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OASIS C 2/16/14

©2013, Selman-Holman & Associates, LLC 1

M1720 When Anxious

¨  Timepoints SOC ROC Discharge ¨  Anxiety includes:

¤ Worry that interferes with learning and normal activities

¤ Feelings of being overwhelmed and having difficulty coping

¤ Symptoms of anxiety disorders ¨  “Nonresponsive” means that the patient is unable to

respond or the patient responds in a way that you can’t make a clinical judgment about the patient’s level of orientation. Examples at 4b-Q124.1

M1730 Depression Screening


Process Measure


¨  Timepoints SOC ROC ¨  If using PHQ-2, then you must interview the patient.

4b-Q124.5

¨  Depressive feelings, symptoms, and/or behaviors may be observed by the clinician or reported by the patient, family, or others, BUT another tool must be used.

¨  If the patient is not cognitively able to respond then must answer 0-No, unless another tool can be used.

¨  If a standardized depression screening tool is used, use the scoring parameters specified for the tool to identify if a patient meets criteria for further evaluation of depression


¨  Identifies if the agency screened the patient for depression using a standardized depression screening tool

¨  CMS does not mandate ¤  That patients are screened ¤  Use of the PHQ-2© or any other standardized tool

¨  Process measures ¤  Capture the agency’s use of best practices following the

completion of the comprehensive assessment ¤  The best practices stated in the item are not necessarily

required in the Conditions of Participation ¤  Note that patients who have been assessed as “unresponsive”,

based on M1710, When Confused and/or M1720, When Anxious, will not be included in the process measure for depression screening.

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¨  Response 1 ¤  PHQ-2© is completed when responding to the question

n The results for rows a & b are for agency use only and will not be encoded and transmitted with OASIS data

n  If the patient/caregiver scores three points or more on the PHQ-2©, then further depression screening is indicated.

¨  The PHQ-2 is only used for patients that appear to be cognitively and physically able to answer the two included questions. After determining the PHQ-2 is an appropriate tool, the patient may be unable to answer the questions, e.g. the patient may not be able to quantify how many days they have experienced the problems. Answer 1 (NA)4b-Q124.5

¨  If the patient states the questions are too personal and/or refuses to answer, the answer is 0-No. Jan 2013

NO: Best practice interventions not included in the POC YES: POC contains orders for treating depression. Includes anti-depressant med on POC. 4b-Q172.9

NA: Patient has no diagnosis or the clinician completed an assessment that indicated the patient has no symptoms of depression (or does not meet criteria for further evaluation or treatment if a standardized depression screening tool is used).

M2250 Plan of Care Synopsis 6

Example ¨  A patient has depressive symptoms as identified

by a PHQ-2 score of “4”, but the patient has no diagnosis or current treatment for depression. If the clinician notifies the physician of the depressive symptoms and is instructed to continue to monitor the patient, with no orders for specific treatment, what response would be selected for M2250d??

¨  After reporting the patient's status, a physician order to continue to assess for signs of depression could be considered an intervention for depression, and be reported as “Yes” for M2250d. 4b-Q172.8.1

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Diagnosis of Depression

¨  Applicable to all patients with a diagnosis of depression (clearly documented in their medical record and/or confirmed by a physician)

¨  Includes diagnoses with depression as a stated or intended component ¤  bipolar disorder with depression, ¤  bipolar disorder - mixed depression and mania ¤  Alzheimer's with depression

¨  The depression best practice is also applicable to all patients who have been screened for depression and exhibit symptoms that require further evaluation for depression, even if a formal diagnosis of depression has not been made. Oct 2012

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Interventions for depression

¨ Interventions for depression may include: ¤ New medications ¤ Adjustments to already-prescribed

medications ¤ Referrals to agency resources (e.g.,

social worker) ¤ Monitoring medication effectiveness ¤ Teaching regarding compliance with med

regimen

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M1740 Cognitive, behavioral, and psychiatric symptoms


q  Timepoints SOC ROC Discharge q  Behaviors can be observed by the clinician

or reported by the patient, family, or others

q  Consider problematic behaviors q Severe enough to make the patient unsafe OR

cause considerable stress to caregivers OR require supervision or intervention

q  Consider frequency of behaviors


¨  The time frame under consideration for M1740, Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week, is defined in the wording of the item - "at least once a week". The phrase "at least once a week" means that a behavior was demonstrated multiple times in the recent, relevant past and the frequency of the occurrence was at least one time a week prior to and including the day of assessment. The assessing clinician will determine "recent, relevant past" based on the patient/caregiver interview, referral information, assessment findings, diagnoses and recent history of medical treatment and its effectiveness. 4b-Q124.5.6

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M1740

¨  If a patient is alert and oriented, but decides not to use their cane because they think they don’t need it (they are unsafe without it) or they decide they aren’t going to take their diuretic because they are going to the doctor and don’t want to have any accident, would you select Response “2 – Impaired decision-making”?

4b-Q124.5.5

M1740

¨  The intent of M1740, Cognitive, behavioral, and psychiatric symptoms, is to capture specific behaviors that are a result of significant neurological, cognitive, behavioral, developmental or psychiatric limitations or conditions. It is not the intent of M1740 to report noncompliance or risky choices made by cognitively intact patients who are free of the aforementioned conditions. The assessing clinician will have to determine if the patient has a disorder that is causing her non-compliance or is the patient making a choice not to comply completely with physician's orders, cognizant of the implications of that choice.

Question 13

M1745 Frequency of Disruptive Behavior Symptoms

Frequency of any behaviors that are disruptive or dangerous to the patient or the caregivers

Behaviors may or may not be listed in M1740

M1745 Frequency of Disruptive Behavior Symptoms

v  Consider if the patient has any problematic behaviors – not just the behaviors listed in M1740 – which jeopardize or could jeopardize the safety and well-being of the patient or caregiver. Then consider how frequently these behaviors occur.

v  Include behaviors considered symptomatic of neurological, cognitive, behavioral, developmental, or psychiatric disorders. Use clinical judgment to determine if the degree of the behavior is disruptive or dangerous to the patient or caregiver.

v  Disruptive/dangerous behaviors v  Sleeplessness v  “Sun-downing” v  Agitation v  Wandering v  Aggression v  Combativeness v  Getting lost in familiar places, etc.

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M1745 - Frequency of Disruptive Behavior Symptoms, only based on disruptive behavior: physical, verbal or other disruptive/dangerous symptoms? Or is this item based on behaviors listed in M1740?

M1740 - Cognitive, behavioral, and psychiatric symptoms, and M1745 – Frequency of Disruptive Behavior Symptoms are not directly linked to one another.

M1740 – M1745

There may be behaviors reported in M1740 that are not reported in M1745 and vice versa.

For example, a patient may express excessive profanity or sexual references that cause considerable stress to the caregivers and be reported in M1740, but in the clinician's judgment, the behavior does not jeopardize the safety and well-being of the patient or caregiver, therefore is not reported in M1745.

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M1745

When completing M1745 - Frequency of Disruptive Behavior Symptoms, do we have to take into consideration if the patient has a fulltime caregiver to watch over her, or do we address it without including the caregiver's presence?

M1745

The environment in which the patient lives and the skills of the caregiver may impact the scoring of M1740 - Cognitive, behavioral, and psychiatric symptoms, and M1745 - Frequency of Disruptive Behavior Symptoms. For example, if a patient has dementia, they may exhibit a number of behaviors listed in M1740, but may not be reported in the OASIS item if they live in a setting specifically designed to care for patients with dementia. The same would be true for M1745. Look to the descriptors for the behaviors that are reportable for both M1740 and M1745 to determine if the behavior would be reportable. 4b-Q124.7

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M1750 Psychiatric Nursing Services

M1750, Psychiatric Nursing Services, reports if the patient is receiving psychiatric nursing services in the home at the time of the SOC/ROC assessment. This is referring to qualified personnel of the home health agency, per physician orders, specifically for the assessment and treatment of psychiatric conditions. When completing the SOC/ROC comprehensive assessment, if an order exists on the plan of care for the agency to provide psychiatric services, then respond "Yes" to M1750.

By home health, not a different

community provider

M1750 Psychiatric Nursing Services

¨  If there are no orders on the referral for psych nursing services, should the skilled nurse answer M1750 “Yes” if she identifies a psych issue on her initial assessment and plans to obtain physician’s orders for the agency’s Mental Health Nurse? Can she answer “Yes” even if the visit by the Mental Health Nurse will not be completed in the 5 day assessment window?

¨  In order to select "Yes" for M1750, Psychiatric Nursing Services, you must have a physician order for psychiatric nursing services on the Start of Care/Resumption of Care plan of treatment. It is not required that the clinician completing the comprehensive assessment be a qualified psychiatric nurse. The first visit by the qualified psychiatric nurse does not have to occur in the time frame allowed for completing the comprehensive assessment, but you must have an order for the psychiatric nursing services to answer "Yes." 4b-Q126.1

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ADL/IADLs M1800-‐M1910 23

ADL/IADL Conventions

¨  ADL questions assess the patient’s ABILITY, not necessarily actual performance

¨  "Willingness" and "compliance" are not the focus of these items.

¨  Items address the patient's ability to SAFELY perform ADLs ¤ current physical status ¤ mental/emotional/cognitive status ¤ Activities permitted/environment.

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•  Ability can be temporarily or permanently limited by ¤ physical impairments (e.g., limited range of

motion, impaired balance), ¤ emotional/cognitive/behavioral impairments

(e.g., memory deficits, impaired judgment, fear),

¤ sensory impairments (e.g., impaired vision or pain),

¤ environmental barriers (e.g., stairs, narrow doorways, location of bathroom or laundry).


¨ Patient’s ability ¤ Condition improves or declines ¤ Medical restrictions are imposed or lifted ¤ Modification of environment

¨ The clinician must consider what the patient is able to do on the day of the assessment. If ability varies over time, choose the response describing the patient’s ability more than 50% of the time period under consideration.


q While the presence or absence of a caregiver may impact actual performance of activities, it does not impact the patient’s ability to perform the task.

q The patient is able to put her clothes on once laid out on the bed. The caregiver has been hospitalized. Is the patient now unable to dress herself?

q Did the patient’s ability change?


¨  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.

¨  The scales present the most independent level first, then proceeds to the most dependent.

¨  Read each response carefully to determine which one best describes what the patient is able to do.; read from bottom to top

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Bedfast DeRined ¨  Ch. 3 of the OASIS-C Guidance Manual…defines bedfast.

