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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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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;
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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
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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
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�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