• E-mail
• Print
• RSS

Audit yourself before the feds do

Rehab Regs, August 16, 2005

Conducting internal audits may sound like a drag, but they're a smart way to stop problems before they start and can keep you off a surveyor's radar screen. Read on to make sure you're auditing your way to success.

"The reason to conduct internal audits is for compliance as well as quality monitoring," says Lisa Stumpf, MS, CCC-SLP, LNHA, director of operations at Therapy Partners in Lakewood, OH. "It's something all organizations should strive to do, even though productivity requirements sometimes make it hard."

In some facilities, the program manager or rehab director is responsible for conducting these audits, while in others, therapists perform a peer review of charts on a rotating basis. Either way, managers can follow up on any issues.

"Whether a problem is a trend or just a one-time issue, you need to address it with the therapist one-on-one," says Stumpf. "Present the information factually by saying, 'Here are the expectations from Medicare or state reviewers.' "

By conducting monthly chart audits, you can gather information about what documentation details stump your therapists. From there, you can address ongoing denial reasons, prepare for JCAHO surveys, and determine what type of inservices or continuing education your staff needs. "Each of our therapists takes turns reviewing the charts," says Keela Barker, outpatient re hab manager at Genesis HealthCare System in Zanesville, OH. "It gives them individual accountability and shows us where we need to improve as a facility."

Genesis compiles this information quarterly and provides it to therapists. The facility then conducts staff education as necessary.

In addition to holding education sessions, bring up ongoing issues during your regular staff meetings, especially if more than one therapist struggles with a certain component, such as thorough daily documentation. Make it a group goal to reach 100% accuracy in that area.

Stumpf also suggests matching someone who needs help with a staff member who documents well. "If you have another therapist who has mastered that piece, you can have [him or her] pass along some ways of wording documentation better," she says.

The easiest way to make sure you cover all of your bases is to create a form for the internal person who audits your facility's charts and any therapist doing peer reviews of rehab documentation.

Experts suggest including the following checklist, and going into additional detail as necessary:

• E-mail to a Colleague
• Print
• RSS
• Archive