OASIS C-2 Changes and Documentation

OASIS C-2 Changes and Documentation Presented by Providers Association for Home Health & Hospice Agencies OASIS CHANGES IN C-2 Format Changes Guidance Changes New Additions It's Finalized OASIS C-2 It will go into effect January 1, 2017 It is Ready for Download at the CMS Website https://www.cms.gov/medicare/quality- Initiatives-Patient-Assessment- Instruments/HomeHealthQualityInits/OASIS- Data-Sets.html 1

Why is OASIS Being Revised Now? Currently the main reason for revising OASIS is to increase standardization with assessment item sets for other post-acute care (PAC) settings and to enable calculation of standardized, cross-setting quality measures, pursuant to the provisions of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. IMPACT Act Improving Medicare Post Acute Care Transformation Act of 2014 Requires providers to standardize and submit patient assessment and quality data Compares data from just these settings Long term care hospitals Inpatient rehab facilities Skilled nursing facilities Home health agencies Goal of IMPACT Act Improve quality in all post acute settings Improve transition between care settings Compare care and outcomes in different post acute settings 2

Revisions Some changes in C-2 are due to the IMPACT Act The revisions are to make comparing the data easier and in a standardized form Format Changes Many items have changed to have a response Box Items that had multiple check boxes were also changed to include a Box Box Time Points 3

Time Points cont. All of these assessments, with the exception of transfer to inpatient facility and death at home require the clinician to have an in-person encounter with the patient during a home visit. Transfer to an inpatient facility requires collection of limited OASIS data (most of which may be obtained through a telephone call). Not all OASIS items are completed at every assessment time point. Collection of Data OASIS data are collected using a variety of strategies, including observation, interview, review of pertinent documentation (i.e. hospital discharge summaries), discussions with other healthcare providers where relevant (eg. Phone calls to physician to verify diagnosis), and measurement (eg. Intensity of pain). There should be congruency between documentation of findings from the comprehensive assessment and the Plan of Care. Process of Care Process of care data items (process items) document whether certain evidenced-based practices were implemented. Process items collected at SOC/ROC document assessment and care planning interventions such as: Whether the patient was assessed to be at risk for certain conditions like pain, falls, or pressure ulcers. Whether interventions to address the conditions were incorporated into the Plan of Care. 4

Process Measure Domains Domain Timely Care (1) Care Coordination (1) Assessment (4) Measure Title Timely Initiation of Care HHC Physician Notification Guidelines Established Depression Assessment Conducted HHC Multifactor Fall Risk Assessment Conducted for Patients 65 and over HHC Pain Assessment Conducted HHC Pressure Ulcer Risk Assessment Conducted HHC Care Planning (6) Depression Intervention in Plan of Care Diabetic Foot Care and Patient Education in Plan of Care Pain Interventions in Plan of Care Fall Prevention Steps in Plan of Care Pressure Ulcer Prevention in Plan of Care HHC Pressure Ulcer Treatement Based on Principals of Moist Wound Healing in Plan of Care Process Measure Domains Domain Care Plan Implementation (5) Measure Title Depression Interventions Implemented Diabetic Foot Care and Patient/Caregiver Education Implemented During Short Term Episodes HHC Heart failure Symptoms Addressed During Short Term Episodes Pain Interventions Implemented Druing Short Term Episodes Treatment of Pressure Ulcers Based on Principles of Moist Wound Healing Implemented Education (2) Drug Education On High Risk Medications Provided to Patitent/Caregiver at Start of Episode Drug Education On All Medications Provided To Patient/CareGiver During Short Term Episodes Process Measure Domains Domain Prevention (6) Measure Title Influenza Immunization Received for Current Flu Season HHC Pneumococcal Plysaccharide Vaccine Ever Received HHC Potential Medication Issues Identified and Timely Physician Contact at Start of Episode Potential Medication Issues Identified and Timely Physician Contact Falls Prevention Steps Implemented Pressure Ulcer Prevention Implemented During Short Term Episodes https://www.medicare.gov/homehealthcompare/search.html 5

