Breaking Compliance News Blog

Nursing and Therapy - Essential Compliance Allies

Posted by Andrew Buffenbarger on 7/31/13 11:53 AM

Compelling Incentives

We all know that the OIG is increasingly concerned about over-utilization of therapy, and accuracy of care plans. Care plans that are insufficiently documented or overly aggressive, or that are not tailored to the specific resident can lead to false claims - including the over-utilization of therapy services. In order to maximize compliance and avoid penalties related to therapy utilization and care plan accuracy, nursing and therapy must work together.

Togetherness in Care Planning

A care plan that is well documented and appropriate for each resident is essential for effective compliance. Both nursing and therapy must be engaged. If one party drops the ball, then the result will be an assessment that does not reflect the resident's actual condition or capability - and a potential compliance problem for both providers.

Assume that your therapy program is wonderful. Its outcomes are great and the residents get personal, professional attention. Assume also that therapy's evaluations are not individualized. They are repetitious and can be characterized as canned or one-size-fits-all.

There are a couple of compliance red flags here: 
  • Assessments are supposed to be resident-specific. What is the facility doing to verify this?  
  • Even though therapy is providing good results, the services provided will not match the assessment in many cases, thereby opening the door to false claims. Despite the fact that the rendered services may have been appropriate, the basis for providing them - i.e., the resident assessment - may prove to be suspect. Because your documentation doesn't pass muster, you have created your own compliance problem - even if the care provided was appropriate.

Things get worse if the care plan says one thing and the therapy services rendered indicate another.

Both therapy and nursing must engage in cooperative care planning efforts. Evaluations must be specific to every resident. Objectives must be reasonable; the services provided by nursing and therapy cannot reflect contrary objectives. Getting the planning right at the beginning of care delivery will make a huge difference in your ability to effectively audit for compliance.

Regular revisits of the care plan are commonplace in skilled nursing. Adjustments based on resident conditions or changes are expected - in fact, required. Applying the same discipline to care plan adjustments is just as important as setting the original program.

Topics: Quality Assurance, Billing and Claims Submission, medical necessity

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