"Bedfast refers to being confined to the bed, either per physician restriction or due to a patient's inability to tolerate being out of the bed." If the patient can tolerate being out of bed, they are not bedfast unless they are medically restricted to the bed. The patient is not required to be out of bed for any specific length of time. The assessing clinician will have to use her/his judgment when determining whether or not a patient can tolerate being out of bed. For example, a severely deconditioned patient may only be able to sit in the chair for a few minutes and is not considered bedfast as she/he is able to tolerate being out of bed. A patient with Multiple System Atrophy becomes severely hypotensive within a minute of moving from the supine to sitting position and is considered bedfast due to the neurological condition which prevents him from tolerating the sitting position. 4b-Q151.14

M1800-‐M1900

A patient may demonstrate that they can safely ambulate while using a walker, but then as a matter of choice, decide to walk without it. Another patient may demonstrate that they can safely ambulate while using a walker, but then consistently walk without it, forgetting that they have a walker.

For the purposes of OASIS scoring, non-conformity or non-compliance should not automatically be considered indicative of a deeper psychological impairment. The assessing clinician will have to use clinical judgment to determine if the patient’s actions are more likely related to impairment, or to personal choice made in awareness of the potential related risk.

M1800-‐M1900

The response related to "assistance of another person" includes those patients, actively participating in performing a task, but needing assistance of one or more person(s) to safely complete included tasks. 4b-Q127.4

Service animal counts as a device, NOT as assistance. 4b-Q127.1

M1800 Grooming

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M1800 Grooming

¨  Timepoints SOC ROC Discharge ¨  Grooming excludes

¤ Bathing ¤ Shampooing hair ¤ Toileting hygiene

¨  Consider the frequency with which selected activities are necessary ¤ washing face and hands vs. fingernail care

¨  Patients able to do more frequently performed activity should be considered to have more ability in grooming

¨  If the patient requires a “spotter” for safety, response 2.

M1810 Current Ability to Dress Upper Body

M1820 Current Ability to Dress Lower Body

M1810/M1820 Current Ability to Dress Upper/Lower Body

q  Timepoints SOC/ROC/FU/Discharge q  Identifies the patient’s ability to

¤ Dress upper and lower body ¤ Obtain, put on and remove upper and

lower body clothing ¤ Put on whatever clothing is routinely

worn (look in the closet). q  Specifically includes the ability to manage

zippers, buttons, and snaps if these are routinely worn.

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Prosthetic, orthotic and other support devices

q  Prosthetic, orthotic, or other support devices

applied to the upper body (e.g., upper extremity prosthesis, cervical collar, or arm sling) should be considered as upper body dressing items.

q  Prosthetic, orthotic, or other support devices applied to the lower body (e.g., lower extremity prosthesis, ankle/foot orthosis [AFO], or TED hose) and including ace wraps should be considered as lower body dressing items. 4b-Q132.4

M1810/M1820 Current Ability to Dress

q Observation/interview the patient or caregiver

q Observe spinal flexion, joint range of motion, shoulder and upper arm strength, and manual dexterity

q Ask the patient to demonstrate the body motions involved in dressing

Dressing

¨  The patient’s clothes are hung over the chair in the bedroom, therefore he is safe getting his clothes? ¤ Is this his permanent solution? 4b-Q132.3

¨  What if closets etc are adapted for your wheelchair bound patient? 4b-Q132.1

¨  If a patient modifies the clothing they wear due to a physical impairment, the modified clothing selection will be considered routine if there is no reasonable expectation that the patient could return to their previous style of dressing.

M1810 & M1820. The guidance in M1810 & M1820 states that you assess the patient's ability to obtain, put on and remove the clothing items usually worn. Other guidance states that items such as prosthetics, corsets, cervical collars, hand splints, Teds, etc. are considered dressing apparel. Do we include the other items, like a splint, if the patient doesn't usually wear it? Our patient just injured their wrist and will only be wearing it for a week; he doesn't usually wear a splint.

What response? 4b-Q132.4

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July 2013 Q&A #14

Q: Are wound dressings included as an upper or lower body dressing task for M1810/1820? A: Wound dressings are NOT one of the included dressing items. Note that elastic bandages, including ACE wraps, worn for support and compression should be considered as a lower body dressing item, but wraps utilized solely to secure a wound dressing would not be considered a dressing (clothing) item.

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M1830 Bathing

¨ Timepoints SOC ROC F/U Discharge ¨ Specifically excludes washing face and

hands, and shampooing hair. ¨  If the patient requires standby

assistance to bathe safely in the tub or shower or requires verbal cueing/reminders, then select Response 2 or Response 3, depending on whether the assistance needed is intermittent (“2”) or continuous (“3”).

M1830 Bathing

v  Response 2--Intermittent v Patient's ability to transfer into/out of the tub or

shower is the only bathing task requiring human assistance

v Patient requires one, two, or all three of the types of assistance listed in Response 2 but not the continuous presence of another person

v  Response 3--Continuous v If a patient requires one, two, or all three of the

types of assistance listed in Response 2 and the continuous presence of another person

M1830 Bathing

OASIS C 2/16/14


¨  Response 4 The patient must be able to safely and independently bathe outside the tub/shower, including independently accessing water at the sink, or setting up basin at the bedside, etc.

¨  Response 5 The patient must be unable to bathe in the tub/shower, can participate in bathing self but needs assistance (even if just to wash his back).

¨  Response 6 The patient is totally unable to participate in bathing and is totally bathed by another person, regardless of where bathing occurs or if patient has a functioning tub or shower.

M1830 Bathing

¨ Response 4 or 5- If the patient does not have a tub or shower in the home, or if the tub/shower is nonfunctioning or not safe for patient use, the patient should be considered unable to bathe in the tub or shower, select based on the patient’s ability to bathe outside the tub/shower.

¨ Note: The patient’s status should not be based on an assumption of a patient’s ability to perform a task with equipment they do not currently have.

M1830 Bathing

M1830 Q&A October 2014 Category 4 Question #7

¨ At SOC It was noted that Mr. Ronzo was not taking a shower due to a fear of falling secondary to recent (L) BKA. At the SOC the RN was able to successfully instruct on the safe and proper use of the tub/bench and Mr. Ronzo was able to safely bathe w/ the use of a long handled sponge. How will you answer M1830? **Hint: Before answering—think about assessment time period…

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¨ At SOC Response 4 –Unable to bathe in tub/shower ….should be selected

¨ At the next OASIS assessment time point (if pt. remains w/ same ability) Response 2 will be selected. YES!! Patient showed improvement!!

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M1830 Q&A April 2013

Q5: Patient allowed to bathe, but medically restricted from getting LE cast wet; unable to put water protective sleeve on, but once someone applies the protective sleeve for him, he can get in/out of tub using transfer bench and wash entire body with hand-held shower. Does this medical restriction impact patient’s ability scoring M1830? A5: Medical restrictions that impact OASIS-included bathing tasks are considered, so the tasks required to allow compliance with medically prescribed precautions for bathing could impact patient’s ability. Response 2 is appropriate since patient needs intermittent human assistance to bathe in tub/shower.

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M1840 Toilet Transferring


•  Timepoints SOC/ROC/FU/Discharge •  Identifies patient’s ability to safely:

¤  Get to and from the toilet or commode ¤ And transfer on and off the toilet or

bedside commode •  Excludes personal hygiene and

management of clothing when toileting


¨  Response 0—Able… ¤ Patient can get to and from the toilet during the day

independently, but uses the bedside commode at night for convenience 4b-Q143

¨  Response 1—When reminded… ¤ Patient needs assistance getting to/from the toilet or

with toileting transfer or both (even if they don’t have a caregiver 4b-Q146)

¤ Patient who can independently get to the toilet, but who requires assistance to get on and off the toilet

¤  If the patient requires any degree of hands-on assistance and/or standby assistance and/or verbal cueing/reminders to get to/from the toilet and/or transfer on/off the toilet safely

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•  Response 3 ¤ Patient who is unable to get to/from the

toilet or bedside commode, but is able to place and remove a bedpan/urinal independently

¤  This is the best response whether or not a patient requires assistance to empty the bedpan/urinal.

Bedpan and Urinal

¨ If the bedfast patient needs assistance to get on/off the bedpan, the appropriate M1840 Response is "4-Is totally dependent in toileting" even if they can place and remove the urinal. 4b-Q146.1

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¨  Observation and Interview ¨  Ask the patient if he/she has any difficulty

getting to and from the toilet or bedside commode

¨  Observe the pt during transfer and ambulation note: ¤ Difficulty with balance ¤ Strength ¤ Dexterity ¤ Pain, etc.

¨  Determine the level of assistance needed to safely use the toilet or commode.

M1840. If my patient has a urinary catheter, does this mean he is totally dependent in toileting transferring?

The item simply asks about the patient’s ability to get to and from the toilet or bedside commode and their ability to transfer on and off toilet/commode. This ability can be assessed whether or not the patient uses the toilet for urinary elimination. 4b-Q142

A patient with MS is transferred via a Hoyer. She is non weight bearing. She does not participate in the transfer process.

1- “when reminded, assisted or supervised…” requires the patient to be participating in the task. If the patient cannot effectively participate in the effort required, she is scored a 4-”totally dependent in toileting” 4b-147.5

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M1840. If a patient uses a bedside commode over the toilet, would this be considered “getting to the toilet” for the purposes of responding to M1840?

Yes, a patient who is able to safely get to and from the toilet and transfer should be scored at response levels 0 or 1, even if they require the use of a commode over the toilet. Note that the location of such a commode is not at the "bedside," and the commode is functioning much like a raised toilet seat. 4b-Q148

M1845 Toileting Hygiene


v Timepoints SOC ROC Discharge v Toileting hygiene includes several

activities, including pulling clothes up or down and adequately cleaning (wiping) the perineal area.

v This item refers the patient’s ability to manage personal hygiene and clothing with or without assistive devices.


v  “Assistance” refers to assistance from another person by verbal cueing/reminders, supervision, and/or stand-by or hands-on assistance.

v  Majority of tasks rule doesn’t apply. If they cant pull down their pants they cant be a ‘0’ or ’1’

v  Response 2--Patient can participate in hygiene and/or clothing management but needs some assistance with either or both activities or Patient requires standby assistance or verbal cueing.

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M1850 Transferring

M1850 Transferring

¨  Timepoints SOC/ROC/FU/Discharge ¨  Identifies the patient’s ability to safely transfer

from bed to chair (and chair to bed), or position self in bed if bedfast.

