Inservices

Each and every day clinicians are presented with opportunities to significantly improve lives. Many times ethical behavior occurs without question. However, occasionally, either knowingly or unknowingly, fraud occurs. The purpose of this memo is to remind you of the various types of fraud often found in home health, Lifespan's response and stance on fraud, as well as the penalties for such actions,.

Consequences

After each report of fraud, an investigation is carried out. System logs, patient and family interviews, hospital discharge paperwork, the accounts of other clinicians, and your written explanation of events will all be collected. If it is found that unethical behavior has occurred, Lifespan will immediately conclude our business relationship and submit evidence to the authorities, including the appropriate therapy board.

From there, the relevant therapy board may revoke your ability to practice. Additionally, health care fraud can lead to lengthy prison sentences. Falsifying a claim or statement for a Medi-Cal or Medicare patient can result in a 5 year prison sentence per offense and a fine of $250,000.

What is fraud?

Not all forms of fraud are easy to spot. Some are even, unfortunately, common within the industry. As such, other working experiences may cloud your judgement. However, Lifespan routinely refuses to commit fraud, regardless of financial losses that may be incurred, and hopes for the same from all business entities. Below are common types of fraud in home health.

Examples of fraud

• Moving visits to a date they did not occur, usually to beautify the chart for audits or resolve the billable status due to authorization.

• Signing consents or visit notes for a patient (AKA forging signatures!)

• Modifying the length of time documented, such as staying in the home for 20 minutes, but documenting 45 minutes.

• Billing for visits that did not occur (even accidentally!)

• Claiming services are medically necessary when they are not

Moving forward

Together we can squash out fraud within the industry. If you require assistance with organizing your visits, feel you may have made a mistake, lose a patient's signature due to technical difficulties, have been asked to do something unethical, or otherwise need support, please reach out.

More Information

Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases 

CMS Reporting Fraud

Overview:

• Patient rights are critical in healthcare, protected by federal and state laws.

• Health care providers must educate patients about their rights, documented in the Patient’s Bill of Rights.

Accessibility and Education:

• The Patient’s Bill of Rights must be accessible to all: posted in the office, included in the client’s admission packet, and additional copies available upon request.

• Upon admission, nurses must explain the Bill of Rights to the client/caregiver, allowing questions, and document the receipt in the clinical record.

• Clients must be informed they can exercise their rights without fear of reprisal.

Key Areas of the Bill of Rights:

1. Rights can be exercised anytime.

2. Equal quality care regardless of race, creed, nationality/origin, lifestyle, or diagnosis.

3. Right to refuse care.

4. Informed consent before care initiation.

5. Privacy and protection of PHI (Protected Health Information).

6. Informed of charges before service initiation.

7. Right to safety and respectful treatment.

8. Right to voice concerns/grievances without fear of reprisal.

Interacting with Clients:

• Use appropriate titles and client names; avoid terms of endearment.

• Respect client property; observe cultural considerations.

• Clients should know who you are and what you are doing.

  • Introduce yourself and wear your ID badge.

  • Explain procedures before starting and answer questions honestly.

• Maintain professionalism and positivity.

Handling Complaints/Grievances:

• Clients can voice concerns; the agency must resolve issues promptly and satisfactorily.

• Remain calm, objective, and professional when addressing complaints.

• Do not personalize complaints; focus on problem-solving.

Responsibilities of Healthcare Providers:

• Listen to patient needs without assumptions.

• Explain procedures in an understandable way.

• Maintain honesty and client privacy.

• Encourage patient independence and secure client information.

• Avoid gossip and respect client confidentiality.

HIPAA Overview:

• HIPAA addresses public concerns about insurance and managed care.

• Ensures coverage despite pre-existing conditions, family health status, or job changes.

• Contains privacy and security provisions to protect patient information.

• Establishes the “minimum necessary rule” to limit shared information to what is needed for treatment and legal purposes.

• Mandates patient rights to privacy, information access, amendment requests, and tracking disclosures.

• Requires agencies to appoint a privacy officer, develop compliance processes, and provide staff training.

Patient Advocacy:

• Nurses play a crucial role in advocating for patient safety and preferences.

• Encourage patients to voice their wishes and represent them when they cannot.

• Advocacy involves confronting unsafe practices and ensuring patient-centered care.

Patient Rights and Responsibilities:

• Patients have the right to be fully informed, choose providers, participate in care planning, and expect privacy and respect.

• Responsibilities include providing accurate medical information, following treatment plans, and respecting healthcare staff.

