Will your agency’s documentation stand up to scrutiny?

imageHome health agencies are heading into 2016 with some degree of apprehension about how well their documentation will stand up to scrutiny in a health market rife with regulatory risk.
Flawed documentation could threaten agencies with everything from legal issues to claims denials, and the compliance burden fattened up this month as new G Codes for home health and hospice took effect.
Curtailing risk requires not only an eagle eye approach to all records, but ongoing training efforts for staff whose notes are a crucial component in demonstrating quality care, according to J’non Griffin, owner of Home Health Solutions LLC.
“Agencies must sharpen their documentation skills, making certain their staff really understands how to capture critical information and integrate it with a cohesive, justifiable and well-defined care plan,” she says.
“At the same time, they’ll need to avoid the inconsistencies, omissions and errors that create red flags for auditors.”
Easier said than done? Maybe not. With the right focus on achieving quality, some guidance and a bit of practice, J’non believes, most agencies will successfully navigate these new complexities.
Home Health Solutions works with agencies of varying sizes to streamline operations and shore up bottom lines by identifying and improving weaknesses. Documentation is one of the areas where weaknesses are most likely to occur.
“Our clients often have unique needs and face different challenges, but when it comes to documentation errors, many of the same mistakes show up no matter how large or how small an agency is,” J’non says.

Four ways to clean up your documentation

With those recurring trends in mind, J’non and her HHS team members have identified four primary goals which any agency can use as a checklist in the pursuit of quality documentation:

1. Be defensive.

Your documentation is a legal record, and must stand up to examination by many sets of eyes.
“The quality of your documentation is the quality of care delivered to your patient,” says HHS Director of Appeals and Special a Projects  Heather Calhoun. “What is written there becomes the indisputable record of whether something was done, and why.”
The record will grow as your team members work from it and with it to develop and deliver patient care; each addition must not only be accurate and complete, for its integrity to be maintained, but must build on the other parts.
Eventually this record may well be seen not just by by auditors, but by licensing, accreditation and government reviewers — and could, in a case involving legal proceedings, even be viewed by judges or juries.
“It must be able to defend itself to each new pair of eyes as an error-free, easy-to-understand, complete record with all parts in place to show exactly how and why your agency provided quality patient care,” J’non says.

2. Be specific.

With auditors now able to pull out records of visits by type and ask specific questions, details have become more important than ever before.
Vague areas in records are the black holes of the home health field, costing agencies thousands of dollars, and must be bridged with clear, concise summaries showing cause, goals and intent as well as all specific actions taken.
“And the need for specificity begins at the very start of all care,” Heather says. Agencies must start each case by first establishing the medical necessity for care and continue to document each step in the process through the filter of why it was necessary.

3. Be realistic.

One of the most important skills agencies must master to meet new documentation requirements is goal-setting. Determining a realistic course of patient improvement within a 60-day window requires consideration of comorbidity and a comprehensive approach across all home health disciplines.
Holly Kolitz, HHS Quality Assurance Manager, describes the right approach as a careful balance of common sense and measurable achievement.
“Goal-setting is a very patient-specific process,” she says. “It’s very important to be realistic about what you can expect a particular patient to fully understand and achieve, as well as in selecting the parts of that process which must be captured in documentation.”

4. Be comprehensive.

Does your documentation work together to tell a comprehensive story about a patient, with each piece fitting together like an interlocking puzzle? The pieces must match on multiple levels, with each document both standing on its own merit AND integrating seamlessly with each of the other documents.
“This is critical to demonstrating cohesive continuity of care,” Heather says. “Inconsistencies in documentation can potentially cost agencies a great deal of money.”
In addition to supporting all others, each piece of documentation in a file must support all related bills and claims.

All this may sound like a tall order, but focusing on these four fundamental goals really can make a marked difference in the quality of your agency’s documentation procedures.
“And if your agency needs additional help to untangle new documentation requirements, HHS can provide the customized services you need to transition successfully into 2016,” J’non says.

Beginning tomorrow, the HHS team will take documentation practices a step further, breaking down each of the four fundamentals covered here with some specific strategies for each.

TUESDAY:  Think Like An Auditor (A Checklist of Common Mistakes)