Demystifying the 485/POC

Tammy Marie Baker RN DOCS

After completing this module the learner will have better understanding of:

Purpose and Review of POC/485

Purpose /use of each locator box within the 485

Archiving the 485

Tracking orders

Identifying appropriate orders for individual patient needs

2

Learning Objectives

Locator Box # 1

Patient Insurance ID #

Generates from EMR or Manually Entered

Patients Insurance ID number

Audit trend: Missing

Locator Box # 2

Start of Care

SOC :Start of Care

Date you provide first Billable service

Date will remain the same as long as the patient has stayed active

Audit trend: Wrong date/billing

errors Dating errors

Locator # 3

Certification Period: 60 Calendar Days From Date= Begins with original cert

date To Date: = last date of the POC “the

60th Day” Recertification Date will start after the

60th day Recertification date is one day

forward from day 60. ie: if cert date ends on June 1st then the first date of the recert will begin June 2nd

Audit trend: Overlapping dates Not moving recert date one day

forward Dates not changed at all

Locator # 4 Medical Record #

Generates from the EMR system

If a Client is discharging and then readmitting an alphabet letter should be added to the origonal number

MR number should be used on nurses notes

Audit trend: Missing on nurses notes Not changed on readmissions

Locator # 5

Provider number

Corporate to enter when the

branch data base is created

Audit trend: Missing

Locator Box # 6

Patient’s name, address and phone numbers

Entered by branch upon admission

Audit trend: Missing phone

numbers Client moved /

address not updated

Locator # 7

Providers name, address and telephone number

Tech support to enter when the branch data base is created

*NOTE: If your branch moves,

Addresws needs to be updated by IT department for accuracy and billing

Audit trend: Not updated when

branch moves

Locator Box # 8

Date of birth

Check on admission

Audit trend: Incorrectly entered

years

Locator # 9

Patients Gender

Entered by Branch upon admission

Audit trend: Wrong gender

entered

Locator # 10Medications:

Include concentration / dosage / frequency /and route

Parenthesis around your ( concentration) will make it stand out

SELECT ROUTINE OR PRN

Use Sort box to organize the order in which they appear

Include PRN indication “why” and parameters duration/frequency”as ordered

Include OTC meds such as Vitamins ointments; pain relievers

Remember Oxygen is a medication

Enter an “N” for medications that are new within the last 30 days

Enter “C” for changed medications in the past 60 days

Enter “R” for medications renewed

Enter “O” for ongoing medications

Audit trend: Missing Concentrations Missing date of start Routine of prn not selected PRNS’s missing reason and duration OTC excluded from Med profile Missing verbal orders never made it

to Med Profile Reconciliation not completed at visits

and meds not accurate to home MARS to 485

Locator # 11 Principal Diagnosis:

The ICD9 code that best describes the principal reason for home health services + Add Date of onset

The most acute condition

Do not use V codes as primary diagnosis

When entering the ICD9 code

Note that the medications should correlate to the diagnosis.

Example: client is on Albuterol and Zopenex there fore Patient should have a Respiratory Diagnosis

Note; a change in medications associated with this diagnosis

could signify an exacerbation

Audit trend: ICD 9 code is not the primary reason

for service V Codes as primary Diagnosis( wrong

) Diagnosis don’t match or reflect

prescribed meds Date of onset missing

Locator # 12

Surgical Procedures Such as GT/ VP shunt/ ostomy ect..

May Use V codes here

Audit trend: Missing GT or trach status Missing procedure codes

here but discussed latter in box 21 of 485

Locator # 13

Other Pertinent Diagnoses:

Place in order of seriousness

Most important Diagnosis entered first

Justifies the discipline and services being rendered

Note that “ All medication’s ”should tie into a diagnosis code

Audit trend: Missing ICD 9 codes Codes not updated to current

condition

Locator # 14

DME: ( Durable Medical Equipment )

Current Durable Medical Supplies

List all equipment in the home related to the care of the client

Equipment maybe in other areas of the home (scavenger hunt )

Ask the family what Medical Equipment they are using.

