oasis-c… - Laff Associates

Report
OASIS-C - Managing The
Bumps In The Road
Lynda Laff, RN, BSN, COS-C
Laff Associates
OASIS-C…Fast Track to P$P
 *CMS ultimately plans to create a standard patient
assessment that can be used across all post-acute care
settings.

Harmonization of practice across settings
*Federal Register/Vol. 74, No. 44, Monday, March 9, 2009
*OASIS –C: Public comments & Responses
2
OASIS-C Process Measures
• Standardizing assessment/quality measurement
across (post-acute) health care settings. The PAC demo
began in 2008 and will result in a report to Congress in
2011 in the potential to use a single instrument to
measure patient care and costs longitudinally. In the
interim, OASIS, MDS, and the IRF to create the CARE
TOOL. This tool will be determining like elements that
can be described and measured the same way across
settings of care.
3
Value Based Purchasing
 Payment contingent on outcomes performance
Clinical
Financial – cost savings
 High performers = higher payments
 Medicare providers will be subject to three patient outcomes
measures for APU update!
End Result Outcomes
Process Outcome Measures
HH-CAHPS
4
Outcomes Reporting
Home Health Compare Report Method
and CASPER Report
Schedule
OASIS-B1
CASPER
Date Available
Data Period of:
12/2009
10/2008-9/2009
OASIS-B1
HH Compare
1/2010
10/2008-9/2009
OASIS-B1
HH Compare
4/2010
1/2009-12/2009
OASIS-C Process
CASPER
9/2010
1/2010-6/2010
OASIS-C Process
HH Compare
10/2010
1/2010-6/2010
OASIS-C Outcome
CASPER
05/2011
3/2010-2/2011
OASIS-C Outcome
HH Compare
07/2011
4/2010-3/2011
5
Information Deficit
• “Black Hole” for end result outcomes
Will not be reported until (CASPER) May 2011
Will be publically reported (HHC) July 2011
• Process measures
Reported (CASPER) September 2010
Publically reported October 2010
• Will you be driving blind?
This is the information you need to know…
6
Home Health Compare
Process Measure Summary
7
See Where You Stand…
8
9
Patient Detail Report …
lets you sort by any column.
10
End Result Outcomes
Home Health Compare
Improvement in Upper Body
Dressing
% of HH episodes where patients
improved in ability to dress upper
body
(M1810) Current Ability to Dress
Upper Body
Improvement in Lower Body
Dressing
% of HH episodes where patients
improved in ability to dress lower
body
M1820) Current Ability to Dress
Lower Body
Improvement in Bathing
% of HH episodes of care during
which the patient got better at
bathing self.
(M1830) Bathing
Improvement in Bed Transferring
% of HH episodes of care during
which the patient improved in
ability to get in and out of bed.
(M1850) Transferring
Improvement in AmbulationLocomotion
Percentage of home health
episodes of care during which the
patient improved in ability to
ambulate.
(M1860) Ambulation/Locomotion
Improvement in Management of
Oral Medications
Percentage of home health
episodes of care during which the
patient improved in ability to take
their medicines correctly (by
mouth).
(M2020) Management of Oral
Medications
11
End Result Outcomes
Home Health Compare
Improvement in Dyspnea
Percentage of home health
episodes of care during which
the patient became less short
of breath or dyspneic.
(M1400) When is the patient
dyspneic?
Improvement in Pain
Interfering with Activity
Percentage of home health
episodes of care during which
the patient's frequency of pain
when moving around
improved.
(M1242) Frequency of Pain
Interfering with Activity
Improvement in Status of
Surgical Wounds
Percentage of home health
episodes of care during which
the patient demonstrates an
improvement in the condition
of surgical wounds.
(M1340) Does this patient
have a Surgical Wound?
(M1342) Status of Most
Problematic (Observable)
Surgical Wound
Improvement in Urinary
Incontinence
Percentage of home health
episodes of care during which
the patient had less frequent
urinary incontinence, or had a
urinary catheter removed.
(M1610) Urinary Incontinence
or Urinary Catheter Presence:
(M1615) When does Urinary
Incontinence occur?
12
Utilization Outcomes
Home Health Compare
Emergency Department Use
without Hospitalization
Percentage of home health
episodes of care during which
the patient needed urgent,
unplanned medical care from a
hospital emergency
department, without admission
to hospital.
(M0100) Reason for
Assessment(
M2410) Inpatient Facility
Admission
(M2300) Emergent Care
Acute Care Hospitalization
Percentage of home health
episodes of care that ended
with the patient being
admitted to the hospital.
(M0100) Reason for
Assessment
(M2410) Inpatient Facility
Admission
(M2430) Reason for
Hospitalization
Discharged to community
Percentage of home health
episode after which patients
remained at home.
(M0100) Reason for
Assessment
(M2420) Discharge Disposition
13
Potentially Avoidable Events
Home Health Compare
Emergent care for wound
infections, deteriorating
wound status
Percentage of home
health episodes of care
during which the patient
required emergency
medical treatment from a
hospital emergency
department related to a
wound that is new, is
worse, or has become
infected
(M2300) Emergent Care
(M2310) Reason for
Emergent Care
Increase in Number of
Pressure Ulcers
Percentage of home
health episodes of care
during which the patient
had a larger number of
pressure ulcers at
discharge than at start of
care.
(M1306) Unhealed
Pressure Ulcer at Stage II
or Higher(
M1308) Current Number
of Unhealed Pressure
Ulcers at Each Stage
14
Measurable Processes
•
•
•
•
•
•
•
Timely Care
Coordination of Care
Assessment
Care Planning
Intervention Implementation
Patient and Caregiver Education
Prevention Strategies
15
Process Outcome Measures
Home Health Compare
Timely Initiation Of Care
(Timely Care)
% of home health episodes of care
during which the start or
resumption of care date was either
on the physician-specified date or
within 2 days of the referral date.
(M0102) Date of Physician-ordered
Start of Care
(M0104) Date of Referral
(M0030) Start of Care Date
(M0032) Resumption of Care Date
(M0100) Reason for Assessment
Depression Assessment Conducted
(Assessment)
% of home health episodes of care
during which patients were
screened for depression (using a
standardized depression screening
tool) at start of home health car
(M1730) Depression Screening
Multifactor Fall Risk Assessment
Conducted For Patients 65 And Over
(Assessment)
Percentage of home health episodes
of care in which patients 65 and
older had a multi-factor fall risk
assessment at the start of
care/resumption of care.
(M1910) Multi-factor Fall Risk
Assessment
(M0066) Birth Date
(M0090) Date Assessment
Completed
Pain Assessment Conducted
(Assessment)
Percentage of home health episodes
of care during which the patient was
assessed for pain using a
standardized pain assessment tool,
at start/resumption of home health
care
(M1240) Pain Assessment using a
standardized pain assessment tool
16
Process Outcome Measures
Home Health Compare
Pressure Ulcer Risk
Assessment Conducted
% of home health episodes
of care in which the patient
was assessed for risk of
developing pressure ulcers at
start of care/resumption of
care.