General OASIS Item Conventions Understand the time period under consideration for each item. Report what is true on the day of assessment unless a different time period has been indicated in the item or related guidance. Day of assessment is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home. If the patient's ability or status varies on the day of the assessment, report the patient's usual status or what is true greater than 50% of the assessment time frame, unless the item specifies differently. General OASIS Item Conventions Minimize the use of NA and Unknown responses. Some items allow a dash response. A dash (-) value indicates that no information is available, and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred, discharged, or dies before the assessment of the item could be completed. CMS expects dash use to be a rare occurrence. General OASIS Item Conventions When an OASIS item refers to assistance from another person. Assistance is not limited to physical contact and can include verbal cues and/or supervision. The use of the term Specifically means scoring of the item should be limited to only the circumstances listed. The use of for example, means the clinician may consider other relevant circumstances or attributes when scoring an item. 6

Specifically For Example Conventions Specific to ADL/IADL Items Understand what tasks are included and excluded in each item and select the OASIS response based only on included tasks 7

Conventions Specific to ADL/IADL Items Report the patient's physical and cognitive ability to perform a task. Do not report on the patient's preference or willingness to perform a task The level of ability refers to the level of assistance (if any) that the patient requires to safely complete a specified task. While the presence or absence of a caregiver may impact the way a patient carries out an activity. It does not impact the assessing clinician's ability to assess the patient in order to determine and report the level of assistance that the patient requires to safely complete a task. Conventions Specific to ADL/IADL Items If the patient's ability varies between the different tasks included in a multi-task item, report what is true in a majority of the included tasks, giving more weight to tasks that are more frequently performed. Assessment Consider majority assign weight 8

OASIS Data Accuracy OASIS data are used to produce quality reports for agencies, public reports on Medicare Home Health Compare website, and to determine payment. It is imperative that the OASIS data that HHAs collect and submit be accurate and complete. CMS recommends that agencies develop internal systems for monitoring data accuracy in addition to data checking features incorporated into CMS-supplied data entry software and other data entry systems. Example Numbering As in C-1, the numbers will change with the item changed. M1500-M1501 (Symptoms in Heart Failure Patients) M1510-M1511 (Heart Failure Follow Up) M2015-M2016 (Pt/Cg Drug Education) M2300-M2301 (Emergent Care) M2400-M2401 (Intervention Synopsis) 9

Pressure Ulcer Stages Arabic Numerals will now replace Roman Numerals (C-1 version) Pressure Ulcer Stages Arabic Numerals will now replace Roman Numerals (C-2 Version) Documentation Considerations Remember ulcers that have healed are not considered for this item. Terminology referring to healed vs. unhealed ulcers can refer to whether the ulcer is closed vs open. Stage 1 pressure ulcers and suspected Deep Tissue Injury(sDTI), although closed (intact skin), would not be considered healed. Unstageable pressure ulcers, whether covered with a non-removable dressing or eschar or slough, would not be considered healed. 10

Number Changes Again, numerical changes when the item changes. M1311 Current Number of Unhealed Pressure Ulcers M1313 Worsening in Pressure Ulcer Status M2001 Drug Regimen Review M2003 Medication Follow Up M2005 Medication Intervention Revised Look Back Period Occurs on M1501, M1511, M2016, M2301, and M2401. Also the Medication Intervention M2005 Revised from: At the time of or any time since the previous OASIS assessment To At the time of or any time since the most recent SOC/ROC assessment Example M2005 11

New Items Three brand new items were added due to their potential significant impact upon pressure ulcer developing and worsening. M1028 This item identifies whether two specific Diagnoses are present, and active. They influence a patient's functional outcome or increased risk for worsening of the pressure ulcers. M1028 Active Diagnoses of PVD, PAD, or DM You can also have related diagnoses Atherosclerosis of the Native arteries and/or Bypass Grafts 170.2xx to 170.7xx Generalized Atherosclerosis of the Extremities 170.91 Chronic Total Occlusion of the Artery of the Extremeties 170.92 Other Peripheral Vascular Disease 170.3xx 12

M1028 To Mark Response They must be diagnosed as active by MD Can be directly stated or may be inferred as active by having statements related to med management, treatment changes, need for skilled nursing monitoring. There should be interventions/orders to reflect diagnosis If not found in referral information you can confirm by communication signature/order. M1028 DM Related Diagnoses E08.xx DM due to underlying conditions E09.xxx Drug or chemical induced Diabetes E10.xxx Type 1 DM E11.xxx Type 2 DM E13.xxx Other specified DM Steps for Assessment The diseases and conditions in this item require a physician (or Non Physician Practitioner [NPP]) documented diagnosis at the time of assessment. 13

