Understanding the Importance of CASPER

The acronym, CASPER, stands for Certification And Survey Provider Enhanced Reports. It is the computer system that compiles the OASIS data of every certified home health agency (HHA), and provides benchmarking information for your HHA’s current metrics against a prior period and national data. The data that is shown on the reports come from the OASIS assessment and is collected from two time-points:

  • Start of Care (SOC) to Discharge (D/C) and
  • Resumption of Care (ROC) to Discharge

Outcome Reports

Several outcome reports are accessible via your state’s Quality Improvement Evaluation System (QIES) website, which is the same one utilized for OASIS submissions.  When reviewing these reports, the bar graph portion is the most meaningful.  It will show your percentages for the current and prior periods as well as for the current national.  It is key to pay attention to asterisks, which designate the statistically significant meaningful data.

The following reports are available:

  • Agency Patient Related Characteristics

This report provides great information on your agency, such as patient demographics, payment sources, number of therapy days, length of patient stay, diagnoses and the results of many M items.  Your risk adjustment is affected by many of the items displayed in this report.It provides very useful information regarding differences between your agency and other HHAs.

  • Risk Adjusted Outcome Report

There are two types of Risk Adjusted Outcome Reports – OASIS based and claims based.  The outcomes from OASIS based are categorized as improvement items, stabilization items and other items.  Outcomes are compared on a bar graph report, providing information on the percentage of patients who improved and/or stabilized in various M items.The Risk Adjusted Outcome Report can provide your HHA a competitive advantage because you can improve in known poor performance areas and demonstrate how your HHA excels over other agencies in your area.

  • Potentially Avoidable Events(PAE) Reports

There are two types of PAE reports -Potentially Avoidable Event Risk Adjusted Report and Potentially Avoidable Event Patient Listing Report.  These reports are an excellent source of information for your QAPI program.  PAEs refer to significant changes in a patient’s clinical condition as demonstrated by emergent care or a patient’s health or general decline.

  • Process Measures Report

This report covers process measures, which are defined as the standards for home health best practices.The report includes your agency’s performance for every measure.  Proper clinical care planning and understanding of OASISM questions relating to the process measure are critical for good performance in the different measures.

How to Effectively Use CASPER Reports

To receive the most out of every CASPER report, someone should be assigned the task of looking into the system monthly for updated versions.  Once the reports are pulled, an analysis of the data should be conducted, focusing on the statistically significant areas.  Once you identify outliers for your HHA, an action plan should be developed for those items and incorporated into your agency’s QAPI program for on-going monitoring.It is essential that the results from these reports and QAPI are shared with all staff, including contracted staff to improve outcomes within the agency.

It is important to keep in mind that all of the information within the CASPER reports originates from what the clinician enters into the OASIS Assessment.  Home Health Compare is a website that publicly displays many of the outcomes from the CASPER reports, which can be found at: The type of information that is displayed on this website and made available to the public offers great marketability for those HHAs with better patient outcomes.This site also enables the public to choose the right quality home health agency that best fits their needs.

We can Help Your Staff with CASPER

CASPER is a key source of information that can help or hurt a home health agency’s reputation.  Our expert teamat 5 Star Consultants offers multiple years of experience working with CASPER and have performed CASPER analysis for agencies throughout the country.  We can help ensure your staf fis knowledgeable about its many reports and the key ways to achieve quality outcomes that are a step above your competition.  To learn more, please contact us at [email protected] or 866-428-4040.

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Sitecare SupportUnderstanding the Importance of CASPER

QAPI – Are you Struggling to be Compliant with the new Conditions of Participation

To have a compliant and effective QAPI program in order to avoid deficiencies in 484.65 G640 / and the other ten G tags, you first must understand what a QAPI program requires.

Quality programs have always been meant to help your organization ensure it is improving patient care/outcomes and maintaining compliance with all regulations. A good Quality program – QAPI – should never be “busy work”, but should be an agency wide program that helps you understand where your agency stands, and then gives you opportunities to improve. QAPI is a key component of a well-run organization. It not only assists in minimizing risk, but it also increases an agency’s quality and efficiency. A good QAPI program should be incorporated into everyday operations and can lessen the day-to-day challenges!

But How do you Comply to the QAPI Condition?

The CoP (Condition of Participation) is very specific and prescriptive, which should help agencies to develop their programs.

There are key elements that an agency must include and address in their QAPI program, including: reflecting the complexity of the org and services, involving all services, indicators focusing on improving outcomes, including emergent care and rehospitalizations, integrating infection prevention and preventing/reducing medical errors.
A key part of a Quality program is to identify what your high volume, high risk, problem prone areas are. When looking at the complexity of your services, a high risk and problem prone area may be IV therapy services or pediatric services. Perhaps you do a high volume of lab draws, wound care, therapy services – although they are relatively routine procedures, there can be areas in which to improve due to the high volume/ problem prone nature. By evaluating your HHA program and selecting high volume, high risk and problem prone areas, you are able to begin to identify the Quality Indicators you will include in your program.

In addition, it is necessary to include outcomes from the CASPER OASIS Outcome Reports and Home Health Compare, particularly those in which you are statistically significant to the nation, state, and/or your agency prior period. The selected outcomes would also be written as Quality Indicators.

