A compliance plan won't work unless your staff understand what it means
A compliance plan won't work unless your staff understand what it means
Make sure your employees know the rules inside-out
The federal government may have found only a handful of termites eating away at Medicare money in the basement of the home care industry, but it is fumigating the whole neighborhood. With the toxic cloud of suspicion hanging over each home care employee's head, it is essential - more than ever - that agencies have corporate compliance plans and that they effectively educate their staffs about what these plans mean.
"We instill in our employees to be proud of their work place and its image, and if they see someone doing something wrong, they have an obligation to go to that person and try to get the person to do the right thing," says Ruth Constant, RN, BSN, MSN, EdD, CHCE, president and chief executive officer of Ruth Constant and Associates of Victoria, TX.
If the employee who has made a mistake fails to correct the error and report it to management, then the person who caught the mistake is obliged to do so, Constant adds.
The company is the home office for three Texas home care agencies, including Wichita Home Health Service of Wichita Falls, Port Arthur Home Health of Port Arthur, and Beaumont Home Health Services of Beaumont.
`Innocent' error? To the OIG, there's no such thing
The Office of Inspector General (OIG) has been closely scrutinizing home care agencies in recent years because Medicare covers an unlimited number of visits, and beneficiaries have no copayments, experts say.
This has made it too easy for home care employees to claim they made visits that were not made or to provide services to patients who would no longer be considered homebound under Medicare's guidelines. (See story on home care fraud laws, p. 57.)
If the OIG investigates your agency, you can bet they will look for "innocent" errors, as well, and these could prove costly. So, Constant and other experts say it's crucial for each home care agency to have its own compliance plan and to teach employees everything about it. (See guidelines for compliance plan, p. 54.)
Constant says her company created its own corporate compliance plan to show employees and the government that the company practices what it preaches. "We're doing everything we can to comply with the law, even more than we have to do because the compliance plan is not mandated yet," Constant explains.
Now the company's three full-service, free-standing home care agencies teach each new employee about compliance during their orientation. Then all employees attend annual inservices on compliance. Also, each employee receives a booklet with details about the corporate compliance program.
Homecare Education Management asked education managers of five home care agencies, including the three Texas agencies, what steps they have taken to educate their staffs about corporate compliance and Medicare. Their suggestions are as follows:
1. Discuss reimbursement issues.
Education managers should teach staff the details of payers' requirements, especially those of Medicare, Medicaid, health maintenance organizations, and other payers.
Each type of payer has requirements that must be met, and home care employees need compliance information about all of these, says Kelly McCue, RN, education coordinator for Middlesex Hospital Home Care in Middletown, CT. The agency serves the eastern part of Connecticut. (See Southern Home Care's orientation to Medicare, p. 51.)
McCue says the staff should know Medicare's basic eligibility requirements, such as that patients must be 65 years or older, or disabled for 24 months, or blind, or have end-stage renal disease, or be a railroad worker retiree. (See story on mandatory Medicare inservice, p. 59.)
Then there are the more subtle requirements that staff should understand, such as when and why certain services are covered and others are not.
"They need to understand the difference between wants and needs," says Lorraine Waters, RNC, BSN, MA, director of Southern Home Care of Jeffersonville, IN. The agency is based at Clark Memorial Hospital in Jeffersonville, IN, and serves seven counties in southern Indiana.
"Wants" are those services that a patient feels he or she needs, and "needs" are those services that Medicare or other payers say he or she needs. (See story about reasonable care, p. 55.)
2. Start with standards and procedures.
Education managers need to cover the fraud and abuse problems that have plagued the home care industry's reputation in recent years.
Many compliance problems that show up in government investigations involve errors, not intentional fraud, experts say. So it's important to show staff how to be diligent in filling out medical records and documenting visits and what took place during those visits.
Also, every home care employee should memorize Medicare's definition of homebound status because this is where ignorance could be very costly to an agency. (See homebound guide, p. 50.)
Confidentiality also is a big part of standards and procedures. Everyone on the staff must be aware of how important it is to keep patients' records and information confidential, says Jackie Godwin, RN, agency director of Wichita Home Health Service Inc. of Wichita Falls, TX. The agency serves a mostly suburban area in north-central Texas.
"All of our staff sign a letter of confidentiality, including the janitorial staff in case there are any case records left out," Godwin says.
