Are You Exposed? Building a Home Care
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Risk Management Program
Pauline Barry, BSN, MPS, CPHRM, FASHRM Assistant Vice President Risk Management Allied World Healthcare Debra Healey, RN, MSN, CPHRM Executive Director Middlesex Hospital Home Care
Enterprise Risk Management
Enterprise risk management is a discipline that engages professionals in the practice of identifying, managing, controlling, and monitoring all risks to the organization.
Enterprise Risk Management Handbook for Healthcare Entities First Edition,
Enterprise Risk Management
Enterprise risk management can best be described as an ongoing business decision making process instituted and supported by the healthcare pp y organization’s board of directors, executive administration and medical staff leadership. ERM recognizes the synergistic effect of risks across the continuum of care, and has as its goals to assist the organization reduce uncertainty and process variability, promote patient safety and maximize the return on investment through asset
t e etu o est e t t oug asset
preservation, and the recognition of actionable risk opportunities.
Enterprise Risk Management Handbook for Healthcare Entities First Edition,
American Health Lawyers Association
Domains of Risk
Operational Legal/regulatory Financial Human Resources Strategic Technology EnvironmentalOperational Risks
Documentation
P f I t I iti ti
Performance Improvement Initiatives
Adverse event management
Patient assessment
Communications with providersp
Operational Risks,
cont’dMedication and infusion therapy
Transparency
Chain of Command
Patient safety
C l l i
Legal & Regulatory Risks
CMS & DHHS
Licensure & accreditation
HIPAA
Stark
HITECH
HITECH
OSHA
Human Resources Risks
Environmental Hiring Practices Hiring Practices Competency Supervision Codes of conduct Job descriptions
Human Resources Risks
cont’d.Policies and procedures
Workers Compensation
Sexual harassment
Violence and personal safety
I f ti t l
Infection control
Transportation
Technology Risks
Electronic medical record
Telehealth
Medical equipment/devices
Laptops
S it b h
Environmental Risks
Physical environment
Fire
Electrical
Patient valuables
Infectious and hazardous waste management
Security
Emergency preparedness
Strategic Risks
Managed care relationships
M k ti /Ad ti i /S l Marketing/Advertising/Sales Reputation Antitrust Contract administration Contract administration Insurance coverage
Financial Risks
Billing, collection and accounts receivable
Corporate compliance
Fraud & abuse
Capital equipment
Days of cash on hand
Growth in programs and facilities
Why Develop an ERM Program?
Higher consumer expectations
I d f i t t f h lth i f ti
Increased use of internet for health information
Change in patient demographics
Continuous need for and access to outcome data
Competition
Increased financial security
Increased financial security
Increased regulatory requirements
How to Get Started?
Identify your risks
-Review incident reportsp -Conduct FMEAs
-Survey leadership -Ask staff
Categorize risks by domains
Current risk mitigation efforts
Next Steps
Risk Assessment & Evaluation
Identify potential likelihood and severityde t y pote t a e ood a d se e ty
Prioritize risks
Develop organizational-wide solutions and strategies of handling the risks
I l t l ti
Implement solutions
ERM Success Factors
Leadership support Employee involvement Employee involvement Consistency in processes Benchmarking resultsUse of evidence based practices
Internal & external monitoring & evaluation
Insurance Coverage
Professional liability
General liability
Directors & Officers
Employment Practices liability
Crime & Fiduciary
T h l
Technology
Auto
What do Underwriters Evaluate?
The quality of an organization -Financial
-Medical/performance improvement -Leadership
-Risk management/patient safety
Exposure
L
Losses
Selecting an Insurance Carrier
Commercial v. self-insurance v. captive v. RRG
Financial due diligence
Financial due diligence
AM Best rating
Occurrence v. claims made
Tail, prior acts coverage
Claims management philosophy
Homecare Specific Risks
Employee Honesty
Falls in the home with injury
Emergent Wounds, pressure ulcers and skin
integrity declines
Failure to rescue a patient
Failure to meet a treatment standard of care
Structuring a Risk Management Plan for Homecare
Components of the Plan
– List the Risks addressed by the planList the Risks addressed by the plan – Describe the action plan to prevent risks – Present the plan to Professional Advisory
Committee
– Review and adjust the plan as needed – Educate Staff
– Report any potential events to the TPA or Insurance Company
Case Studies
Case Study Number 1-Employee Dishonesty
Case Study Number 1 Employee Dishonesty
Case Study Number 1-Skin Integrity
Employee Dishonesty
The Patient - A 75 year old female patient who lived alone in an elderly housing apartment. Family support y g p y pp was a distant relationship with a daughter. The patient was seen under the State of Connecticut Homecare for Elders program and only had HHA services where the RN supervised the plan of care twice a month.
The Employee - The HHA was hired using the
The Employee The HHA was hired using the
standard protocol of background checks, references and a licensure search for any previous disciplinary reports or arrests. All the pre hire screening were
The Situation
Over the course of 4 months, the HHA was able to
withdraw $25,000 from the patients checking account $ , p g using her debit card.
The withdrawals were discovered by the patient’s daughter who immediately called the police.
The Home Health Agency received notice of this
dishonesty when a police officer called the HHA Supervisor dishonesty when a police officer called the HHA Supervisor asking her to cooperate with the alleged criminal act.
The HHA was brought in by the Supervisor for questioning
and initially denied all allegations.
The Situation Continues…
Initially the patient was reluctant to discuss the situation with the HHA supervisor.
Upon further investigation it was discovered that the HHA had been seeing the patient after hours, bringing her places in her vehicle and had offered to get the patient money, hence the possession of the debit card.
The patient had no idea that this much money had been
taken from the account until the daughter audited the account.
The patient ended up hurt and angry as she had
established a close relationship with the HHA and felt a loss of her friendship and a betrayal.