¨  For most patients, the transfer between bed and chair will include transferring from a supine position in bed to a sitting position at the bedside, then some type of standing, stand-pivot, or sliding board transfer to a chair at the bedside. 4b-Q151.7

«  If the patient does not sleep in a bed, assess the transfer from his usual sleeping place.

(Recliner-4b-Q151.7.1

Sitting Surface not at Bedside

¨  If the sleeping surface is in the bedroom and the sitting surface is down the hall in the bathroom and the patient is independent moving from the supine to sitting position, sitting to standing, and then standing to sitting, but requires minimal human assistance or an assistive device to ambulate from the bed to the sitting surface, the appropriate M1850 score would be a "1". If the patient requires more than minimal assistance or requires both minimal human assistance and an assistive device, the appropriate score would be a “2”. 4b-Q150.1

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DeRinitions

q “Minimum human assistance”--individual assisting the patient is contributing less than 25% of the total effort required to perform the transfer

q “Minimal human assistance” could include any combination of verbal cueing, environmental set-up, and/or actual hands-on assistance. 4b-Q148.2

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M1850 Transferring

•  Response 1 ¤ Patient is able to transfer self from bed to

chair, but requires standby assistance to transfer safely, or requires verbal cueing/ reminders

¤ If the patient transfers either with minimal human assistance (but not device), or with the use of a device (no human assistance) •  “Minimal human assistance” could include any

combination of verbal cueing, environmental set-up, and/or actual hands-on assistance.

M1850 Transferring

•  Response 2 ¤ Patient requires both minimal human

assistance and an assistive device to transfer safely

¤ Patient can bear weight and pivot, but requires more than minimal human assist

¤ Patient must be able to both bear weight and pivot

•  Response 3 ¤ Patient is unable to do one or the other and

is not bedfast

M1850 Transferring

¨  Response 4 or 5 (Depending on the patient’s ability to turn and position self in bed) ¤ Patient is bedfast

n Bedfast refers to being confined to the bed, either per physician restriction or due to a patient’s inability to tolerate being out of the bed.

¨  CMS is in the process of defining assistive devices and will provide guidance when the issue is clarified.

¨  Service animals are ‘devices’

M1850. A quadriplegic is totally dependent, cannot even turn self in bed, however, he does get up to a gerichair by Hoyer lift. For M1850, is the patient considered bedfast? 4b-Q151.3

A patient who can tolerate being out of bed is not “bedfast.” If a patient is able to be transferred to a chair using a Hoyer lift, response 3 is the option that most closely resembles the patient’s circumstance; the patient is unable to transfer and is unable to bear weight or pivot when transferred by another person.

Responses 4 and 5 only apply for the patient who is bedfast according to CMS’s definition.

The frequency of the transfers does not change the response, only the patient’s ability to be transferred and tolerate being out of bed.

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M1850. When scoring M1850, Transferring, the assessment revealed difficulty with transfers. The patient was toe-touch, weight bearing on the left lower extremity and had pain in the opposite weight bearing hip. The patient had a history of falls and remained at risk due to medication side effects, balance problems, impaired judgment, weakness, unsteady use of device and required assistance to transfer. The concern is the safety of the transfers considering all of the above. Would "2" or "3" be the appropriate response? 4b-Q151.6

Safety is integral to ability, if your patient requires more than minimal human assistance or they need minimal assistance and an assistive device to safely transfer, and can bear weight and pivot safely, Response 2 should be reported. If you determine the bearing weight and pivoting component of the transfer is not safe even with assistance, then the patient is not able to bear weight or pivot and the appropriate selection would be Response 3 – Unable to transfer self and is unable to bear weight or pivot when transferred by another person.

July 2013 Q&A #15

Q: Do the responses that reference weight bearing and pivoting include an individual that uses a sliding board and would be weight bearing and pivoting using only the upper extremities, not the lower? A: The term “bear weight and pivot” may include both a standing pivot transfer and multiple sitting pivot transfers, such as those using a slide board. Same response guidelines apply.

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M1860 Ambulation/Locomotion

M1860 Ambulation

¨  Timepoints SOC/ROC/FU/DC ¨  Ambulatory, charifast, or bedfast? (majority rule does

NOT apply) ¨  Even and uneven surfaces defined at 4b-Q155.2 ¨  Observe the patient ambulating across the room or

to the bathroom and the type of assistance required. ¨  Note if the patient uses furniture or walls for support ¨  Assess if patient should use a walker or cane for

safe ambulation ¨  Observe patient’s ability and safety on stairs if used ¨  If chairfast, assess ability to safely propel wheelchair

independently whether the wheelchair is a powered or manual version.

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M1860 Ambulation

¨  Response 1—one-handed device AND no human assistance ((This is true for blind patients utilizing a cane to ambulate safely, canes used for weight bearing, and a white cane used to detect objects in the path of the user.)) 4b-Q155.1.1

q  Response 2—two-handed device and/or intermittent human assistance

q  Response 3—Continuous human assistance or supervision at all times

q  What if they used a cane and also needed assistance to get up stairs?

M1860 Ambulation

¨ What if a patient does not require human assistance and is able to safely ambulate with a walker in some areas of the home, but must use a cane in other areas due to space limitations, distances, etc.?

¨  The clinician will select the response that reflects the device that best supports safe ambulation on all surfaces the patient routinely encounters. ¤ For example select Response 2 if a walker is

required for safe ambulation in the hallway and living room, even if there are some situations in the home where a cane provides adequate support.

M1860 Ambulation What if a patient does not have a walking

device but is clearly not safe walking alone? ¤ The clinician will select Response 3, able to walk

only with the supervision or assistance-- unless the patient is chairfast. 4b-Q155.1

¨  Responses 4 and 5 refer to a patient who is unable to ambulate, even with the use of assistive devices and/or continuous assistance. A patient who demonstrates or reports ability to take one or two steps to complete a transfer, but is otherwise unable to ambulate should be considered chairfast, and would be scored 4 or 5, based on ability to wheel self.

M1860 Q&A Jan. 2013

¨  Patient ambulates only with a gait belt with therapy assist and a device.

¨  If the assessing clinician determines the patient is safe ambulating with constant human assistance, they are ambulatory. This is true whether the assistance needed is verbal cueing, reminders, contact guard, or any level of hands-on assistance. If the patient is not bedfast, and is not safe ambulating even with a combination of continuous assistance and a device, they are chairfast. If the patient can only take a couple of steps safely, they are not ambulatory.

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M1860 Ambulation

¨  We have a patient who is ambulating in the home. The clinician assesses that the patient is not safe ambulating with an assistive device, even with the supervision of another person at all times. The patient does not have a wheelchair in the home. What is the appropriate response to M1860, Ambulation/Locomotion, for this patient? 4b-Q155.3.1

¨  A patient is considered chairfast if they cannot be made safe ambulating even with the combination of a device and the assistance of another person at all times. They are not bedfast unless they are medically restricted to the bed or cannot tolerate being out of bed. If there is no wheelchair in the home, the assessing clinician cannot make assumptions about their ability to propel it safely. The appropriate M1860 response in this case is “5-Chairfast, unable to ambulate and is unable to wheel self”.

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M1870 Feeding or Eating


¨ Timepoints SOC/ROC/Discharge

¨  Identifies the patient’s ability to feed him/herself, including the process of eating, chewing, and swallowing food

¨ Excludes prep of food and transport to the table

¨ History of aspiration pneumonia, forgets to swallow, pockets food, what response? 4b-Q156.2


¨  Assessing the assistance needed by the patient to feed himself once the food is placed in front of him. ¤ Assistance means human assistance by verbal

cueing/reminders, supervision, and/or stand-by or hands-on assistance.

¨  Meal "set-up" (Response 1) includes activities such as mashing a potato, cutting up meat/ vegetables pouring milk on cereal, opening a milk carton, adding sugar to coffee or tea, arranging the food on the plate for ease of access, etc. -- all of which are special adaptations of the meal for the patient.

OASIS C 2/16/14


M1880 Current Ability to Plan and Prepare Light Meals

M1880 Current Ability to Plan and Prepare

Light Meals ¨  Timepoints SOC/ROC/Discharge ¨  Response 0 Patient has the consistent

physical and cognitive ability to plan and prepare meals

¨  Response 1 Patient has inconsistent ability to prepare light meals (e.g., can’t prepare breakfast due to morning arthritic stiffness, but can prepare other meals throughout day).

¨  Response 2 Patient does not have the ability to prepare light meals at any point during the day of assessment.

M1880 Current Ability to Plan and Prepare Light Meals

¨  Consider any prescribed diet requirements (and related

planning/preparation) when selecting a response 4b-Q158

¤  May be physically able to heat meal or make a sandwich, but if the patient doesn’t know his therapeutic diet, then is 1-unable to prepare meals on a regular basis due to physical, cognitive or mental limitations.

¨  Patient’s prescribed diet consists either partially or completely of enteral nutrition ¤  Assess the patient’s ability to plan and prepare their

prescribed diet ¤  Patient’s knowledge of feeding amount and ability to prepare

the enteral feeding, based on product used

¨  Note that the ability to set up, monitor and change the feeding equipment is excluded from M1880, as it is addressed on row “e” of M2100.

M1890 Ability to Use Telephone

OASIS C 2/16/14


M1890 Ability to Use Telephone

¨ Timepoints SOC/ROC/Discharge ¨ Ability to use telephone identifies the

patient’s ability to safely ¤ Answer the phone ¤ Dial a number ¤ Response “1” Effectively use the telephone

to communicate n If a speech impaired patient can only

communicate using a phone equipped with texting functionality, able to use a specially adapted telephone would be selected.

Q&A#7 April 2013

Q7: When should a patient’s ability to access the location and/or implements needed to complete ADL/IADL tasks be considered when scoring the OASIS items M1830, M1845, M1870, M1880, and M1890?

86

Q&A#7 April 2013

A7: The OASIS ADL/IADL items consider the patient’s ability to access the needed items and/or locations where the task is performed unless item guidance specifically excludes these from consideration. There are 5 ADL/IADL items where there are exclusions:

87

Q&A#7: Exclusion for M1830

¨ Focus is on patient’s ability to access tub/shower, transfer in/out, and bathe entire body once needed items are in reach. Ability to access bathing supplies and prepare water in tub or shower are excluded from consideration when assessing patient’s bathing ability.

88

OASIS C 2/16/14



Focus is on patient’s ability to access needed supplies and implements, and manage hygiene and clothing once at the location where toileting occurs. The ability to access the toilet or BSC, transfer on/off bedpan, and to use urinal are excluded from consideration when answering the patient’s toileting hygiene ability.

