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Covering Integumentary Items in OASIS-D

Integumentary refers to an organ system consisting of the skin, hair, nails, and exocrine glands.  The skin is the largest organ in the human body.  In OASIS-D there are nine M items (M1306, M1307, M1311, M1322, M1324, M1330, M1334, M1340 and M1342) dealing with pressure ulcers/injuries relating to this system.  This blog will define these nine M items and provide preliminary guidance regarding each one.

Dealing with Resource Discrepancies

Before reviewing each M item, it is essential to know what resources are out there that can be used by Home Health agencies (HHAs). CMS has adopted the guidelines from the Wound, Ostomy and Continence Nurses Society (WOCN), whichwere developed to facilitate the classification of wounds.

Today, many home health agencies are using the NPUAP (National Pressure Ulcer Advisory Panel) guidelines in their clinical practice and documentation instead.  Discrepancies exist between the two guidelines as the definitions do not perfectly align at each stage. When encountering these discrepancies, it is best that a HHA use and rely on the guidelines adopted by CMS.

M Items

  • M1306 deals with patients who have at least one unhealed pressure ulcer/injury at Stage II or higher or designated as unstageable. It does not deal with Stage I, healed Stage II or closed Stage III and Stage IV pressure ulcers/injuries.

Once the pressure ulcer has fully granulated and the wound surface is completely covered with new epithelial tissue, it is considered healed.  However, note that the tensile strength of the skin overlying a closed full thickness pressure ulcer is only 80 percent of normal skin tensile strength; therefore, agencies should ensure preventative measures are put into place that will mitigate the re-opening of a closed pressure ulcer.

  • M1307 identifies the oldest Stage II ulcer that is present at the time of discharge and is not fully epithelialized (healed). This item takes into consideration the length of time the ulcer remained unhealed while receiving care from the HHA.  It also identifies patients who develop Stage II ulcers while under the HHA’s care.

The HHA should not reverse the stage of a pressure ulcer as way to document healing.  This method does not accurately characterize what is physiologically occurring as the ulcer heals.

  • M1311 identifies the number of unhealed pressure ulcers/injuries at each stage (Stage II, Stage III and Stage IV), except Stage I. However,those observed on assessment are designated asu  At time of discharge, this item also identifies if each pressure ulcer/injury present on the discharge assessment was observed at the same stage at the time of the most recent SOC/ROC.

When designating a pressure ulcer/injury as “healed” vs. “unhealed”, it is the same as referring to it as “closed” vs. “open”.  However, unstageable pressure ulcers/injuries, whether covered with a non-removable dressing, eschar and/or slough, would not be considered healed.

  • M1322 deals with the number of Stage I pressure ulcers/injuries.

When dealing with M1322, it is critical to review past medical records, and ask physicians, caregivers and family first before coding.  The HHA needs to determine if the redness can be attributed to a previous Stage III or Stage IV pressure ulcer/injury.

  • M1324 is concerned about the most problematic unhealed pressure ulcer/injury that is stageable.

This M item excludes any pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar, or deep tissue injury.  Also, any pressure ulcers/injuries that have healed should not be considered.  The HHA should use the response that most accurately describes the stage of the most problematic stageable pressure ulcer/injury as per the definitions of each stage detailed in M1311.  NA should be used if the patient does not have any pressure ulcers or only has unstageable pressure ulcers.

  • M1330 deals with stasis A stasis ulcer is an ulcer that develops in an area in which the circulation is sluggish, and the venous return is poor.  One of the most common locations for a stasis ulcer to develop is the ankle.

It is key to differentiate stasis ulcers from other types of skin lesions because they DO NOT include arterial lesions or ulcers.  Once a stasis ulcer has completely epithelialized, it is considered healed and should not be reported as a current stasis ulcer.

  • M1332 identifies the number of stasis ulcers that are observable.The responses for this item range from one to four or more.
  • M1334 is concerned with the most problematic stasis ulcer that is observable. A stasis ulcer can be categorized as the most problematic because it is the largest, the most resistant to treatment, and/or infected.