Development of the QAPI Plan

Agencies often lack the formality of a Quality program, causing deficiencies. That is, an audit tool may be utilized to review records for a certain area, such as wound care, however, there is no quality indicator written, and/or the audits are not analyzed objectively, with an action plan to improve the results. An example of a Quality Indicator and action plan for wound care is:

The QAPI coordinator will review 20 percent of patient records with wound care quarterly to focus on following physician orders with a goal of 90 percent compliance.

Audit tool criteria would include wound care physician orders are updated as necessary. SN visit notes document wound care performed accurately to the physician orders.

Example: Ten records were reviewed in a quarter with the compiled results at 60 percent. The goal was not achieved; therefore, a specific action plan will be developed and implemented in order to improve the results.
Findings example: Six of ten records reviewed indicated that physician orders for wound care were not followed.

What do you do with the Data?

Many agencies perform a lot of audits, gather a lot of data, but then do not do the most important steps in a QAPI program.

Analyzing, Trending and Developing Action Plans

By utilizing specific criteria on audit tools and compiling the results, it becomes simple to analyze and trend results in order to develop action plans. Often agencies write very generic action plans instead of specific steps to follow. Action plans often include education to staff on particular topics, process and/or policy change, and, of course, the QAPI monitoring.

Action Plan Example:

  1. Wound care expert in-service and competency performed, with focus on following current physician orders.
  2. Joint supervisory home visits made with all nurses on wound care patients by next quarter.
  3. Process change – On patients from ‘567 Wound Care Clinic’, the Clinical Manager will contact SN on the same day with order changes.
  4. Process change – On patients from ‘567 Wound Care Clinic’, the Clinical Manager will contact SN on the same day with order changes.

In QAPI, it is important for indicator results to improve and then sustain that improvement. An annual QAPI calendar is an easy way to monitor results and progress as well as to share with staff and Governing Body:


Indicator Freq Goal Jan Feb Mar
Clinical Record Review q 90% 82% 88%
Wound Care q 90%  60% 90%
Improving Pain q 79% 65% 72%
Fall Reduction q <10%  15% 9%
Infection Surveillance q <2% 1%  3%


Whenever an indicator is lower than the goal or has significantly varied over the time periods of collection, it is important to update the action plan. Be more specific than simply stating to “continue to monitor”. Drill down to the items that you will perform this time period in order to improve and sustain.

QAPI Projects

You may find that a deficiency is high risk, high volume and problem prone.  It may be widespread, effecting many services as well as office and field staff.  Or the results of an indicator are not improving.  These examples could be candidates for a Performance Improvement Project.

The projects can involve performing a root cause analysis, where a task force of stakeholders drills down to the challenges involved.  Often communication is key – between clinicians, office staff, physicians and patients/ caregivers.  And, very often processes and policies need to be revised.

Example: IV therapy can involve many parties, including physicians, home infusion, pharmacy, supply delivery, nursing, patient and caregiver – who requires education on high risk procedures.

QAPI SUCCESS – Get Everyone in your Agency Involved

Having a large QAPI team and rotating them every six months to a year is a great way to get all staff involved.  The team will brainstorm on action plans, indicators, audit tools, etc.  Assign team members to cover parts of the action plan, example: clinical record reviews, education, and process development.

Your agency will improve in many ways when your staff is involved in QAPI, including having better understanding of regulations, improved documentation, communication and patient care.

QAPI Never Stops! 

Indicators may be able to be discontinued once you find sustained and complete improvement.  However, the evaluation must continue.  This graphic below demonstrates the steps in a successful QAPI program:

Need Assistance with QAPI?

In conclusion, a QAPI program is not just busy work that must be done because of the new CoP, but a true tool to enhance an agency’s outcomes, quality and operation. Your agency and your patients will benefit from a QAPI Program! The team at 5 Star Consultants has extensive experience with QAPI, including speaking on this key topic at conferences around the country. To learn how we can put our expertise to work for your agency,

please contact us at [email protected] or 866-428-4040.

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Sitecare SupportQAPI – Are you Struggling to be Compliant with the new Conditions of Participation

How to Deal with Overpayment Recoupment by CMS

Overpayment recoupment by CMS (Centers for Medicare & Medicaid) can happen, but recently there have been a few cases in the news involving large amounts owed by home health agencies (HHAs), bringing this issue to the forefront.  These types of large monetary errors can be devastating to a home health agency.  In this blog, we will discuss the issue of overpayment recoupment and the different options to handle it effectively.

Defining Overpayment

A Medicare overpayment is defined as a payment an agency receives that is in excess of the amount that is payable under Medicare statutes and regulations.  Common occurrences, which can be attributed to overpayment include:

  • Insufficient documentation
  • Medical necessity errors
  • Duplicate payments
  • Administrative and processing errors

This overpayment is considered a debt that the HHA owes to the Federal government.  The collection process begins once Medicare identifies an overpayment of $25 or more.  This process is initiated by an agency’s servicing Medicare Administrative Contractor (MAC), beginning with a letter requesting payment, otherwise, known as the Demand Letter.  If the HHA identifies an overpayment within the “look back period”, which is within six years of the overpayment, it must be reported and returned.  The overpayment must be returned within 60 days of its identification date or the date any corresponding cost report is due, if applicable.  The later date of these two conditions should be followed.