89


¨ Focus is on patient’s ability to eat, chew, and swallow once the meal is placed in front of the patient and needed items are within reach. The ability to access the location where the meal is prepared and consumed, and transporting food to the table are excluded from consideration when assessing the patient’s feeding and eating ability.

90


¨ Focus is on patient’s ability to plan and prepare meals once patient is in the meal preparation location. The ability to access the location where meals are prepared is excluded from consideration when assessing patient’s meal planning and preparation ability.

91


¨ Focus is on patient’s ability to use a phone once it is within reach. The ability to access the location where the telephone is stored is excluded from consideration when assessing patient’s ability to use the telephone.

92

OASIS C 2/16/14


M1900 Prior Functioning ADL/IADL


¨  Independent ¤  Can complete the activity by him/herself

n  with or without assistive devices n  without physical or verbal assistance from a helper.

¨  Needed some help ¤  Patient contributed effort but required help from another

person to accomplish the task/activity safely. ¨  Dependent

¤  Patient was physically and/or cognitively unable to contribute effort toward completion of the task, and the helper must contribute all the effort.

¨  If the patient was previously independent in any of the tasks, but needed help or was completely dependent in others, pick the response that best describes the patient’s level of ability to perform the majority of included tasks.


• Refers specifically to grooming, dressing, bathing, and toileting hygiene

•  Medication management is not included in the • definition of self-care for M1900 as it is • addressed in a separate question (M2040)


• Refers to walking (with or without assistive device).

• Wheelchair mobility is not directly addressed in this item (wheelchair bound means dependent).

OASIS C 2/16/14



• Refers specifically to tub, shower, commode, and bed to chair transfers


• Refers specifically to light meal preparation, laundry, shopping, and phone use.

M1910 Fall Risk Assessment

Process Measure


v Timepoints SOC ROC v Process Measure v Patients under the age of 65 will be

excluded from the denominator of the publicly reported measure

v Completed within specified time frames v 5 days after SOC v 48 hours for ROC v By the assessing clinician

OASIS C 2/16/14



¨  Multi-factor Falls Risk Assessment—one component must be a standardized tool appropriately validated for identifying falls risk in community dwelling elders

¨  MAHC-10 Falls Risk Assessment Tool is now standardized and validated, therefore it may be used alone to satisfy the requirements of this item

¨  CMS does not endorse any specific tool


¨  For Responses 1 and 2 (Yes) ¤ Fall risk assessment must have been completed

by the clinician completing the SOC or ROC ¨  Select Response 0 (No)

¤ Multi-factor falls risk screening was not conducted ¤ Multi-factor falls risk screening was conducted but

NOT during the required assessment time frame ¤ Multi-factor falls risk screening was conducted

during the assessment time frame, but by someone other than the assessing clinician

¤ Multi-factor falls risk screening was conducted that was not appropriate for the patient

M1910 Q&A October 2013 Category 4 Question #8

¨ M1910 should be assessed at SOC and ROC. The MAHC-10 Fall Risk Assessment Tool is to be assessed at SOC and Recert……what’s a clinician to do????

103

104

¨  CMS requires M1910 at SOC and ROC—CMS requires clinician to answer the question, not perform the fall risk assessment—you as a clinician and your agency determine if you will complete the assessment.

¨  A clinician can also decide to perform the assessment more often.

¨  It should be noted that the fall risk assessments conducted outside of the SOC or ROC assessment time frames should not be considered when selecting a response for M1910

OASIS C 2/16/14


Medications M2000s 105

Contact with physician -‐ Terms DeRined:

•  Contact with physician is defined as communication by: ¤ Telephone ¤ Voicemail ¤ Electronic means ¤ Fax ¤ Or any other means that conveys the

message of patient status

Clinically signiRicant medication issues -‐ Terms DeRined:

¨ Clinically significant medication issues that pose an actual or potential threat to patient health and safety: ¤ Drug reactions ¤ Ineffective drug therapy ¤ Side effects ¤ Drug interactions ¤ Duplicate therapy ¤ Medication omissions ¤ Dosage errors ¤ Non-adherence to prescribed medication regimen

Medication Interaction DeRined

¨  The impact of another substance upon a medication. Substances include ¤  Other medication(s) ¤  Nutritional supplements ¤  Herbal products ¤  Food ¤  Substances used in diagnostic studies

¨  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.

OASIS C 2/16/14


Adverse Drug Reaction DeRined

•  Adverse drug reaction (ADR) ¤ Form of adverse consequences ¤ May be a secondary effect of a medication

that is usually undesirable and different from the therapeutic effect of the medication

¤ Any response to a medication that is noxious and unintended and occurs in doses for prophylaxis, diagnosis, or treatment.

5 Types of Adverse Drug Reactions

¤ The categories of ADRs n Side effects

n An expected, well-known reaction that occurs with a predictable frequency and may or may not constitute an adverse consequence.

n Hypersensitivity n Idiosyncratic response n Toxic reactions n Adverse medication interactions.

M2000 Drug Regimen Review


v Timepoints SOC ROC v Include all medications / all routes

v Prescribed v OTC

v  Process Measures v Captures agency’s use of best practices v This one is required in CoPs

OASIS C 2/16/14



v Portions of the drug regimen review may be completed by agency staff other than the assessing clinician e.g., identification of potential drug-drug interactions or potential dosage errors v Review findings must be communicated to

the assessing clinician so that the appropriate response for M2000 may be selected


v This collaboration does not violate the ‘1 clinician’ requirement for the completion of the OASIS v Each Agency will need to create a workable

process to ensure compliance v The M0090 date (date assessment is

completed) would be the date the two clinicians collaborated and the assessment was completed.

M2000

v In therapy only cases, can an LPN in the office work cooperatively with the therapist to complete the Drug Regimen Review by performing elements of the drug regimen review that the therapist will not be completing?

4b-Q160.3.1

M2000

¨ No. Only registered nurses, physical

therapists, speech language pathologists and occupational therapists are qualified to perform comprehensive assessments. LPNs are not qualified to perform comprehensive assessments, so they may not work cooperatively with therapists in order to complete the drug regimen review.

OASIS C 2/16/14


What about a pharmacist?

Current guidance states that only clinicians qualified to perform comprehensive assessments may collaborate on the Drug Regimen Review. On therapy only cases, can the therapist collaborate with a pharmacist when completing the Drug Regimen Review? 4b-Q160.3.2

Yes!! Agency policy and documentation requirements?

July 2013 Q&A #16

Q: Can we answer M2000 “yes” if we did not check for drug interactions within the 5-day time period? A: There is no “yes” response in M2000. You must perform a complete drug regimen review, as defined in the OASIS Guidance Manual in order to select Response 1 – “no problems found during review” or Response 2 – “problems found during review”. If elements of the DRR were skipped, for example, as you stated, drug interactions, Response 0 – not assessed/reviewed is appropriate as a complete drug regimen review was not performed.

118


¨  Response 1 No problems found ¤ Medication list from inpatient facility matches the

medications patient shows the clinician at the SOC/ROC assessment

¤ Assessment shows that diagnoses/symptoms are adequately controlled by meds as prescribed

¤ Patient possesses all medications prescribed ¤ Patient has a plan for taking meds safely at the right

time ¤ Patient is not showing signs/symptoms that could be

adverse reactions caused by medications.


¨  Response 2 Problems found ¤ Med list from the inpt facility does not match

the medications the patient shows the clinician ¤ Diagnoses/ symptoms for which patient is

taking meds are NOT adequately controlled ¤ Pt seems confused about when/how to take

meds indicating a high risk for med errors. ¤ Pt has not obtained meds or indicates that he/

she will probably not take prescribed meds due to financial, cultural, or other issues with medications.

OASIS C 2/16/14



q  Response 2 Problems found ¤ Patient has signs/symptoms that could be adverse

reactions from medications. ¤ Patient takes multiple non-prescribed medications

(OTCs, herbals) that could interact with prescribed meds q  Use the timeframe to try to resolve the problems

found. q  If a med related problem is identified and resolved

by the agency staff by the time the assessment is completed, the problem does not need to be reported as an existing clinically significant problem. 4b-Q160.4


•  Consider the potential for an increased risk due to ¤ impairment or decline in an individual’s

mental or physical condition or functional or psychosocial status

¤ Complex medication plan ¤ Multiple physicians ¤ Multiple pharmacies

1. Is oxygen considered a medication? (M2000 - Drug

Regimen Review) 4b-Q160.1

Yes, oxygen is included as a medication when answering M2000 - Drug Regimen Review.

2. In M2000 - Drug Regimen Review, are ALL drug

interactions considered "potential clinically significant medication issues"? 4b-Q160.2

No, the OASIS-C Guidance Manual states that potential clinically significant medication issues include serious drug-drug, drug-food and drug-disease interactions.

Not all potential med side effects are considered clinically signiRicant med issues

Problems found during review, should be selected if the “Patient has signs/symptoms that could be adverse reactions from medications.” It further defines a side effect as "an expected, well-known reaction that occurs with a predictable frequency and may or may not constitute an adverse consequence."

A side effect would be considered "a potential clinically significant medication issue" if it "poses an actual or potential threat to patient health and safety".

4b-Q160.3

OASIS C 2/16/14


Not all potential med side effects are considered clinically signiRicant med issues

The determination of whether a medication issue meets this threshold should be based on the clinician's judgment in conjunction with agency guidelines and established standards for evaluating drug reactions, side effects, interactions, etc. Online resources or these standards can be found in Chapter 5 of the OASIS-C Guidance Manual.

4b-Q160.2, 160.3

M2002 Medication Follow-‐up


¨  Timepoints SOC ROC ¨  Medication ‘issues’ Communicated with

physician (or designee) within one calendar day

¨  Someone else may communicate with the physician but who has to answer the data item?

¨  What about the on-call physician who says to call back Monday? 4b-Q160.5

¨  Agency policy must define this process ¨  Process Measure


¨  Response “1” ¤ Physician responds to the agency communication

with acknowledgment of receipt of information and/or further advice or instructions

¤  If the physician or physician designee responds within one calendar day and there is a resolution to the clinically significant medication issue or a plan to resolve the issue

¤ Two way communication AND reconciliation or plan by the end of the next calendar day. 4b-Q160.6

¨  Response “0” ¤  Interventions are not completed as outlined in this

item and Clinician should document rationale in the clinical record

OASIS C 2/16/14


Example

•  A clinically significant medication issue is identified on day 5 after the SOC and the physician is notified. The physician doesn’t respond until the 6th day after SOC, what is the answer? 4b-Q160.5.1

X

M2002; M2004

¨ Multiple clinically significant medications issues were identified as I completed the SOC assessment. Only one was resolved within one calendar day. How do I answer M2002 and then 2004?