(M1300) Pressure Ulcer Risk
Assessment
Pressure Ulcer Prevention In
Plan Of Care
(Care Planning)
% of home health episodes of
care in which interventions to
prevent pressure ulcers were
included in the physicianordered plan of care for
patients assessed to be at
risk for pressure ulcers.
(M2250) f. Intervention(s) to
prevent pressure ulcers plan
of care
Diabetic Foot Care And
Patient/Caregiver Education
Implemented During Short
Term Episodes Of Care
(Implementation)
% of short term home health
episodes of care during which
diabetic foot care and
education specified during the
physician-ordered care plan
was implemented for patients
with diabetes.
(M0100) Reason for
Assessment (M2400) a.
Diabetic foot care
intervention(s)
(Assessment)
17
Process Measures – HHC
Heart Failure Symptoms
Addressed During Short Term
Episodes Of Care
(Implementation)
Percentage of short term
home health episodes of care
during which patients
exhibited symptoms of heart
failure for whom appropriate
actions were taken
(M0100) Reason for
Assessment (M1510) Heart
Failure Follow-up:
Pain Interventions
Implemented During Short
Term Episodes Of Care
(Implementation)
Percentage of short term
home health episodes of care
during which the patient had
pain and pain interventions
were included during the care
plan and implemented by the
end of the episode.
(M0100) Reason for
Assessment (M2400) d.
Intervention(s) to monitor
and mitigate pain
Drug Education On High Risk
Medications Provided To
Patient/Caregiver At Start Of
Episode
(Education)
Percentage of
patients/caregivers educated
about high-risk medications
at start/resumption of care
and instructed on how to
monitor the effectiveness of
drug therapy, how to
recognize potential adverse
effects, and how and when to
report problems.
(M2010) Patient/Caregiver
High Risk Drug Education
18
Process Measures – HHC
Drug Education On All
Medications Provided To
Patient/Caregiver During Short
Term Episodes Of Care
(Education)
Percentage of short term home
health episodes of care during
which patient/caregiver was
instructed on how to monitor
the effectiveness of drug
therapy, how to recognize
potential adverse effects, and
how and when to report
problems
(M0100) Reason for
Assessment (M2015)
Patient/Caregiver Drug
Education Intervention
Influenza Immunization
Received For Current Flu
Season
(Prevention)
Percentage of home health
episodes of care during which
patients received influenza
immunization for the current flu
season
(M1040) Influenza
Vaccine(M1045) Reason
Influenza Vaccine not received
Pneumococcal Polysaccharide
Vaccine Ever Received
(Prevention)
Percentage of home health
episodes of care during which
patients were determined to
have ever received
Pneumococcal Vaccine (PPV).
(M1050) Pneumococcal Vaccine
(M1055) Reason PPV not
received
19
Process Measures – HHC
Potential Medication Issues
Identified And Timely Physician
Contact At Start Of Episode
(Prevention)
Percentage of patients whose
drug regimen at start or
resumption of home health care
was assessed to pose a risk of
clinically significant adverse
effects or drug reactions and
whose physician was contacted
within one calendar day.
(M2002) Medication Follow-up
Potential Medication Issues
Identified And Timely Physician
Contact During Short Term
Episodes Of Care
(Prevention)
Percentage of home health
episodes of care in which the
patient's drug regimen during the
episode was assessed to pose a
risk of significant adverse effects
or drug reactions and whose
physician was contacted within
one calendar day.
(M0100) Reason for Assessment
(M2004) Medication Intervention
Pressure Ulcer Prevention
Implemented During Short Term
Episodes Of Care
(Prevention)
Percentage of home health
episodes of care in which
interventions to prevent pressure
ulcers were included in the
physician-ordered plan of care
and implemented since the
previous OASIS assessment.
(M0100) Reason for Assessment
(M2400) e. Intervention(s) to
prevent pressure ulcers
20
Outcome Improvement
• Requires Episode Management
Case management and accountability
Continuity and coordination of care
Admission Nurse Models
• Hand-offs = errors
• The more staff involved – the less the accountability
• Look back questions – M2400
Primary nursing
• Requires adequate staffing model
• Must provide incentive for patient management
• Scheduling is a process – not care management!
Cannot dictate patient care
Must respect continuity
21
Therapy Case Management/Collaboration
• Therapy Case Management
Management of assistants
Reporting on utilization and outcomes
• Scope of Practice
– PT- only patients – set expectations / work with limitations
• Medication management – APTA recommendations
• PT/INR – lab monitoring
• Team Players
Team management
Participation and reporting
Paring therapists with RN case manager
Contract therapists
22
Supervise and Manage
• Management and Supervision
How do you know?
What checks are in place?
How long does it take?
Who is validating information?
Were the suggested corrections actually made?
What “tools” do you use?
Are there repeated errors? If so – WHY?
– Repeated errors cost money
23
Case Conference
•
•
•
•
One on one review of patients on census – not a 2 hour meeting!
Expect clinician to be prepared
Can be done remotely
Must be done without fail…no excuse accepted
• Danger Zone…
Clinician “does not know patient”
“Hasn’t seen patient in 3 weeks”
“Cookie cutter” scheduling
Visits never increase or decrease – always a 60 day episode
Frequent patient declines
Potentially avoidable events
Abundance of “missed visits”
LOS longer than national benchmark
Case weight extraordinarily low
24
Team Conference
• Can be done remotely or in office – bi-weekly
Attendance required not recommended
Clinicians must be prepared
Discuss ONLY those patients –
Multiple disciplinary problems or care plan changes
Not progressing according to plan
Potential for early discharge
3 weeks from recertification or discharge
• Must be documented
25
Common OASIS-C Challenges
M1510
M2002, M2004, 2010, 2015
Heart Failure Follow-up
Medication Management
M 1300, M1302, M1306, M1307, Wound Assessment; Pressure
1320, M1324, M1350
Ulcer Prevention; Pressure Ulcer
Treatment
M2250
Evidence of communication with
the physician to include
specified best practice
interventions in the plan of care.
M2400
Evidence that specified
interventions were included in
the physician-ordered plan of
26
care AND implemented
Process Measure Audit
OUTSOMES MEASURE
Yes
No
OASIS ITEMS
Did Pt. receive flu vaccine for current
season?
(M1040) Influenza Vaccine
(M1045) Reason Flu Vaccine
Not Given
Has Pt. ever received the pneumonia
vaccine?
(M1050) Pneumonia Vaccine
(M1045) Reason Not Given
Was patient admitted as ordered by
MD or within 48 hours of referral
or hospital discharge?
(M0102) Date of Physicianordered Start of Care
(M0104) Date of Referral
(M0030) Start of Care Date
(M0032) Resumption of Care
Date
(M0100) Reason for
Assessment
(M2250) A. Patient-specific
parameters for notifying MD on
485?
Were patient specific parameters
included in the plan of care?
Was a depression assessment
completed?