Separate Equipment listed with a Semi colon : or a / (see sample )

Audit trend: Missing DME Provider name and

number Missing DME and latter stated in

body of 485

DME: Apria (800)543-7123Nebulizer/Neb sets/ Suction portable/ suction regular/ Pulse ox/ Pulse ox probes/oxygen/ o2 concentrator /wheel chair/AFO’s/ stander/ cough assist.

Locator Box #15Safety Measures:

These can be physician ordered or identified upon admission. See Examples:

Universal Precautions

Seizure Precautions

Falls Precautions

Sharps Precaution

Toddler Precautions

Safety Precautions

Immune suppression Precautions

Anaphylaxis Precautions Audit trend: Missing measures pertinent to

the patient condition

Locator Box # 16

Nutritional Requirements:

Type of formula /(KCAL/ML)

DOSE /FREQUENCY/ ROUTE

Method of Administration : pump/ bolus

Nutritional Risk (high, med, low)

Flushes/ free water : Dose/freguency

Elocare Jr 1.5 (Kcal/ml) give 220 ml with 120 water qid via GT(8am/12pm/4pm/8pm)*Flushes 10 ml water pre/post meds and feeds**Free water (restricted/ unrestricted) _____ml/day

Example:

Audit trends: GT FEEDS AND/ OR FLUSH DOES NOT MATCH NURSING DOCUMENTATION

Allergies:

NKDA or NKA if none

List All allergies

Seasonal and environmental as well

Locator Box # 17

Audit trend: comprehensive assessment or written

medication profile list allergies not transcribed on the 485

Missing Seasonal / Environmental Allergies

Epi Pen in meds and no allergies listed?

Locator # 18 A & B Functional Limitations:

As assessed by physician and/or the agency

Write ins can be added such as communication impaired/blind/deaf/assist all ADLS/ assist all ADLS ect...

Verify what is documented on the assessment, Oasis, PRIF to ensure transcription onto the 485

Audit trend: Communication Impaired

Locator # 19

Mental Status:

1.List All allergies select a status

2. May use add : Locked in/infant / Oriented x person only ect.....

Audit trend: Missing

Locator # 20

Prognosis: select choice appropriate to Patient outcome:

Poor

Guarded

Fair

Good

Exellant

Audit trend: Missing

Locator # 21

Orders of Discipline & treatments: Skill Level/ Hours/Frequency and Duration of services provided x 60 days:

SN RN/LPN____hrs/day x ____days/week x 60 days.

matches the current authorization

May use a flex order 8-16 hours per day x 5-7 days/week ( this covers gaps in services)

Services provided

Clear order sets

Use good clinical judgment for clear, concise and complete orders,

Specify Equipment name/ size of tubing's/ settings on equipment / duration/ frequency and when to use apnea monitor

List the skilled order sets in head to toe format.

Audit trends Frequency and duration does not

match authorization Incomplete order sets Wrong GT size, wound orders, IV

orders Wrong ventilator, oximeter or

apnea monitor and/or missing frequency of use

List emergency Contact number:

List All Physician

Vital signs : time/frequency with age appropriate parameters

Pain Assessment

Head to Toe assessment with Systems: Pain /Neuro/Cardiovascular/Respiratory/Gastrointestinal/Genitourinary/Integumentry/Musculoskeletal/Psych-Social

Nursing Diagnosis per system

All treatments listed per system

All parameter Time/duration/ frequency per medical treatment

Box 21 Locator continued:

Audit Trends: Ancillary MD on case not

included Pain assessment /treatment

missing Times/duration and

frequency's omitted

Vital Additions to the POC :

Patient Education: must be addressed and pertinent to Diagnosis

Communication Impairment: How can SN/PCG facilitate clients communication

Safety: Pediatric/Toddler /Falls/Elderly

Care Coordination: Case managers; MD appointments; school; therapist ect.

Discharge Planning: Begins at admission and continues through out care

Audit Trends: missing key pieces :

Patient Education not noted Communication impairment

not addressed Care Coordination

Admission Summary

History of patients Illness

Birth/gestation

Reason for Admission

PMH: ( Past medical History )

Snap shot picture of your client

*Insert a brief admission summary into the 485 history at the bottom of your box 21 section. ( Who is this client and why are they under services)

Audit Trends: Admission summary

missing Who is this patient?

Inquiring clinicians want to know?

