Learn

By Carissa Podesta, Compliance Officer

A couple of recent therapy compliance incidents caused some Ensign facilities to part ways with good therapists who made poor decisions.

I want everyone to know that these situations could have been avoided had those therapists sought help and support instead of acting in a way that placed their license and position in jeopardy. I personally feel bad that these individuals did not recognize that help and support existed and want to make sure that each of you understands what to do if you are ever in such a situation.

Holding Ourselves Accountable

Our Compliance Manual and Code of Conduct:

1. Prohibits conduct that violates our policies or the law.
2. Requires that we report any violations or suspected compliance violations.
3. Prohibits retaliation against anyone who reports a compliance violation.

These standards are absolute and without exception. So, for example, we cannot violate policies or the law and then claim someone else made us do it. We also cannot fail to report a violation for fear of retaliation.

One of our organization’s Core Values is “Accountability.” We are asked to hold ourselves to the highest standards of care and professionalism. That means something more than just following policies or the law; it means acting ethically and with integrity in all of our actions as employees. Let this guide everything you do.

Our culture is one in which asking questions and challenging one another is encouraged. We will only become better if we make ourselves better. This means questioning the status quo and questioning anything or anyone that impacts our ability to act legally, ethically, with integrity or be accountable. This aligns wonderfully with our compliance responsibilities.

The take away – always report anything suspicious, always act legally, ethically and with integrity, never hesitate to question things and understand that there is never a valid excuse for doing otherwise.

Holding Others Accountable

At the conclusion of the two recent therapy compliance incidents, the therapists involved said they engaged in misconduct because (1) their supervisor told them to do it or (2) their supervisor made an unintelligent comment that was interpreted as a directive to act unethically.

If you believe anyone, even your supervisor, is instructing you to do something wrong, you must hold them accountable. Let’s apply the standards discussed above.

1. Refuse to act on the request to engage in illegal or unethical conduct.
2. If you feel comfortable, question or challenge the request. Tell the person why the request is inappropriate and use it as a teaching moment.
3. If you feel uncomfortable, go to your operation leader, contact your local Therapy Resource or call the Compliance Hotline at 1-866-256-0955 (you may remain anonymous if you prefer).
4. Be confident in the knowledge that you are doing exactly the right thing and that you are protected from retaliation.

The therapists involved in the recent therapy compliance investigations did none of the above. I truly wish they had understood that they were not alone, had another choice and had the complete support of this organization.

Questions and comments are welcomed. Contact: cpodesta@ensigngroup.net

WE LOVE OUR THERAPISTS! To learn more about the February Learning “Oppties” program, please read the introductory articleposted January 31. Today’s Learning “Opptie” is related to billing the proper mode of treatment. There are 3 modes of treatment defined in the RAI Manual: Individual, Concurrent and Group. Individual treatment is defined as the treatment of one resident at a time. The resident has the full attention of the therapist or therapist assistant for the treatment. Concurrent treatment for a Medicare Part A patient is defined as the treatment of two residents, who are not performing the same or similar activities, at the same time, both of whom must be in the line of sight of the treating therapist or assistant, regardless of payer. For Medicare Part B, however, the treatment of two or more residents who may or may not be performing the same or similar activity, regardless of payer source, at the same time is documented as group treatment. While group treatment for a Medicare Part A resident is defined as the treatment of 4 residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or assistant who is not supervising any other individuals.

Whew! Did you get all of that information? Well, let’s put it into application with the following challenge:

Mrs. V, whose stay is covered by SNF PPS Part A benefit, begins therapy in an individual session. After 13 minutes the therapist begins working with Mr. S., whose therapy is covered by Medicare Part B, while Mrs. V. continues with her skilled intervention and is in line-of-sight of the treating therapist. The therapist provides treatment during the same time period to Mrs. V. and Mr. S. for 24 minutes who are not performing the same or similar activities, at which time Mrs. V.’s therapy session ends. The therapist continues to treat Mr. S. individually for 10 minutes. Based on the information above, what is the answer to the following questions?

