Super Health Care Protocol/101
6795 E Tennessee Ave
Denver, CO 80224
(303) 991-1009
Documentation: Super Health Care Devero, Signature required in SOLI and Devero
Billing: Alpine Kinnser
Protocol:
***Super Health Care’s Devero
SOC - Please pick up SOC books in the HH office, address above
· Consents (can be emailed to superhealth25@yahoo.com)
- Clinical summary needs to be completed on last page (page 17) of Oasis. Can skip assessment summary on page 16 and instead write your summary on page 17. Summary needs to summarize entire assessment, not just PT eval.
- Need to add PT interventions - use PT not physical therapy when searching for interventions in Devero or else you won’t find any interventions.
- Under eligibility, click on drop down menu and select face to face, homebound or non homebound. Don’t need dates or MD info but if homebound need to put x by all of the reasons why pt is homebound.
- Medication profiles need to be completed in 24 hours of SOC. DC oasis needs med rec. done as well. Med profile needs height, wt and diagnosis completed. No medication profile for evals - need to update profile if new meds added however.
- For coding - do your best to enter appropriate codes and use I10 code if stuck and don’t know what to code. Super Health Care can update and/or fix after you submit your SOC.
- Goal percentages need to be entered - click on goal and enter goal % achieved. If goals not achieved at DC, need to state why. This is needed to show progress between visits and overall progress at DC.
· The following is a list of forms to be completed at SOC (while in the home with patient). Some forms will be duplicated as some may need to be left with the patient (in booklet) as well as being completed in Devero (electronically). Taking a picture and uploading into Devero is NOT an option.
o Forms (to stay with the patient – in SOC booklet)
§ Admission Consent (signature needed)
§ Emergency Preparedness Plan (go over, no signature needed)
§ Visit Schedule (please fill out)
o Forms (to be completed electronically in Devero)
§ Packets – OASIS SOC Packet
o Admission Consent
o Patient Emergency Plan
o Super Health Care ABN No ABN is needed for this company on a regular basis; an ABN form is only used if we are going to bill Medicare for denial (pt does not meet Medicare requirements i.e. no skill, not homebound, etc...) and will be then billing their secondary insurance. See end of protocol for more details on ABN.
· The following is a list of forms to be completed in Devero (as part of your documentation process)
o Shared Forms – Medication Profile: Medication Review - A MEDICATION REVIEW/RECONCILIATION MUST BE DONE AT DISCHARGE. YOU CAN DO THIS BY GOING INTO THE MEDICATION PROFILE FOR THE PATIENT, RUN AN INTERACTION, ANSWER THE Y/N QUESTIONS WITH RESPONSE EXPLANATIONS, THEN ESIGN THE MEDICATION PROFILE.
o Clinical Forms – Berg Balance Test/Tinetti Assessment Tool/Timed Up and Go Test (Pick 1)
EVALUATION GUIDELINES
· Forms assign evaluation to yourself, assign MD orders
· Evaluation
o Once referral is received, evaluation to be completed within 5 days (try to complete within 3 days if possible) from the SOC date. If past 5 day window, please provide reasoning on evaluation. Ex: Delay in start of care secondary to pt request
· SOC
o Once referral is received, you must complete within 24-48 hrs. If completed past this time, a physician order is needed for delay to include a VO.
· Report
o After Eval/SOC completed, please call and/or send a brief synopsis by email to DON to include the reason for referral, why services will be needed related to the specific discipline, and the frequency.
AUTHORIZATIONS
· Allotted Visits
o In order to see how many visits have been authorized, please go to patients chart. Click Patient Schedule at top right hand corner. Authorizations will pull up on the next page.
INSURANCE SPECIFIC GUIDELINES
· Medicare/Medicaid – PDGM model 16 visits total (all disciplines max), up to 20 if necessary.
· Call or email after the evaluation to discuss frequency ASAP
PAPERWORK GUIDELINES
· ALL paperwork must be completed within 24 hours
REFUSAL OF EVALUATION/SOC or Inability to reach patient
o FIRST - Notification – Call the office and ask for the DON to notify
o Care Coordination Note
§ Shared Forms – Care Coordination Note
§ Please be very specific as to why eval is being refused
§ Complete comm note in Alpine Kinnser as well
o Physician Order
§ Clinical Forms – Physician Orders
§ Please notify physician of refusal of services, VO not needed.