Homecare’s Investigation
The Executive Director of Homecare took charge of the
Investigation.
The HHA was notified of the allegations and that since it was criminal in nature, there would be complete
cooperation with the police.
The investigating Detective interviewed the HHA and
produced evidence that were bank pictures showing the HHA making withdrawals from the account that were HHA making withdrawals from the account that were tracked back to the bank records and added up to the amount missing from the account.
What Happened Next
The Executive Director of Homecare kept in close touch
with the patient, her daughter and a lawyer they had p , g y y engaged.
The hospital put the insurance company on notice that provides employee dishonesty coverage. At first the claim was denied as the insurance investigator cited that there was a chance that the patient contributed to the loss by providing the debit card and PIN number.
Eventually the claim was paid by the insurance company.
What Happened to the HHA
The HHA was put on administrative leave as soon as the
allegations were known. Once she confirmed her
relationship with the patient employment was terminated relationship with the patient, employment was terminated
The Home Health Agency cooperated with the
investigation and sent a statement to the court that they wanted to seek restitution for the funds.
The HHA appeared in court and within one year she was
d i l f d h i d h
sentenced to restore partial funds to the patient and she received a jail sentence and loss of her Certification as a Home Health Aide.
The patient attended every hearing and felt satisfied with the result.
Risks to the Homecare Department
Reputational Risk - Several large articles appeared in the local newspaper that cited the names of the patient, employee and Homecare Agency. This sparked a large p y g y p g reaction from the community.
Employee Satisfaction Risk - The Agency respected
confidentiality and there was a large outcry from the remaining HHA’s that all of their reputations were tarnished.
Patient Reaction Many patients questioned staff about
Patient Reaction - Many patients questioned staff about the incident and wanted to know what measures the Homecare Agency would take to make sure this didn’t happen again. Several other patients came forward with additional theft allegations.
Risk Management Plan
Reviewed policy and procedure for employee handling
of Patient’s Money and re-educated staff with in-y service education followed up by a memo. RNs reviewed policy with patients.
Met in small HHA groups to educate and discuss the
incident.
Required all staff to notify supervisors if there is any
Required all staff to notify supervisors if there is any request by a patient to handle money outside of the policy.
Reviewed the case study with Executive Staff and
Professional Advisory Committee.
Ramifications to the Homecare Agency
Department of Public Health
Licensure
Licensure
– During the routine licensure visit by the
Department of Public Health, there was a
request to review all information related to
the incident and the medical record was
reviewed for compliance.
Lessons Learned
Ongoing education to employees and patients
concerning relationship boundaries and handling g p g patients money is essential.
Providing a team of HHAs who see the patient vs.
one HHA assists in decreasing the change that boundaries will be crossed.
Providing in person unannounced HHA orients can
assist with the monitoring of the care plan.
Case Study # 2 Skin Integrity
An 75 year old female patient came referred to Homecare by
her surgeon after a successful hospital stay that involved a coronary bypass She had moderate cardiac disease and coronary bypass. She had moderate cardiac disease and was discharged 6 days after surgery with Homecare orders for an SN, PT, OT and HHA evaluation.
The RN admitted her within 24 hours of her arrival home
and completed the OASIS-C and requested a HHA 3 times
k i h OT d PT l i Th l f
per week with an OT and PT evaluation. The plan of care also included SN visits 3 times a week for 3 weeks then decreasing to 2 times a week for 3 weeks and finally 1 time a week for 3 weeks if needed. Telemonitoring services were
Skin Integrity Cont…..
No skin integrity issues other than the surgical wound were noted on the OASIS C data set nor were any pressure or stasis ulcers or reddened areas identified. The PT and OT evaluation visits were completed with no mention of any skin integrity issues.On the third RN visit the RN noted new pedal edema bilaterally at +2. This edema continued for the next 2 RN visits with the patient reporting increased pain in the right great toe. On the last nursing visit there was no palpable pedal pulse.
During the next two weeks the right great toe developed a red open area and the swelling continued. No PT or OT note
mentioned this and there was no documentation of any telephone call to the MD to report the change in condition.
Skin Integrity Cont….
The RN documented extensive patient teaching on the need
to keep the foot elevated and to continue to monitor for increased swelling
increased swelling.
The cardiac condition improved and the patient began to
resume usual activities of daily living including driving.
During the 6th week of Homecare the patient was
discharged as the PT and OT plan of care were complete, with no further need for a HHA and the patient able to follow up with her MD.
Skin Integrity Cont…..
Two weeks later the patient followed up with her MD. At that time all of her toes were red with the small toe on the right foot black. The patient required an amputation of the toes.
The patient brought a suit against the Homecare Agency
for failure to properly assess skin integrity, failure to notify the MD of a change in medical condition and premature discharge from care
premature discharge from care.
The patient also wrote a letter of complaint to the Homecare Agency with a copy to the Department of Public Health and CMS
What Happened Next…..
The suit was settled out of court with a confidentiality clause in place that would prevent disclosure of the p p settlement amount.
The Department of Public Health investigated the
complaint and required an action plan to be put in place that required re-education of all RNs on skin
assessment and reporting changes in conditions to the MD
MD.
A licensure investigation was conducted with a
reprimand to the RN for improper physical assessment, lack of follow up with the MD.
Changes in Professional Practice
The Homecare Agency reviewed the skin assessment policies anddeveloped an education plan for reminding staff to conduct and document complete and thorough skin assessment.
A self audit tool was developed that was completed by RN staff on every patient with a wound. Data was tracked to monitor compliance with skin integrity documentation.
All wound patients were discussed in IDT and case conferences ith i
with supervisors.
A six month follow up prevalence study revealed increased compliance with documentation and follow up with MD. This data was submitted to DPH.
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