The Demand Letter

The Demand Letter received by a HHA covers the following stipulations:

  • The reason for the overpayment
  • Interest terms, which include accruement if not repaid in full within 30 days
  • Options to request immediate recoupment
  • Options to request an Extended Repayment Schedule (ERS)
  • Rebuttal rights
  • Appeal rights

Demand Letter Responses – Payment Options

There are several payment options a HHA can consider when responding to a Demand Letter, which include:

  • Immediate Payment – This is the most straight forward option with the HHA just submitting payment as stated per the Demand Letter.
  • Recoupment – There are two types of recoupment – Immediate Recoupment and Standard Recoupment. Immediate Recoupment involves Medicare recovering an overpayment by offsetting future payments.  This type of recoupment can be partial or complete.  The MAC can begin it immediately per the instructions in the Demand Letter.  Unless otherwise specified, Immediate Recoupment will apply to all current and future debts.  With Standard Recoupment, the MAC automatically begins recoupment according to the Overpayment Debt Activities chart.  Interest accrues if the debt becomes delinquent.
  • ERS – If a HHA is unable to pay the overpayment in full in the required timeframe, the instructions in the Demand Letter, requesting an ERS from the MAC must be followed.

Other Options to Consider

Paying back an overpayment may not always be the answer for a HHA.  Below are other ways to address an overpayment by CMS:

  • Rebuttal – Within 15 days of the Demand Letter, a HHA can submit a rebuttal to its MAC. In the rebuttal, the HHA should explain or provide evidence why the MAC should not initiate recoupment.  A rebuttal is not considered an appeal; therefore, recoupment activities do not cease, but the MAC will evaluate this information.
  • Appeal – If a HHA disagrees with the overpayment decision, an appeal can be filed. The process for Medicare Part A and B appeal involves five levels:
  1. Redetermination by a MAC – It requests a second look at the claim by an employee who was not involved with the initial determination
  2. Reconsideration by a Qualified Independent Contractor (QIC)
  3. Hearing by an Administrative Law Judge (ALJ) or Review by an Attorney Adjudicator at the Office of Medicare Hearings and Appeals
  4. Review by the Medicare Appeals Council
  5. Judicial Review in U.S. District Court

Work with 5 Star Today to Avoid Overpayment Recoupment Issues Tomorrow

The team at 5 Star Consultants offers extensive experience in all facets of home healthcare.  Our experts work with HHA staff to ensure insufficient documentation and administrative and processing errors do not turn into bigger issues, such as overpayment recoupment by CMS.  If you would like to discuss our services and how they can help your HHA, please contact us at [email protected] or 866-428-4040.

Source: CMS Medicare Learning Network, “Medicare Overpayments”, October 2017

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Sitecare SupportHow to Deal with Overpayment Recoupment by CMS

Time for the Plan of Correction

Your home health agency (HHA) recently went through a survey and was cited for deficiencies, which is a common outcome nowadays.  The next step is to write a Plan of Correction (POC).  Instead of viewing this task as a nuisance, you should consider it an opportunity.  The process of writing an acceptable POC allows you to develop a rapport with the surveyor and learn how your agency can ensure the goal of providing safe, quality care and services in compliance with the new Conditions of Participation (CoPs).  In this blog we will provide further details regarding the Plan of Correction.

Defining the Plan of Correction

A Plan of Correction is a documented agency reply to a survey summary of findings (SOF) and/or summary of deficiencies (SOD), which are received ten days after an on-site agency survey by the State Agency (SA) or National Accrediting Organization (AO).  A POC explains how the agency citations of noncompliance will be corrected and the process that will be implemented to prevent recurrence.  A Plan of Correction is required for several reasons:

  • The State requires the POC for licensure compliance.
  • CMS requires a POC for federal certification compliance.
  • The POC is submitted to meet established state and federal laws.

By completing the survey and certification process, CMS can evaluate compliance with the Home Health Conditions of Participation.  And, an agency’s compliance with the Home Health Conditions of Participation demonstrates it is providing quality patient care and services that meet minimum health and safety standards, resulting in positive patient outcomes.

When to Write the Plan of Correction

It would seem that the Plan of Correction should begin after the survey is completed, but actually it should start during the survey process itself when the surveyor shares findings with the agency.  The agency should correct any deficiencies, as applicable, while the surveyor is present.  Now is the time to provide evidence of the corrected deficiency to the surveyor because the surveyor may not cite the deficiency if it is an AO standard deficiency.  The surveyor must cite CoP deficiencies, but citations corrected during the survey could be considered when determining the classification of citation to be assigned.

During the Exit Conference with the surveyor, the HHA should include as many staff members as are available to attend in order to hear firsthand the findings and concerns.  If possible during the Exit Conference, the State Agency or Accrediting Organization will inform the agency if a return on-site visit to evaluate the correction of deficiencies and compliance will be required.  However, there are times when the surveyor will have to defer this information to the Summary Report.