4b-Q160.6.2

¨  In order to select ‘yes’ on M2002/M2004, ALL clinically significant issues must have been resolved (or plan to resolve) within one calendar day.

M2004 Medication Intervention M2004 Medication Intervention

q Timepoints Transfer Discharge q Identifies if potential clinically significant

problems such as adverse effects or drug reactions identified at the time of the most recent OASIS assessment or after that time were addressed with the physician

q Process measure

OASIS C 2/16/14


M2004 Medication Intervention

¨ Response 1 – Yes ¤ Physician responds to the agency

communication with acknowledgment of receipt of information and/or further advice or instructions within the specified timeframe.

¨ Response 0 – No ¤ Interventions are not completed as outlined in

this item and the clinician should document rationale in the clinical record.

¨ Collaboration between clinicians does not violate the ‘1 clinician’ rule

M2004 Medication Intervention

¨  If the last OASIS assessment completed was the SOC or ROC, and a clinically significant problem was identified at that SOC or ROC visit, the problem (and/or related physician communication) would be reported at both the SOC/ROC (on M2002), and again at Transfer or Discharge (on M2004), since the time frame under consideration for M2004 is since OR AT the previous OASIS assessment

M2010 Patient/Caregiver High Risk Drug Education

High Risk Drugs DeRined

¨  High-risk medications are those identified by quality organizations as having considerable potential for causing significant patient harm when they are used erroneously. ¤ Institute for Safe Medication Practices (High Alert

Med List) ¤ JCAHO, etc.

¨  Examples of high risk meds that could have a severe negative impact on patient safety and health ¤ Hypoglycemics ¤ Anticoagulants

OASIS C 2/16/14


M2010 Patient/Caregiver High Risk Drug Education

q Timepoints SOC ROC q Educate on high risk meds first

¤ Unrealistic to expect that pt education on all meds can occur on admission

q Remember the timeframe q Others can provide the education, but

who has to mark the data item? 4b-Q161.4

M2010 High Risk Drug Education

¨  Response “0” ¤ Interventions were not completed as outlined in

this item. n Clinician should document rationale in the clinical

record, unless the patient is not taking any drugs ¨  Response “1”

¤ High risk meds are prescribed and education was provided

¤ ALF—staff are considered caregivers; may or may not be appropriate to educate those administering medications 4b-Q161.3

¤ Education can be over the phone 4b-Q161.4

M2015 Patient/Caregiver Drug Education Intervention

M2015 Drug Education Intervention

¨  Timepoints Transfer Discharge ¤  Identifies if clinicians instructed the pt/cg (ALF

—staff are considered caregivers; pharmacists are considered caregivers) 4b-Q162.3, 162.4

¤  Education can occur over the phone 4b-Q161.4

¨  How to manage meds effectively and safely through ¤ Knowledge of effectiveness ¤ Potential side effects ¤ Drug reactions ¤ When to contact the appropriate care

provider

OASIS C 2/16/14



q  Response No--

q  Interventions are not completed as outlined in this item

q Care provider should document rationale in the clinical record

q  Response Yes— q  Includes education by any agency staff ¤ Has to be all 4 components

¨  Note that just including written materials in the bag with the medications at the time the medication is dispensed may not provide the specified education.


Mr. Walt’s ROC was completed November 8th. The SN documented education on all (high risk and non high risk meds) of the patient’s meds was completed at that time. The SN’s documentation included how and when to report problems that may occur.

Mr. Walt is transferred to the hospital on November 10th. How will you complete M2015? 4b-Q162.2

M2015 - Patient/Caregiver Drug Education Intervention, reports if, at the time of or since the previous OASIS assessment, the patient and/or caregivers were educated regarding ALL their medications (not just the high risk medications), including how and when to report problems that may occur. If this specified education was accomplished for all medications at the time of the previous OASIS assessment, the appropriate response for M2015 would be “Yes”.

M2015

When answering M2015 - Patient/Caregiver Drug Education Intervention, if you provide education intervention on all medications during the first episode, but no education in the second episode because the patient had no new medications and there was no need to re-teach on all medications, do you have to answer “No” for M2015 at Transfer/Discharge?

OASIS C 2/16/14


The Condition of Participation 484.55 requires a Drug Regimen Review (DRR) at every comprehensive assessment time point. When performing the DRR, at the Recertification, if the assessing clinician evaluated the patient's retention of prior teaching and determined and documented that the patient possessed all the required knowledge related to all medications, then M2015 would be answered "Yes" at Transfer/Discharge. If the assessing clinician had not re-assessed the patient's medication knowledge and found the patient to be fully knowledgeable or not provided drug education related to all medications at the time of or since the previous OASIS assessment, the M2015 response would be "No" at Transfer/Discharge

M2020 Management of Oral Medications


¨  If patient’s ability to manage oral meds varies from medication to medication, consider the medication for which the most assistance is needed when selecting a response.

¨  If the medication is ordered prn, and on the day

of assessment the patient needed a reminder for this prn, then the patient would be a "2". If on the day of assessment, the patient did not need any prn medications, therefore no reminders, then assess the patient's ability on all of the medications taken on the day of assessment. Ch 3


¨  Assess patient’s ability to take medications

reliably and safely at all times ¨  Identifies patient’s ability, not willingness or

compliance or actual performance ¨  Patient must be viewed from holistic perspective

¤ Mental ¤ Emotional ¤ Cognitive status ¤ Activities permitted ¤ Environment

OASIS C 2/16/14



¨  Ability can be temporarily or permanently limited by: ¤ Physical impairments (e.g. limited manual

dexterity) ¤ Emotional/cognitive/behavioral

impairments (e.g., memory deficits, impaired judgment, fear)

¤ Sensory impairments, (e.g., impaired vision, pain)

¤ Environmental barriers (e.g. access to kitchen or medication storage area, stairs, narrow doorways)


¨  Timepoints SOC/ROC/DC ¨  Includes all prescribed and OTC oral meds

included on the POC ¨  Excludes topical, injectable and IV meds ¨  Excludes inhalation meds and sublingual meds

(Oct 2012)

¨  Excludes swish and expectorate meds (Jan 2013)

¨  Meds given per gastrostomy or other tube are not po 4b-Q167.8

¨  Does not include filling/reordering 4b-Q166

¨  Meds swallow & absorbed through GI system!!


v  Response 0 Patient sets up her/his own ‘planner

device’ and is able to take the correct med in the correct dosage at the correct time

v  Response 1 v Patient is independent in oral med

administration, but requires v another person to prepare individual doses

(e.g., sets up a planner device) v And/or if another person develops a drug

diary or chart which the patient relies on to take meds appropriately


q Response 2 ¤ Patient requires another person to

provide reminders q What about a device that provides

reminders? ¤ Who sets up the device? 4b-Q167.5

OASIS C 2/16/14


Examples of Response 3 4b-‐Q167.5.1

¨  A patient who decided not to take her new medications, because the varying doses worried her, and she was unsure of the instructions. There had not been a medi-set up, nor reminders tried. The clinician would select Response 3 because it is unclear until reassessment if the interventions will be successful.

¨  A patient who, upon assessment, was not able to take prescribed medications at the correct time and doses even though reminded.

¨  A patient who, on the day of assessment, was prescribed oral medications, but was unable to safely swallow.

¨  The patient is on multiple medications which span 3 times a day. Yesterday, the doctor started her on a varying dose of Prednisone. The patient admits to being confused about the directions and right dosage. The clinician observes that the med box the patient set up is filled correctly with all usual medications, but not correctly with the prescribed Prednisone administration. The clinician also notes that the medication for last evening remained in the pill planner. Upon questioning, the patient admits to being tired and forgetting to take her evening medication. The nurse discusses the use of an alarm clock to remind her to take her evening medication and fixes the Prednisone dosage for the rest of the week. Considering this patient needed help with setting up one medication (Response 1) and a reminder for another (Response 2) in the last 24 hrs, what is the correct scoring with rationale for this situation?

¨  4b-Q167.9

"3-Unable to take medication unless administered by another person because on the day of the assessment, the patient did not possess the ability to take the Prednisone at the correct time and dose and demonstrated that through her report and actions (required knowledge of the drug's dose and administration schedule ) Rationale: • Day of assessment • Do not report ability after skilled intervention, as this is not a reflection of what was true in the most dependent medication during the day of assessment. • The patient has to demonstrate success at taking meds as ordered, at all times to move from a ‘3’.

M2020

¨  If the patient does not have her prescribed medications in the home because she cannot afford them and she does not plan on getting them, what is the most appropriate response for M2020?

4b-Q167.5.2

OASIS C 2/16/14


M2020

You are reporting the patient's ability to take all oral medications reliably and safely at all times on the day of the assessment. If the patient did not take her medications on the day of the assessment because they were not present in the home, you cannot make assumptions about a patient's ability to take medications she doesn’t have. If the medications were not in the home, you would not be able to determine if she could take each medication at the correct time and dose. The patient's status would be reported as “3-Unable to take medications unless administered by another person”.

Quiz

¨  Mrs. Wobble is unsteady while ambulating and requires supervision for ambulation. She possesses the knowledge to take their medications reliably and safely if the bottles are placed near, or if she has supervision while ambulating to the medication storage area. Please advise how this patient would be scored for M2020, Management of Oral Medications. The item intent instructions include guidance related to the patient’s ability to access the medication, how does this play into the question when the physical impairment causes the patient to require human supervision or assistance and not the cognitive aspect (such as for reminders)?

4b-Q167.5.3

158

Answer

¨  M2020 reports a patient's ability on the day of the assessment to take the correct oral medications at all the correct times. This would include the tasks of accessing the medications from the location where they are routinely stored in the home, preparing the medications (including opening containers or mixing oral suspensions), selecting the correct dose and safely swallowing the medications, typically involving having access to a beverage. If someone other than the patient must do some part of the task(s) that are required for the patient to access and/or take the medication at the prescribed times, then the patient would NOT be considered independent (Response 0).

159

More Scenarios

¨  Scenario: Medications are routinely stored in the refrigerator located downstairs. The patient requires someone to assist them at medication administration time to walk to the location where the medications are routinely stored, or someone must retrieve the medications and bring them to the patient; Response "3" would apply. In this situation, just someone preparing the doses in advance did not enable the patient to self-administer their medications.