—For how many minutes did Mrs. V. receive individual therapy? For how many minutes did she receive concurrent therapy?

— For which mode of treatment did Mr. S. receive 24 minutes? And, for which mode did he receive 10 minutes? (HINT: Use the Medicare Part B definition).

WE LOVE OUR THERAPISTS! To learn more about the February Learning “Oppties” program, please read the introductory article posted January 31. Today’s learning opptie is related to guidelines for recording minutes. According to the RAI Manual for MDS 3.0, v1.07, Co-Treatment minutes for a Medicare Part A patient should be recorded using the following rule: When two clinicians, each from a different discipline, treat one resident at the same time (with different treatments), both disciplines may code the treatment session in full. All policies regarding mode, modalities and student supervision must be followed. The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented for each patient.

Describe a scenario with a Medicare Part A patient where co-treatment might be clinically indicated. Be sure to include the therapist or therapist assistants discipline(s), the total treatment time and how each discipline would record minutes. Have you ever participated in a co-treatment session with a patient?

Please be sure to blog your answer in the reply space below. Include your first and last name, your facility and your e-mail address (your e-mail address will not be visible on the website), to be entered to win your “Opptie”. THIS WEEK’S “OPPTIES” AWARD WINNERS WILL BE POSTED ON MONDAY, FEBRUARY 6. Be sure to check back.

WE LOVE OUR THERAPISTS! To learn more about the February Learning “Oppties” program, please read the introductory articleposted January 31. Today’s learning opptie is related to a tool used in Skilled Nursing Facilities to report the assessment of care and services required. It’s called the Minimum Data Set or MDS. The purpose of this manual is to offer guidance on how to code and use the Minimum Data Set Version 3.0 (MDS 3.0) correctly and effectively. The Centers for Medicare and Medicaid Services (CMS) has an electronic version of the MDS 3.0 RAI manual available on the website at cms.gov. Your MDS Nurse also uses an RAI Manual and will know the answers (or at least how to find the answers) to questions you may have regarding the MDS. Did you know that, according to the RAI Manual, the time required to adjust equipment or otherwise prepare the treatment area for skilled rehabilitation service is the set-up time and is to be included in the count of minutes of therapy delivered to the resident? Set-up may be performed by the therapist, therapy assistant, or therapy aide.

In Chapter 3, Section O, on page 18, the manual talks about recording minutes for set-up time and gives specific instructions on HOW to record set-up time. Use these instructions to answer the following question: Under which mode of treatment (individual, concurrent or group) should set-up time be recorded? Please be sure to blog your answer in the reply space below. Include your first and last name, your facility and your e-mail address (your e-mail address will not be visible on the website), to be entered to win your “Opptie”. Also, if you have any suggestions regarding some continuing education courses you’d like to see us bring to your area, please include those ideas in your blog, as well. Thank you for participating and HAVE FUN!

WE LOVE OUR THERAPISTS! To learn more about the February Learning “Oppties” program, please read the introductory article posted January 31. Today’s Learning “Opptie” is designed to inspire you to explore! On the front page of the www.ensigntherapy.com website under our knowledge tab, you will find a splinting workshop scheduled for sometime next month. What is the date of the workshop and where is it scheduled to be held? What are the names of the workshop instructors? What is the fee for therapists who work in facilities supported by Ensign Facility Services, Inc.? Please fill out the reply information below to be entered to win your “opptie”. Don’t forget to include your first and last name, your facility and your email address. Your e-mail address will not be published! Thank you for participating and don’t forget to check back tomorrow.