Following the Exit Conference, the agency should conduct a staff meeting to gather staff input on how to correct and prevent noncompliance going forward.  It is not necessary to wait for the final Summary Report before beginning the POC.

Developing the Plan of Correction should be a team effort, involving all staff members who participate in the survey process.  Then administrators should share the findings with contract and other agency staff, requesting their input regarding how to correct deficiencies and prevent noncompliance in the future.

Completing a Plan of Correction

The SOF/SOD will cover the specific regulatory citations of noncompliance and the number of days the agency has to complete and submit the Plan of Correction.  Typically, the POC must be submitted within 10 calendar days, but it can be fewer or more depending upon the type of deficiency and the accrediting organization (please see our previous blog for further details).  After the HHA receives the SOF/SOD, additional staff meetings should be scheduled to complete the POC.  If an agency is cited for a Condition-Level Deficiency, the date of compliance is usually within 10 calendar days from the date the agency received the SOF.

The State Agency or Accrediting Organization will provide the form for completing the Plan of Correction, which will provide instructions, the required components and its due date.  Usually, a sample POC is provided to the HHA.

The Plan of Correction consists of five components:

  • The deficiency cited
  • Specific action to be taken
  • Date to be completed
  • Position responsible
  • Process to ensure the deficit will not recur

The last four items must be completed by the agency.  Any of the deficiencies cited should not be a surprise because the agency should have an understanding of each one based on the Exit Conference with the surveyor.  However, if the agency needs further clarification after receiving the SOF/SOD, the SA or AO should be contacted.

Need Help and Support?

The survey process can be nerve wracking!  By being prepared and having a support system for the survey process, correcting citations and developing a plan of correction to prevent recurrence can greatly improve the survey outcomes and staff experiences.

5 Star Consultants offer a wealth of experience.  Every RN consultant on our team is also a former or current AO surveyor; therefore, we can guide your staff through the survey process and with the completion of the POC.

If you would like to discuss our services further, please contact us at [email protected] or 866-428-4040.

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Sitecare SupportTime for the Plan of Correction

Are Deficiencies Dogging Your Home Health Agency?

For a home health agency (HHA) to operate, it must be in compliance with the Medicare Conditions of Participation (CoPs).  Of course, it is difficult for agencies to comply with many of the new home health CoPs; therefore, to ensure compliance, a home health agency is subjected to unannounced on-site agency surveys.  These surveys determine if the HHA meets the minimum health and safety standards, delivers patients services, and achieves positive patient outcomes.  After the survey, the HHA receives a summary of findings (SOF) and/or statement of deficiencies (SOD) requiring a Plan of Correction (POC).  This first blog in our series on “How to Write a POC”, we will explore the different classes and types of deficiencies a HHA may experience.

Classifications of Deficiencies

In today’s home health industry, it is almost unheard of that no deficiencies are cited after a survey.  However, the seriousness of the different deficiencies varies quite a bit.  Below are details about the three classifications of home health deficiencies:

  • Standard-Level Deficiency means noncompliance with one or more of the standards that make up each Condition of Participation for HHAs. Some common deficiencies include:
      • Aide not following the Aide Care Plan
      • Not following physician orders
      • Breaking infection control technique on a home visit
      • No medication reconciliation

While writing the POC, keep in mind that the date of compliance will be typically within 30 – 60 days from the date the HHA received the summary of findings/statement of deficiencies.  The Plan of Correction must be approved by the regulatory body citing the standard level deficiency.  Most of the time, there is no follow up survey for Standard-Level Deficiencies.

  • Condition-Level Deficiency is a more serious type of deficiency cited, and is issued if a surveyor determines that a HHA is not in compliance with a Condition, such as not having a formal agency wide QAPI program. A Condition-Level Deficiency may be cited if a HHA receives two – three (or more) Standard-Level Deficiencies.  An example of this is if under the Aide Condition.  For example, the aide does not follow the Aide Care Plan, the Aide Care Plan is not completed specifically, and/or the aide supervisory visits are not timely.  The date of compliance must typically be within 10 calendar days from the date the agency received the summary of findings/statement of deficiencies.  A return survey visit will be made by Day 45 from the last day of the survey, and the agency must show that they are in substantial compliance.

If a Condition-Level Deficiency is not cleared, this could affect the agency’s Medicare certification, as this may indicate that the provider is not able to furnish adequate care or adversely affects the health or safety of patients.

  • Immediate Jeopardy (IJ) is defined by CMS as “a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient.” Once a HHA receives an IJ rating, a follow up survey will typically be conducted within 7-21 days, and the POC survey will have to provide evidence that the deficient findings have been corrected.  The Plan of Correction must also be completed after the survey report is received.  However, often the return survey is occurring concurrently due to the short time period.  Keep in mind that an IJ can be and often is cited for potential harm to a patient.  We have seen recently where an IJ was cited due to adverse conditions or changes assessed in patients in which the clinicians did not notify the physician (i.e. high blood glucose readings, low blood pressure, increasing wound drainage).  If the surveyor does not see this immediate compliance in the HHA, which many times involves policy/process changes, education, performance improvement projects, etc., CMS can terminate the HHA’s Medicare certification.