Patient at risk for
depression?________
Was a multi-factor Fall Risk
Assessment Conducted for pts.
 65
Score__________
Was a pain assessment conducted?
INTERVENTIONS
Yes
No
Was MD contacted if indicated?
(M1730) Depression Screening
(M2250)d. Depression
interventions
Were depression interventions
implemented if indicated?
(M1910) Risk Assessment
M0066 Birthdate
(M0090) Date Assessment
Completed
Were Fall prevention
interventions implemented if
indicated?
(M1240) Pain Assessment using
standardized tool
If assessment indicated pain were
measures to mitigate pain
27
Process Measure Audit
OUTSOMES MEASURE
Was a pressure Ulcer Risk
Assessment Conducted?
Score__________
Yes
No
OASIS ITEMS
(M1300) Pressure Ulcer Risk
Assessment
(M2250) Interventions to
prevent PU
Were principles of moist wound
healing included in 485?
(M2250) Pressure Ulcer
Treatment on 485
Were Diabetic Foot Care orders and
Patient Education included in
Plan of Care?
(M2250) b. Diabetic foot care in
plan of care
M2400)
Was patient diagnosed with heart
failure?
(M0100 Reason for Assessment
(M1510) Heart Failure Follow
Up
Was a complete drug regimen
review performed?
(M2000) Drug Regimen Review
(M2015) Pt./Cg. Drug
Education
Was patient identified to be taking
high risk medications?
(M2010)Pt./Cg High Risk Drug
Education
M2015)Pt./Cg. High Risk Drug
Intervention
INTERVENTIONS
Were pressure ulcer
prevention measures
included in the 485 and
implemented?
Yes
No
Were measures to
address diabetic foot
care included in the 485
and patient education
implemented if
indicated?
T
Were heart failure
symptoms addressed
during the episode of
care if indicated? T
Was patient instructed to
monitor the
effectiveness of drug
therapy, to recognize
adverse effects and
when to report
problems?
Evidence of pt/cg
education about high
risk medications?
28
M1510 Home Health Compare
• Measure:
• Heart Failure Symptoms Addressed During Short
Term Episodes Of Care (Implementation)
Percentage of short term home health episodes of care
during which patients exhibited symptoms of heart
failure for whom appropriate actions were taken
(M0100) Reason for Assessment
(M1510) Heart Failure Follow-up:
• NQF Endorsed
29
Heart Failure Follow Up
(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure
and has exhibited symptoms indicative of heart failure since the previous OASIS
assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)
⃞ 0 - No action taken
⃞ 1 - Patient’s physician (or other primary care practitioner) contacted the same day
⃞ 2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency
room)
⃞ 3 - Implemented physician-ordered patient-specific established parameters for
treatment
⃞ 4 - Patient education or other clinical interventions
⃞ 5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change
in visit frequency, telehealth, etc.)
Time Points: Transfer/D/C
30
Must Have Heart Failure Diagnoses
•
The patient must have a diagnosis of heart
failure in the
following;
M1010: Inpatient Diagnoses,
M1016: Diagnoses Causing Change in Treatment, or
M01020/1022/1024: Primary/Secondary diagnoses for home
care.
 Consider any new or ongoing heart failure symptoms that
occurred at the time of the previous OASIS assessment or
since that time.
31
Heart Failure Follow Up Tips
• Tele-monitoring
• Disease management protocols
Vital sign monitoring
Weight gain
Medication management – standing orders
Diet instruction
• Telephone contact –
Must call if visited only 1 x week
Document a telephone visit on a standardized form
• Develop heart failure indicators/thresholds
Flow charts
•
•
•
•
Discuss parameter variances at case conference
Reports to case manager by team members
Scope of practice for physical therapists – develop cardiac rehab protocols
Last professional clinician out - responsible
32
Medication Regimen Review
(M2000) Drug Regimen Review: Does a complete drug regimen review
indicate potential clinically significant medication issues, e.g., drug reactions,
ineffective drug therapy, side effects, drug interactions, duplicate therapy,
omissions, dosage errors, or noncompliance?




0 - Not assessed/reviewed [ Go to M2010 ]
1 - No problems found during review [ Go to M2010 ]
2 - Problems found during review
NA - Patient is not taking any
medications [ Go to M2040 ]
Time Points: SOC/ROC
33
M2000 Scenario
During a SOC visit the SN notes a potential drug –
drug interaction when two drugs are taken
simultaneously. The issue was resolved during
the visit by educating the patient to take one of
the medications in the AM and the other in the
PM.
How should the SN answer M2000?
34
Drug Regimen Review
(M2000) Drug Regimen Review: Does a complete drug
regimen review indicate potential clinically significant
medication issues, e.g., drug reactions, ineffective drug
therapy, side effects, drug interactions, duplicate
therapy, omissions, dosage errors, or noncompliance?
⃞ 0 - Not assessed/reviewed [ Go to M2010 ]
⃞ 1 - No problems found during review [ Go to
M2010 ]
⃞ 2 - Problems found during review
⃞ NA - Patient is not taking any medications [ Go to M2040
]
35
OCCB January Q & As
Question 33:
The assessing clinician identifies a problem with medications. The
patient has not picked up a prescription because she was not sure
she absolutely needed it. If the assessing clinician’s education
results in the resolution of the situation prior to the completion of
the comprehensive assessment, can the clinician indicate on M2000
that there is no clinically significant problem, eliminating the need
to address it in M2002 Medication Follow-up?
Answer 33: If a medication related problem is identified and
resolved by the agency staff by the time the assessment is
completed, the problem does not need to be reported as an
existing clinically significant problem.
36
M2002 – Home Health Compare
• Measure:
• Potential Medication Issues Identified And Timely
Physician Contact At Start Of Episode (Prevention)
– Percentage of patients whose drug regimen at
start or resumption of home health care was
assessed to pose a risk of clinically significant
adverse effects or drug reactions and whose
physician was contacted within one calendar day.
• (M2002) Medication Follow-up
• NQF Endorsed
37
M2002 Medication Follow Up
(M2002) Medication Follow-up: Was a physician or the
physician-designee contacted within one calendar day to
resolve clinically significant medication issues, including
reconciliation?
 0 - No
 1 – Yes
Time Points: SOC/ROC
38
M2000, M2002
• During the initial assessment, the SN reviewed the
medications in the home and included them in the patient’s
med list.
• The PT visited the patient the next day, noted that the SN had
not checked for drug – drug interactions. He ran the
program and discovered a potential for a high risk interaction.
• He contacted the SN and called the MD’s office about the
potential drug interaction but the MD was out of town until
the following day.
• The receptionist told the SN that the patient had been taking
those two medications for several months with no problems.
39
M2000, M2002
• How should the SN answer M2000?
(M2000) Drug Regimen Review: Does a complete drug regimen review
indicate potential clinically significant medication issues, e.g., drug
reactions, ineffective drug therapy, side effects, drug interactions,
duplicate therapy, omissions, dosage errors, or noncompliance?