WE LOVE OUR THERAPISTS! And, to CELEBRATE our PASSION FOR LEARNING, therapists, assistants and therapy techs working in facilities supported by Ensign Facility Services, Inc., will have the opportunity to LEARN AND WIN. In the July 2010 issue of Spirit Magazine (Southwest Airlines), Jay Heinrichs authored an article about a concept of giving back to employees by rewarding them with something that can help make them a little better. Heinrichs termed these rewards, “oppties”. We loved the idea and WE LOVE OUR THERAPISTS! So, for each day during the month of love (yes, February), a new learning opportunity related to various topics will be posted to the “LEARNING OPPTIES” page on www.ensigntherapy.com. Read the message, review the question and blog your response by hitting the “Discuss” link. You can also fill out the “reply” section located just below the question. Timely and correct responses will be entered to win “Oppties”. In addition to individual winners, there will also be other “Oppties” awarded, such as highest number of participants from a facility therapy department over a period of time and teams with the most consistent participation throughout a period of time. Winners will be posted. Don’t forget to check us out at www.ensigntherapy.com each day, beginning February 1, 2012, for your opportunity to LEARN AND WIN!

 

Date:   Nov 17 and 18, 2012

Time:   8 AM – 5:30 PM each day

                (1 hour lunch break)

:

University of North Texas
Allied Health Center
Fort Worth, TX

Ensign Facility Services hosts seminars in facilities that are ADA accessible. Please let Jon Anderson, jonanderson@ensigngroup.net know if you need any special accommodation.

Instructor:

‘Dee’ Virginia Ellis, PTA, CKTI

Dee is a Physical Therapist Assistant who has practiced in many different settings and states. Dee specializes in aquatic therapy, Pilates based spinal stabilization and orthopedic outpatient rehab. She has been a PTA for 15 years, graduating with her A.A.S. from Community Colleges of Southern Nevada in Las Vegas with a Gerontology Wellness Specialty. She also did undergraduate study at San Diego State University in California. Dee has a special interest in wellness and prevention.

Dee has been a Certified Kinesio® Taping Practitioner for 8 years and has been a Certified Kinesio® Taping Instructor since 2005. Dee has her American Physical Therapy Association (APTA) Advanced Proficiency in the musculoskeletal realm and was the recipient of the Texas Physical Therapy Association’s (TPTA) Joy Davenport award in 2008. She is an active volunteer in the APTA, the TPTA and the Aquatic Section of the APTA. Dee has presented continuing education on Electrical Modalities, Aquatic Physical Therapy and Kinesio® Taping: Fundamentals and Whole Body Techniques.

Dee currently works for as a PRN for local south Texas hospital systems and home health agencies.

Topic:

Kinesio Tape Course (KT1 and KT2)

 KT1: Fundamental Concepts & Basic Muscle Applications (To be taken in conjunction with KTAI approved KT2 course)
The KT1 course is designed to introduce practitioners to the Kinesio Taping® Method. During this eight-hour class, the instructor will introduce Kinesio Taping® concepts, theory and history, and discuss the four major physiological effects; skin, muscle, circulatory/lymphatic, and joint. During lab sessions, attendees will have ample time to practice Assessment Tests approved for the enhancement of their Kinesio Taping® skills and muscle applications for both the upper and lower body. Upon completion of this course, attendees will be able to discuss and apply the Kinesio Taping® Method to relax overuse syndromes, stimulate weak muscles, and decrease pain and swelling. 

KT2: Advanced Concepts & Corrective Techniques (To be taken in conjunction with KTAI approved KT1 course – prerequisite is completion of KT1 course)
The KT2 course builds on material learned in KT1. During this eight-hour class, the instructor will introduce the six Corrective Techniques (Mechanical, Functional, Space, Fascia, Ligament/Tendon, and Lymphatic) and discuss their application in a variety of clinical conditions. During lab sessions, attendees will have ample time to practice applying these techniques to a variety of upper and lower body conditions. Upon completion of this course, attendees will be able to discuss and apply the Kinesio Taping® Method to orthopedic and neurological conditions. 

COURSE OBJECTIVES

 Upon completion of this course, the participant will be able to:

• Describe the concepts of Kinesio Taping.
• Review muscular anatomy as it is related to Kinesio Taping.
• Explain and apply the concepts of the Kinesio Taping Method.
• Describe the unique qualities of the Kinesio Tex Tape.
• Recognize the principles of Kinesio Tex Tape application.
• Utilize and demonstrate application skills in guided laboratory sessions.
• Demonstrate application skills during lab sessions.
• Practice the various cutting techniques and their clinical application.
• Apply Kinesio Taping method to relax and stimulate muscles.
• Apply Kinesio Taping methods for pain, swelling, joint mobility and stability.
• Apply various taping techniques for treatment of the spine, and upper/ lower extremity dysfunction
• Apply various taping techniques for treatment of unique conditions using the concepts and principals of the Kinesio Taping Method.