Both monetary and non-monetary sanctions may be given to a HHA for Condition-Level Deficiencies and will be given for Immediate Jeopardy situations.  Non-monetary can include temporary management, directed Plan of Correction and/or education.  A monetary sanction can range from $500- $21,000 per day, which is fined until the deficiencies have been cleared.  In addition, there is a suspension of payments for new admissions.  This, of course, is a tremendous burden for home health agencies.

When an agency receives a Condition-Level Deficiency or IJ, they may not competency their home health aides for two years.  This is not related to solely Aide Deficiencies, but for any Condition-Level Deficiency; therefore, the HHA must contract outside to have their aides competencied.

It is of course critical for agencies to be in continual survey readiness so that they are not vulnerable to receiving Condition Level-Deficiencies, and particularly Immediate Jeopardy.  The stress and financial burden to an agency are excruciating.  So be prepared!  Mock surveys are the best method to ensure that an agency is not vulnerable.  These should be done annually.  An agency can conduct their own annual self-assessments and then have an objective expert, such as 5 Star Consultants, perform a mock survey every three years at minimum.  This mock survey should always be performed at least six months prior to its next scheduled survey so that areas found can be fixed in a realistic timeframe.

Next Steps

When an HHA has been cited with deficiencies, then a POC is the next step.  However, you may ask what is involved with a Plan of Correction?  Our next blog will provide details about this important document.  However, if you have an immediate need, please contact us today [email protected] or 866-428-4040. The 5 Star team of experts can help your team through the critical POC step now!

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Sitecare SupportAre Deficiencies Dogging Your Home Health Agency?

OASIS-D is Coming. Make Sure Your Staff is Ready!

Over the past two decades, the Outcome and Assessment Information Set (OASIS) has been developed, tested and refined, and major changes continue to occur.  Now home health agencies (HHAs) need to be prepared for OASIS-D, which will go into effect on January 1, 2019.

Reasons Behind the Introduction of OASIS-D

The main reason behind the introduction of OASIS-D is the IMPACT Act (Improving Medicare Post-Acute Care Transformation Act of 2014).

  • The purpose of the IMPACT Act is to standardize patient assessment data collected for Post-Acute Care (PAC) providers, specifically Long-Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs). The standardization of data develops an improved quality measure (QM).  Plus, the data can be utilized to compare all four PAC providers for quality.   
  • Another key area the IMPACT Act seeks to improve is the coordination of care and discharge planning between the post-acute care providers and the transition from acute care to post-acute care.
  • The changes in OASIS-D for the Impact Act are making it feasible to obtain reports of “what happens where to a patient”. For example – did a new or worsening pressure ulcer occur during a home health admission or a long-term care admission?  Were functional abilities improved during home health for a patient as the agency projected they would improve?

OASIS-D Changes

OASIS-D does have a lot of deletions, causing CMS to estimate that the amount of time required to complete the data set will decrease, but as we know, not all OASIS items are equal. 

OASIS-D Deletions OASIS-D Additions
M0903: Date of Last / Most Recent Home Visit GG0100: Prior Functioning: Everyday Activities
M1011: Inpatient Diagnosis GG0110: Prior Device Use
M1017: Diagnosis Requiring Medical or Treatment Regimen Change Within Past 14 Days GG0130: Self-Care


M1018: Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days GG0170: Mobility


M1025: Optional Payment Diagnosis J1800: Any Falls Since SOC / ROC
M1034: Overall Status J1900: Number of Falls Since SOC/ROC
M1036: Risk Factors
M1210: Ability to Hear
M1220: Understanding Verbal Content
M1230: Speech & Oral (Verbal) Expression of Language
M1240: Pain Assessment
M1300: Assessment for Pressure Ulcer Risk
M1302: Risk for Pressure Ulcers Identified
M1313: Worsening in Pressure Ulcer Status
M1320: Healing Status of Most Problematic Pressure Ulcer
M1350: Skin Lesion or Open Wound
M1410: Respiratory Treatments
M1501: Symptoms in Heart Failure
M1511: Heart Failure Follow-up
M1615: When Does Urinary Incontinence Occur
M1750: Psychiatric Nursing Services
M1880: Ability to Plan and Prepare Light Meals
M1890: Ability to Use the Telephone
M1900: Prior Functioning ADL/IADL
M2040: Prior Medication Management
M2110: How Often Does the Patient Receive ADL or IADL Assistance from Caregiver
M2250: Plan of Care Synopsis
M2430: Reason for Hospitalization


The GG items are set up very much like the GG0170 item that was introduced last year in that OASIS iteration (lying in bed to sitting on side of bed with feet on the floor). They all have the six-point scale with which to score depending on the type of assistance the patient needs to perform each task.  And, they all have the projected score for each item at discharge.

The difference is that there are many more items to assess for each GG item and this will take time, assessment strategies, and more than one visit – so utilization of the five-day assessment period with collaboration of the varied disciplines in the team.