It is critical that a HHA utilize the WOCN guidelines when determining the most problematic, observable stasis ulcer.

  • M1340 identifies the presence of a wound resulting from a surgical procedure.

If there are no surgical wounds that are identified, the clinician can skip to item M1400.

  • M1342 covers the status of the surgical wound. According to WOCN guidelines,a surgical site closed primarily (with sutures, staples, or a chemical bonding agent) is a surgical wound until re-epithelialization has been present for approximately 30 days, unless it has dehisced or shows signs/symptoms of infection.After 30 days, it is generally described as a scar and is no longer reported as a surgical wound.

A dehisced wound or one healing by secondary intention is considered“not healing” when the amount of a vascular tissue is ≥25 percent.An important thing to note is that the presence of staples does not mean the surgical wound is not healing. Steri-strips are skin closures and are not considered a dressing or device.If the steri-stripsenable sufficient visualization of the wound, appropriate healing should be reported by the HHA.

Confused?

There is so much more to know about the M items related to integumentary.  Whether you need coding, consulting and/or training, our team offers the services that can best help you sift through the industry’s constant changes and hence, often confusion.  To learn more, please contact us at [email protected] or 866-428-4040.

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Dealing with M2020 – Management of Oral Medications

OASIS-D just went into effect on January 1, and 28 M items were deleted. M2020 will continue to be included in this new version of OASIS.  M2020 identifies the patient’s current ability to prepare and take all oral medications (always excludes injectable and IV meds) reliably and safely at all times.  This includes administration of the correct dosage at the appropriate times/intervals.

Ability Assessment

Note that item M2020 refers to the patient’s ability to safely take oral medications, not the patient’s compliance or willingness.  This ability can be temporarily or permanently limited by several factors, such as physical impairments (i.e. limited manual dexterity), emotional/cognitive/behavioral impairments (i.e. memory deficits, impaired judgment, and/or fear), sensory impairments relating to vision and/or pain, and environmental barriers such as stairs, and narrow doorways.In order to accurately assess and score the OASIS, it is key to view the patient from a holistic perspective. This will also assist in improving the patient’s outcome in this medication management item.

M2020 Responses

  • Response 0

Enter Response 0, if the patient can set up her/his own “planner device” for medications, and consequently takes the correct medication in the correct dosage at the correct time.The following should be included in the assessment of the patient’s ability:

  • Obtain the medication from where it is routinely stored,
  • Read the label (or otherwise identify the medication correctly),
  • Open the container,
  • Select the pill/tablet or milliliters of liquid, and
  • Orally ingest it at the correct times.
  • Response 2

Enter Response 2, if daily reminders to take medications are necessary, regardless of whether the patient is independent or needs assistance in preparing individual doses (for example, setting up a “pill planner”).  If a medication is ordered PRN and the medication is needed by the patient on the day of assessment, AND the patient needed a reminder to take this PRN medication on the day of assessment, then Response 2 should be entered.

  • Response 3

Enter Response 3, if the patient does not have the physical or cognitive ability on the day of assessment to take all medications correctly (correct medication, correct dose, and correct time) as ordered and it has not been established (the clinician cannot assume) that set up, diary, or reminders have already been successful. The clinician should return to assess if the interventions, such as reminders or a med planner, were adequate assistance for the patient to take all medications safely!

Even if a patient resides in an assisted living facility where the facility holds and administers medications, item M2020 should still be used to continue to report the patient’s ability to take the correct oral medication(s) and proper dosage(s) at the correct times.  Clinicians should report the ability based on assessment of the patient’s vision, strength, and manual dexterity in the patient’s hands and fingers, as well as cognitive ability, despite the facility’s requirement.

Ways to Improve Medications

There are many ways to improve medications.  It should start with the staff requesting that the patient gather all drugs, prescription and OTC, at SOC.  This will allow assessment of the physical ability and safety to get to the meds.  Next, assess if the patient knows what the drugs are for and what to report.  It is critical that all high-risk meds are taught at SOC/ROC visits.  These drugs should be documented by name in the clinical note.  If the patient’s med box is present, check that it is accurately filled for the times meds are due. Finally, always compare to discharge med list and call on any medication issues at SOC. This includes duplicate drugs and medication interactions.