 Who Should Attend?  PTs, OTs, ATs, DCs, LACs, MTs, PTAs, OTAs and other medical practitioners. THIS COURSE IS INTENDED FOR LICENSED HEALTH CARE PRACTITIONERS ONLY

 

CEUS:

You can submit 16 hours continuing education credits to TX Physical Therapy Association. The Kinesio Taping Association is an approved provider for AOTA (Provider # 4489). The assignment of AOTA CEU’s does not imply endorsement of specific course content, products, or clinical procedures by AOTA. The Kinesio Taping Association is recognized by the Board of Certification, Inc. (BOC) to offer continuing education for certified athletic trainers (provider # P2293). Kinesio Taping Association is approved by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) as a Continuing Education Approved Provider (Provider #450030-06).

 

Cancellation/Refunds:

 No refunds

Class Schedule:

KINESIO TAPING® AGENDA

Day 1 – Fundamental Kinesio Taping

7:30	Sign in
8:00	Instructor Introduction and Bio
8:10 – 10:00	Introduction to Kinesio Taping Concepts, Theory and History, Qualities of Kinesio Tape, Differences, Benefits and Finger Demonstration, introduction of Five Major Physiological Effects and Skin Function, Circulatory Function, KT Skin & Fascia Function, Iliocostalis Lumborum Demo Lab, KT Muscle Function and Basic App Concepts
10:00	Break
10:15-11:30	Joint Function; Biotensegrity; Application Basics, Directional Lab – Upper Trapezius, Challenges, Contraindications & Precautions, Intro to KT Assessment Tests
11:50	Q&A
12:00	Lunch
1:00-3:00	KT Cervical Flexion Assessmet, Longissimus Cervicis (Cervical Paraspinals) Application Lab, KT Cervical Extension Assessment, Scalenus Anterior Lab, KT Trunk Flexion Assessment, Rectus Abdominis App Lab, KT Pectoral Girdle Assessment, Pectoralis Major and Rhomboid Major Lab,
3:00	Break
3:15 – 4:30	KT Hip Rotation Assessment with Lab, Gluteus Medius App Lab, KT Leg Raise Assessment with Lab, Quadriceps Femoris App Lab, Review Five Major Physiological Systems, App Concepts, Assessment Questions, Extensor Digitorum Lab, Hamstrings Lab
4:30-5:30	Assessment Q&A; KT1 Review & Q&A, Application Requests; Conclusion

Day 2- Advanced Kinesio Taping

8:00 – 10:05	Overnight Responses, Troubleshooting, Assessment Questions, & KT1 Review, Basic Concepts of Corrective Techniques, Tension guidelines, & Precautions., Mechanical Correction, Y Technique with tension in the Tails and base, Mechanical Correction, I Technique, Mechanical Correction Lab: Patellar Tracking, Mechanical Correction, Shoulder Instability, Mechanical Correction Lab: Shoulder Instability
10:05	Break
10:20 – 11:30	Introduction to Fascia Correction, Fascial Oscillation and Gliding. “Y” Tension in Tails, Tension in Base, Rams Head., Fascia Correction, Y Technique with tension on the tails.  Manual Fascial Glide Correction With Tension through the tails., Fascia Correction Lab, Fascia Correction, Y Technique with tension through the base.  Manual Fascia Winding Correction Technique with tension in base., Fascia Correction Lab, “Y” Strip: Tension on Tails, Rams Head App, Fascia Correction Lab
11:30	Lunch
12:30 – 3:10	Introduction To Space Correciton. Space Correction “I” Technique, Space Correction “Donut Hole” App. Space Correction Lab, Space Correction “Star” App. Space Correction “Button Hole & I Strip” App. Space Correction Lab, Space Correction “Web” App and Lab, Introduction To Ligament/Tendon Correction, Ligament Correction, Tendon Correction “I” & “Y” Techniques, Ligament & Tendon Correction Lab
3:10	Break
3:25 – 5:15	Tendon Correcton with Plantar Fasciitis App, Tendon Correction With Plantar Fasciitis Lab, Introduction to Functional Correction, Function Correcton Technique, Functional Correction Lab, Introduction To Circulatory / Lymphatic Correction, Circulatory / Lymphatic Correction “Fan” Technique Lab, KT Clinical App Finger, Documentation, Billing, Precautions, Contraindications and Rules, Assessment Questions, Glossary Review, Application Requests and Q&A
5:10 – 5:30	Assessment Questions, Glossary Review, Application Requests; Q&A; Conclusion