When you read the GG items for the first time, you will be surprised at the level of detail in many of the items.  Here is the synopsis of each one:

GG0100: Prior Functioning: Everyday Activities

Self-care items – bathing, dressing, toileting, and eating.

GG0110: Prior Device Use

This is just to select the device.

GG03130: Self Care

This item is a very specific one with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, and putting on/taking off footwear. All have specifics for each section and this is for assessment SOC/ROC and discharge and follow up when applicable.

GG00170: Mobility

This item is beyond specific and includes:

Roll left and right

Sit to lying

Lying to sitting on side of bed, which we already have been doing for the past year

Sit to stand

Chair/bed to transfer

Toilet transfer

Car transfer

Walk 10 feet

Walk 50 feet with 2 turns

Walk 150 feet

Walking 10 feet on uneven surfaces

1 Step (curb)

4 Steps

Picking up object

Wheel 50 feet with 2 turns

Wheel 150 feet

So, in reading the new GG items, you can understand why the collaboration of the multi-disciplinary team and the five-day assessment window are necessary in order to accurately identify what your patients are able to do, as well as what their discharge goals are.

JJ Items are looking at falls, asking in JJ1800 if there have been falls since the most recent SOC/ROC, and then in J1900, how many falls have there been.

The CMS OASIS Guidance Manual has very specific examples for the GG and JJ items and are very helpful to train your clinicians.

You do not Need to be Overwhelmed!

5 Star Consultants is here to help you navigate the changes OASIS-D will bring to your HHA.  Our home health experts are providing OASIS-D training and can do so for your agency!  Find out today about how we can help ensure your team is ready for OASIS-D on January 1, 2019.  To learn more, please contact us at [email protected] or 866-428-4040.

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Sitecare SupportOASIS-D is Coming. Make Sure Your Staff is Ready!

Going Back to the Roots of Healthcare: Home Health

Home care or nowadays known as home health is a return to the roots of healthcare.  In the early 19th century, doctors and nurses provided care in patients’ homes, but often female family members, neighbors, and sometimes servants assisted.  However, individuals who did not have this type of support system often had few care options.

The United States’ First Organized Home Health Services

The first attempt at providing home care services started in 1813 when the Ladies Benevolent Society (LBS) was formed by a group of women volunteers in Charleston, South Carolina.  This group of untrained women not only provided home care, but also helped the sick poor to obtain medicines, food and supplies.

However, in the North initially it was a different story.  Women from wealthy northern families volunteered to help those who were sick poor, but it was quickly realized that trained nurses were necessary to help these folks overcome diseases.  The trained nurses who were hired came to be known as “visiting nurses”, which was based on the “district nurse” model started in 1875 in England by the National Nursing Association for Providing Trained Nurses for the Sick Poor.  These nurses not only attended to the physical needs of their patients, but also taught them about how disease spreads and the importance of maintaining a clean home to prevent the spread of infection.

Next, the Visiting Nurse Societies were established in major cities in the Northern United States, and they also were based on England’s model mentioned above. Using this model, rapid growth was experienced with 21 home care visiting nursing associations by 1890.  However, the mission changed and expanded so that care was not only provided for the sick poor, but also preventative services for infants, children, mothers and those with infectious diseases, such as tuberculosis, were offered too.  Even though deaths related to infectious diseases decreased, the concern for prevention and good hygiene increased.

The first organization to reimburse for home care was the Metropolitan Life Insurance Company in 1909.  It hoped that home care would reduce the number of death benefits claimed.  However, in the late 1920s many home care agencies closed their doors due to the poor economy as a result of the Great Depression, and then the nursing shortage during World War II caused further issues.  Even though The Health Insurance Plan of Greater New York and Blue Cross tried to include coverage for home care services, it was not widely accepted at the time.

Home Care Becomes Popular Again

During the late 1950s and early 1960s it became clear once again that there was a growing need for home care services.  Patients with chronic illnesses could be cared for in their homes instead of hospitals.  This not only saved money, but also the negative long-term effects due to lengthy hospitalizations became apparent.

In 1965 when Medicare was established in the United States for people over 65 years of age, home care services were once again covered by insurance.  Medicaid was also established that same year, and continues to provide health insurance coverage today for people with low income, which is one in five Americans.

Home health has a long and varied history, but it has solidified its position in today’s healthcare market.  Currently, it is the fastest growing industry in the United States not only due to the aging Baby Boomers, but also to an increasing number of treatments, such as joint replacements, which are provided in outpatient settings with the bulk of care handled in patients’ homes immediately following surgeries.  According to the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary,  the annual growth rate for home health spending is predicted to be 6.7 percent by 2020 and will be almost $173 billion annually by 2026, outpacing the U.S. gross domestic product, which is anticipated to increase 4.5 percent per year.

We can Help with Your Home Health Needs

Finding good talent is becoming increasingly difficult in the quickly expanding home health market.  As your home health agency’s needs grow, the 5 Star team is here to help with its RN certified coders, many training options and consulting services.  To learn more, please feel free to contact us at [email protected] or 866-428-4040.


©2018 Elizabeth E. Hogue, Esq.  All rights reserved.