Healthcare ethics involves making well researched and considerate decisions about medical treatments, while taking into consideration a patient's beliefs and wishes regarding all aspects of their health. The healthcare industry, above any other, has a high regard for the issues surrounding the welfare of their patients. Doctors, nurses, and other professionals who have the ability to affect a patient's health are all forced to make ethical decisions on a daily basis. This power over a patient's wellbeing creates a mandatory need for all healthcare organizations to develop an ethics committee.

Health care professionals practice in an environment that is complex, with many regulations, laws and standards of practice. Performing an abortion is legal but may not be considered ethical by other health care professionals or members of the public at large. Other ethical dilemmas arise at the end of life, when a decision must be made to turn off life-support machines and allow death to occur. Other common ethical issues a health care professional might face are confidentiality, relationships with patients and matters related to consent, especially in the treatment of minors. 

The agency’s goal is to establish a written code of ethics that details the policies and procedures that determine proper conduct for all employees. The Ethics committee meets and gives direction to assist the staff, patients and their families; all working together cohesively to identify,understand, and resolve difficult ethical decisions. There are many ethical issues that may arise in regards to a patient's healthcare.

These major issues as well as ways to manage them are as follows:

• Confidentiality- Confidentiality is both an ethical and a legal issue. Keeping information about a patient confidential is a way of showing respect for the person’s autonomy; releasing information can damage the patient. There are also specific laws regarding the release of information under the Health Insurance Portability and Accountability Act, or HIPAA. The laws define exactly what information can be released and to whom. Insurance companies, for example, may not have the right to certain aspects of a patient’s medical record. However, if there is risk to a third party, an ethical health care professional may need to break confidentiality to prevent harm. The Administrator needs to make sure that its patients' medical records are safeguarded.

• Transmission of diseases- The risk posed to healthcare professionals of acquiring a communicable disease from patients is a concern to those serving on ethical committees. This is especially true if a patient's health history is not made available to the providers. While healthcare providers do not want to make the patient uncomfortable by taking obvious protective measures, they still have every right to protect themselves from any pathogens that may be able to spread by direct or indirect contact.

• Aggressive marketing practices - Certain guidelines, ethics, and standards need to be adhered to when promoting and marketing an agency’s services. It is extremely inappropriate for agencies to recommend unnecessary services to a patient just for the sake of profit. The main goal of the agency should be patient care, not marketing schemes. Ethical committees should always be involved in the agency’s marketing practices in some way so that the result of any marketing campaign is tasteful and sincere.

• Provided information- The information that an agency provides to advertising needs to be 100% accurate and honest. It is important that the advertisements for the agency and its services are not misleading or false. Again, the patients' welfare is most important.

• Patient welfare - A doctor, nurse, and any other type of healthcare professional involved in the care of a patient needs to remember their main motive: safeguarding the welfare of their patients. All personal information needs to be kept private. It is also important that physicians are honest with their patients. No matter what the healthcare provider's personal beliefs are; a patient should never be discriminated against based on race, income, or sex. Reports of such discrimination should be taken very seriously.

• Elderly patients- Dealing with patients of advanced age may sometimes pose problems in regards to ethical decision making since they are not capable of making rational decisions on their own. As a result, their families are left with the responsibility of making difficult choices. This task can be incredibly difficult when the patient is terminally ill and wants to end their life in order to avoid unnecessary suffering. Even if the ethical committee has a difference of opinion regarding such matters, proper ethical protocol needs to be adhered to at all times. It is always best to check if the patient has a living will so that unnecessary confusion can be avoided.

• Terminally ill patients - As with elderly patients, terminally ill patients may have specific wishes for the manner in which they want their lives to end. Dealing with an issue such as euthanasia is very difficult and therefore requires a deep understanding of ethical processes.

• Sexual harassment - The ethical committee should be very strict about sexual harassment of any kind at the healthcare facility. There is a risk of occurrence not only between a patient and a doctor, but also between two medical practitioners. When such situations arise, the ethical committee should involve a branch of ethics called sexual ethics, which involves any issue regarding sexuality and sexual behavior. 

• Therapies - There are different techniques and therapies that can be performed with a patient or victim so that any trauma or stress related to an offending incident can be alleviated. Hearings and investigations into the incident may also occur.

• Relationships- Relationships with patients, particularly sexual relationships, are forbidden by both the medical and nursing code of ethics. Such actions are considered serious misconduct and can result in expulsion from the profession and losing the license to practice. A sexual relationship is considered to be an abuse of power on the part of the physician or nurse, as patients are dependent and vulnerable. A sexual relationship with a patient can be very harmful, and an ethical practitioner will avoid even the appearance of sexual interest in a patient.