· Ex. Pt refusing (OT/PT/ST) services at this time
Notified Dr. Smith on 3/29/20 @ 13:26
CHART REVIEW
· PMH/Additional Information
o These records can be found by clicking Patient Chart (located on dashboard next to pull down menu of patients)
§ Scanned Documents: Found at the very bottom of patients chart
SIGNATURES
· In addition to zuum, please make sure to get signatures for any and all visits in Super Health Care Devero.
o You will be able to complete this on your phone/tablet: Go to dashboard and click on appropriate document. Scroll all the way to the bottom of the first page of the document. You will see a box labeled Patient’s Signature. Please click inside this box and a larger box will appear to have pt sign in.
EVALUATION ONLY – NO FURTHER TX NEEDED
· Notify Physician
o Please make sure to notify eval was completed even though no additional treatment is needed. Make sure to document.
§ Clinical Forms – Physician Orders
· Notification
o Even though patient is eval only, please reach out to the DON to make sure she is aware to include reasoning.
EVALUATION PAPERWORK (Super Health Care Devero)
· Pertinent Diagnoses, medical history and reason for home care
o Include detail of hospitalization (any dates known), why they are considered homebound, and any PMH.
· Vital Signs
o In addition to providing numerical value, please fill corresponding bubbles.
· Tests/Scales
o PT: Berg, TUG, DGI, Other (Tinetti) – Please pick 1
o OT: The Barthel Index
· Assessment Summary
o Please use this to explain why home health is needed and what interventions will be implemented (HEP, ADL/Gait//Dynamic Balance Training…..)
VERBAL ORDERS
· SOC
o Please place VO on the SOC itself. This can be placed at the very end of the SOC OASIS in Care Planning/Coordination section (very bottom of the last page).
· Evaluation
o Place on eval once received
§ Care Planning/Coordination – Verbal Order for plan of care received from
Ex. VO obtained from Maria, LPN (agent for Dr. Smith) on 3/12/19 @
3:22
****VO Not Allowed****
o If a doctor is unwilling to give a VO for either an evaluation or SOC, a separate physician order must be written to be faxed (by Super Health Care).
o Please make sure to notify DON for assistance
*****Orders - any time your frequency changes, pt placed on hold, updated POC etc. a new MD order needs to be completed with VO.
· Standardized Testing – anything measurable and standardized with associated goals
· Verbal Orders – input Devero,
MISSED VISITS
· Complete missed visits, by adding a form for missed therapy visit
o Must be marked as missed in both Alpine Kinnser and Devero!!!!
o Clinical Forms – (PT/OT/ST) Patient Missed Visit
o Please complete (as able) on Fridays showing multiple attempts have been made throughout the week.
o When writing up a MV, please be very SPECIFIC! This should always be patient driven. Please include how needs were met even with a missed visit, include notification to doctor, and verbiage “services to resume per plan of care at next visit.”
o MISSED VISITS – you must notify the PHYSICIAN. THE PHYSICIAN NEEDS TO BE NOTIFIED OF MOST MISSED VISITS AND IT IS THE CLINICIAN'S RESPONSIBILITY TO DO THAT AND DOCUMENT WHO THEY SPOKE TO OR LEFT MSG FOR AT THE PHYSICIAN OFFICE.
§ THE EXCEPTIONS TO THE RULE ARE IF THE MISSED VISIT IS CAUSED BY THE PATIENT SEEING A PROVIDER THE DAY OF THE SCHEDULED VISIT OR THE CLINICIAN CAN DOCUMENT THE NEEDS OF THE PATIENT WILL BE MET. THE CLINICAL MANAGER SHOULD ALSO BE NOTIFIED IF THERE IS AN ISSUE THAT NEEDS ATTENTION. PTA'S AND COTA'S CAN NOTIFY THE PHYSICIAN AND THE CASE MANAGER ON THE CASE.
· Notification
o For each missed visit completed in Devero, please notify the DON.
PAIN ASSESSMENT
· Greater than 6
o If the patients pain level is above 6, you must call and report to doctor. Please make note of this in your documentation. No separate order is needed.
FALL/INCIDENT REPORT
· Incident Report - Fall
o Clinical Forms – Incident Report-Fall
· Notification
o Please notify DON of incident to include a brief report
RE-EVALS (ONCE FREQUENCY IS COMPLETED)
· Must be completed every 30 days per home health rules and regulations
DISCHARGES
· The Final Discipline – Communicate with the DON to ensure you are the one to complete the DC OASIS.