Proper Assessment and Scoring of M2020

As with any OASIS item, it is key to be well informed to ensure proper coding.  5 Star’s coders are HCS-D coding and OASIS certified Registered Nurses.If your home health agency needs OASIS review and diagnosis coding, or OASIS D education, our RNs would like to help you!  To learn more about our consulting services, please contact us at [email protected] or 866-428-4040.

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OASIS-D – Dealing with New Section J Items

OASIS-D is a major change with the revision of seven items, removal of 28 items and introduction of two new items.  In our last blog we addressed the new Section GG items dealing with Functional Abilities and Goals.  The other new item, Section J, addresses health conditions or more specifically falls, and this blog will review it in further detail.

Section J – Health Conditions

  • J1800

Assessment item, J1800, deals with any falls since start of care (SOC) or since resumption of care (ROC), depending upon which is most recent.  The intent of this item is to identify if the patient had any witnessed or unwitnessed falls since the most recent SOC/ROC.  The time point items include transfer to an inpatient facility, death at home or discharge from agency – not to an inpatient facility.

According to this assessment item, a fall is defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface such as a bed or chair.  The fall may be witnessed or unwitnessed.  It can be reported by the patient or an observer or identified when a patient is found on the floor or ground.  The fall is not a result of an overwhelming external force such as a person pushing the patient.

An intercepted fall is also considered a fall per this assessment item.  An intercepted fall is defined as when the patient would have fallen if he or she had not caught him/herself or had not been intercepted by another person.  However, CMS understands that challenging a patient’s balance and training him/her to recover from a loss of balance is an intentional therapeutic intervention.  Anticipated losses of balance that occur during supervised therapeutic interventions are not considered intercepted falls.

Response specific instructions include reviewing a patient’s home health clinical record, incident reports and any other relevant clinical documentation such as fall logs.  Also, the patient and/or caregiver(s) should be interviewed about the occurrence of falls.

Coding instructions for this assessment item are:

  • Code 0: No – If the patient has not had any fall(s) since the most recent SOC/ROC.
  • Code 1: Yes – If the patient has fallen since the most recent SOC/ROC.
  • A dash is a valid response for this item. CMS expects dash use to be a rare occurrence.
  • J1900

The intent of the second new assessment item, J1900, is to identify the number of falls a patient has had since the most recent SOC/ROC, and any fall related injury.  The time point items are the same as for J1800, which include transfer to an inpatient facility, death at home or discharge from agency – not to an inpatient facility.

The following definitions are used when addressing J1900:

  • Injury related to a fall includes any documented or reported injury that occurred as a result of or was recognized within a short period of time (i.e. hours to a few days) after the fall and can be attributed to the fall.
  • No injury means that there is no evidence of any injury noted on the assessment; no complaints of pain or injury by the patient; no change in the patient’s behavior is noted after the fall.
  • Injury (except major) includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains or any fall-related injury that causes the patient to complain of pain.
  • Major injury is defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.

Response specific instructions include review of the home health clinical record, incident reports and any other relevant clinical documentation, such as fall logs. The patient and/or caregiver(s) should be interviewed about the occurrence of the falls.  The number of falls that occurred since the most recent SOC/ROC should be determined, and the level of fall-related injury for each should be coded.  No matter where the fall occurred, it should be coded, but each fall should only be coded once.   If the patient sustains multiple injuries in a single fall, then code the fall for the highest level of injury.

