each patient individually. Look for mismanagement of W case, actions which should ha% been ordered and/or taken, but were not, and any issue which is not covered by a specific element, but may represent a quality concern. 1om**1 W