• Malpractice- Health care practitioners of all sorts face the risk of being sued for malpractice. A lawsuit may be brought from an injury related to surgery, defective equipment or medical products, care that was omitted or a deliberate act that causedharm to a patient. The risk of litigation is such that many health care professionals practice what is called defensive medicine -- for example, ordering a test or performing a procedure primarily to ensure that the patient cannot allege negligence.

• Consent- Patients must provide informed consent for treatment to be legal. A surgery performed without proper consent is generally considered assault, according to a 2009 article in the "Internet Journal of Surgery." When treating an adolescent, the health care professional faces potential conflict between ethics and the law in certain situations. The professional might believe that parents should be kept informed of their child’s health issues. In California, however, a 12-year-old can consent to medical care and counseling related to the treatment of a drug or alcohol problem, the National Center for Youth Law reports. The treating doctor cannot disclose information to the parents without the child’s consent except in very specific circumstances, such as risk to another person.

• Discrimination- Discrimination is also another very serious issue in medical ethics. Discrimination can be because of race, gender, color, or even religion. This may happen between a patient and a medical practitioner or between a medical practitioner and another member of the healthcare team. All members of the team must always protect the welfare of the patients and of themselves as well.

• Honesty- Being honest and giving out authentic pieces of information to the concerned parties are also common ethical issues in healthcare. When results of diagnostic tests are available, these pieces of information must be relayed to the patients and their families. Their diagnosis and other important data should also be discussed properly by the physician and the nurses so that there will be transparency in the treatment process. Giving false hopes and false reassurances are strictly discouraged

Caring for people who are not very mobile tends to involve a great deal of lifting. You may need to assist them from the bed to the chair or the wheelchair and back to bed, and at times, you may need to help a person who has fallen onto the floor.

Improper lifting could injure your back and jeopardize your future ability to work. Do you know correct techniques for lifting and transferring that might keep you from injuring yourself or the person you are assisting?

General tips for lifting and transferring

• When lifting and transferring, the most important consideration is safety for yourself and the client.

• Ask for help and use teamwork. Talk to your helpers about what you plan to do, and talk to each other about what you are doing as you do it.

• When needed, use the right equipment.

• Plan the job. Move anything that is in the path.

• Maintain the correct posture: Keep your back straight and knees bent. If you must bend from the waist, tighten your stomach muscles while bending and lifting. Bending our knees slightly will put the stress on your legs, not your back.

• Never twist when lifting, transferring, or reaching. Pick up your feet and pivot your whole body in the direction of the move. Move your torso as one unit. Twisting is one of the leading causes of injuries.

• Maintain a wide base of support. Keep your feet at least shoulder-width apart or wider when lifting or moving.

• Hold the person or object close to you, not at arm’s length. Holding things close to your body can minimize the effects of the weight.

• Pushing is easier than pulling because your own weight adds to the force.

• Use repeated small movements of large objects or people. For example, move a person in sections, by moving the upper trunk first and then the legs. Repeated small

movements are easier than lifting things or people as a whole all at once.

• Always face the client or object you are lifting or moving.

• Always tell a client what you are planning to do, and find out how he or she prefers to be moved.

Transferring from the bed to a wheelchair or bedside chair

• Plan the job and prepare to lift.

• Place the chair at a slight angle to the side of the bed.

• If using a wheelchair, lock both brakes. Fold up the foot pedals and remove the footrests.

• Stabilize the bed so it will not move.

• Put footwear on the client.

• Lower the bed so the client’s feet will reach the floor.

• Move the person to the edge of the bed. First, move the upper trunk, then the legs one at a time.

• Place the person’s legs over the side of the bed.

• Place your arms around the person, circling the back in a sort of hug.

• Raise the person to a sitting position on the side of the bed.

• Place a gait belt around the client’s waist if you so desire (recommended).

• Gradually slide or “walk” the person’s buttocks forward until his feet are flat on the floor. “Walk” the buttocks by grasping both legs together under the knees and swinging them gently back and forth as the buttocks move forward.

• Place your feet on both sides of the person’s feet for support. Your feet should be far enough apart to give you a good base of support.

• Have the person lean forward and if possible place his arms around your shoulders. Do not allow his arms around your neck, as this can injure your neck.

• Allow the person to reach for the far wheelchair arm.

• Bend your hips and knees while keeping your back straight.

• Place your arms around the person’s waist. If using a gait belt, grasp the belt at the sides of the back with both hands. Do not hold the person under the arms— this can cause injury to the client.

• Keep the person’s knees stabilized by holding your knees against his.