Sometimes even the most innocent of activities could breach confidentiality. For example, if a nurse or home care aide had patients sign an assignment sheet that also lists other patients' names, this would allow people to see confidential names, says Delilah Gregory, RN, BSN, continuing education coordinator of Port Arthur (TX) Home Health. The agency serves the Gulf Coast of Texas, near Louisiana and along the eastern edge.
"People might not think of that as a breach of confidentiality, but it is," Gregory says.
A common challenge to confidentiality is when employees have several patients who live in the same housing complex or apartment building, Godwin says. It's fairly common for a patient to ask the nurse or home health aide how a neighbor is doing, since the patients will talk among themselves.
The employee is not permitted to answer that kind of friendly query, Godwin explains. "They should very nicely explain, `I'm sorry, but I'm unable to give you that information because it's confidential information.'"
Other standards and procedures involve employee ethics and responsibilities, which may include statements about responsibility to clients, colleagues, and the agency, and professional competence. (See employee code of ethics, p. 52 and above.)
Education managers also need to make sure the staff understands all of the rules about gifts and gratuities, Gregory says.
"No employee may accept a gratuity or tip or gift," Gregory says. If an employee is offered a gift, then he or she should say to the client, "I'm very sorry, but we're here to help you, and I can't accept something like this," Gregory says.
3. Cover safety and health.
Staff at Beaumont (TX) Health Services and the other Ruth Constant and Associates' agencies are required to fill out a variance report if they or their patients experience any safety or health problems, says Jackie Unger, RN, continuing education coordinator for Beaumont Health Services, which serves a seven-county area in southeastern Texas. (See variance report, inserted in this issue.)
"I want them to report it to protect themselves," Unger says, adding that nurses face potential safety problems each day when they visit people in their homes.
Unger tells employees that they need to report any instance in which a patient or family member harasses them, no matter how minor the incident may be. "Then we'll take care of it by talking to the family and making whatever adjustments we need to."
Other examples of variances include incidents of omission or mistakes. For instance, a nurse might have been told to draw a laboratory sample, and she drew only part of what was needed. Or maybe a nurse was given orders from the physician and didn't follow through with them. All of this needs to be documented on the variance report, Unger says.
The purpose of the variance report is not to find fault with employees but to track and trend errors to see if there is a problem within the system or process, Unger explains.
"Most of us would prefer that if we have done something wrong that we come up and write our variance rather than have someone point the finger at us and say, `You did something wrong,'" Unger says.
4. Emphasize staff training.
The staff doing the training, as well as the staff being trained, need to be aware of compliance issues, Godwin says.
At Wichita Home Health Services, all nurses are observed performing procedures, and the supervisors use a one-page skilled nursing check-off list. (See skilled nurse check-off list, inserted in this issue.)
"We make sure all employees are trained before they're sent off to a patient's home, and if they are unable to do a procedure then they need to be re-educated," Godwin says.
And this applies both to skills required by state and federal agencies, as well as the agency's own requirements. "Say I had a home health aide who had passed a certification program, but she didn't know how to shave a male patient," Godwin says. "She would not be allowed to go into the field until she was able to demonstrate the correct procedure."
The nurse's skilled check-off covers basic skills, the types of procedures they do on a routine basis. The home health aides' check-off is done in a patient's home and not in a lab setting, according to state guidelines, Godwin adds.
5. Describe internal investigation procedures.
Beaumont Home Health Services and the other Ruth Constant and Associates agencies perform investigations on any employee accidents, Unger says.
"We go back and check for witnesses, get statements, and follow-up with employees' medical treatment evaluation," Unger says.
The agency teaches employees about these policies in orientation and compliance inservices. The agency tells employees to be sure to report any of their own mistakes or accidents because if they don't someone else will report it for them.
"We're all human, and we do make errors," Unger says.
Omissions and minor errors are to be expected, but dishonesty of any kind is not tolerated, and the compliance program makes that policy clear, Constant says.
"We say, `You recall when you were hired that you have to commit two things to memory: The first line of our mission statement, and the second thing is the best way to get fired is to falsify records,'" Constant explains. "If you break the law, there will be consequences."
(Editor's note: For more information about Medicare's tougher anti-fraud and abuse measures, see "Ignorance is no excuse: Education can keep you out of Medicare trouble," published in the July 1997 issue of Homecare Education Management.)
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