¨  Scenario: The patient requires someone to prepare the medication doses in advance (e.g. visually they can't discern the appropriate dose) and to walk with them at all times to be safe. Someone prepares the medi-planner and sets it within the patient's reach with the water they need to take the meds, the appropriate score is a "1", as the patient can access the medications from where they are routinely stored and has the water available to swallow the medication safely. 4b-Q167.5.3

160

OASIS C 2/16/14


More Scenarios

¨  If the medications were routinely stored in the kitchen and/or the water was not available for the patient to self-administer and the patient required someone to assist them to the location where the meds were stored and or to water, the appropriate score would be a "3".

¨  Scenario: Patient does not need doses prepared in advance, but the medications are routinely stored in a location that the patient cannot access due to a physical, sensory, or environmental barrier. The patient is scored a "3". During the episode, an environmental modification was made, e.g. changing the medication storage and water supply to a location that the patient can access, the patient could be scored a "0" at the next OASIS data collection time point. 4b-Q167.5.3

161

M2030 Management of Injectable Medications


¨  Timepoints SOC/ROC/FU/Discharge ¨  Assess patient’s ability to take all injectable

meds reliably and safely at all times ¨  Excludes

¤ IV medications ¤ Infusions (i.e. meds given via pump) ¤ Meds given in the physician’s office or

other settings outside the home 4b-Q168.3

M2030 Management of Injectable Meds

¨  Response -0 ¤ Patient sets up own meds with correct med, dose and

time ¨  Response -1

¤ Patient independent in injectable med administration except that another person must prepare doses and/or if another person must develop a drug diary or chart

¨  Response -2 ¤ Reminders to take meds are necessary, regardless of

whether the pt is independent or needs assistance in preparing individual doses and/or developing a drug diary or chart.

¤ Note: Reminders provided by a device that the patient can independently manage are not considered ‘assistance’ or ‘reminders’

OASIS C 2/16/14


M2030 Management of Injectable Meds

¨  Response 3—Unable to take medication unless administered by another person ¤ The physician orders the nurse to administer the

medication (represents a medical restriction against self-administration) if not for convenience 4b-Q168.2, 168.3

¨  If an injection is ordered but not administered the day of assessment, the clinician will use the assessment of the patient’s cognitive and physical ability and make an inference regarding what the patient would be able to do. 4b-Q168.3


v  If patient’s ability to manage injectable meds varies from medication to medication, consider the medication for which the most assistance is needed when selecting a response.

v  The patient administers his own insulin safely and reliably but his doctor has ordered B12 IM. v What response? 4b-Q168.4

v What if the doctor wants the patient to come into his office for the IM injection?

v  The doctor orders that the patient receive a flu vaccine?? 4b-Q168.5.1

What does M2030 include?

¨  M2030 requires an assessment of the patient's cognitive and physical ability to draw up the correct dose accurately using aseptic technique, inject in an appropriate site using correct technique, and dispose of the syringe properly." My patient, at the SOC, was throwing his used needles and syringes into the trash. He stated he was never told how to properly dispose of them. 4b-Q168.3.1

¨  If the patient lacked the knowledge regarding safe needle and syringe disposal on the day of the assessment, the patient was unable to take injectable medication unless administered by another person, Response 3. If the patient needed reminders regarding safe needle/syringe disposal, they would be scored a "2".

167

M2030 at Discharge

¨  Scenario 1: The first two weeks of the episode, the patient had Lovenox SQ ordered. The patient is being discharged 4 weeks later with no injectable medications currently ordered. At discharge, is the answer NA - no injectable medications prescribed or do we assess their ability from earlier in the episode?

¨  Scenario 2: Is the order to administer the flu vaccine at the beginning of the episode included when selecting a response for M2030 at the Discharge assessment?

¨  Answer to both: If there are no current, ongoing orders for an injectable to be administered IM or SQ via needle and syringe in the home at the time of the assessment, the appropriate response is NA. 4b-Q168.1.1

168

OASIS C 2/16/14


• Timepoints SOC ROC • If patient’s ability varies from one med to another, consider the med that takes the most assistance when selecting your answer • Includes only those administered at home 4b-Q168.5.2

M2040 Prior Medication Management


q  Independent ¤ Patient completed activity by him/herself

(with or without assistive device) ¤ Without physical or verbal assistance

from a helper or reminders from another person

¤ Reminders provided by a device that the pt can independently manage are not considered assistance or reminders


¨  ‘Needed some help’ means that the patient

required some help from another person to accomplish the task/activity.

¨  ‘Dependent’ means that the patient was incapable of performing any of the task/activity. For oral meds this means that the pt was capable only of swallowing meds that were given to him/her. For injectable meds, this means that someone else must have prepared and administered the meds.

¨  NA There were no oral or injectable meds

M2100 Types and Sources of Assistance

¨  Timepoints SOC ROC Discharge

¨  Identifies availability and ability of the caregiver(s) to provide categories of assistance needed by the patient.

¨  Anticipated availability and ability of caregiver assistance (it’s Monday and that particular assistance is provided on Fridays) 4b-Q168.5.5

¨  Select response reflecting the most need ¨  Do not have to identify the primary caregiver

¨  Note that this question is concerned broadly with types of assistance, not just the ones specified in other OASIS items, e.g. shampooing may be included

OASIS C 2/16/14



¨ Refers to the assistance needed by the patient in the home and the availability and ability of a caregiver to meet those needs. It does not capture assistance provided to the patient outside of the home setting such as they might receive at Adult Day Care or a dialysis center. Assistance needed to transport the patient out of the home, (e.g., to/from medical appointments) is included, but services received once outside the home setting should not be considered.

173


¨ Caregiver(s) not likely to provide

assistance—unable or unwilling ¨ Unclear if caregiver(s) will provide

assistance—may express willingness but their ability is in question or there is a reluctance on the part of the caregiver that raises questions about whether they will provide needed care

• ADLs include basic self-care activities such as the examples listed


• IADLs include activities associated with independent living necessary to support the ADLs such as the examples listed. Determine the IADL with the most need • Includes Meals on Wheels 4b-Q168.5.6


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Only meds received at home. • Medication administration refers to any type of medications (prescribed or OTC) and any route of administration including oral, inhalant, injectable, topical, or administration via g-tube/j-tube, etc. • C/G needs help to fill pill box—2 Oct 2012

M2100 Types and Sources of Assistance—ONLY include meds administered at home CMS

Q&A July 2010

• Medical procedures/treatments include procedures/ treatments that the physician or physician designee has ordered for the purpose of improving health status. Some examples of these procedures/ treatments include wound care and dressing changes (including change of the sponge of the wound vac), range of motion exercises, intermittent urinary catheterization, postural drainage, electromodalities, etc.


M2100

¨  What is the appropriate response for M2100, Types and Sources of Assistance, in cases where the physician has ordered the RN to provide the treatment, e.g. a wound VAC procedure?

¨  Could fall under Medical procedures and management of equipment 4b-Q170.10

¨  3-Caregivers not likely to provide. 5-if there is no caregiver involved 4b-Q170.11

Management of equipment refers to the ability to safely use medical equipment as ordered. Examples of medical equipment include oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies, continuous passive motion machine, wheelchair, hoyer lift, wound vac, etc. **Includes canes, walkers* 4b-Q170.5

Flush only—syringe is equipment 4b-Q170.4


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M2100 e. Is dialysis thru a central line considered for this question?

As long as the dialysis occurs in the home. M2100 e. reports the caregiver’s ability and willingness to manage the equipment used for the delivery of oxygen, IV/infusion therapy, enteral/parenteral nutrition, ventilator equipment or supplies. Dialysis is an infusion therapy.

If the patient were receiving such therapy outside the home, (e.g. at a dialysis center), then M2100 e. would be marked “No assistance needed in this area”, assuming the patient care did not include use of any other included services at home (oxygen, enteral nutrition, etc.). 4b-Q170.2

Infusion of pain medication—Assess caregiver’s ability and willingness to use associated equipment. 4b-Q169


• Consider cognitive, functional, or other health deficits. • May include:

• Calls to remind the patient to take medications • ‘In person’ visits to ensure that the home environment is safe • Physical presence of another person in the home to ensure that the patient doesn’t wander • Fall or for other safety reasons

• Includes: • Filling prescriptions • Making subsequent appointments



¨  The types of assistance that a foley catheter patient might need may be captured in multiple rows in M2100, Types and Sources of Assistance, as described below:

¨  a- ADL assistance as part of toileting hygiene? - Examples: cleansing around the catheter/peri care

¨  d- Medical procedure? Examples: insertion/removal of catheter, e.g. self cath or intermittent catheterization

¨  e- Management of equipment? - Examples: emptying the bag, changing the bag

4b-Q170.7

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¨  How is "Assistance needed, but no Caregiver(s) available" defined? Would it apply to a son who is managing equipment and assists with ADLs safely and independently, but is unwilling to assist with medication administration and is unable to take the patient to doctor's appointments?

¨  "Response 5 - Assistance needed, but no Caregiver(s) available" means the patient has no one involved in providing any level of care to them at all. In your example, the patient has a son who is providing some level of caregiver assistance; therefore, Response 5 would not be an appropriate response. If the son was willing and able to manage equipment and assist with ADLS, the appropriate responses for Row a and Row e would be "1-Caregiver currently provides assistance." If the son was unwilling to assist with medication administration and unable to take the patient to doctor's appointments, the appropriate responses for Row c, Medication administration and Row g, Advocacy or facilitation would be "3-Caregiver not likely to provide assistance" because this response is defined as including situations where the caregiver is unwilling or unable to provide the needed care.

4b-Q170.12

185

M2110 How often does the patient receive ADL or IADL assistance…?

M2110 How often does the patient receive ADL or IADL assistance…?

¨  Timepoints SOC ROC Discharge ¨  Question is concerned broadly with ADLs and

IADLs not just the ones specified in other OASIS items

¨  In M2100 you report the response that represents the most need and the availability and ability of the caregiver to meet that need. In M2110, simply report the frequency that the patient receives assistance with any ADLs/IADLs. Because of the different approaches with these items, a logical "tie" between the two may not always be apparent.

