17. Common audit and denial risks
System-specific patterns that draw denials and additional documentation requests, with the corrected pattern and the Segment 6 cross-reference. The full catalog lives in Denial Patterns.
Risk | Why it fails | Corrected pattern |
|---|---|---|
“Safe” without screen | A safety conclusion with no fall-risk screen or hazard review. | Document the fall-risk screen, hazards, and medication review. (See Denial Patterns 6.1.) |
Cloned safety narratives | Identical safety language copied visit to visit. | Re-document the visit's actual findings and any change. (6.2.) |
Hazard noted, not addressed | A hazard charted with no mitigation. | Document the mitigation and the coordination. (6.3.) |
Safety taught, no response | Fall-prevention or medication-safety teaching with no teach-back. | Document topic, method, audience, and mastery percentage. (6.4.) |
Notification without outcome | “MD notified” of a fall with no orders or response. | Close the loop: time, content, response/orders, follow-through. (6.5.) |
Med reconciliation not done | Medications listed with no reconciliation or high-risk review. | Reconcile against the order and flag high-risk medications. (6.6.) |
Skilled need not tied to dx/risk | Generic safety claim. | Connect the assessment and mitigation to the diagnosis and risk. (6.7.) |
Unsupported homebound | “Remains homebound” with no safety-related evidence. | Cite the fall risk or assistance need and the taxing effort. (6.8.) |
Findings inconsistent with POC | Safety findings conflict with orders or the plan. | Align findings and mitigation to the plan of care. (6.9.) |
Risk not aligned to OASIS | Narrative risk conflicts with the coded OASIS risk items. | Align the narrative with the OASIS-E2 risk-assessment items. (6.10.) |