Coding instructions vary based on the type of fall:

  • J1900A – No Injury
    • Code 0, None, if the patient had no injurious falls since the most recent SOC/ROC.
    • Code 1, One, if the patient had one non-injurious fall since the most recent SOC/ROC.
    • Code 2, Two or more, if the patient had two or more non – injurious falls since the most recent SOC/ROC.
    • A dash is a valid response for this item. However, CMS expects dash use to be a rare occurrence.
  • J1900B – Injury, Except Major
    • Code 0, None, if the patient had no falls with injury, except major, since the most recent SOC/ROC.
    • Code 1, One, if the patient had one fall with injury, except major, since the most recent SOC/ROC.
    • Code 2, Two or more, if the patient had two or more falls with injury, except major, since the most recent SOC/ROC.
    • A dash is a valid response for this item. However, CMS expects dash use to be a rare occurrence.
  • J1900C – Major Injury
    • Code 0, None, if the patient had no falls with major injury since the most recent SOC/ROC.
    • Code 1, One, if the patient had one fall with major injury since the most recent SOC/ROC.
    • Code 2, Two or more, if the patient had two or more falls with major injury since the most recent SOC/ROC.
    • A dash is a valid response for this item. However, CMS expects dash use to be a rare occurrence.

Prepare Now
 
With an effective date of January 1, 2019, OASIS-D changes will be here very soon.  5 Star Consultants can help to prepare your staff for these changes with online or on-site training options.  To learn more, please contact us at [email protected]5starconsultants.net or 866-428-4040.

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OASIS-D – Many New Items, Very Little Time

OASIS-D changes are coming at home health agencies (HHAs) fast and furious with a January 1, 2019 implementation date.  The main reason for revising OASIS-D is to increase standardization across post-acute care (PAC) settings, and enable calculation of standardized, cross-setting quality measures (QMs), pursuant to the provisions of the IMPACT Act.  This standardization involves SPADEs (standardized patient assessment data elements), which are questions and response options that are identical across all four PAC assessment instruments, and include identical standards and definitions.

As we mentioned in our OASIS-D blog in August, several items will be deleted come January.  However, in this blog we will focus on the additions, not the deletions.  We will provide high level information regarding the new GG items in particular.
 
Section GG – Functional Abilities and Goals 

  • GG0100

The intent of assessment item, GG0100, is to deal with the patient’s usual ability regarding everyday activities, prior to the current illness, exacerbation or injury.  The time point items are completed at start of care (SOC) and at resumption of care (ROC).  The response-specific instructions include interviewing the patient or family members.  However, another option is to review the patient’s clinical records describing the patient’s prior functioning as related to everyday activities.

When coding, Codes 1-3 can be used, but there two new codes also:

  • Code 8: Unknown, if the patient’s usual ability prior to the current illness, exacerbation or injury is unknown.
  • Code 9: Not Applicable, if the activity was not applicable to the patient prior to the current illness, exacerbation or injury.

Also, A dash is a valid response for this item.  However, CMS expects the use of a dash as a rare occurrence.

  • Coding Tip: If no information about the patient’s ability is available after attempts have been made to interview the patient and/or family members, and after reviewing the patient’s clinical record, then use code 8 – Unknown.
  • GG0110

Assessment item, GG0110, identifies the patient’s use of devices and aids immediately prior to the current illness, exacerbation, or injury to align treatment goals.  Like GG0100, the time point items are completed at SOC and at ROC.  The response-specific instructions include interviewing the patient and/or family members or reviewing the patient’s clinical record describing use of prior devices and aids.  When coding, check all devices that apply, which may include a manual wheelchair, a motorized wheelchair and/or scooter, a mechanical lift, a walker, or orthotics/prosthetics.  However, if the patient did use any of these listed devices or aids immediately prior to the current illness, exacerbation, or injury, then item Z, none of the above, should be checked.  A dash can be a valid response too, but it should be used rarely. 

  • GG0130

The intent of assessment item, GG0130, is to identify the patient’s ability to perform the listed self-care activities, and discharge goal(s).  Unlike the other GG items described above, the time points completed for GG0130 include start of care, resumption of care, follow-up, and discharge from agency – not to an inpatient facility.  The response-specific instructions include the preferred method of direct observation, but reviewing reports from the patient, clinicians, care staff, and/or family members is another acceptable option.  When possible, CMS advocates a multidisciplinary approach to patient assessment.