4b-Q171.5.1

Frequency of Assistance

¨  Is M2110 asking how many days the patient receives help or how many times someone visits and provides help? My patient has two daughters. Daughter 1 visits and helps with laundry on Sunday morning, daughter 2 visits Sunday afternoon and Wednesday to help her mother in and out of the bathtub. Should I select “2-Three or more times a week” because 3 visits were made or “3-One to two times per week” because the patient received help on two days?

¨  M2110, Frequency of ADL/IADL Assistance, reports how many times a week a caregiver provides some level of assistance with any ADL or IADL. In your scenario, the appropriate response would be “2-Three or more times a week” since there was 3 distinct times that someone provided assistance with an ADL/IADL. 4b-Q171.5.2

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Plan of Care Synopsis M2250 and Intervention Synopsis M2400

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190

191

M2250 Plan of Care Synopsis

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q  Timepoints SOC ROC q  May be answered ‘YES’ prior to the receipt of

signed orders but must be able to show communication w/ the physician to include specified best practice interventions in the POC

q  When completing M2250 at the ROC, orders for the specified best practices must be obtained within 2 calendar days of the patient's discharge from the inpatient facility, or within 2 calendar days of knowledge of the patient’s return home in order to answer "Yes". However…

q  Be sure to correlate (M0090)

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194

M2250 When you are completing M2250 - Plan of Care

Synopsis, at the ROC and the initial orders for fall risk, pressure ulcers, etc. were received at SOC from the physician and have not been discontinued, meaning they remain as a current order, does the RN doing the

ROC need to rewrite these orders? Does the RN need to contact the physician to see if it is OK to continue them?

The OASIS-C process measures are not changing the expectations and requirements related to physician's orders. If, at ROC, orders received at SOC remain as

current orders, then the presence of those orders can be reported in M2250. 4b-Q172.2

(Recommended) Standard on POC

¨ Hold home care orders for any inpatient admission.

¨ Resume home care orders upon discharge from inpatient facility.

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¨  Yes POC contains orders for best practice interventions as specified in each row, based on the patients needs. (Even though these are general interventions often performed without orders, CMS expects orders. 4b-Q172.3)

¨  No The best practice interventions specified in this item are not included in the plan of care that was developed as a result of the comprehensive assessment, unless the plans/ interventions specified in that row are not appropriate for this patient - see guidance on selecting NA for each row below.

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¨  Could it be determined that all these specific best practice orders were present if the communication with the physician were more general (like the patient's clinical findings are discussed with the physician and there is an agreement as to the general POC between the admitting clinician and the physician. Then the formal detailed POC is sent to the physician for signature, outlining the specific parameters and interventions)? 4b-Q172.9.2

¨  The OASIS-C process measures are not changing the expectations and requirements for communicating with the physician to obtain verbal orders prior to providing services. The Medicare Benefit Policy Manual, defines clearly how orders can be obtained verbally if complete orders were not provided in the referral. Chapter 7, Section 30.2.5 states: "Services which are provided from the beginning of the 60-day episode certification period based on a request for anticipated payment and before the physician signs the plan of care are considered to be provided under a plan of care established and approved by the physician where there is an oral order for the care prior to rendering the services which is documented in the medical record and where the services are included in a signed plan of care."

Q & A January 2014 Category 4b M2250

¨ Q--At SOC the assessing clinicain determines the pt is not depressed, has no s/s of depression, no dx of depression. The clinician will continue to assess the pt for s/s of depression she selects the intervention ‘Skilled O&A of s/s of depression on the POC. Can the clinician answer ‘Yes’ on M2250 Row d since the POC has a depression intervention?

198

Q & A January 2014 Category 4b M2250

¨ A—If the clinician determines it would be appropriate for a specific pt and obtains an order for ‘Skilled O&A for s/s of depression’ from the physician during the SOC or ROC allowed timeframe, M2250d may be answered ‘Yes’ even if the formal assessment was negative and/or the pt has not been formally dx w/ depression. **Note, just checking off an intervention on a POC does not equate to obtaining a physician’s order.

199

M2400 Intervention Synopsis 200

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M2400 Intervention Synopsis

¨  Timepoints Transfer Discharge ¨  Were there specific interventions that were ordered by

the physician AND implemented as part of the plan of care? ¤  Used to calculate process measures to capture use of best

practices ¤  Problem specific interventions referenced in the item may

or may not directly correlate to stated requirements in the CoPs

¨  Included in the POC, but not implemented, then NO ¤  Every ‘NO” requires documentation for rationale ¤  Multiple interventions but only some or one implemented,

‘yes’ 4b-Q182.7

¨  If not appropriate for this patient, then NA.

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M2400 Intervention Synopsis

¨  You may say "Yes" to M2400 b - e, if the specified clinical interventions were included in the physician ordered plan of care and implemented at the time of or since the previous assessment whether or not a formal assessment was performed. However, the Response Specific Instructions state that for Rows b-e, in order to select "NA-Not applicable", a formal assessment must have been performed as defined in the relevant OASIS items. 4b-Q172.9.4, 172.9.5

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Interventions Prior to SOC

¨  For situations where best practices are provided during an initial assessment visit that is conducted BEFORE the SOC date, would those clinical assessments/interventions be considered as being provided "since or at the last OASIS assessment" or "within the outcome episode"? For example, in a situation of a Friday referral for a therapy only case, the RN makes a non-billable visit on a Saturday to meet the federal requirement that the initial assessment visit must occur within 48 hours of the referral. No nursing need existed and no billable service was provided, therefore Saturday was not the SOC date. The patient was a diabetic, but had no skilled nursing needs related to their diabetes, the nurse however, assessed the lower extremities for lesions, found no lesions, and verified the patient understood how to care for her feet. The PT did not assess the lower extremities for lesions and did not address the foot care education in any way before discharge.

¨  None of the interventions that the nurse provided on the initial assessment visit would be considered when responding to M2400, Intervention Synopsis, even if orders existed, because the interventions were completed before the quality episode began on the SOC date.

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"Yes" if the plan of care includes specific parameters ordered by the physician for this specific patient or after reviewing the agency's standardized parameters with the physician, s/he agrees they would meet the needs of this specific patient. • "No" if there are no patient specific parameters on the plan of care and the agency will not use standardized physician notification parameters for this patient. • "NA" if the agency uses their own agency standardized guidelines, which the physician has NOT agreed to include in the plan of care for this particular patient. The parameters must appear on the POC!! “Follow AHA guidelines” not acceptable! 4b-Q172.5.3


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NO: POC contains orders for only one (or none) of the interventions YES: POC contains both orders for a) monitoring the skin of the patient’s lower extremities for evidence of skin lesions AND patient education on proper foot care NA: Patient does not have a diagnosis of diabetes or is a bilateral amputee **Note: This question does not apply to diagnosis Diabetes Insipidus 4b-Q172.6

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206

(M2400) Intervention Synopsis

NO: If POC contains orders for only 1 of the interventions and/or only 1 type of intervention (monitoring or education) or there is no supportive doc in clinical record YES: POC must contain both orders for monitoring the skin AND patient education on proper care of lower extremities AND there is supportive clinical documentation that this was done at the time of the previous OASIS assessment or since that time N/A: Patient does not have a diagnosis of diabetes or is a bilateral amputee

NO: Best practice interventions not included in the POC YES: POC includes planned clinical interventions to reduce pressure on bony prominences or other areas of skin at risk for breakdown. NA: Patient was not indentified as at risk for pressure ulcers


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NO: POC does not include interventions to prevent pressure ulcers and/or no interventions were documented in the clinical record YES: POC contains interventions to reduce pressure on bony prominences or other areas of skin at risk for breakdown and the clinical record contains documentation that these interventions were performed at the time of the previous OASIS assessment or since that time . NA: Formal assessment indicates the patient was not at risk for pressure ulcers

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Prevention of Pressure Ulcers

¨ Planned interventions can include ¤  teaching on frequent position changes ¤  proper positioning to relieve pressure ¤  careful skin assessment and hygiene ¤  use of pressure-relieving devices such

as enhanced mattresses, etc.

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NO: Best practice interventions not included in the POC YES: POC contains orders for pressure ulcer treatments based on principles of moist wound healing (e.g., moisture retentive dressings) OR if such orders have been requested from the physician NA: Patient has no pressure ulcers needing moist wound healing treatments (physician says ‘no’) 4b-Q172.9.1


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NO: POC does not include interventions for treatments based on principles of moist wound healing and/or no treatments based on principles of moist wound healing documented YES: POC contains interventions for pressure ulcer treatments based on principles of moist wound healing and there is supportive documentation in the clinical record interventions were carried out at the time of the previous OASIS assessment or since then. NA: dressings that support the principles of moist wound healing were not indicated for this patient’s pressure ulcers OR patient has no pressure ulcers with need for moist wound healing.

Only one ulcer has moist wound treatment

¨  A patient has two pressure ulcers for which wet-to-dry dressings are ordered. After the SOC assessment, the assessing clinician requests and receives an order for moist wound healing treatment for one of the pressure ulcers, without any discussion about appropriateness/inappropriateness of moist wound healing for the second ulcer. The moist wound healing treatment is provided and documented for the one pressure ulcer as ordered. How should 2400 be answered?

4b-Q172.9.3.1 ¨  There is no requirement that every pressure ulcer be treated

with moist wound healing in order to mark "Yes" for M2250 (g) or M2400 (f). If the agency has orders for and implements moist wound healing treatment for at least one pressure ulcer within the required time frames, then M2400 (f) should be "Yes".

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Moist Wound Healing

¨ Principles of moist wound healing promote an optimal wound environment and includes films, alginates, hydrocolloids, hydrogels, collagen, negative pressure wound therapy, unna boots, medicated creams/ointments

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If a clinician teaches Diabetic foot care, Prevention of falls, and/or pressure ulcers etc. on the discharge visit and then finds out that these were not included on the Plan of Care Synopsis, what would be the best way to answer M2400 - Intervention Synopsis?

The response would have to be “No” if there were no

orders for these best practices. In order to answer M2400 – Intervention Synopsis "Yes", the physician-ordered plan of care at the time of or since the previous OASIS assessment must have included the specified best practice intervention, in addition to evidence that the interventions were implemented. Please remember that the physician plan of care includes the plan of care for certification/recertification in addition to all other addendum orders. 4b-Q182.5

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M2400 and Long Term Patients

¨  For example, foley catheter patient—all teaching has been done so further visits to do teaching are non-covered.