“The History of Home Healthcare”,

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Sitecare SupportGoing Back to the Roots of Healthcare: Home Health

There is no Place for Violence in Home Health

According to the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary,  the annual growth rate for home health spending is predicted to be 6.7 percent by 2020 and will be almost $173 billion annually by 2026, making it higher than any other category tracked and outpacing the U.S. gross domestic product, which is anticipated to increase 4.5 percent per year.  This type of growth means it is key that there are workers to fill home health positions.  And, these employees need to work in a safe environment, which is not always the case.  As home health workers provide medical assistance to ill, elderly, convalescent or disabled persons, unfortunately they are often exposed to potentially serious or even life-threatening hazards while on the job.

Managing Home Health Violence

Every time a home health worker enters a patient’s home, he/she becomes vulnerable to a range of violence, from verbal abuse and stalking to more serious threats dealing with assault or even homicide.  According to a recent state survey of home health workers conducted in Oregon, 50.3 percent experienced verbal aggression and 23.6 percent experienced workplace violence in a single year.  This abuse is not always from the patient either.  Often family members or even others in the patient’s community are the sources of this type of abuse.

To help deal with this grave issue, the Centers for Disease Control and Prevention (CDC) and the National Institute for Occupational Safety and Health (NIOSH) have teamed up to publish recommendations for avoiding violence in home health.  The policy of “zero tolerance” for any type of violence, including from animals, must start at the top with management.  Home health managers must develop a written policy that is strongly enforced to protect employees and contractors.

All employees and contractors must be responsible for reporting and documenting all incidences of violence, even minor ones.  As many details as possible should be included in every report.

The following guidelines from NIOSH1 will help home health workers to better manage violet situations:

  • Be sure of the locations of patients’ homes and have accurate directions.
  • Keep the windows of your vehicle rolled up and the doors locked.
  • Park in well-lit areas, away from large trees or shrubs where person(s) could hide.
  • Keep equipment, supplies and personal belongings locked in the trunk of your vehicle.
  • Before getting out of your vehicle, check surrounding areas and do not leave the vehicle if there are any threats to your security.
  • Contact your supervisor(s) in the event of threatening circumstances.
  • During visits, you should remain alert and watch for signs of possible violence, such as verbal expressions of anger and frustration, threatening gestures, signs of drug or alcohol use or the presence of weapons. There should be a “zero tolerance” policy for visible weapons.
  • When you are verbally abused in a patient’s home, you should ask the speaker(s) to stop. If the verbal abuse continues, you should leave the patient’s home and notify your supervisor(s) that you have done so.
  • If possible, you should identify more than one exit from the patient’s home and keep a clear path to at least one of them.

Let’s Not Repeat the Past

Unfortunately, many home health employees have experienced violence while on the job.  It is critical to ensure that everyone, from top management to the frontline home health caregiver, are in sync regarding a safe, working environment. We all must strive to help ensure a violent past is not repeated.


1 ©2018 Elizabeth E. Hogue, Esq.  All rights reserved.

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Sitecare SupportThere is no Place for Violence in Home Health

Exploring Coordination of Care Scenarios

Proper coordination of care is only possible if the entire interdisciplinary team caring for the patient works together.  This team must be proactive and collaborative in order to achieve its primary goal of enhancing patient outcomes through a course of interventions and a goal-oriented plan.  Only a comprehensive team that includes everyone across all disciplines can successfully treat the patient.  Physician(s), contractors, the clinical team manager, assistants, aides, patient caregiver(s) and representative(s), and the patient must be considered part of this team.  To better illustrate how an interdisciplinary team must work together to achieve excellent patient outcomes, we have provided a few different scenarios below.

Case Study #1 – Mrs. Jones

Mrs. Jones is admitted to home health with a primary diagnosis of Diabetes with peripheral neuropathy. To achieve the best outcome for her the following plan of action is documented and implemented:

  • Jones has SN, PT, OT and Aide ordered.
  • One of her comorbidities is CHF. She has had no signs/symptoms of CHF since her admission.
  • The PT / PTA are seeing Mrs. Jones for difficulty walking, muscle weakness and previous falls – partially caused by her peripheral neuropathy.
  • During the 3rd week of home health services, the PTA makes a visit to Mrs. Jones. This PTA has seen the patient on two previous visits.
  • Today the PTA notes that the patient is coughing, has more ankle edema and while walking with Mrs. Jones, the patient is more fatigued than on other days.
  • This is the first time that the PTA has noted these signs and symptoms in Mrs. Jones. The patient says that they started the day before.
  • The PTA knows that Mrs. Jones has CHF as a comorbidity, so he lets the other team members know this information via the communication notes in the EMR.
  • In order to prevent Mrs. Jones from having further symptoms without the physician being informed, the PTA contacts the RN Case Manager by telephone as well to report these signs/symptoms in the next hour.
  • The nurse has a visit ordered for this week. However, she moves it and makes a visit on Mrs. Jones that day to assess the patient and identify all status changes.
  • The nurse notes that what the PTA stated and documented is continuing for the patient; therefore, she calls the physician and reports these changes in the patient. The physician orders an extra dose of the diuretic that the patient is prescribed.
  • This coordination of care prevents Mrs. Jones from having a CHF exacerbation – with an ER visit or rehospitalization.