0 - Not assessed/reviewed [ Go to M2010 ]
1 - No problems found during review [ Go to M2010 ]
2 - Problems found during review
NA - Patient is not taking any
medications [ Go to M2040 ]
40
M2000, M2002
• How should the SN answer M2000?
(M2000) Drug Regimen Review: Does a complete drug regimen review
indicate potential clinically significant medication issues, e.g., drug
reactions, ineffective drug therapy, side effects, drug interactions, duplicate
therapy, omissions, dosage errors, or noncompliance?
 0 - Not assessed/reviewed [ Go to M2010 ]
 1 - No problems found during review [ Go to M2010 ]
 2 - Problems found during review
 NA - Patient is not taking any
medications [ Go to M2040 ]
41
M2000, M2002
• How should the SN answer M2002?
(M2002) Medication Follow-up: Was a physician or the physiciandesignee contacted within one calendar day to resolve clinically significant
medication issues, including reconciliation?
 0 - No
 1 – Yes
42
M2000, M2002
• How should the SN answer M2002?
(M2002) Medication Follow-up: Was a physician or the physiciandesignee contacted within one calendar day to resolve clinically significant
medication issues, including reconciliation?
 0 - No
 1 – Yes
43
Questions / Answer October 2009
M2002 Medication Follow-up and M2004 Medication
Intervention
Question 34: Must the physician acknowledgement of the
agency’s communication, and resulting reconciliation occur
in the specified time frame (within one calendar day), in
order to select response “1” for M2002 or M2004?
Answer 34: Yes, in order to select response 1, the two-way
communication AND reconciliation (or plan to resolve the
problem) must be completed by the end of the next
calendar day after the problem was identified.
44
M2004 – Home Health Compare
• Measure:
• Potential Medication Issues Identified And Timely
Physician Contact During Short Term Episodes Of
Care (Prevention)
Percentage of home health episodes of care in which
the patient's drug regimen during the episode was
assessed to pose a risk of significant adverse effects or
drug reactions and whose physician was contacted
within one calendar day.
(M0100) Reason for Assessment
(M2004) Medication Intervention
45
M2004- Medication Intervention
(M2004) Medication Intervention: If there were any clinically
significant medication issues since the previous OASIS assessment,
was a physician or the physician-designee contacted within one
calendar day of the assessment to resolve clinically significant
medication issues, including reconciliation?



0 - No
1 - Yes
NA - No clinically significant medication issues identified since
the previous OASIS assessment
Time Points: Transfer/DC not to inpatient facility
46
M2004 Medication Intervention - Tips
• What would you do….
– If it was YOUR MOTHER?
• Medical Director
• When you know of a potential adverse event…
Help!
47
M2010 -Medications
(M2010) Patient/Caregiver High Risk Drug
Education: Has the patient/caregiver received
instruction on special precautions for all high-risk
medications (such as hypoglycemics,
anticoagulants, etc.) and how and when to report
problems that may occur?
 0 - No
 1 - Yes
 NA - Patient not taking any high risk drugs OR patient/caregiver
fully knowledgeable about special precautions associated with all
high-risk medications
Time Points: SOC/ROC
48
M2010 High Risk Drugs - Tips
•
Identify high risk drugs – access high risk drug information
from internet, accrediting body etc.
•
Create a laminated list of high risk drugs including special
precautions for each drug.
•
Access software packages with teaching guides for high risk
drugs.
•
Develop high risk drug education handouts to give to patients.
•
Include a high risk drug list as an item on a “check off” list for
clinicians to complete after a SOC, ROC, Recertification and/or
medication change as appropriate.
49
High-Alert Medications
Potentially Used In Home Health Care
Drug Category
Medications (Does not include all drugs that could potentially be
listed in this category)
Anticoagulants: An anticoagulant is a drug that
helps prevent the clotting (coagulation) of
blood
Heparin, Coumadin, Lovenox, Plavix, ASA, Anisindione,
Dicumarol
Inotropic Medications: Affecting the force of
muscle contraction. An inotropic heart drug is
one that affects the force with which the heart
muscle contracts.
Digoxin, Milrinone, Lanoxin,Digitek, digibind, Caduet
Oral hypoglycemics: Used for controlling blood
sugar in adult-onset diabetes
Actos Oral , Januvia, Diflucan (Fluconazole ), lyrica (Pregabalin ),
Glucotrol (Glipizide ), Glucotrol XL
Insulin: Insulin is a naturally-occurring
hormone secreted by the pancreas. Insulin is
required by the cells of the body in order for
them to remove and use glucose from the
blood.
Lente, Lantus SubQ, Humalog, Regular human insulin (Novolin
R, Humulin R) NPH human insulin (Novolin N, Humulin N)
Narcotics, Opiates : Narcotics are drugs that
numb the senses, relieve severe pain, and
induce sleep
Methadone, Codeine, Meperidine, Morphine, hydrocodone,
Oxycontin, Percoset, Zanex, Haldol, Diazepam, Roxanal
Chemotherapuedic Agents: Cancer treatment
drugs
Azathioprine, Busulfan, Chlorambucil, Cyclophosphamide,
Cytarabine, Cytoxan, Fluorouracil, Mercaptopurine, Taxol,
Taxotere, Ixempra, velban, vincristine, Oncovin
Methotrexate (Non oncologic use)
50
M2015 –
Home Health Compare
• Measure:
• Drug Education On All Medications Provided To
Patient/Caregiver During Short Term Episodes Of
Care (Education)
Percentage of short term home health episodes of care
during which patient/caregiver was instructed on how
to monitor the effectiveness of drug therapy, how to
recognize potential adverse effects, and how and when
to report problems
(M0100) Reason for Assessment
(M2015) Patient/Caregiver Drug Education Intervention
NQF Endorsed
51
M2015 Drug Education
(M2015) Patient/Caregiver Drug Education Intervention: Since the
previous OASIS assessment, was the patient/caregiver instructed by
agency staff or other health care provider to monitor the effectiveness of
drug therapy, drug reactions, and side effects, and how and when to
report problems that may occur?
 0 - No
 1 - Yes
 NA - Patient not taking any drugs
Time Points: Transfer/Discharge
52
M2015 Item Guidance
• Drug education interventions should address all
medications the patient is taking – prescribed and
over-the-counter – by any route.
• Education must be clearly documented.
• Effective, safe management of medications
includes knowledge of effectiveness, potential side
effects and drug reactions, and when to contact
the appropriate care provider.
53
Purchase or Develop
Teaching Sheets
• Identify most commonly used drugs
Access pharmacy teaching tools
Computer programs
• Use patient – friendly language
• Keep it simple
54
M1300 Pressure Ulcer
Risk Assessment
• Measure:
• Pressure Ulcer Risk Assessment Conducted
% of home health episodes of care in which the patient
was assessed for risk of developing pressure ulcers at
start of care/resumption of care.
