Guest Post: When Are Patients “Unsafe” for Home Care?

Daymarck Home Care Thought Leader Guest Posting

When Are Patients “Unsafe” for Home Care?

Elizabeth E. Hogue, Esq.

Office: 877-871-4062

Fax: 877-871-9739

E-mail: ElizabethHogue@ElizabethHogue.net

Discharge planners/case managers are likely to encounter instances in which home care, hospice, and home medical equipment (HME) providers state that they cannot accept patients because they are “unsafe” at home. The use of this term may be confusing to discharge planners/case managers. What is it about patients’ homes that make it “unsafe” for them to receive services there? Aren’t all patients appropriate for home care?


First, discharge planners/case managers may not have provided services in non-institutional settings. If so, it may be difficult to make a crucial distinction between institutional care and home health services.

New Day, New Programs

With the implementation of OASIS-C Jan 1st, agencies have the ability to do an extreme makeover and position themselves for Pay for Performance (P4P). Yes, P4P will still come despite all the other changes that are occurring. The Demonstration project ended in December. Findings will be published in the near future.

April will be the last Caspers report until this fall. Home Health Compare will also not update for 6 months. What is done with OASIS-B is done. Quality reports are going to be wiped clean and the first full OASIS-C episodes will begin your new quality report tallies. Some quality measures will remain, others will be added.

So what should agencies focus on? Continue to do business as usual. Defiantly not! Agencies need to take a step back and look at their operations to see what is working and what is not. Are you a proactive agency or a reactive agency? Proactive agencies foresee the problems as they arise and put checks and balances in place to prevent rework and poor outcomes. Reactive agencies are always looking hindsight and trying to figure out what went wrong. They are so busy looking backwards they do not see the opportunities going forward.

Advance Practice Providers Ordering Home Care

Senator Collins (R-ME) and Senator Conrad (D-ND) introduced senate bill 2814 on November 20, 2009. This bill would allow for advance practice providers other than physician to order and monitor home care services for patients. Despite several State laws that already allow this, it is not allowed by the Federal Government so it is prohibited under federal reimbursed payment systems such as Medicare and Medicaid.

This legislation is way overdue. Not clear is if it will allow for these advance practice providers to bill for Care Plan Oversight. This should be allowed due to the regulatory requirements for reviewing and communicating with the home health agency.

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What Agencies Must Do to Survive

Home Care Leadership: What Agencies Must Do to Survive
By: Nick Dobrzelecki, Founder and Chief Executive Officer, Daymarck
January 2010

As the debate over health care reform continues, home health agencies are facing an increasingly complex array of rules and guidelines that will dramatically reshape future business operations.

For many agencies, the new rules and guidelines can seem daunting. Recently, the Centers for Medicare & Medicaid Services released the Final Rule updating the policies and rates associated with the Medicare home health prospective payment system (HH-PPS) for calendar year (CY) 2010.  In addition, the Department of Health and Human Services' Office of the Inspector General (OIG) has released its Work Plan for the fiscal year 2010, describing the areas and issues that the OIG will audit, evaluate and inspect in the coming year.

OASIS Surgical Wound Score

I have been on a mission to either get better understanding or change the CMS guidance on OASIS surgical wound score related to venous access devices. With the implementation of OASIS-C, there is better guidance as far as staging surgical wounds. However there is significant confusion on how to score M1340 related to central venous access devices and the WOCN guidance did not cover this issue.

Previous guidance from CMS states that central venous access devices are always considered surgical wounds. I believe the original intent was that the skin break (surgically created) which the access device was placed into the body is actually the surgical wound. CMS has taken the original written guidance to mean that the actual device is the surgical wound. Previous guidance states that when a venous access device such as a mediport is in place, even if not used, it will always be considered a surgical wound. This is confusing the homecare industry.

With the new OASIS guidance which states, "For the purpose of this OASIS item (M1340), a surgical site closed primarily (with sutures, staples or a chemical bonding agent) is generally described in documentation as a surgical wound until re-epithelialization has been present for approximately 30 days, unless it dehisces or presents signs of infection. After 30 days, it is generally described as a scar and should not be included in this item." 


Industry consultants and CMS representatives state that venous access devices fall out of this guidance although the official OASIS-C guidance manual does not state this. They say that this is because WOCN stated in the past that a central venous access device is always considered a surgical wound therefore CMS has taken that stance.

There needs to be clarification from the WOCN on how to score venous access devices. Here are my suggestions:

***These guidelines are not approved by CMS or WOCN. These are just my suggestions for what they need to change. ***

First, the term of venous access devices needs to be broken down into two subcategories; implanted venous access devices and other central venous access devices.

Implanted venous access devices (i.e. mediport)

When scoring M1340 such as a mediport, the clinician will assess the surgical implantation site wound. If the wound has been epithelized for greater than 30 days, the clinician will mark No.

If the site is epithelialization is less than 30 days then M1340 would be marked 1 or 2. If 1, then score M1342 accordingly.

Other central venous access devices (i.e. central lines)

As the access device is keeping the original surgical wound open, M1340 would be answered 1 and then M1342 would be marked non-healing. Once the access device is removed, the surgical would then be scored accordingly to the WOCN guidelines. Once the site is epithelized for greater than 30 days, it is no longer considered a surgical wound.

***These guidelines are not approved by CMS or WOCN. These are just my suggestions for what they need to change. ***

These suggestions have been submitted to CMS and the Chairperson from the WOCN OASIS-C Committee. We will see if common sense prevails or not.