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Accurately Assessing Pressure Ulcers

A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (

Pressure ulcers are costly, painful and are often perceived as the result of poor quality care.  The Center for Medicare and Medicaid Services has included pressure ulcer risk assessment and implementation of prevention protocols in the OASIS-C. Home health agencies that fail to identify patients at risk are missing an important step to preventing pressure ulcers that occur under the care of the agency.

Tools for Outcome Measurements

Pressure ulcer prevention begins with risk assessment.  In the  OASIS-C item M1302, The Center for Medicare and Medicaid (CMS)  asks that patients be identified with or without a formal pressure ulcer screening tool. Agencies should choose a validated pressure ulcer screening tool. The Braden Scale (Bergquis & Frantz, 2001) has been validated with home care populations, but it is not the only validated tool available. The Norton and the Waterlow Scale are also good alternatives. What is more important is accuracy and consistency in use. This can only be accomplished through staff education.

Once the risk assessment is completed, implementation of  pressure ulcer prevention measures should be based on the information obtained. The Braden Scale has a set of measures correlated to the risk identified ( Many clinicians use the overall Braden score as a starting point for deciding risk. However, when sub-scale scores such as mobility, incontinence or shearing are triggered, it is just as important to address these with appropriate prevention measures.

Several factors impact pressure ulcer prevention in the home. Taking these factors into prevention planning will improve an agency’s ability to avoid pressure ulcers in their patients.

Accurately Assessing Pressure Ulcers

What is Team Building?

What could your team achieve if it were moving in complete coordination rather than as many individual, moving parts? Staff retention would increase, management could be freed up to focus on company growth, and communication would become seamless. Sound impossible? It isn’t with a well-coordinated team behind you.

We provide this future for healthcare companies across the U.S. with experiential team building strategies that are proving to be immensely successful. As teams become more productive and efficient, patient outcomes improve, revenue grows, and your reputation as a great healthcare provider spreads throughout your community.

NEWSFLASH for Certified Home Health Agencies

The fact that CMS has announced the 2014 homecare rates which represents a cost reduction has the home care industry buzzing. This and the newly expected ICD-10 codes are enough to send any executive into a panic, however home care executives now have another worry. CMS is now expecting that all surveyors investigate agencies with new rules of interpretation using the current Federal Condition of Participation.

If you own or operate a certified home health agency you are now at risk of more strict surveys that investigate patterns within certain conditions of participation can lead to condition level deficiencies. With a condition level deficiency a provider is at risk of losing the Medicare provider number.  Once a condition level deficiency is cited you have 45-90 days to clear it. For instance; if you have had issues with having the physicians sign the plan of care within the required time frame of your state, issues with missed visits, and any other issues regarding the plan of care including the therapists participating; all of these citations fall within the plan of care section of 484.18 and you are now at risk of receiving a condition level deficiency. The new interpretation looks for a specific pattern in section 484.18. There are other specific patterns for Patient Rights (484.10), compliance with Federal, State, and local laws (484.12) etc.

If you are an accredited organization you usually pay several thousand dollars (depending upon the agency’s census) for the site visit, as well as travel with some accreditation companies.  You will also have to pay for the return site visit within 45-90 days plus you now risk losing your business.

Wouldn’t it be worth it to have an expert at your side? No loss of business, no worries. Call for a free 30 minute consultation 800-530-3789 extension 1. Ask for Michelle.

Organizational Leadership and Coaching

Healthcare agencies that fail to optimize are fated to spend more and more hours on less and less output. Problems accumulate, management gets spread too thin, and patient care deteriorates. The solution to this quandary is better analytical tools and more detailed reports on operational efficiencies.

At Global Healthcare Associates, we identify the snags and hang-ups that are plaguing your business. We look at staff efficiency, patient outcomes and referrals to identify ways to increase the productivity of every billable hour, every patient interaction, and every staff meeting on a consistent basis.