Medical Record Sources for the Physician Diagonsis Transfer documents Physician progress notes Recent history and physical Discharge summary Medication sheets Physician orders Consults and official diagnostic reports Diagnosis/problem list(s) Other resources as available Caution When using medication sheets as a source of diagnosis use caution as to other uses for the drug. Rule of Thumb should be to NEVER indicate a diagnosis that is not documented if there are other possibilities. Use medication sheet primarily to confirm a diagnosis or to indicate another exists that may have been resolved or overlooked on documentation. Per Guidance Manual Available documentation may be limited at admission/start of care. Admission/start of care assessment may indicate symptoms associated with one of this item's listed conditions while a documented diagnosis is not present in available records. The clinician should contact the physician (or other, as listed above) to ask if the patient has the diagnosis. Once the diagnosis has been identified, determine if the diagnosis is active. 14

Also Only diagnoses confirmed and documented by the physician (or NPP) should be considered when coding this item. Other Considerations If information regarding active diagnosis is learned after the assessment completed date, the OASIS Data set should not be revised to reflect this new information. The OASIS data set should reflect what was known and documented at the time of the assessment. If, however, it comes to light that a documented active diagnosis was not indicated, the Home Health Agency should modify the OASIS data set in accordance with the instructions in the Survey and Certification. M1060 15

M1060 - Height and Weight These items support calculation of the patient's BMI. Diminished nutrition and hydration status can lead to debility that can affect wound healing and increase risk for development of pressure ulcers. Weight measurement is also used in assessment of heart failure. M1060 - Height and Weight A Dash (-) is acceptable in rare situations when a patient unexpectedly transfers, discharges, or expires and you can not get the information. Also if a patient can not be weighed or measured due to extreme pain, immobility, or risk of pathological fractures. M1060 Height Steps for Assessment Measure height in accordance with the agency's policies and procedures, which should reflect current standards of practice (shoes off, etc.). Measure and record height in inches. Round to the nearest whole inch. When reporting height for a patient with bilateral lower extremity amputation, measure and record the patient's current height (i.e. height after bilateral amputation). 16

M1060 Weight Steps for Assessment Measure weight in accordance with the agency's policies and procedures, which should reflect current standards of practice (shoes off, etc.). Measure and record weight in pounds. Round upward to the nearest whole pound. If a patient can not be weighed, enter the dash value ( - ) and document the rationale on the patient's medical record. GG0170C - Mobility GG0170C - Mobility Assess the same as other functional values must be able to do it safely They can do it without a device Notice reversal of scale values 06 independent 05-02 help from another person 01 - dependent 17

GG0170C - Mobility Purpose Identifies the patient's need for assistance with the mobility task of moving from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Rationale GG0170C - Mobility Mobility limitations can adversely affect wound healing and increase risk for the development of pressure ulcers. Report the patient's usual status at SOC/ROC using the 6-point scale, or using one of the three activity was not attempted codes, and report the reason the activity was not attempted. GG0170C - Mobility Steps Assess the patient's functional status based on direct observation and/or on report by the patient, caregiver/family Patients should be allowed to perform activities as independently as possible, as long as they are safe. If caregiver assistance is required because patient's performance is unsafe or of poor quality, enter the response according to amount of assistance required to be safe. 18

GG0170C - Mobility Steps cont. Activities may be completed with or without assistance device(s). Use of assistive device(s) to complete an activity should not affect the scoring of the activity. If the patient's self-care performance varies during the assessment time frame, report the patient's usual status, not the patient's most independent status and not the patient's most dependent status. GG0170C - Mobility Answers 06 Independent if the patient completes the activity by him/herself with no human assistance. 05 Setup or clean-up assistance. If the caregiver sets up or cleans up. Caregiver assists only prior to, or following the activity. Example, the patient requires assistance putting on a shoulder sling prior to the transfer, or requires assistance removing bedding from lower body before task. GG0170C - Mobility Answers cont 04 Supervision or touching assistance. If the caregiver must provide verbal cues or touching/steadying assistance for patient to complete the activity. 03 Partial/moderate assistance. If the caregiver must provide less than half the effort. Caregiver lifts, holds, or supports trunk or limbs, but provides less than half the effort. 19