$569 for licensed professionals

$369 for students (limited space available)

Questions/Information/Sign Up:

Kelly Wallerstedt, Ensign Therapy Resource Assistant

kwallerstedt@ensigngroup.net

Pay via paypal on ensigntherapy.com 

 

Get patients to the next Level of Care in a shortened amount of time, with quality outcomes.

The expectation is that patients will achieve their highest level of function with the support of community resources (eg., Home Care, Outpatient therapy.)

Manage clinical needs and financial implications according to contracted levels.

Pay attention to over and under utilization of therapy.

Negotiate a higher level of care/reimbursement rate if patients can tolerate more therapy.

Goals should be written according to specific prior level of function.

Begin working with patient/ family from day 1 to determine a reasonable and achievable discharge plan.

Drive the d/c date from the time of admission.

Be mindful of the health plan goal = decreased LOS/ next Level of care.

Meet weekly with the clinical team to discuss progress/ barriers to goals.

Discuss the PLOF with the entire team after admission; they may have valuable information to add from discussions with the family.

Address the D/C plan every week to ensure it is reasonable. If not, evaluate alternative options with the patient/ family quickly.

Work with your Administrator to ensure you have assigned one, knowledgeable person to effectively communicate skilled therapy services provided, goals/ barriers, estimated LOS, and the discharge date/ plan weekly with the health plan case manager.

Understanding, Preventing and Managing Challenging Behaviors – A Cognitive Link
By Pat Jakubiec, Clinical Resource

Challenging behaviors are one of the most stressful aspects of care giving. They result in caregiver stress, excess disability and increased care costs. Recent research suggests that pharmologic approaches are not always effective and they can cause potentially harmful secondary side effects, including an increased risk for falls. Research shows promise for engagement in meaningful activity tailored to an individual’s ability can reduce depressive and agitated behaviors as well as reduce caregiver stress.

Behavior is a way individuals express a need or desire. It can result from an emotion, and sometimes the behavior remains the focus not the emotion (Pollard, 2005). Individuals with cognitive disabilities can be misunderstood and sometimes blamed for their behavior. The reason is usually related to underlying neuro-biological causes that include global cognitive abilities, speed of brain function and personality traits.

Every change in a person’s environment will require the individual to cope and adapt, using extra effort and energy. Many people with cognitive impairment are not able to learn to adapt to new routines, procedures and physical changes in the environment. The individual biologically has difficulty noticing and processing information, therefore they cannot use the information to influence behavior. Functional performance beyond an individual’s ability cannot be expected especially in novel situations. When this occurs, performance failures can be anticipated.

Some researchers describe the anterior cingulate cortex of the brain as a key area between thought emotion and the body’s response to what the brain is feeling. An individual’s responses represent value judgments within a social context. The individual with cognitive disability often times has difficulty understanding the full scope of the social environment and difficult behaviors can represent this challenge. When the brain declines in its ability to work as a global unit, agitation can be viewed as a loss of control over behavior and the ability to process the environment.