  • Coding Tip: Assessment item, GG0130B, deals with Oral Hygiene. If a patient does not perform oral hygiene during home visit, then determine the patient’s abilities based on performance of similar activities during the assessment, or on the patient and/or caregiver report.
  • GG0170

The final new GG assessment item, GG0170, deals with mobility.  It identifies the patient’s ability to perform the listed mobility activities, and discharge goal(s).  Similar to GG0130, the time points completed include SOC, ROC, follow-up and discharge from agency – not to an inpatient facility.  Also similar to GG0130, response-specific instructions include the preferred method of direct observation, but reviewing reports from the patient, clinicians, care staff, and/or family members is also acceptable.

Be Informed
 
With the busy schedules of home health staff, it is often difficult for them to find time to review the CMS OASIS Guidance Manual.  5 Star Consultants has a better option for bringing your team up to speed.  We offer a pre-recorded webinar on the OASIS-D changes titled OASIS-D:  Be Prepared for New, Detailed Assessment Items.  This session is led by Sharon Litwin, a Senior Managing Partner and Founder of 5 Star Consultants, LLC, and a renowned speaker at state and national conferences.  The 90-minute webinar will cover the upcoming changes in detail, making it easy for your team to be informed before the January 1, 2109 effective date.  To learn more, please contact us at [email protected] or 866-428-4040.

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Completing the Survey Process

Your Plan of Correction (POC) may be written and submitted, but this does not necessarily mean the survey process has been finalized for your home health agency (HHA). Yes, your HHA has completed many of the critical steps, but you may ask what comes next? In this blog we will explore what to expect after you submit your Plan of Correction.

What to Expect Next

After your HHA completes and submits its POC, the State Agency (SA) or Accrediting Organization (AO) will inform you if your Plan of Correction has been accepted or if it needs to be revised. If your POC needs to be revised, the report will cover the areas of concern that need to be addressed, why the POC was not accepted with its revisions, evidence necessary for compliance and the allotted time frame in which the revised POC must be submitted to the SA or AO. The evidence to support correction of each deficiency and to demonstrate compliance is typically due 90 days from the date of the survey. However, in addition to addressing these concerns, sometimes a return on-site follow-up visit is required.

Addressing Condition-Level Deficiencies

As we addressed in our blog on deficiencies, a Condition-Level Deficiency is a more serious type of deficiency than a Standard-Level Deficiency. This level of deficiency is issued if a surveyor determines that your HHA is not in compliance with a Condition of Participation (CoP), such as not having a formal agency wide QAPI program. Also, a Condition-Level Deficiency may be cited if your HHA receives two – three (or more) Standard-Level Deficiencies.

When a Condition-Level Deficiency is cited, the State Agency or Accrediting Organization will notify Medicare that the HHA has a Condition-Level Deficiency. The SA or AO typically will return for a follow up on-site visit in approximately 30-60 days from the last day of the HHA’s survey. The purpose of this visit is twofold: evaluation of agency deficiency corrections and compliance. If it is determined that the HHA is still noncompliant and cannot show evidence of performance improvement, then Medicare Certification can be terminated. Also, it can be terminated if upon a return visit (usually in another 30 to 60 days) improvement is demonstrated, but still the HHA is not within total compliance. In addition, a HHA will not be able to competency aides for two years for any condition received, not just Aide Services.

The Plan of Correction for the Condition-Level Deficiency includes the same elements that require a specific action plan to correct and prevent future noncompliance. The difference is that the Condition-Level Deficiency typically must be abated within 10 calendar days of the survey findings.

It is key to remember that the Plan of Correction is an important legal HHA document that the Administration should understand. It is more than a process that must be completed and then filed away. The Plan of Correction should be used in the QAPI plan for ongoing monitoring of compliance and can be used in litigation if applicable.

Ensure Compliance is no Longer an Issue

Since opening our doors in 2003, 5 Star Consultants have helped ensure hundreds of home health agencies are in compliance. Whether they have received Standard-Level or Condition-Level Deficiencies, our team of former or current AO surveyors has worked side-by-side with a HHA’s staff to help guarantee any deficiencies have been corrected and Medicare Certification will not be terminated. For further information about our services and how we can possibly assist your home health agency, please contact us at [email protected] or 866-428-4040.

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