(M1300) Pressure Ulcer Risk Assessment
• NQF Endorsed
55
M1300 Pressure Ulcer
Risk Assessment
(M1300) Pressure Ulcer Assessment: Was this
patient assessed for Risk of Developing Pressure
Ulcers?
⃞ 0 - No assessment conducted [ Go to M1306 ]
⃞ 1 - Yes, based on an evaluation of clinical factors, e.g., mobility,
incontinence, nutrition, etc.,
without use of standardized tool
⃞ 2 - Yes, using a standardized tool, e.g., Braden, Norton, other
Time Points: SOC/ROC
56
NPUAP
Risk Assessment Criteria
•
Risk Assessment
Consider all bed-bound and chair-bound persons, or those whose ability to
reposition is impaired, to be at risk for pressure ulcers.
Use a valid, reliable and age appropriate method of risk assessment that
ensures systematic evaluation of individual risk factors
Assess all at-risk patients/residents at the time of admission and at every
visit.
Identify all individual risk factors (decreased mental status, exposure to
moisture, incontinence, device related pressure, friction, shear, immobility,
inactivity, nutritional deficits) to guide specific preventive treatments.
Document risk assessment subscale scores and total scores and implement a
risk-based prevention plan
National Pressure Ulcer Advisory Panel
*
57
Pressure Ulcer
“Best Practice” Tips
•
•
•
•
Develop a policy and process for pressure risk assessment for all bedbound and chair-bound persons, or those whose ability to reposition is
impaired AT LEAST at admission, resumption of care AND recertification
to ensure that an appropriate plan is initiated for patients identified to
be at risk for pressure ulcers.
Educate clinicians to have the patient undress!
Educate clinicians to assess high risk patients every visit
Observe patient’s ability to
Follow directions
Hear and understand
Observe patient’s
Manual dexterity
Potential for SOB upon exertion
Implement an evidence based pressure ulcer risk assessment tool
58
M1306 Unhealed Stage II PU
(M1306) Does this patient have at least one
Unhealed Pressure Ulcer at Stage II or Higher
or designated as "unstageable"?
 0 - No [ Go to M1322 ]
 1 - Yes
Time Points: SOC/ROC/F/U/D/C
59
M1307- Oldest NE
Stage II PU
(M1307) The Oldest Non-epithelialized Stage II Pressure
Ulcer that is present at discharge
⃞ 1 - Was present at the most recent SOC/ROC assessment
⃞ 2 - Developed since the most recent SOC/ROC assessment: record date
pressure ulcer first identified:
__ __ /__ __ /____ __ __
month / day / year
⃞ N/A - No non-epithelialized Stage II pressure ulcers are present at discharge
OASIS-C:
Time Point: Discharge
60
M1307
This is a Really BIG deal!
•
The intent of this item is to;
Identify the oldest Stage II pressure ulcer that is present at the
time of discharge and is not fully epithelialized
Assess the length of time this ulcer remained unhealed while the
patient received care from the home health agency.
Identify patients who develop Stage II pressure ulcers while
under the care of the agency.
•
In other words, was there anything the agency could or should have done
to prevent and/or heal the PU?
•
What “best practice” was implemented?
61
M1307- Oldest NE
Stage II or Higher PU
• Audit every patient record of patients discharged with a stage
II (or higher) PU
• How do you “look back”
Software system
Data scrubber
Manual report
• How do you validate information?
Audit
Case conference
• Educate clinicians
Wound staging
WOCN and NPUAP guidelines
OASIS-C Home Health Compare Outcomes
62
M1320 Most Problematic PU
You admitted a patient with a pressure ulcer on his heel.
50% of the wound bed of the ulcer was covered with
eschar. How would you score M1320?
(M1320) Status of Most Problematic (Observable) Pressure Ulcer:





0 - Newly epithelialized
1 - Fully granulating
2 - Early/partial granulation
3 - Not healing
N/A - No observable pressure ulcer
Time Points: SOC/ROC/D/C
63
M1320 Status of
Most Problematic PU
(M1320) Status of Most Problematic (Observable) Pressure
Ulcer:
 0 - Newly epithelialized
 1 - Fully granulating
 2 - Early/partial granulation
 3 - Not healing
 N/A - No observable pressure ulcer
A pressure ulcer with necrotic tissue (eschar/slough) obscuring the wound base
cannot be staged, but its healing status is either Response 2 – Early/partial
granulation if necrotic or avascular tissue covers <25% of the wound bed, or
Response 3 - Not healing, if the wound has ≥25% necrotic or avascular
tissue.
*Clinicians often incorrectly score N/A here
64
M1324 Stage of
Most Problematic PU
Same patient – how would you score M1324?
(M1324) Stage of Most Problematic Unhealed (Observable)
Pressure Ulcer:





1 - Stage I
2 - Stage II
3 - Stage III
4 - Stage IV
N/A - No observable pressure
ulcer or unhealed pressure ulcer
65
Guidelines
• (When determining the healing status of a pressure ulcer for
answering M1320, the presence of necrotic tissue does NOT
make the pressure ulcer NA – No observable pressure ulcer.)
• When scoring M1324 – remember - a pressure ulcer with
necrotic tissue (eschar/slough) obscuring the wound base
cannot be staged, but its healing status is either Response 2 –
Early/partial granulation if necrotic or avascular tissue covers
<25% of the wound bed, or Response 3 - Not healing, if the
wound has ≥25% necrotic or avascular tissue.
66
M2400 - Home Health Compare
• Measure:
• Pressure Ulcer Prevention Implemented During
Short Term Episodes Of Care (Prevention)
Percentage of home health episodes of care in which
interventions to prevent pressure ulcers were included
in the physician-ordered plan of care and implemented
since the previous OASIS assessment
(M0100) Reason for Assessment
(M2400) e. Intervention(s) to prevent pressure ulcers
• NQF Endorsed
67
(M2400) Intervention Synopsis: Since the previous OASIS assessment,
were the following interventions BOTH included in the physician-ordered
plan of care AND implemented? Time Points: Discharge/Transfer
Plan / Intervention
No
Yes
N/A
Not Applicable
(
a. Diabetic foot care including
monitoring for the presence of skin
lesions on the lower extremities and
patient/caregiver education on proper
foot care
b. Falls prevention interventions
c. Depression intervention(s) such as
medication, referral for other treatment,
or a monitoring plan for current
treatment
d. Intervention(s) to monitor and
mitigate pain
e. Intervention(s) to prevent
pressure ulcers
f. Pressure ulcer treatment based on
principles of moist wound healing
 0
 0
 1
 1
 2
Patient is not a diabetic or is a bi-lateral
amputee
 2
Formal multi-factor Fall Risk Assessment
indicates the patient was not at risk for falls
since the last OASIS assessment
 0
 1
 2
Formal assessment indicates patient did not
meet criteria for depression AND patient did
not have diagnosis of depression since the last
OASIS assessment
 0
 1
 2
Formal assessment did not indicate pain since
the last OASIS assessment
 2
Formal assessment indicates the patient
was not at risk of pressure ulcers since
the last OASIS assessment
 0
 0
 1
 1
 2
Dressings that support the principles of moist
68
wound healing not indicated for this patient’s
pressure ulcers OR patient has no pressure
M2400 Intervention Synopsis
Pressure Ulcer Intervention
•
Yes – ONLY if the clinical intervention was
included in the plan of care AND implemented at
the time of the previous OASIS assessment or
since that time.
