OASIS Alert

Published on Sat Feb 02, 2008 PDF

Don't let inconsistent medical records put your agency in jeopardy

Your home health agency may not see state surveyors often, but when they do come, you want them to leave you smiling -- not staring at a list of deficiencies.

Unfortunately, your OASIS assessment hands surveyors the perfect tool to focus on your agency's weak spots. The medical records will contain the initial and any subsequent OASIS assessments. And the information in these documents is like a collection of clues.

Example: The list of diagnoses in M0230, M0240 and M0246 can be compared to other required forms to see if the documents are complete and accurate.

It's not surprising that the most common survey deficiencies result from problems with documentation, communication and collaboration. These are areas all agencies struggle with.

Chicago-based regulatory consultant Rebecca Friedman Zuber dissected the top 10 survey citations in her Eli-sponsored audioconference Home Health: Common Survey Prob-lems and How to Prevent Them. Here are four ways your OASIS assessment can be used against you -- if you let it:

1. G236. One of the most common home health agency survey deficiency is tag G236, Zuber reported. This condition of participation says: "A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician, drug, dietary treatment and activity orders; signed and dated clinical progress notes; copies of summary reports sent to the attending physician; and a discharge summary."

But a mismatch between the OASIS assessment and the plan of care could result in a G236 citation because the "documentation does not clearly communicate the patient's needs and services delivered," Zuber explained.

Example: M0445 on the OASIS assessment documents a pressure ulcer, but the plan of care contains no mention of prevention or treatment services for the ulcer.

Protect yourself: Establish a process to carefully review the plan of care, especially in comparison with the comprehensive assessment, Zuber recommended.

2. G159. Many of the deficiency citations are linked, Zuber explained. G159 (the third most common deficiency) is one that may show up with G236. Tag G159 says: "The plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, and safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items."

If you look at the laundry list of what must be included, it's easy to see how a comparison of the OASIS assessment and the plan of care could identify inconsistencies, Zuber said.

What to do: "The plan of care and the OASIS assessment really ought to be about the same person," Zuber emphasized. And don't forget to document the care coordination and show consultation among staff in developing the POC.

3. G337. The fourth most common deficiency cited also penalizes poor coordination between the OASIS assessment and the rest of the medical record. Tag G337 says: "The comprehensive assessment must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy."

You may see this tag cited when pain issues are not sufficiently addressed, Zuber said. For example, on M0420 (Frequency of pain interfering with patient's activity or movement), you report that the patient has pain. But in the plan of care you don't identify any pain medication. Unless the record shows that the pain is being treated using some non-medication route, you will be cited for this.

4. G164. Tag G164 is the fifth most common HHA survey deficiency. It says: "Agency professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care."

The OASIS assessment may direct the surveyor to this citation if a follow-up OASIS shows the need for changes in the plan of care but they have not been addressed, Zuber said. Agencies need to monitor documentation and follow-up assessments to be sure physicians are contacted and plans of care updated as the patient's needs change, she advised.