GG0170C - Mobility Answers cont 02 Substantial/maximal assistance. If the caregiver must provide more than half the effort. Caregiver lifts or holds trunk or limbs and provides more than half the effort. 01 Dependent. If the caregiver must provide all of the effort. Patient is unable to contribute any of the effort to complete the activity; or the assistance of two or more caregivers is required for the patient to complete the activity. GG0170C - Mobility Answers cont If the patient does not attempt the activity and the caregiver does not complete the activity, report the reason the activity was not attempted. 07 Patient refused. If the patient refuses to complete the activity. 09 Not applicable. If the patient did not perform the activity prior to the current illness, exacerbation, or injury. GG0170C - Mobility Answers cont 88 Not attempted due to medical condition or safety concerns. If no information is available or assessment is not possible for reasons other than the above, enter a dash ( - ) for 1-SOC/ROC Performance. 20

Dashes CMS States: A dash (-) value indicates that no information is available, and/or an item could not be assessed. This most often occurs when the patient I unexpectedly transferred, discharged or dies before assessment of the item could be completed. CMS expects dash use to be a rare occurrence. GG0170C - Mobility Discharge Goal Report the discharge goal using the 6-point scale. Do not enter 07, 09, or 88 for the discharge goal. The assessing clinician, in conjunction with the patient and family input, can establish the discharge goal. Report expectation of progress, decline, or maintenance GG0170C - Mobility Example 1 Mr. Rothschild Mr. R. is able to push himself up from the bet to get himself up from a lying to a sitting position. 2 out of 3 times, however, you have to help steady him, because he starts to fall to the side as he scoots to the edge of the bed. Answer 04 the patient required steadying/touching assistance in order to safely complete the task. 21

GG0170C - Mobility Example 2 Ms. Ladybug Ms. L. says she can get up by herself. When being observed, however, her caregiver provides much of the lifting assistance. The caregiver provides the lifting assistance for her to sit, and then provides assistance for her to scoot to the edge. Answer 02 Substantial/maximal assistance (more than half the effort) GG0170C - Mobility Example 3 Mr. Esebo Mr. E. is recovering from surgery. The caregiver partially assists with him sitting up and then he scoots to the edge of the bed himself. Answer 03 partial/moderate assistance. Mr. E required limited assistance that was more than verbal, but less than half the effort. GG0170C - Mobility Example 4 Ms. Vader Ms. V. is also recovering from surgery. The caregiver has to provide complete assistance. She is a very determined person. Based on prior functional status and a good prognosis you expect she will only require help with her legs by discharge. Answer 02 substantial/maximal assistance. Discharge goal = 03 partial/moderate assistance. 22

M1017 M1017 Diagnoses Requiring Medical or Treatment Changes Considers the last 14 days prior to SOC. Refers to new or exacerbated conditions. Can be one from inpatient diagnoses M1011 and should be congruent with Home Health diagnoses for treatment. The purpose of this question is to help identify the patient s recent history by identifying new diagnoses or diagnoses that have exacerbated over the past 2 weeks. M1017 Diagnoses Requiring Medical or Treatment Changes This should never be marked NA. Essentially, that would mean you are admitting a patient who is already stable and no changes in health condition that preceded SOC. 23

Calculating For any question that refers to the 'last 14 days' Use the date in M0090 as Day '0'. The day prior to that date is Day '1'. M1306 24

M1306 Unhealed Pressure Ulcer Stage 2 or Higher Consider ONLY stage 2 or higher Agencies should adopt the National Pressure Ulcer Advisory Panel (NUPAP) guidelines for clinical practice and documentation. Default to CMS OASIS instructions if discrepancy exists between OASIS instructions and NUPAP. M1306 Unhealed Pressure Ulcer Do not include the 'closed' Stage 3 or 4 in this question anymore. For the purposes of OASIS, since we do not account for 'resolved' or 'healed' conditions, the closed pressure ulcers would only be addressed in the narrative, as the word 'healed' would reflect those 'closed' ones too. M1306 Unhealed Pressure Ulcer Always be sure to address it in the narrative since the area is at higher risk. If you suspect an ulcer, it is not reportable, so those under non-removable dressings or devices are not considered. If it is a known ulcer, but not stageable, you can answer yes. 25