69
NPUAP Skin Care for
PU Prevention
• Skin Care
– Perform a head to toe skin assessment at least daily, especially checking
pressure points such as sacrum, ischium, trochanters, heels, elbows, and the
back of the head.
– Individualize bathing frequency. Use a mild cleansing agent. Avoid hot water
and excessive rubbing. Use lotion after bathing. For neonates and infants
follow evidence-based institutional protocols
– Establish a bowel and bladder program for patients with incontinence.
– When incontinence cannot be controlled, cleanse skin at time of soiling, and
use a topical barrier to protect the skin. Select under pads or briefs that are
absorbent and provide a quick drying surface to the skin. Consider a pouching
system or collection device to contain stool and to protect the skin.
– Use moisturizers for dry skin. Minimize environmental factors leading to dry
skin such as low humidity and cold air.
– Avoid massage over bony prominences.
*National Pressure Ulcer Advisory Panel
70
NPUAP Nutrition
PU Prevention
• Identify and correct factors compromising protein/ calorie
intake consistent with overall goals of care.
• Consider nutritional supplementation/support for
nutritionally compromised persons consistent with overall
goals of care.
• If appropriate offer a glass of water when turning to keep
patient/resident hydrated.
• Multivitamins with minerals per physician’s order
*National Pressure Ulcer Advisory Panel
71
NPUAP Staff Education
Recommendations
• Education
• Implement pressure ulcer prevention educational programs that are
structured, organized, comprehensive, and directed at all levels of health
care providers, patients, family, and caregivers.
• Include information on:
–
–
–
–
–
–
–
–
–
•
Etiology of and risk factors for pressure ulcers
Risk assessment tools and their application
Skin assessment
Selection and use of support surfaces
Nutritional support
Program for bowel and bladder management
Development and implement individualized programs of skin care
Demonstration of positioning to decrease risk of tissue breakdown
Accurate documentation of pertinent data
Include mechanisms to evaluate program effectiveness in preventing
pressure ulcers.
*National Pressure Ulcer Advisory Panel
72
Mechanical Loading &
Support Surface Recommendations
• Mechanical Loading and Support Surfaces
– Reposition bed-bound persons at least every two hours and chair-bound persons
every hour consistent with overall goals of care.
– Consider postural alignment, distribution of weight, balance and stability, and
pressure redistribution when positioning persons in chairs or wheelchairs.
– Teach chair-bound persons, who are able, to shift weight every 15 minutes.
– Use a written repositioning schedule.
– Place at-risk persons on pressure-redistributing mattress and chair cushion
surfaces.
– Avoid using donut-type devices and sheepskin for pressure redistribution.
*National
Pressure Ulcer Advisory Panel
73
Mechanical Loading &
Support Surface Recommendations
•
Use lifting devices (e.g., trapeze or bed linen) to move persons rather than drag
them during transfers and position changes.
•
Use pillows or foam wedges to keep bony prominences, such as knees and ankles,
from direct contact with each other. Pad skin subjected to device related pressure
and inspect regularly.
•
Use devices that eliminate pressure on the heels. For short-term use with
cooperative patients, place pillows under the calf to raise the heels off the bed.
•
Place heel suspension boots for long-term use.
•
Avoid positioning directly on the trochanter when using the side-lying position;
use the 30° lateral inclined position.
•
Maintain the head of the bed at or below 30° or at the lowest degree of elevation
consistent with the patient’s/resident’s medical condition.
•
Institute a rehabilitation program to maintain or improve mobility/activity status.
*National Pressure Ulcer Advisory Panel
74
M2400 – Pressure Ulcer Intervention
•
•
•
•
•
Teach patient and/or caregiver about frequent position
changes
Instruct regarding proper positioning to relieve pressure
Careful skin assessment and hygiene including education for
the patient and/or caregiver on daily skin assessment,
hygiene and skin care.
Use of pressure-relieving devices such as enhanced
mattresses and chair cushions.
Initiate physical therapy as appropriate to teach safe
mobility.
75
M1334 Problematic Stasis Ulcer
(M1334) Status of Most Problematic
(Observable) Stasis Ulcer:




0 - Newly epithelialized INCORRECT ANSWER!
1 - Fully granulating
2 - Early/partial granulation
3 - Not healing
Time Points: SOC/ROC/F/U/D/C
For the purpose of this OASIS item, when complete epithelialization
has been present for more than 30 days, the stasis ulcer is no longer
described as a stasis ulcer and should not be included in this item.
76
Surgical Wound
or Pressure Ulcer?
Scenario:
• A patient was admitted to home care with a pressure ulcer
that was 50% covered with black eschar. Measurements were
6 cm (L) by 2cm (W). The patient ultimately was hospitalized
for a flap procedure.
• The flap procedure failed and the flap graft or pedicle was
revised.
• At ROC, should the wound be identified as a dehisced surgical
wound or is it now a pressure ulcer since the flap procedure
has failed?
77
M1340 Surgical Wound
(M1340) Does this patient have a Surgical Wound?
 0 - No [ Go to M1350 ]
 1 - Yes, patient has at least one (observable) surgical wound
 2 - Surgical wound known but not observable due to nonremovable dressing [ Go to M1350 ]
Time Points: SOC/ROC/F/U/D/C
78
Is It a Surgical Wound
or Is It Pressure Ulcer?
• OASIS C guidance indicates that this wound is no
longer a pressure ulcer once a flap procedure has
been performed. It is a surgical wound. If the current
wound began with dehiscence of the flap, it is still a
dehisced wound. If the flap had healed and
subsequently broken down, it would be a pressure
ulcer.
79
M1340 “Cheat Sheet”
Is A Surgical Wound
Not A Surgical Wound
Non-epitelialized, non-infected wound
closed by sutures, staples or chemical
bonding
Healed incision, scar, keloid
A muscle flap, skin advancement flap, or
rotational flap replacing a pressure ulcer
Debrided pressure ulcer
A surgical "take-down" procedure of a
previous bowel ostomy
Skin graft
Orthopedic pin sites, central line sites,
stapled or sutured incisions, and wounds
with drains
Ostomies (no ostomy is considered a
surgical wound)
Medi-port sites and other implanted
infusion devices or venous access devices
PICC line (inserted peripherally)
Cataract surgery of the eye, surgery to
the mucosal membranes, or a
gynecological surgical procedure via a
vaginal approach
80
M1350
Sara Jones has a mole on her arm, a keloid
scar on her leg and a tattoo on her shoulder.
None of the above items are addressed in the
plan of care. M1350 “Does this patient have
a wound” ?
