Home Care RN Protocol/101
2620 South Parker Rd #164
Aurora, CO 80014
(720) 535-8652
Documentation: Alpine Kinnser; Signature in Sandata and SOLI
Billing: included with your documentation in Alpine Kinnser, no need to bill
***Please input all VOs in as a separate Physician Order in Alpine Kinnser
***Agency will pay for drive by’s via case conference codes in ATS Kinnser under the patient you drove by in the event the patient was not home or refuses care.
Sandata STX Number for Home Care RN
Sandata Call in Instructions when the Sandata App isn’t working
DME - call Deb at 720-919-1757 and/or fax DME requests to 720-778-2298
Home Care RN Flyer (what they offer)
SOC
Protocol:
SOC – All OASIS visits to be completed by Home Care RN staff
EVALUATION GUIDELINES – Once referral is received, evaluation to be completed within 5 days from the SOC date. If past 5 day window, please provide reasoning on evaluation. Ex: Delay in start of care secondary to pt request. (Completed in Alpine Kinnser)
· Evaluation documentation must be completed with 24hrs to send to the MD timely
· Delay in evaluation per patient request – notify the DON For Home Care RN, write a comm note and once evaluation is completed, write delay evaluation per patient request in the physician order.
§ Click File – New – Order
§ Please notify physician of delay of evaluation
· Ex. Patient has requested a delayed evaluation for PT on 5/1/2020, VO from Sally, NP for Dr Smith on 4/30/2020 @12:00pm
INSURANCE SPECIFIC GUIDELINES
· Medicaid: Given a 60 day approval timeframe, can be continued past 60 days that may overlap two cert periods. Patients with Acute Medicaid can be given additional therapy days. Please communicate with the DON at Home Care RN office and ATS Task Force for questions.
· Medicare: After evaluation is completed, please call the DON at Home Care RN to speak to someone regarding your frequency to insure PDGM is followed per company standards. (ex. 2w3, 1w5)
· BCBS: Authorization is required for managed care plans such as BCBS. Please call the DON at Home Care RN to discuss frequency after evaluation for the green light to continue once auth has been received.
REFUSAL OF EVALUATION
· Communication Note
§ Click File – New – Communication
§ Please be very specific as to why eval is being refused
· Physician Order
§ Click File – New – Order
§ 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
· Call the DON for Home Care RN to notify the treatment team
INABILITY TO REACH A PATIENT
· Communication Note
§ Click File – New – Communication
§ Please be very specific as to how many times you have tried to reach and any communication with Home Care RNt.
· Call the DON for Home Care RN to notify and ask if there is an alternate number to call. Ask if anyone else on the treatment team has had trouble reaching this patient. DO not write as a non-admit before speaking with the DON for Home Care RN.
CHART REVIEW
· PMH/Face Sheet (additional numbers for patient)
o These records can be found by going to the Episode Manager
§ Misc Tab: Discharge Order/Referral/PMH – Click on tab icon
SIGNATURES
· Soli signature is required 100% as this is the only means for visit verify while documenting in Alpine Kinnser.
EVALUATION PAPERWORK (Alpine Kinnser)
· Standardized Testing – no specific guidelines, please utilize a measurable tool for goal writing and insurance approval to deem the importance of skilled therapy
· Verbal Orders - Required to continue services, but if you are having trouble obtaining VO timely, please call the DON at Home Care RN ASAP. This company does make exceptions for VO in certain situations as they believe the patient should continue therapy if it is essential to begin immediately.
o Place VO on eval once received
§ Care Coordination Section – Conference with Other
Ex. VO obtained from Maria, LPN (agent for Dr. Smith) on 3/12/19 @
3:22
o If an MD does not give VO, please complete your evaluation ASAP and call the DON for Home Care RN to fax the evaluation ASAP for continuation of care. Home Care RN will notify you once the evaluation comes back signed. You cannot continue care without a written signature from the MD.
MISSED VISITS
· Write details in each missed visit and pay attention to the number of consecutive missed visits, i.e. if a patient misses 3x, please call the Home Care RN office to discuss possible DC due to lack of compliance.
o DO not discharge for compliance reasons without talking to Home Care RN first.
DISCHARGES
· The Final Discipline
o OASIS – completed by a Home Care RN staff member
· Regular Discharges – complete in Alpine Kinnser
o Please complete the appropriate paperwork:
§ PT Discharge w/ Discharge Summary
§ OT Discharge Eval w/ Discharge Summary
§ ST Discharge
o HEP (home exercise program)
§ To be attached under “other document” in misc tab at time of DC.
o Agency Discharge Order
§ Click File – New – Order (Nsg/Therapy Discharge Order)
· Complete for Agency Discharge and make sure to include effective date (this is not built into the template).
o
TRANSFERS
**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 account specialist & the primary contact for each company with the above information
· 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 Soli due to hospitalization at end of cert.
ADDING A DISCIPLINE
· Physician Order
o Click File – New – Order (Add on discipline order)
o Call the DON for Home Care RN to notify for staffing
FALL/INCIDENT REPORT
· Accident/Incident Report
o File – New – Communication (Accident/Incident Report)
RE-EVALS
o Must be completed every 30 days per the rules and regs for home health
o If you plan to extend and do not have orders to extend or a change of frequency is needed, please contact the DON for Home Care RN.