Considerations Pressure ulcers are defined as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. If pressure is not the primary cause of the lesion, do not report the wound as a pressure ulcer. Considerations 'Known' pressure ulcers are Pressure ulcers that are known to be present but that are unobservable due to a dressing/device, such as a cast, that cannot be removed to assess the skin underneath. 'Known' refers to when documentation is available that states a pressure ulcer exists under the non-removable dressing/device. M1307 Oldest Stage 2 Pressure Ulcer at Discharge 26

Item Intent The intent of this item is to: a)identify the oldest stage 2 pressure ulcer that is present at the time of discharge and is not fully epithelialized (healed). b)assess the length of time this ulcer remained unhealed while the patient received care from the home health agency. c)identify patient who develop Stage 2 pressure ulcers while under the care of the agency. Clinical Documentation Do not reverse stage pressure ulders. Clinical standards require that a Stage 4 pressure ulcer is a Stage 4 pressure ulcer until it has healed. Stage 2 (partial thickness) pressure ulcers heal through the process of regeneration of the epidermis across a wound surface called, 're-epithelialization'. Responses Response 1 only if the oldest Stage 2 pressure ulcer that is present at discharge was already present as a stage 2 pressure ulcer when first assessed at the SOC/ROC. Response 2 if the oldest Stage 2 pressure ulcer that is present at discharge was NOT a stage 2 pressure ulcer at the most recent SOC/ROC. 27

Responses If Response 2 is entered, specify the date the Stage 2 pressure ulcer was first identified. If no pressure ulcer existed at the SOC, then a stage 1 pressure ulcer developed, which progressed to a Stage 2 by discharge, enter Response 2, and specify the date that the pressure ulcer was first identified as a Stage 2 ulcer. Responses Enter 'NA' if the patient has no Stage 2 pressure ulcers at the time of discharge, or all previous stage 2 pressure ulcers have healed. M1311 Current Number of Unhealed Pressure Ulcers 28

M1311 Continued M1311 Changes from C-1 M1311 Current Number of Unhealed Pressure Ulcers This determines which ulcers were present at admission and which occurred during episode. Report ulcers at the initial assessment stage. When any bone, muscle, tendon or joing capsule is present (stage 4) are visible report as stage 4 regardless if you can see the wound bed or not. A pressure ulcer treated with a skin graft/flap is considered a surgical wound (until healed) known or likely' wording removed. 29

Assessment Identifies the number of Stage 2 or higher pressure ulcers at each stage present at the time of assessment. Stage 1 pressure ulcers and ulcers that have healed are not reported in this item. Terminology referring to 'healed' vs. 'unhealed' ulcers refers to whether the ulcer is 'closed' vs. 'open'. Terminology 'Present on Admission' For the OASIS, Present on Admission and Present at SOC/ROC have equivalent meanings. If the pressure ulcer was unstageable at SOC/ROC, but becomes numerically stageable later, when completing the Discharge assessment, its 'Present on Admission' stage should be considered the stage at which it first becomes numerically stageable. Terminology 'Present on Admission' If the pressure ulcer subsequently increases in numerical stage, do not report the higher stage ulcer as being 'present at SOC/ROC' when completing the discharge assessment. 30

M1313 M1313 Worsening in Pressure Ulcer Status Since ROC/SOC This item documents the number of pressure ulcers present at Discharge that were not present (are new) or have worsened (increased in numerical stage) since the most recent Start or Resumption of Care assessment. Compares the same ulcer to itself, so it allows a more accurate assessment of the pressure ulcers that have either healed or worsened. M1313 Worsening in Pressure Ulcer Status Since ROC/SOC If the pressure ulcer was unstageable for any reason at the most recent SOC/ROC Do not consider it worsened if it had become stageable and remained at the same stage at discharge. Only note it as 'worsened' if it changed after it was staged when visible or debrided. 31