81
M1350
Answer:
M1350 Does this patient have a wound?
No
Rationale:
1. Skin lesions or open wounds that are not receiving clinical
intervention from the home health agency should not be
considered when responding to this question.
2.
Do not include tattoos, piercings, and other skin alterations unless ongoing
assessment and/or clinical intervention by the home health agency is a part of
the planned/provided care.
82
M1350
Bob Green has a new tracheostomy with
orders for dressing changes to the surgical
site. How would you answer M1350 “Does
this patient have a wound”?
83
M1350
Answer: M1350 “Does this patient have a wound”?
Yes
Rationale:
Ostomies, other than bowel ostomies, (e.g.,
tracheostomy, thoracostomy, urostomy) ARE
considered to be skin lesions or open wounds if
clinical interventions (e.g., cleansing, dressing
changes) are being provided by the home health
agency during the home health care episode.
84
M1350 “Cheat Sheet”
YES - Is a Skin Lesion
or Open Wound
No - Not A Skin Lesion
or Open Wound
Ulcers, rashes, persistent redness
w/o break in skin
Bowel Ostomy
Any skin condition that is clinically
assessed and included in the plan of
care
A skin condition not assessed or treated;
not in plan of care
Burns, diabetic ulcers, cellulitis,
abscesses, wounds caused by
trauma of various kinds, etc.
Cataract surgery, gynecological surgery
performed vaginally, mucosal surgery
PICC lines and peripheral IV sites
Tattos, piercings unless clinical intervention
is performed by HHA
Ostomies (trachestomy,
thoracotomy, urostomy) when
clinical intervention is performed by
HHA
85
(M2250) Plan of Care Synopsis: Does the physician-ordered
plan of care include the following: Time Points: SOC/ROC
Plan / Intervention
No
Yes
N/A
Not Applicable
a. Patient-specific parameters for notifying
physician of changes in vital signs or other
clinical findings
 0
 1
 2
Physician has chosen not to establish
patient-specific parameters for this
patient. Agency will use standardized
clinical guidelines accessible for all care
providers to reference
b. Diabetic foot care including monitoring for
the presence of skin lesions on the lower
extremities and patient/caregiver education
on proper foot care
 0
 1
 2
Patient is not a diabetic or is a bilateral amputee
 0
 1
 2
Patient is not assessed to be at risk for
falls
 0
 1
 2
Patient has no diagnosis or symptoms
of depression
 0
 1
 2
No pain identified
 0
 1
 2
Patient is not assessed to be at risk for
pressure ulcers
 0
 1
 2
Patient has no pressure ulcers with 86
need for moist wound healing.
c. Falls prevention interventions
d. Depression intervention(s) such as
medication, referral for other treatment, or a
monitoring plan for current treatment
e. Intervention(s) to monitor and mitigate
pain
f. Intervention(s) to prevent pressure ulcers
g. Pressure ulcer treatment based on
principles of moist wound healing OR order
for treatment based on moist wound healing
has been requested from physician
Home Health Compare
• Timely Initiation Of Care (Timely Care)
• Measure:
% of home health episodes of care during which the start
or resumption of care date was either on the physicianspecified date or within 2 days of the referral date.
•
•
•
•
•
•
(M0102) Date of Physician-ordered Start of Care
(M0104) Date of Referral
(M0030) Start of Care Date
(M0032) Resumption of Care Date
(M0100) Reason for Assessment
NQF Endorsed
87
M0102, Physician Ordered SOC date
M0104, Date of Referral
Question 2:
When determining the physician-ordered SOC or the date of
referral should communication from the hospital/SNF DC
planner be considered as representing physician referral?
Answer 2:
Yes, a referral received from a hospital or SNF discharge
planner on behalf of the physician should be considered when
determining the physician-ordered SOC date or the date of
referral.
88
M0104, Date of Referral
Question 3:
The home health agency received a referral on June 1st, and
then on June 2nd received a faxed update with additional
patient information that indicates a possible delay in the
patient’s hospital discharge date. What is the referral date
for M0104?
Answer 3:
If start of care is delayed due to the patient’s condition or
physician request and no date was specified as the start of
care date, then the date the agency received
updated/revised referral information for home care
services to begin would be considered the date of referral.
In your scenario, June 2 is the correct response for M0104.
89
M104 Guidance
• If the originally ordered start of care is delayed due to the
patient’s condition or physician request (e.g., extended
hospitalization), then the date specified on the
updated/revised order to start home care services would be
considered the date of physician-ordered start of care
(resumption of care).
90
M1730 - Home Health Compare
• (M1730) Depression Screening
• Measure:
% of home health episodes of care during which patients
were screened for depression (using a standardized
depression screening tool) at start of home health care
(M1730) Depression Screening
• NQF Endorsed
91
Home Health Compare
• (M1910) Fall Risk Assessment
• Measure:
% of home health episodes of care in which patients 65 and
older had a multi-factor fall risk assessment at the start of
care/resumption of care.
(M0066) Birth Date
(M0090) Date assessment Completed
(M1910) Multi-factor Fall Risk Assessment
• NQF Endorsed
92
Home Health Compare
•
•
(M1240) Pain Assessment
Measure:
Percentage of home health episodes of care during
which the patient was assessed for pain, using a
standardized pain assessment tool, at
start/resumption of home health care.
(M1240) Pain Assessment using a standardized pain
assessment tool
•
NQF Endorsed
93
Pain Assessment & Mitigation
Scenario:
• A pain assessment was conducted and the patient was
identified to have no severe pain (score 1 at M1240)
• At M1242 Frequency of pain interfering with movement was
answered “2” - less often than daily
• The patient is controlling his pain with Tylenol and the nurse
reviewed this with him.
• How would you answer row d M2250 Intervention(s) to
monitor and mitigate pain?
94
M2250 Guidance
• Row e: If the physician-ordered plan of care contains
interventions to monitor AND mitigate pain, select “Yes.”
(Medication, massage, visualization, biofeedback, and other
intervention approaches have successfully been used to monitor or
mitigate pain severity).
• BUT - If the physician-ordered plan of care contains orders for
only one (or none) of the interventions select “No.”
95
(M2400) Intervention Synopsis: Since the previous OASIS assessment,
were the following interventions BOTH included in the physician-ordered
plan of care AND implemented? Time Points: Discharge/Transfer
Plan / Intervention
a. Diabetic foot care including
monitoring for the presence of skin
lesions on the lower extremities and
patient/caregiver education on proper
foot care
b. Falls prevention interventions
c. Depression intervention(s) such as
medication, referral for other treatment,
or a monitoring plan for current
treatment
d. Intervention(s) to monitor and
mitigate pain
e. Intervention(s) to prevent pressure
ulcers
f. Pressure ulcer treatment based on
principles of moist wound healing
No
 0
 0
Yes
 1
 1
N/A
 2
Not Applicable
Patient is not a diabetic or is a bi-lateral
amputee
 2
Formal multi-factor Fall Risk Assessment
indicates the patient was not at risk for falls
since the last OASIS assessment
 0
 1
 2
Formal assessment indicates patient did not
meet criteria for depression AND patient did
not have diagnosis of depression since the last
OASIS assessment
 0
 1
 2
Formal assessment did not indicate pain
since the last OASIS assessment
 0

1
 2
Formal assessment indicates the patient was
not at risk of pressure ulcers since the last
OASIS assessment
 0
 1
 2
Dressings that support the principles of moist
wound healing not indicated for this patient’s
96
pressure ulcers OR patient has no pressure
Home Health Compare
• Measure:
• Diabetic Foot Care And Patient/Caregiver Education
Implemented During Short Term Episodes Of Care
(Implementation)
% of short term home health episodes of care during
which diabetic foot care and education specified during
the physician-ordered care plan was implemented for
patients with diabetes.