Case Study #2 – Mrs. Jones

  • In the 5th week of home health services, the Aide sees that the patient has a red area on the left buttock that wasn’t there on previous patient visits.
  • She documents this in the EMR note section to the team. Also, in her visit note she states this and that she reported this to the RN.
  • The Aide also calls the RN since she recognizes that this change in skin condition indicates that the nurse needs to know prior to her next re-synchronization of his laptop when he will see the note.
  • The RN acknowledges the conversation and her actions in the Notes section of the EMR.
  • The RN states that she will visit the patient the next morning.
  • She also asks the rest of the team members to ensure that the patient teaching on skin care, repositioning, and reporting any changes is done on each visit.

Keeping You Current on Coordination of Care

5 Star Consultants provides many ways for home health agencies to stay on top of industry changes such as the recently revamped CoPs dealing with coordination of care.  Care management between the interdisciplinary team has assisted numerous agencies in implementing much better communication, compliance with patient care/ clinical record documentation and increasing patient outcomes through care management models.  5 Star Consultants can provide remote and onsite consultation partnering with your agency in order to help you with your coordination of care to comply with the new CoPs and to increase your star ratings!

With our many training options and manuals, your staff can always be informed, ensuring that deficiencies and fines do not plague your HHA.  To learn more, please contact us at [email protected] or 866-428-4040.

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Pain Management Techniques and Strategies

Coping with pain is never easy.  When people feel pain probably their first thought is to reach for a medication that will hopefully relieve it.  However, pain can be managed in various ways, including without prescription and/or over the counter (OTC) drugs.  In this blog we will cover the various ways to manage pain – without medication.

Thinking Outside of the Pain Management Box

There are many techniques for easing pain.  There are great standalone alternatives without medication or they can be used in conjunction with medication.  Below are several different ways to think “Outside of the Box”:

  • Meditation

Meditation has been so effective in relieving stress and in a lot of cases decreasing pain symptoms that on any given day you can find numerous articles about the positive effects of meditation.  I have been doing meditation for almost a year, and I see a difference in myself already, as do others.  Meditation focuses the mind.  It lets you live in the moment and as a result causes stress and therefore, pain symptoms to decrease in many cases.  It is so simple and yet so hard to do!  Just focus on your breath – designate a time and place every day and sit, stand or walk and just focus on your breath.  Count your breaths to 10 and then start again.  Sounds easy, right?  But rarely will you get even to the 4th breath, before your “Monkey Mind” is jumping from branch to branch and tree to tree.  Each time you realize that your mind has diverted from the breath to another subject, just gently acknowledge it and go back to the breath.  Try it!  And, for your patients, ask the physicians if they think that meditation is a good adjunct therapy for the patient.  You may be surprised at how many are very accepting of meditation!

  • Music Therapy

According to studies, a great pain reduction therapy and diversion is music therapy.  One study examined the effectiveness of using music as an intervention for relieving pain caused by osteoarthritis experienced by people over 65 years and living in a community.  The results were astounding!  Seniors who listened to music experienced a significant reduction in pain.  Results show that the experimental group experienced a decrease, both in the perception as well as in the intensity of pain, throughout the entire period of the study.  However, the control group maintained relatively the same level of pain.  So, do not disregard music as an effective intervention for patients with chronic pain.  I know personally music helps me a LOT with pain – it helps me to relax and basically forget about the pain symptoms!

  • Aromatherapy

With aromatherapy, scents from essential oils are either applied directly to the patient’s skin or inhaled.  This type of alternative pain management dates back thousands of years with it being used by the Chinese, Indians, Egyptians, Romans and Greeks.  Studies have demonstrated that it has been effective in easing pain for those with rheumatoid arthritis, headaches and cancer.  Note:  Be sure to have a physician’s order for this therapy.

  • Massage

Massage can be used for managing various types of pain.  By manipulating the body’s soft tissues, not only the muscles, but also circulation, and lymphatic and nervous systems are positively impacted.  According to multiple recent trials, massage is beneficial for chronic lower back pain.  Note:  Be sure to have a physician’s order for this therapy and use a trained massage therapist for patients.

  • Getaway in a Bag

This is an alternative pain management technique offered by Duke University’s Homecare Pain Management Program.  Along with medications, the home health team offers patient education on ways to manage the pain without drugs during every visit.  The patient receives a bag that includes a variety of opportunities for relaxation, aroma and guided imagery therapies, and a meditation CD, as well as a squeeze ball and cuddly item for general comfort.  This program has resulted in increases in outcomes and patient satisfaction.  So, your agency can make their own Package for Pain relief for all patients that your interdisciplinary team has identified.  The patient’s pain is an outcome that they will strive to improve during the home health admission!

Pain Medication is not the Only Answer

In conclusion, do not only rely on pain medications to help your patients or yourself!  Non-pharmacological techniques can be very successful and what works for one person may not work for another.  Remember, home health is meant to be holistic, so don’t just teach medications for pain!

Please contact us at [email protected] or 866-428-4040 for further information.

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Sitecare SupportPain Management Techniques and Strategies