Having a Compliance Plan Saves Time and Money

Are you spending most of your time putting out fires?  Wouldn’t you prefer to have time to proactively work on your strategic plan to both increase and improve your business?   Most providers report that they are spending too much time putting out fires due to a lack of internal resources.  Having both a compliance program in place and being able to outsource important tasks to experts ensures that your operational systems are working efficiently allowing you the time you need to attend to your key business concerns.

A compliance program can be as simple as having practical and thorough policies and procedures combined with an outside consultant to perform periodic audits along with your Quality Improvement initiatives.  This not only improves efficiency and your use of resources, but an outside eye can catch things daily workers won’t see or have a tendency to be lenient on. Although some providers state they “can’t afford” outside consultants, it’s a fact that attorneys cost much more to resolve matters after the fact.

Did you know that CMS (Center for Medicaid and Medicare Services) recently proposed that Home Health Agencies pay a fee for follow up state survey visits; anywhere from $168.00 for an offsite review to $1600.00 for a site visit review?   Many opposing forces state that the surveyor now has a motive to make more money for the state and are apt to find more problems in order to charge an onsite fee.   Although this has yet to be settled in Congress, you know more than anyone else that the business of providing services is becoming more complex, and maintaining an agency’s compliance is paramount to business.

Global Healthcare Associates LLC is prepared to assist healthcare organizations with a full clinical review. As part of our compliance plan we review your clinical documentation for maximization for reimbursement and can handle administrative reviews.

We also specialize in local / state / federal / accreditation compliance requirements. With an experienced team behind you, your time to manage the business and profits all increase! Call 1-800-530-3789

“What is a Patient-Centered Medical Home?”

You might have heard of a patient-centered medical home a concept that is taking off throughout the county — but do you know what it means?

The concept combines the old-fashioned care you used to get from your family doctor with high-tech centralized monitoring and coordination of your healthcare records.

Highmark, Inc. recently established more than a dozen medical home pilot practices in central Pennsylvania, adding to the number of health systems testing the concept. Penn State Milton S. Hershey Medical Center, Pinnacle Health System and Holy Spirit Health System all have family health centers that are acting as medical homes. The main problem, however, is that most people don’t understand what a medical home is — and, no, it’s not a nursing facility.

To understand the concept and how it’s being implemented, The Patriot-News talked to Dr. Andrew Bloschichak, senior medical director at Highmark, and Dr. William Bird, vice chairman of patient care, Department of Family and Community Medicine at Hershey Medical Center. In a nutshell, here are the facts:

Defining a medical home

It’s a primary care practice, led by a physician (usually an internist or family doctor). It brings together a team of medical professionals to coordinate and personalize all of your medical care. The “home” refers to the doctor’s office.
Your physician is your primary contact. He or she directs your medical team and provides comprehensive care for you, arranging care with other health care professionals when needed.

When the American Academy of Pediatrics created the medical home concept in 1967, it meant the place that a child’s medical records were kept. The concept has now expanded and has really come to the forefront in the past few years as part of the efforts to reduce health care costs.

Medical homes are not like insurance HMOs with a gatekeeper. You are free to see any specialist you select. Additionally, some insurance companies, including Highmark, have restructured physician reimbursement to allow your doctor to spend more time with you.

Medical home team

The team, captained by your physician, is made up of nurses, nurse care managers, medical assistants, office support staff and, in some instances, pharmacists and/or social workers, all of whom work together to oversee your well-being. Their job is to keep you healthy by making sure you’re on track with your medicines, appointments and medical tests. They also will advise you on your diet or ongoing treatment and educate you in ways to stay well, recuperate or deal with a chronic health problem. It’s all about communication.

In the case of the pilot practices started by Highmark, clinically trained nurse care managers are provided to jump-start each pilot practice and coordinate the social work aspect in evaluating patients and developing plans of care. For example, they work with patients who transition from the hospital to home, or home to a nursing facility, answering questions and making sure follow-up appointments are kept.

Technology is key

Through a centralized electronic records base, your complete medical history, with all test results, are stored in one location that can be accessed by your medical team to coordinate your care.

