Virtual Documentation Training

[Audio] Patriot Care: Kennedy Care LCP Visit Note Documentation Training.

[Audio] Training Purpose: Explain the VA Homemaker and Home Health Aide Care Program (H/HHA) requirements in order to reach compliance with visit note documentation standards..

[Audio] Home Care for Veterans: What is the VA Homemaker and Home Health Aide Care Program? The homemaker and home health aide care (H/HHA) program is one of many home and community-based services the VA offers. The goal of the program is to help veterans remain safe and independent while continuing to live in their own homes..

[Audio] What Does the VA H/HHA Program Require? "Requires personal care services each time he or she completes three or more of the seven activities of daily living (ADL) listed in the definition of an inability to perform an activity of daily living in this section, and is fully dependent on a caregiver to complete such ADLs" (Copy and pasted directly from the Veterans Affairs website).

[Audio] What Does This Mean? In order for a veteran to qualify for these services they must require assistance with 3 or more ADLs. ADLs must be completed every shift. A veteran can lose their benefits for not allowing ADLs..

[Audio] What is an Activity of Daily Living (ADL)? Activities of daily living (ADLs) means the functions or tasks for self-care usually performed in the normal course of a day, i.e., mobility, bathing, dressing, grooming, toileting, transferring, and eating..

[Audio] What are Instrumental Activities of Daily Living (IADLs) ? The VA defines Instrumental Activities of Daily Living (IADLs) as: meal preparation, light housekeeping, laundry, using the telephone, handling medications, shopping, and transportation..

[Audio] Can I Assist With IADLs ? YES! The VA program allows for assistance with some IADLs after ADLs are completed. These include meal prep, light housekeeping, laundry, assistance scheduling appointments, etc. The VA will not allow shopping, transportation, or any assistance with medications..

[Audio] Documenting for the VA H/HHA Program Did we tell you that writing all ADLs complete would be adequate for documenting? Yes! Was that incorrect information? Also Yes! Visit notes should be short and to the point, but must contain the specific ADLs that we completed. Remember that 3 are required. No other information should be listed in the visit notes section, including IADLs..

[Audio] What if I have a Concern I Feel I Need to Document? If you feel something further needs to be documented please reach out to your Care Coordinator after the shift to discuss this with them. Your Care Coordinator will document your concern under the appropriate note type, and, if necessary, will notify the VA..

[Audio] How do I Document IADLs? IADLs are charted in the task section of the shift. Checking the box that the task was completed will suffice as proper documentation. We are able to see what tasks were and were not checked..

[Audio] What if the Veteran I Work With is Refusing ADLs? The VA H/HHA Program has an application process. The Veterans Social Worker or Primary Care Physician has to do an eligibility assessment with the Veteran, and based on the results, makes a determination on the amount of hours needed. This program also has a waiting list. Therefore, at no point in time should the Veteran you are working with be surprised by the ADL requirement..

[Audio] What if the Veteran I Work With is Refusing ADLs? If the Veteran is refusing ADLs during your visit, you are responsible for offering/suggesting a minimum of three times throughout the shift. This should be reflected in your visit notes. Example: Offered Veteran assistance with shower, dressing, and grooming 3 times. Veteran refused each time. Report being made to Care Coordinator..

[Audio] What if the Veteran I Work With is Refusing ADLs? After the shift is over you will need to reach out to your Care Coordinator. You and your Care Coordinator will discuss potential solutions to the refusal. A call will also be made to the Veteran to remind them of the H/HHA Program requirements..

[Audio] What if the Veteran I Work With is Refusing ADLs? Most times calling the Veteran is enough to resolve the issue. However, if the refusals continue, the VA will remove the Veterans benefits. The VA does random audits of visit notes to ensure that our agency and the Veterans are in compliance with the program requirements..

[Audio] VA Audits At any point in time the VA can request an audit. Audits can be done with randomly selected Veterans, or for specific individuals they want to check up on. These audits can determine whether or not a Veteran can remain on the program. INCORRECT DOCUMENTATION CAN CAUSE A VETERAN TO LOSE THEIR BENEFITS!! Without our Veterans our jobs would not exist. In order to best serve these individuals we should work together to meet program requirements and document correctly..

[Audio] Visit Notes Pulled From Generations "Swept and mopped and made lunch and cleaned and talked with client" This note does not include any ADLs! If an audit was done by the VA for this Veteran there is a good chance they would lose their H/HHA benefits..

[Audio] Visit Notes Pulled From Generations "We had a great day today. I did dishes and fixed breakfast. I assisted with his shower and dressing. I cleaned up the bathroom and kitchen. We also visited." Although this visit note does contain ADLs that were completed, there are only two, and the remaining information is unnecessary. Example: Assisted Veteran with getting in and out of shower, washing, and getting dressed..

[Audio] Visit Notes Pulled From Generations "Assisted client with getting dressed and transfers to come downstairs for lunch. Transferred into his recliner to watch TV. Social Worker from VA came and visited with client. Cough/breathing much better than last week. Assisted him with using his nebulizer. Assisted with toileting/changed brief. Socialized. Assisted with ADLs. Made him a grilled cheese for a snack." Example: Assisted Veteran with the following ADLs: dressing, transferring, toileting, using nebulizer.

[Audio] Visit Notes Pulled From Generations "Washed dishes, air dry, put away. Cleaned kitchen. Cleaned bathroom. Swept and mopped. Vacuumed. Client took meds. Client wants to visit for remainder of shift." This visit note does not contain any ADLs and mentions medications. An audit of this shift could cause the VA to pull this Veterans H/HHA benefits. NEVER MENTION MEDICATIONS, INCLUDING REMINDERS. Not only are medication reminders an IADL, but incorrect wording can be confused with passing and can lead to termination..

[Audio] Visit Notes Pulled From Generations "Assisted Client with lympha press machine Compression stockings put on. Standby at all times" PERFECT! THIS NOTE HAS 3 ADLs LISTED AND DOES NOT CONTAIN ANY OTHER INFORMATION AS IT IS ALREADY CHARTED IN THE TASK LIST.

Questions?. Questions?. Questions?.