• Pull up to lift the client, straightening your knees and hips as you both stand.

• Keep the client close to your body. Keep your knees and hips slightly bent.

• When the person is high enough to clear the armrest or chair surface, turn by taking small steps. Keep the person’s knees blocked with your own knees.

• When turned, bend your hips and knees to squat, lowering the client to the seat.

• Replace the footrests. Adjust the height of the foot pedals so the person will be sitting with a 90-degree angle at the hips and knees.

• When transporting a person in a wheelchair, pull it backwards up steps or curbs.

• Follow the same principles to return the person to bed.

If a client begins to fall

• Once a client has started to fall, it is almost impossible to stop the fall.

• Instead of trying to stop the fall, try to guide the client to the floor.

• Once the client is on the floor, get help to lift him.

Lifting from the floor

• You might find that someone has slipped to the floor but is not seriously injured. He or she may be able to help you help him or her up.

• Always get a coworker to help you get a client up if the client cannot assist you. Assistance of four to six people may be required. When appropriate, use a mechanical

lift or hoist to raise a client.

• Roll the client onto a blanket or lift sheet.

• Have two or more people stand on each side. Each person should kneel on one knee and get a secure hold on the blanket. On the count of three, everyone should lift the client and stand up, moving the client onto a bed or stretcher.

Transferring in and out of a car

• Put the front seat of the car as far back as possible.

• Position the wheelchair at a 90° angle to the car seat.

• Bend your knees and hips in a squat.

• Place your arms underneath the person’s armpits and around the upper part of his back. He may place his arms around your shoulders, not your neck. Grasp the person’s upper back and do not pull under his arms. Hold him close to you.

• Straighten your legs and hips slightly as you smoothly lift the person’s torso into the car, placing his buttocks on the seat. Move your feet to turn, do not twist.

• Be sure his buttocks are as far back towards the driver’s side as possible before lifting his legs into the car. When lifting his legs, keep your back straight.

Pulling a client up in bed

• Always get help when pulling a client up.

• Place a draw or lift sheet under the client.

• Remove the client’s pillow from under his head and place it against the head of the bed to provide a cushion between the client’s head and the headboard.

• Place the bed at a comfortable height for you and your coworker. re lifting his legs into the car. When lifting his legs, keep your back straight.

• Both you and the coworker should bend your knees and push with your feet.

• Grasp the draw or lift sheet firmly, holding the sheet close to the client’s body.

• Lean in the direction you want to move the client.

• Instruct the client to lower his chin to his chest if possible. If the client cannot hold his head up, be sure the lift sheet is supporting his neck and head.

• Ask the client to bend his knees so he can assist by pushing backwards.

• On the count of three, lift the draw sheet and pull the client up.

Pulling a client up in a chair

• Have the client fold his arms across his chest. Lock the wheelchair brakes.

• Stand behind the client, bend your knees, and wrap your arms around him, hugging his torso securely by folding your arms just under his in front.

• Straighten your legs, lifting the client’s torso up and back in the chair.

Turning a client from side to side

• Stand at one side of the bed, with the bed raised to waist height.

• Place your arms under the client’s shoulders and hips, or grasp the lift sheet.

• Pull the client to the edge of the bed, trunk first and then legs.

• Cross the client’s leg closest to you over the other leg.

• Place your hands on the client’s shoulder and hip closest to you.

• Lean in toward the client and push the client’s torso away from you.

• Place the top leg in front of the bottom leg.

• Support the client’s shoulders, back, and hips with pillows. Place a pillow between the client’s legs to support the top leg. Adjust for comfort.

Devices that can help you work smarter, not harder

• Draw sheets—make it easier to pull a person up in bed or move them to the side. To place a draw sheet under a client, turn the client on his or her side and lay the draw sheet on the bed. Roll half of the draw sheet up against the client. Turn the client to his other side, rolling him over the rolled-up draw sheet, and pull the rolled draw sheet out and straighten it on the bed. The lift sheet should extend from above the shoulders to below the hips and should support the neck and head if the client cannot do so.

• Bed controls—raise or lower the bed to a comfortable and safe position for you, your coworker, and the client.

• Slide boards—help to reduce friction so the client can slide from the bed to another surface.

• Trapeze over the bed—can allow clients to help you move them. They can grasp the trapeze, pull themselves up and assist as you move them.

• Gait belt—is made from heavy canvas with a sturdy buckle. Place the belt around the client’s waist and use it to assist you in moving him or her.

• Mechanical lifters/hoists—can lift a client who is heavy, or one who has fallen. Ask your supervisor for instructions before using these devices.