(M0100) Reason for Assessment
(M2400) Diabetic foot care intervention(s)
• NQF Endorsed
97
Home Health Compare
• Measure:
• Pain Interventions Implemented During Short Term
Episodes Of Care (Implementation)
Percentage of short term home health episodes of care
during which the patient had pain and pain
interventions were included during the care plan and
implemented by the end of the episode.
(M0100) Reason for Assessment
(M2400) d. Intervention(s) to monitor and mitigate pain
• NQF Endorsed
98
M2400 Instructions
•
Pain intervention must be included in the plan of care AND
implemented at the time of the previous OASIS assessment
or since that time.
•
For “No” responses, the care provider should document
rationale in the clinical record. If the plans/interventions
specified in the row are not appropriate for this patient, NA is
the correct response – see guidance for selecting NA for each
row below.
99
M2250 Instructions
•
Patient-specific parameters for notifying physician –
included in the plan of care
– Row a: If the physician-ordered plan of care contains specific
clinical parameters relevant to the patient's condition that,
when exceeded, would indicate that the physician should be
contacted, select “Yes.” The parameters may be ranges and may
include temperature, pulse, respirations, blood pressure,
weight, wound measurements, pain intensity ratings, intake and
output measurements, blood sugar levels, or other relevant
clinical assessment findings.
– Select “NA” if the physician chooses not to identify patientspecific parameters and the agency will use standardized
guidelines that are made accessible to all care team members.
100
OCCB January Q & As
Question 3:
“Regarding M2250, physician-ordered plan of care: Can the nurse or
therapist communicate the patient's condition to the physician and
request orders for the plan of care through his designee? Or does this
exchange have to be directly with the physician? We generally call the
office and leave information for the physician and request orders for
various disciplines and so on, the physician will either call us back directly
or often he will have his office nurse or assistant call back orders. Does
this meet the expectation for the agreement on the plan of care between
the home health agency staff and the physician?”.
Q & A Clarification:
Question 3: Regarding CMS OASIS OCCB 10/09 Q&A #32, what is meant by
“communication can be directly to/from the physician, or indirectly
through physician’s office staff on behalf of the physician, in accordance
with the legal scope of practice.”? Can the physician’s secretary be
considered Office staff if she/he speaks directly to the physician with the
clinicians questions and then gives the information directly back to the
clinician?
101
OCCB January Q & As
Answer 3:
The reference to “in accordance with the legal scope of practice” refers to the
State requirements defining who can take orders from physicians. Each HHA
should have a policy and procedure consistent with State law that describes who
can take orders from the physician. In most States it is going to be a clinician. It is
important to understand that all orders must come from the physician and
eventually be signed by the physician.
If you receive an order from the physician’s “assistant” that person has to be
legally qualified in your state to take physician orders . The individual at your
agency who receives that order must also be legally qualified to take orders. The
physician is required to have directly communicated the verbal order to his
designated qualified person.
CMS explained that they were concerned that in some cases home health
agencies were taking orders from unknown sources who may not be qualified to
communicate orders and also that those orders may not be directly from the MD.
If you know that the person you are receiving orders from is qualified to
communicate an order (cannot be a secretary unless the state law allows – I know
of none who do!) your RN can accept the order and answer “yes” to the OASIS-C
question.
102
OCCB January Q & As
Question 25:
“In order to report on M2250 that physician orders exist, does
that initial verbal/faxed communication need to include details of
the specified best practice interventions (e.g. fall prevention
interventions, pain monitoring, specific clinical parameters
requiring physician notification, etc.)?”
“Could
it be determined that all these specific practice orders
were present if the communication with the physician were more
general - (like the patient's clinical findings are discussed with the physician
and there is an agreement as to the general POC between the admitting
clinician and the physician. Then the formal detailed POC is sent to the
physician for signature, outlining the specific parameters and interventions)?”
103
OCCB January Q & As
Answer 25:
The OASIS-C did not change the expectations and requirements for
communicating with the physician to obtain verbal orders prior to providing
services.
The Medicare Benefit Policy Manual, defines clearly how orders can be
obtained verbally if complete orders were not provided in the referral.
Chapter 7, Section 30.2.5 states:
"Services which are provided from the beginning of the 60-day episode
certification period based on a request for anticipated payment and before
the physician signs the plan of care are considered to be provided under a
plan of care established and approved by the physician where there is an
oral order for the care prior to rendering the services which is
documented in the medical record and where the services are included in
a signed plan of care."
All orders would be under the same instruction from CMS, including those
which are reported in M2250 and M2400.
104
M2250 Instructions
OCCB April Q & As
•
•
Question: When do I pick NA for M2250a?
Answer: When completing M2250a – Patient Specific parameters, at SOC or
ROC;
• “Yes” if the plan of care includes specific parameters ordered
by the physician for this specific patient or after reviewing
the agency’s standardized parameters with the physician,
the physician agrees they would meet the needs of this
specific patient.
• “No” if there are no patient specific parameters on the plan
of care and the agency will not use standardized physician
notification parameters for this patient.
• “NA” if the agency uses their own agency standardized
guidelines, which the physician has NOT agreed to include in
the plan of care for this particular patient.
105
M2250 Instructions
OCCB April Q & As
• Question: For M2250g May I answer “Yes” if either the physician ordered
plan of care has orders for pressure ulcer treatments based on the
principles of moist wound healing, OR if I requested these orders from the
physician but the physician refused to agree to them or have not been
established yet?
• Answer: M2250, row g may be answered “Yes” if by the end of the
allowed assessment time period (5days for SOC and 2 days for ROC) the
physician ordered care plan includes orders for pressure ulcer treatment
of moist wound healing. You may also answer “Yes” in cases where the
moist wound healing treatment was requested of the physician, by the
end of the allowed assessment time period. It would not be required that
the response from the physician be obtained in order to qualify as a “Yes”.
If the physician response is “No”, moist wound healing is not appropriate
for this patient “NA” would be the correct response.
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Contact Information
Lynda Laff, RN, BSN, COS-C
Laff Associates
Consultants in Home Care & Hospice
Phone: (843) 671-4170
Email: [email protected]
Website: www.laffassociates.com

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