M1313 Reporting Algorithm (part 1) M1313 Reporting Algorithm (part 2) M1313 Reporting Algorithm (part 3) 32

M1840 FYI New Guidance - M1840 Toilet Transferring In the absence of a toilet in the home: Determine if the patient could use a bedside commode or bed pan/urinal as defined in Response 2 or Response 3. If the equipment is not available then Response 4 Totally dependent in toileting would be appropriate. 33

Revision of M2000 to M2001 C-1 Version Revision of M2000 to M2001 C-2 Version Revision of M2000 to M2001 Be Careful Response numbers have changed OASIS C-1 Answer 1 = No Problems found OASIS C-2 Answer 1 = Problems found 34

M2001 Guidance Compare all MD notes for prescribed medications and reconcile any omissions, non-compliance, absence, refusal, etc... (all the critieria in the OASIS C-1 version) Information is still present in Guidance Manual Be sure to Document the problem and reconciliation. Medication Interaction Definition: the impact of another substance (such as medication, nutritional supplement including herbal products,food, or substances used in diagnostic studies) upon a medication. The interactions may alter absorption, distribution, metabolism, or elimination. These interactions may decrease the effectiveness of the medication or increase the potential for adverse consequences. Adverse Drug Reaction Definition: Adverse Drug Reaction (ADR) is a form of adverse consequences. It may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic effect of the medication or any response to a medication that is noxious and unintended and occurs in doses for prophylaxis, diagnosis, or treatment. 35

ADR vs. Side Effect The term 'side effect' is often used interchangeably with ADR, however, side effects are but one of five ADR categories, the others being hypersensitivity, idiosyncratic response, toxic reactions, and adverse medication interactions. A side effect is an expected, well known reaction that occurs with a predictable frequency and may or may not constitute an adverse consequence. For Review Check: MD list matches what is in patients home Diagnoses and symptoms are controlled with current doses All Meds are in the home Rx, OTC, and supplements Patient can take medications appropriately at the right time. No adverse reactions Issues MD must contact you by midnight of the next day with orders and orders followed through to be able to mark yes to M2003 Order can be no change in orders If multiple issues are identified, they all must be addressed and reconciled to mark yes also. 36

M2005 Considerations Patient's list of medications from the inpatient facility discharge instructions DO NOT match the medications the patient shows the clinician at the SOC/ROC assessment visit. Assessment shows that diagnoses/symptoms for which the patient is taking medications are NOT adequately controlled (as able to be assessed within the clinician's scope of practice.) Patient seems confused about when/how to take medications indicating a high risk for errors. Considerations Patient has not obtained medications or indicates that he/she will probably not take prescribed medications because of financial, access, cultural, or other issues with medications. Patient has signs/symptoms that could be adverse reactions from medications. 37

Considerations Patient takes multiple non-prescribed medications (OTCs, herbals) that could interact with prescribed medications. Patient has a complex medication plan with medications prescribed by multiple physicians and/or obtained from multiple pharmacies so that the risk of drug interactions is high. CMS and OASIS Guidance Any of these circumstances listed above must reach a level of clinical significance that warrants notification of the physician/physician-designee for orders or recommendations-by midnight of the next calendar day, at the latest. Any circumstance that does not require this immediate attention is not considered a potential or actual clinically significant medication issue. Scoring Example During the comprehensive assessment visit, the PT reviews all the patient's medications and identifies no problems except that the patient's newly prescribed pain medication is not in the home. The daughter states they were only going to pick it up from the pharmacy if the pain got bad enough. The PT emphasizes the need to comply with the physician's instructions for the new medication and prior to the PT leaving the home, the daughter has obtained the med. 38

Answer Enter Response 0 No issues found during review. Rationale: The issue did not require physician/physician-designee contact by midnight of the next calendar day to resolve. It does not meet the criteria for a potential clinically significant medication issues. M2016 M2016 Drug Education Drug education should include all medications prescribed, OTC, and herbal by any route. Education should include safe dosing procedures, potential side effects/reactions, effectiveness and when to contact appropriate provider. 39

Planning Ahead Check policies for: POC included interventions/orders when PAD/PVD and/or DM is marked on OASIS. Obtaining Height and Weight. Complete drug regimen review, education, and follow up. Include 'Best Practices'. The End 40