· DC Checklist: "PLEASE CONFIRM WITH (the DON) the day THAT THESE DISCHARGES WILL TAKE PLACE AS SCHEDULED, IF NOT, GIVE (the DON) THE DATE OF PLANNED DISCHARGE, OR IF YOU ARE EXTENDING OR RECERTING.
o A NONMC FORM IS REQUIRED FOR EVERY PATIENT'S OASIS DISCHARGE.
o ONE WILL NEED TO BE PROVIDED TO EACH PATIENT 2 DAYS OR 2 VISITS PRIOR TO THE DISCHARGE OASIS VISIT. IF PATIENT DOES NOT HAVE MEDICARE CROSS OUT MEDICARE AND FILL IN PATIENT'S INSURANCE INFORMATION. PTA'S AND LPN'S ARE ALLOWED TO DO THIS BUT MUST BE INSTRUCTED TO DO SO AND AT WHICH VISIT. YOU ARE TO CONTACT THE PTA OR LPN AND GIVE THEM THE INSTRUCTIONS.
o A MEDICATION REVIEW/RECONCILIATION MUST BE DONE AT DISCHARGE. YOU CAN DO THIS BY GOING INTO THE MEDICATION PROFILE FOR THE PATIENT, RUN AN INTERACTION, ANSWER THE Y/N QUESTIONS WITH RESPONSE EXPLANATIONS, THEN ESIGN THE MEDICATION PROFILE.
o CONTACT THE PHYSICIAN AND OTHER TEAM MEMBERS AND COORDINATE THE DISCHARGE AND DOCUMENT.
o DISCHARGE SUMMARIES ARE DUE NO LATER THAN 5 BUSINESS DAYS FROM THE DC DATE AND ARE EXPECTED TO BE SUBMITTED TIMELY. Super Health Care is REQUIRED TO FAX THEM TO THE PHYSICIAN WITHIN THE 5-DAY WINDOW. THE OASIS IS DUE WITHIN 48 HOURS OF THE DC
o DC summary:
-Make sure to mark if DC is a discipline DC, DC from agency (Oasis) or transfer.
-Med. review at DC needs to be performed if performing Oasis DC.
-NOMNC and ABN at DC need to be signed if performing Oasis DC.
-Reason for DC - click on drop down menu - can’t use “pt remained in community” or NTUC options, have to select something else or it will be sent back to you.
o
· OASIS
§ To be completed by the last discipline (Nursing, PT, OT, ST).
§ Packets – Discharge OASIS With Visit or Discharge OASIS Without Visit
§ In addition to OASIS, complete the appropriate (PT/OT/ST) Discharge/Transfer Summary Non Visit (Clinical Forms).
§ FYI: Do OASIS first and can cut/paste into Discharge Summary. The last page of OASIS is identical to the Discharge Summary.
o NOMNC (Notice of Medicare Non-Coverage Regulation) Located in the SOC booklet and in Devero.
§ To be completed by the last discipline as well
§ The clinician should have the patient sign the NOMNC (in BOTH places) at the visit PRIOR to the discharge visit (at least 2 days of notice needed)
· SOC booklet: Please have pt sign and leave with them
· Devero: Please have pt sign electronically
o Agency Discharge Order
§ Clinical Forms – Physician Orders
· Complete for Agency Discharge to include effective date.
· Regular Discharges
o Please complete the appropriate paperwork
§ (PT/OT/ST) Visit Note
§ (PT/OT/ST) Discharge/Transfer Summary Non Visit
· Regular Discharges
o Discharge order, MD order for any changes
**Transfer (patient went to hospital)
· Make sure to find out 1) what day the patient went to the hospital 2) what hospital they are located and 3) if they were admitted or under observation
o Observation does not require a transfer; Admittance requires a Transfer OASIS
· Notify the ATS Task Force & the primary contact for each company with the above information
· Super Health Care will complete the Transfer OASIS if necessary
· Complete Physician Order (click File – New – Order (Transfer/Hospitilization Order)
· Submit the patient in ZUUM as ‘hospitalized.’
· If patient is still hospitalized after the cert ends, please discharge in ZUUM due to hospitalization at end of cert.
ROCs
· Super Health Care will call ATS to notify to resume services.