Recertification Process Verify frequency and duration against current

authorization

Requires a Complete reassessment of the client

Check all supplemental orders in the past 60 days to verify transcription and include in the 60 day summary

Revise the 485/POC to Include all updates/ changes documented in the patient record over the past 60 days

60 DAY SUMMARY: summation of what occurred with your client in the past 60 days. Written at bottom of 485 post reassesment.

Call MD with updates for RSOC Audit trends:

Updated orders are not included Goals are not updated Summary is incomplete Frequency and duration does not match the current

authorization

Locator Box # 22 GOALS: Match your goals to the Diagnosis / treatment/ services provided per locator #21.

Update the goals with each recertification

Individualized

Measurable

As evidenced by

Timeframes

Discharge planning to be addressed

Rehabilitation to be addresses

Admission summary: Mention all systems in head to toe format and give details on those systems in which we are providing services

Please Don’t forget to include psychosocial and care coordination in the goals sets. ( Holistic Nursing Care )

.

Audit Trends Goals not updated or patient

specific Not evidenced based Psych needs / care coordination

omitted

Locator Box # 23

Nurses Signature and Date of Verbal Start of Care:

Initial POC is dated on SOC This is the Date you received orders for homecare services

Subsequent POCS are Dated on date reassessment was done and Updates called to MD

VSOC for RSOC: Verbal start of care for Recertification (verbal orders for recertification from the physician.)

MD must agree to recertification and sign off on POC

Audit Trends: Incorrect date, missing signature

Locator Box # 24

Physician’s name, address and phone number

Generate from EMR once MD is put into the system

ALL MD’s must be verified for licensure status on line

Check Phone and Fax numbers for accuracy

Audit Trends: MD not verifed Wrong primary Physician

Locator Box # 25

Date HHA received signed POC

Stamp or sign and date POC on Date it is received from MD office returned with MD signature

It is recommended that the agencies date every plan of care upon return from the physician

Audit Trend: This is a missed item which

auditors will access. Date Received not

stamped

Locator Box# 26

Physician Certification Statement:

No entry needed

Acknowledgement for signing physician

Audit trend: n/a

Locator Box # 27

Attending Physician’s Signature and Date Signed:

Time frames State Specific

No rubber stamps

No Nurse Practitioners or PA’s

May accept faxed copies

save the original for clarity

Do not date the physicians signature if S/he did not date, go to box 25

Audit Trends: Stamped

signature Not dated Late

Archiving the 485

Archive every 485 upon admission & recertification in the EMR system of usage: This saves every version / recert of the plan.

Click the Archive Tab

Click the Archive Tab

Click the Physician sign of date and enter date

Save the current Plan of care prior to day 56/60b revision for next cert

This will keep a permanent record of all certification periods

Can also view previous archived 485’s in this area Audit Trends: Inconsistency in

Archiving Missing 485/POC

Miscellanies

The 485 must be entered into order tracking

All 485’s are Archived after MD signs and prior to revisions on next certification period

485 = First Page/487 = All pages after

Maintain a copy of the original 485 in the active patient chart and a signed Md copy both home chart and office chart

Proof reading the 485 us essential and should be done x 2 clinicians prior to sending to the physicians

Audit trend: Missing copies in

the home

Following 485/ Physician’s orders:

Nurses should be educated on the POC/485 and review it with their CS or DON prior to all cases:

When educating our nurses we need to ensure that they clearly understand

The 485 is the physician’s order

The 485/ physician’s order is what governs their practice.

We are NOT to alter the 485/ physician’s without a confirmed physician’s order

We are never to take an order from a parent. If a parent asks you to omit and/or do something that is not supported or in agreement by the 485/ physicians order you must notify the physician immediately Audit trend:

Insufficient training on 485

The 485/ physician’s order should be reviewed by every nurse providing care to client as it is the physicians orders and clients POC

Accuracy should be reviewed for errors

Is it Appropriate and does it meet Client/ patient’s need

Accurate Clearly and thoroughly written

Clinician writing the POC should proof read it prior to signing and faxing to MD

The physician shall be notified for any inaccurate, unclear or incomplete orders

Reviewing orders for Accuracy/ Consistancy

Thanks everyone for participating in this tutorial Tammy Marie Baker, RN