¨  How is M2400 completed? ¤  Since or at the last time OASIS completed

n  If no orders on POC and/or no evidence of implementation, then must mark ‘no’ (unless NA)

¨  During that time period, if specific orders were present, and the clinician confirmed the patient/caregiver possessed the knowledge regarding the best practice that was taught in a prior episode at the Recertification visit or on a subsequent visit, then upon confirmation that the patient/caregiver possessed the knowledge, the intervention may be considered implemented.

M2400 and Long Term Patients

¨  “Reviewed pressure ulcer prevention, pain mitigation, and falls prevention with patient/caregiver. Patient/caregiver state understanding. No further intervention required.” (example note on recert assessment)

¨ Adherence rate of 100% for the process measures???

¨ Note that none of the process measures for long-term episodes (those that include a Recertification or Other Follow-up) are publicly reported

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Emergent Care M2300s 217

M2300 Emergent Care

218

M2300 Emergent Care

¨ Timepoints Transfer/Discharge ¨ Responses to this item include the entire

period since the last time OASIS data were collected, including current events.

¨  “Since the last time OASIS data were collected…” means “since or at the last time” 4b-Q178.1

219

M2300 Emergent Care

¨ Excludes ¤ Urgent care services not provided in a hospital

emergency department ¤ Doctor's office visits scheduled less than 24

hours in advance ¤ Care provided by an ambulance crew without

transport ¤ Care received in urgent care facilities

¨ This item only includes holding and observation in the emergency department setting

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M2300 Emergent Care

¨ Response 0—No

¤ No emergent care in hospital emergency dept OR

¤ Patient is direct admitted to the hospital n Patient was not treated or evaluated in the

emergency room n Patient had no other emergency department

visits since the last OASIS assessment.

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M2300 Emergent Care

¨ Response 1 or 2--Yes

¤ Patient went to a hospital emergency department, regardless of whether the patient/caregiver independently made the decision to seek emergency department services or was advised to go the emergency department by the physician, home health agency, or other health care provider 4b-Q179

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M2300 Emergent Care

¨ Response 2—Yes with admission

¤ Patient went to a hospital emergency department and was subsequently admitted to the hospital

¤ An OASIS transfer assessment is required (assuming the patient stay was for 24 hours or more for reasons other than diagnostic testing).

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M2300 Emergent Care

¨  What if a patient went to a hospital emergency

department, was “held” at the hospital for observation, then released? ¤ The patient did receive emergent care.

¨  The time period that a patient can be "held" without admission can vary

¨  An OASIS transfer assessment is not required if the patient was never actually admitted to an inpatient facility.

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M2310 Reason for Emergent Care 225

M2310 Reason for Emergent Care

¨ Timepoints Transfer/Discharge ¨ Emergency Room only ¨  If more than one reason contributed to the hospital

emergency department visit, mark all appropriate responses (include why even though not diagnosed)

¨  Improper medication administration, regardless of who (patient, caregiver, or medical staff) administered the med improperly. 4b-Q181.5

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M2310 Reason for Emergent Care

¨  If the reason is not included in the choices, mark Response 19 - Other than above reasons.

¨  If Pt received emergent care in a hospital ED multiple times since the last time OASIS data were collected, include the reasons for all visits.

¨  Include both the reasons care was sought and care received. 4b-Q181.5.1

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Injury?

When answering M2310 (Reason for emergent care) how is the term “injury” defined in Response 2-Injury caused by fall? I understand a fractured bone is an injury, but what about ecchymosis, increased edema, neurological changes (no confirmed neurological diagnosis as far as a bleed, etc.), lacerations, abrasions, etc.? 4b-Q181.5.2

Injury means that hurt, damage or loss is sustained by the patient. The assessing clinician may use this definition and clinical judgment to determine whether or not the patient was "injured" when they fell.

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M2410 To which Inpatient Facility has the patient been admitted?

229

ReRegular DC

M2410 Inpatient Facility

¨  Timepoints Transfer Discharge ¨  Special considerations:

•  If admitted to more than one facility n Indicate the facility to which the patient was

admitted first** ¨  Patient dies in a hospital ED

¤ Complete a TRN ¤ Select Response ‘1 Hospital’ for M2410

¨  Nursing home admission ¤ Skilled nursing facility (SNF) ¤ ICF/MR

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M2410 Inpatient Facility

¨  Rehab Facility Admission ¤ Freestanding rehab hospital ¤ Certified distinct rehab unit of a nursing home ¤ Distinct rehab unit in a short stay acute

hospital ¨  Chemical dependency inpatient program of a

hospital whether it is a free-standing drug rehabilitation unit or a distinct drug rehabilitation unit that is part of a short-stay acute hospital is marked “1-Hospital”.

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M2410. A patient receiving skilled nursing care from an HHA under Medicare is periodically placed in a local hospital under a private pay arrangement for family respite. The hospital describes this bed as a purely private arrangement to house a person with no skilled services. This hospital has acute care, swing bed, and nursing care units. The unit where the patient stays is not Medicare certified. Should the agency do a transfer and resumption of care OASIS? How should the agency respond to M0100 and M2410? 4b-Q183

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233

Yes, if the patient was admitted to an inpatient facility, the agency will need to contact the inpatient facility to verify the type of care that the patient is receiving at the inpatient facility and determine the appropriate response to M2410. If the patient is using a hospital bed, response 1 applies; if the patient is using a nursing home bed, response 3 applies. If the patient is using a swing-bed it is necessary to determine whether the patient was occupying a designated hospital bed (response 1 would apply) or a nursing home bed (response 3 would apply). The hospital utilization department should be able to advise the agency of the type of bed and services the patient utilized.

M2420 Discharge Disposition

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¨ Timepoints Discharge ¨ Patients who are in assisted living or

board and care housing are considered to be living in the community with formal assistive services

¨ Friends, family, neighbors who perform services for free are considered informal assistive services

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Formal assistive services include community based

services:

¤ Homemaking services under Medicaid waiver programs

¤ Home delivered meals ¤ Home care or private duty care from another

agency ¤ Paid services by an individual ¤ Other types of community based services

Non institutional hospice is defined as the patient receiving

hospice care at home or a caregiver’s home, not in an inpatient hospice facility

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Formal Assistive Service?

¨ Formal assistive services are supportive community-based services provided through organizations or by paid helpers and do not include medical or rehabilitative services provided outside the home, e.g. outpatient therapy, physician office visits, dialysis, wound care clinic visits. 4b-Q184.1

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M2430 Reason for Hospitalization

238

M2430 Reason for Hospitalization

¨  19--Examples of a scheduled treatment or procedure include joint replacement surgery, non-emergency procedures to improve blood flow or heart function, such as angioplasty or pacemaker insertion, or cataract surgery. 4b-Q185.1

¨  Does not include situation where patient’s health is deteriorating and the physician instructed to monitor the patient’s condition for 2 days and call 911 if the patient doesn’t improve. 4b-Q185.1

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M2440 For what Reason(s) was the patient Admitted to a Nursing Home?

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M2440 For what Reason(s) was the patient Admitted to a Nursing Home?

¨ Timepoints Transfer ¨ Excludes:

¤ Acute care facility ¤ Rehab facility admissions

n These are both defined as admits to a freestanding rehab hospital, a certified distinct rehab unit of a nursing home, or part of a general acute care hospital

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M0903 Date of Last (Most Recent) Home Visit

¨ Timepoints Transfer/Death at Home/DC ¨  If the agency policy is to have an RN

complete the comprehensive assessment in a therapy-only case, the RN can perform the discharge assessment after the last visit by the therapist. M0903 will reflect the nurse’s visit, even if non-billable. 4b-Q189.1

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M0903. Do the dates in M0903 and M0090 always need to be the same? What situations might cause them to differ?

When a patient is discharged from the agency with goals met, the date of the assessment (M0090) and the date of the last home visit (M0903) are likely to be the same. Under three situations, however, these dates are likely to be different. These situations are: (1) transfer to an inpatient facility; (2) patient death at home; and (3) the situation of an “unexpected discharge.” In these situations, the M0090 date is the date the agency learns of the event and completes the required assessment, which is not necessarily associated with a home visit. M0903 must be the date of an actual home visit. See M0100 Q&As for additional guidance on “unexpected discharges.” 4b- Q188

Pronouncement of Death

¨ When state law allows an RN to pronounce death in the home, it is possible that the last visit to the home is the visit to pronounce death.

¨ The visit to pronounce death is covered under the home health benefit.

¨ That visit date would be recorded in M0903.

¨ This represents a change from the answer 10/11. 4b-Q189.2

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M0906 Discharge/Transfer/Death

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M0906 Discharge/Transfer/Death

¨ Timepoints Transfer/Death at Home/DC

¨ The date of discharge is determined by agency policy or physician order.

¨ The transfer date is the actual date the patient was admitted to an inpatient facility.

¨ The death date is the actual date of the patient’s death at home

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M0906 The Death Date

¨ Exclude death occurring in an inpatient facility or in an emergency department, as both situations would result in Transfer OASIS collection and would report the date of transfer.

¨  Include death that occurs while a patient is being transported to an emergency department or inpatient facility (before being seen in the emergency department or admitted to the inpatient facility).

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M0903/M0906. When a speech therapist is the last service in a patient's home, our agency has chosen to use an RN to complete the discharge assessment (with OASIS) as a non-billable visit. If the patient meets the speech therapist's goals on day 50 of the episode, but we cannot schedule an RN until day 51 of the episode, how do we respond to M0903 and M0906? 4b-Q190

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If the agency policy is to have an RN complete the comprehensive assessment in a therapy-only case, the RN can perform the discharge assessment after the last visit by the SLP. This planned visit may be documented on the Plan of Care or not. The RN visit to conduct the discharge assessment is a non-billable visit. M0903 (Date of Last/Most Recent Home Visit) would be the date of the last visit by the agency; in this case it would be the date of the RN visit. The date for M0906 (Discharge/Transfer/Death Date) would be determined by agency policy. The date of the actual agency discharge date would be entered here. When the agency establishes its policy regarding the date of discharge, it should be noted that a date for M0906 (Discharge/Transfer/Death Date) that precedes the date in M0903 (Date of Last/Most Recent Home Visit) would result in a fatal error, preventing the assessment from being transmitted.

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M0906. My patient died at home 12/01 after the last visit of 11/30. I did not learn of her death until 12/04. How do I complete M0903 and M0906? What about M0090?

You will complete an agency discharge for the reason of death at home (RFA 8 for M0100). M0090 would be 12/04 -- the date you learned of her death and completed the assessment. M0903 (date of last home visit) would be 11/30, and M0906 (death date) would be 12/01. 4b-Q191

Questions?? Send to [email protected] or

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