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Therapy Screening Techniques: The Critical Role of the Nurse


While there is a great deal of focus on the management of post-acute patients in the SNF population, many of whom will return to the community, management of long term care patients is equally essential to the provision of services along the continuum of care. According to CMS regulations, long term care patients have a right to function at their highest practicable level, including the delivery of services to slow the progression of decline, as long as these services meet the definition of skilled criteria. In order for these services to be skilled, they must be considered reasonable and necessary and require the skills, knowledge, and judgment of a licensed qualified professional based on their inherent complexity. 

Healthcare Corporate Compliance: Keys to Assembling A Sound Program


A Corporate Compliance Program is the Long Term Care provider's formalized and proactive approach towards detecting fraud, abuse, and waste of precious company resources.  Exact regulations for this important program have not yet been crystallized, so many facilities are left wondering what, if anything, should be implemented immediately.  Harmony (HHI) recommends taking a hands-on approach to Corporate Compliance.  Although the impending regulations remain to be seen, a Corporate Compliance Program is of benefit to every facility.

Skilled Nursing Documentation: Provide Evidence of Respiratory Therapy

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What is Respiratory Therapy?

Nurses Rule the World

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For those of you that have heard me speak about Medicare, Therapy, Case Mix, MDS, PPS or simply my four daughters, there probably has never been a session that I do not utter my favorite words that “Nurses Rule the World!”  Being intimately familiar with the day-to-day tasks (or should I say night-to-night tasks, as well) of patient care, medication administration, documentation, physician interactions, family discussions, caregiver communication, and so on, only one in the healthcare field sees the heart, sweat and tears this profession renders to their patient caseload.  Too often, the value of the nursing profession is taken for granted, especially when they do their job well.  Frequently, the field underestimates the complexity and finesse required to successfully care for the geriatric patient.

Skilled Nursing Documentation and the Continuum of Patient Care


Often times, clinical records reflect the limited skilled nursing documentation representing the critical thinking of a licensed nurse. The documentation that supports the ongoing skilled nursing care including the risk of exacerbation of medical signs and symptoms. Consider patients who require a continuum of care and may present as medically stable, however, require education and preventative treatment to promote optimal health and wellness. 

Daily Skilled Nursing Documentation


Daily Skilled Nursing Documentation
Daily skilled nursing documentation is the basis for providing information that the patient has a need for daily skilled interventions.  Although a patient may actually categorize as a rehab RUG for payment, it is crucial to support the need for daily skilled services through nursing documentation.
Harmony  suggests that the facility provide guidance for the licensed staff  via a format for skilled note writing that adequately reflects the daily skills provided to each patient.
Skin: Capturing pressure ulcers on the treatment sheets when they develop is important for both reimbursement and compliance reasons.  The presence of two Stage II ulcers (i.e., bilateral reddened heels or bilateral reddened buttocks) can increase a patients RUG score from a Clinically Complex group to the Special Care group.  This is advantageous for both PPS and OBRA assessments.  It has been Harmony's experience that skin care, pressure ulcers, and coding in Section M of the MDS are areas of which state surveyors pay special attention.  Pristine documentation in this area is required to avoid citation.
Fever: Another area that is often overlooked in daily skilled nursing documentation is capturing fevers with other conditions.  Fever, in combination with the following, can potentially increase patients' RUG scores to the Special Care group.
Weight loss.
Tube feeding. 
The documentation of the presence of fever with these conditions can positively affect both a PPS and OBRA assessment.  This advantage is intensified when the assessment can be dually coded as a PPS and an OBRA-required assessment, because it will affect both Medicare and Case Mix reimbursement.

Wound Care Documentation in the SNF


Wound Care Documentation in the SNF
Wound assessment requires an assessment of the patient with the wound, not just the wound itself.  When completing dressing changes or treatments the nursing documentation should include the current assessment of the wound. If the dressing is not being changed an assessment of the dressing and the skin around the dressing should be documented.