There is a fine balance between doing too much for the individual that may lead to depression, excess disability and a decreased sense of self. Doing too little can result in agitation, problematic behavior and an increased risk for accidents. It is important to assess an individual’s abilities and personal factors in the context of holistic assessment. The degree or level of behavioral reaction can be attributed to an individual’s personality traits and how they have handled life situations.

In 1995 Cohen-Mansfield described behavioral symptoms into 4 groupings:

• Physical aggressive behaviors
• Verbally aggressive behaviors
• Non-aggressive physical behaviors
• Non-aggressive verbal behavior

A careful medical assessment needs to be included. Certain conditions and illnesses, unmanaged pain, and medication changes all need to be considered.

Environmental assessment and management become critical. Changes in the physical environment can cause challenges as the person may have difficulty processing the physical space. Consistent nurse aide assignments with ongoing team education provide a supportive human environment. Integrating lifelong habits and routines promotes cognitive strengths and a sense of self. An integrated environment promotes overall feelings of well-being and security.

Use of the cognitive disabilities model allows healthcare clinicians to understand different levels of global brain activity. The six levels (ACL scale) describe distinct patterns of behavior that can be anticipated. These behaviors can be measured and managed by skilled clinicians, offering a cognitive systematic approach to management and intervention. Strategies can be developed integrating personal factors that can be employed by everyone. This provides a pro-active approach to care and may prevent some challenging behaviors before they occur.

Behavior Patterns Observed in the ACL Scale

Bathing Challenges/Process

Resisting care, especially during bathing is a common challenge that causes distress for both the individual and the caregiver. Interventions are meant to be used as a guideline and are meant to be modified by the treating therapist in the context of a comprehensive holistic assessment.

Reasons for referral

• Recent decline in function and or participation
• Resisting care- verbal or physical aggression
• Refusing or withdrawal
• Individuals requiring more than one nurse aide to complete bathing /showering
• Issues of safety associated with bathing and showering

Evaluation

• Complete a comprehensive holistic assessment
• Establish a functional cognitive level through the use of at least 2 standardized tools and observe a stable pattern of behavior
• Have the family complete an Advance Lifestyle Directive “Life Story gathering instrument.” Gather as much data related to the person’s lifelong bathing/ showering habits to include time of day, types of products used, frequency, preferences etc.
• Observe the person and caregiver in the actual task environment
• Identify problem behaviors observed and any identifiable patterns of difficult behaviors. (frequency, duration intensity)

Intervention

Clinical analysis of behaviors. Many behaviors can be an expression of an unmet need. This may include:

• Feeling cold; fear; pain
• Embarrassment/vulnerability
• Loss of control
• Not able to process the environment, or understand what is happening
• Fatigue
• Unable to understand what the caregiver is communicating

Compare cognitive level with actual task participation. If excess disability is present determine why and what therapy interventions can be done to improve participation. When excess disability is cognitively related sometimes the caregiver approach can be modified to improve outcomes. This is often witnessed when people are functioning in Allen Cognitive Level (ACL) 3.

Develop a plan to reduce problematic behaviors, maximize patient participation and profile effective communication. Things to include in the plan are:

• Time of day (avoid bathing when fatigue is present, life habit)
• Use of familiar items
• Integration of preferences and lifelong habits/ mode of bathing
• Communication strategies
• Physical environment considerations (room temperature, water temperature, unfamiliar location or change, privacy, noise level, past familiar environment, comfort)
• Pain management strategies
• Strategies for participation
• Safety

Provide treatment sessions to implement and modify strategies and to train the caregiver in the actual task environment.

Document the plan and caregiver training.

Develop a functional maintenance program.

Follow-up with caregivers during and after the procedures have been completed, and note what has been successfully achieved.

Conclusion

This information was adapted from the VCIM Clinical Guide for Understanding, Managing and Preventing Challenging Behaviors. Some of the facilities using this approach have shown a reduction in falls, combative behaviors, reduced use of restraints and reduced use of psychotropic medications. For more information, contact Pat Jakubiec at pjakubiec@ensigngroup.net. Onsite clinical development and training sessions and skype case study consultation are available. Staff development and training is tailored to individual program needs.