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Understanding your role in corporate compliance

Staff Development Weekly: Insight on Evidence-Based Practice in Education, July 22, 2004

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Question: A contracted physical therapist (PT) shows up over a half-hour late at the nursing home he services. He tells the charge nurse that his car broke down on the way, and that he can't make up the time because of other appointments. He says that he'll see the most urgent patients and return the next day. The nurse says that she'd prefer that the patients receive their treatment. However, there isn't much she can do about the situation. Later, reviewing a patient's chart, she discovers that the PT wrote therapy notes for the patient, saying the patient participated in therapy and is making progress; the nurse is certain that this patient was not seen.

What do you do?

Answer: Falsely documenting patient services and conditions could violate the federal False Claims Act. The nurse should make a note of the time and day that the therapist gave care and which patients the therapist saw. The nurse should then bring this information to the attention of the nursing home's compliance officer.
In this case, it seems as though the therapist intentionally wrote false notes. However, sometimes providers get into the habit of documenting the same notes about patient care and patient progress. Should the government investigate a nursing facility, the accuracy of those notes will be paramount to the facility's success. Again, besides the "compliance ramifications," doesn't it serve patients well to document their care accurately? In this way, you could say that correct documentation is a significant element of patient care.

Editor's note: The above case scenario is from the online course, "Understanding your role in corporate compliance for the nursing and clinical staff." For more information on this and other courses in our Compliance library, go to www.hcprofessor.com and click on Compliance.

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