It is important to monitor and track, or reassess, wound status to identify signs and symptoms of complications of failure to heal as early in the process as possible.  Early intervention improves the likelihood of resolving complications successfully and getting the healing process back on track.

Every 8 hours comprehensive nursing wound care documentation should indicate answers to at least the following questions:

What is the location of the wound?
 Is the dressing intact?
 Is there drainage on the outside of the dressing material?
 Is there any odor from the wound?
A non-infected wound usually produces little to no odor.(exception hydrocolloid dressings )
 Is the wound/ area surrounding the wound or dressing, red, hot or swollen? 
The color of skin around the wound can alert you to problems. 
White skin indicates maceration, too much moisture, may need a protective barrier around the wound or a more absorbent dressing.  Red skin can indicate inflammation, infection / excessive pressure.  Purple skin can indicate bruising /trauma.
Is there soreness out of proportion to what should be present given the patient's medical history and the progression and etiology of the wound?
When changing dressings or completing ordered wound treatment, assess and document the current wound status. Assess the wound bed and the surrounding skin only after they have been cleaned (according to facilities policy). 

Medicare Compliance- Therapy and Nursing Documentation


Medicare Documentation
SNFs are in a constant state of review by the Medicare Administrative Contractor in addition to potential reivews by the OIG, RAC and MIC.  Facilities will benefit from having an education calendar containing opportunities to review and teach staff supportive skilled documentation.  Nursing and therapy documentation is what reimbursement is hinged upon under Medical Review.  Many claims that have been brought to Harmony for further review and guidence include treatment plans with utilization of the Rehab Low Program.  The Rehab Low program is about preservation of current functional level and small gains with strengthening, range of motion, bed mobility or other individualized focus for the particular patient.  Rehab documentation should include any gains made but also emphasize what skills that patient would lose without the skilled intervention from therapy and the Restorative Nursing Program.  The therapist's skill is the assessment of the patient and the Restorative Program.  Is the program working, is it too high level for the patient, would the patient have more success if approaches were different, at another time, with various verbal cues?  All these questions and answers should be documented in the skilled therapy notes. 
The therapy goals could stay the same when transitioning from a skilled therapy program to the Rehab Low Program if the goals are set in small enough increments to facilitate attainment by the patient.
PT sample goal:
Transfer from supine to sit, rolling to left and swing legs over side of bed with moderate assist of 1 and 2 verbal cues. 
Corresponding Restorative Nursing goal would be:
Transfer from supine to sit, rolling to left and swing legs over the side of bed with restorative aide providing moderate assist to lift trunk and shoulders as instructed by  PT.

Skilled Nursing Documentation


Skilled Nursing Documentation
Harmony educates many professionals in the long term care industry and stresses that "you must walk before you run."  In other words, to compose nursing documentation that clearly depicts the provision of daily skilled nursing care you must have an understanding of the Medicare regulations which define skilled care. 
Care in a SNF is covered if all of the following three factors are met:
The patient requires skilled nursing services or skilled rehabilitation services;  i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§214.1 - 214.3);
The patient requires these skilled services on a daily basis (see §214.5);
As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in an SNF (see §214.6).
Harmony stresses that daily skilled nursing documentation and services should anchor skilled coverage.   
Daily skilled nursing documentation should:
Focus their assessment and observation on systems/problems with signs and symptoms of acute illness.
Identify the conditions that are becoming unstable.
Identify and communicate the resident's problems, needs and strengths.
Record specific treatments given and response to treatment
Describe positive nursing findings; e.g., "respiratory assessment revealed crackles in the lungs, nursing action taken: increased liquids encouraged coughing and deep breathing, etc."
Describe negative findings; e.g., "no chest pains, no cyanosis."
Document vital signs, if abnormal, describe the nursing action taken.
Determine whether the abnormal signs are chronic or acute.
Describe the patient's response to treatment. Taking antibiotics, describe the condition for which the antibiotics are being administered, as well as the patient's signs and symptoms related to that condition.
Evaluate new medication and any side effects.

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