Centralized electronic medical records allow the team to review a patient’s medications, allergies and comprehensive health care notes, as well as when the last time the patient was seen by a doctor. This eliminates duplication of tests, alerts the staff to a needed appointment or test, and gives the physician a better long-range picture of your health.

Physicians also use the data to compare treatment results to national results, ensuring quality of care. In the Highmark pilot project, data will be collected to review the outcome and assess the project’s success.

Centralized data helps create registries

A registry is a systematic collection of data on specific health characteristics, gathered from a centralized database. The data is broken down into diseases, which enables the physician to look at the entire practice.

Many practices implementing medical homes are starting out by using the registries to track diabetic patients. Bird said the type 2 diabetes registry used by Hershey Med allows him to “look at all the patients in my medical home and find those with high blood sugars; anyone who hasn’t seen me in a while; and who should be seen. I can refer these names to my team to schedule appointments or to contact about tests they should have.”

How this helps doctors

Bird said the medical home is a philosophy of care that asks a lot more of the primary care doctor, but also covers all the bases for care through a team approach.

Hershey joined the Highmark pilot project last summer after having taken part in two other pilot projects.
“About four years ago, Penn State Hershey Medicine decided that the medical home concept was a good model for our 14 primary care practices,” Bird said. “At that time there was no additional reimbursement for doctors from the insurers, but it was the right move for us. The Highmark pilot has helped tremendously because of funding and accountability.

“The most important piece of this is technology,” he said. “Fortunately, at Hershey, we have a great IT resource. Centralized information is now available to help avoid duplication of services and to maintain the current status on each patient.”

How this helps patients

Under the previous system, “if a patient didn’t show up for an appointment, then he or she wasn’t cared for,” Bird said. “We were re-active, not pro-active. Now, with our medical home practice, we’re able to make the best use of time.”

For patients, communication is key. “There is always someone available to address his or her concerns,” Bird said.  And patients are welcome to communicate via emails or phone calls when they have a question, which can help eliminate unnecessary office visits.


The Highmark pilot project will hopefully demonstrate lower re-admission to hospitals, better chronic care management, happier doctors and better-satisfied patients. The hope is that once the pilot is over, medical homes will have the resources to continue with the extended professional staff.

“With positive outcomes, we’ll be able to prove our value to the insurer/payer, which is incentive for this to work,” Bird said. “It’s the future of adult primary care for our country.”

For more information about our consulting services call us at 800-530-3789 or email us at

Department of Labor Announces Period of Non Enforcement of New Rules

Article Courtesy of  Elizabeth E. Hogue, Esq.

The United States Department of Labor (DOL) issued final rules effective on January 1, 2015, which eliminate the Companionship and Live-In Exemptions for home care workers.  The final rule includes significant changes that will alter the operations and practices of agencies providing private duty services.

The DOL issued an announcement on October 9, 2014, however, that will delay enforcement of the final rules.  The DOL emphasizes in the announcement that there is no change in the effective date.  Rather, there will be a “time-limited non-enforcement policy” in effect for six months beginning on January 1, 2015, and continuing until June 30, 2015.  This means that the Department will not bring enforcement actions against any employer that is related to violations of the amended regulations.

Thereafter, the Department will exercise “prosecutorial discretion” from July 1, 2015, until December 31, 2015, to determine whether to bring enforcement actions.  During this period of time, particular consideration will be given to the extent that States and other entities have made good faith efforts to bring their home care programs into compliance with the Fair Labor Standards Act (FLSA) since the final rule was published in October, 2013. Throughout 2015, the Department will also continue to engage in extensive outreach and education and will also provide technical assistance, especially to States regarding publicly funded home care programs.

While this is welcome news for agencies that provide private duty services, they must nonetheless prepare for compliance on January 1, 2015. Below is a summary of the major provisions of the revised rules.  Major changes in the final rule include:

Minimum Wage and Overtime Protections. The final rule revises the definition of “companionship services” to clarify and more narrowly define the duties that fall within the term.  The final rule also prohibits third party employers, such as home care agencies, from claiming the companionship or live-in exemptions.

Companionship Services. The term “companionship services” means the provision of fellowship and protection for an elderly person or a person with an illness, injury or disability who requires assistance in caring for him/herself.

Companionship services also include the provision of “care” if the care is provided attendant to and in conjunction with the provision of fellowship and protection, and does not exceed twenty percent of the total hours worked per person and per workweek.

Fellowship and Protection. According to the final rule, “fellowship” means to engage the person in social, physical and mental activities.  “Protection” means to be present with persons in their homes or to accompany persons when outside of the home to monitor the persons’ safety and well-being.  Examples of fellowship and protection may include: conversation, reading, games, crafts, accompanying persons on walks, and going on errands, to appointments or to social events.

Care. The definition of companionship services in the final rule allows for the performance of “care” services if those services are performed attendant to and in conjunction with the provision of fellowship and protection, and if they do not exceed twenty percent of the employee’s total workweek hours per consumer.  The companionship services exemption is inapplicable when employees spend more than twenty percent of their workweeks performing care. In such workweeks, employees are entitled to minimum wage and overtime.

In the final rule, “care” is defined as assistance with activities of daily living; such as dressing, grooming, feeding, bathing, toileting and transferring and instrumental activities of daily living (i.e., tasks that enable persons to live independently at home; such as meal preparation, driving, light housework, managing finances, assistance with the physical taking of medications, and arranging medical care).

Household Work.  The final rule limits household work to tasks that benefit the elderly person or a person with an illness, injury or disability.  Household work that primarily benefits other members of the household, such as making dinner for other household members or doing laundry for everyone in the household, results in loss of the companionship exemption and thus employees would be entitled to minimum wage and overtime pay for the workweek.

Medically Related Services.  The definition of companionship services does not include the provision of medically related services that are typically performed by trained personnel.  Under the final rule, the determination of whether a task is medically related is based on whether the services are typically required and are performed by trained personnel, such as registered nurses, licensed practical nurses, or certified nursing assistants. The determination is not based on actual training or occupational titles of the workers performing the services. Performance of medically related tasks during the workweek results in loss of the exemption, and employees are entitled to minimum wage and overtime pay for that workweek.

Live-In Domestic Service Employees.  Live-in domestic service workers who reside in the employer’s home permanently or for an extended period of time and are employed by an individual, family, or household are exempt from overtime pay, although they must be paid at least the federal minimum wage for all hours worked.  Live-in domestic service workers who are solely or jointly employed by a third party must be paid at least the federal minimum wage and overtime pay for all hours worked by that third party employer.  Employers of live-in domestic service workers may enter into agreements to exclude certain time from compensable hours worked, such as sleep time, meal time, and other periods of complete freedom from work duties.  If the sleep time, meal period or other periods of free time are interrupted by a call to duty, the interruptions must be counted as hours worked.  Under the final rule, employers must maintain accurate records of hours worked by live-in domestic service workers.  Employers may require the live-in domestic service employees to record their hours worked and to submit records to employers.

Third Party Employers.  According to the final rule, third party employers of direct care workers, such as home care staffing agencies, are not permitted to claim either the exemption for companionship services or the exemption for live-in domestic service employees.  Third party employers may not claim either exemption even when employees are jointly employed by third party employers and individuals, families, and households using the services.  Individuals, families, and households may claim applicable exemptions.  Consequently, if there is a third party employer, the individual, family, or household will not be liable for unpaid wages under the FLSA, provided the requirements of an application exemption are met.

Paid Family or Household Members in Certain Medicaid-Funded and Certain Other Publicly Funded Programs Offering Home Care Services.  According to DOL, the FLSA does not necessarily require that once families or household members are paid to provide some home care services that all care provided by that family or household member is part of the employment relationship. If applicable, DOL will not consider a family or household with a pre-existing close personal relationship with the consumer to be employed beyond a written agreement developed with the involvement and approval of the program and the consumer or consumer’s representative, usually called a plan of care, that reasonably defines and limits the hours for which paid home care services will be provided.

Private duty agencies certainly have their work cut out for them over the next few months!

©2014 Elizabeth E. Hogue, Esq.  All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.