OASIS Alert

Confusion over a standardized tool for this population is resulting in falling scores.

When you answer M1910 -- Has the patient had a multi-factor Fall Risk Assessment? for a bedbound patient, do you automatically list 0 -- No multi-factor falls risk assessment conducted because your patient can't perform the TUG test? If so, your agency is probably seeing poor Home Health Compare results in this area. Take a closer look at this item to up your publicly reported outcomes.

The problem: M1910 requires that your multi-factor falls risk assessment includes at least one standardized tool that has been "scientifically tested and validated as effective in identifying a specified condition or risk in population with characteristics similar to the patient being evaluated. A standardized tool includes a standard response scale, and must be appropriately administered based on established instructions," according to the Centers for Medicare & Medicaid Services OASIS Q&As. But the availability of a standardized tool appropriate for assessing falls risk in bedbound community-dwelling elders has been a problem.

As a result, "even industry experts disagree on how to respond to M1910," said Barbara Rosenblum, CEO of Strategic Healthcare Programs in Santa Barbara, Calif., in a recent blog post.

What does CMS say?

In the most recent annual compendium of OASIS Q&As, CMS addressed the confusion over M1910.

Question: "I'm looking for guidance related to answering M1910 in a patient who is non-ambulatory, bedbound and/or cognitively impaired. Would it be appropriate to use a standardized, validated tool that measures cognition or another factor of falls risk, such as the Folstein Mini- Mental Status Exam or the Gloth Frail Elderly Functional Assessment questionnaire, instead of the Tinetti, Functional Reach or Timed Up and Go, which aren't appropriate in this population?"

Answer: "For an assessment tool to meet the criteria for a 'yes' response on M1910, the assessment would need to have been validated as a tool that specifically measures risk for falls. If the patient is not able to participate in tasks required to allow the completion and scoring of the assessment(s) that the agency chooses to utilize, '0 -- No multi-factor fall risk assessment conducted' should be reported. The agency should be aware there are a number of validated fall risk assessment tools, some which allow the use of assistance, assistive devices, and even provide risk assessment options for non-ambulatory patients. A single tool may not meet the fall risk assessment needs of all patients in the agency."

Another question: So where are these validated fall risk assessment tools which provide risk assessment options for non-ambulatory patients? Well, CMS doesn't offer much in the way of specifics there.

"CMS does not endorse the use of any specific falls risk assessment tool... It is the agency's responsibility to determine if the tools they are considering for the OASIS-C M item best practice assessments meet the requirements as detailed in Chapter 3 of the OASIS-C Guidance Manual and the CMS OASIS OCCB Q&As. An agency may use a standardized falls risk tool from  any organization able to effectively develop, test and validate the tool for use on a population of community dwelling elders," CMS says.

"I am convinced there are agencies who have searched for and been unable to find an available validated tool for bedbound and chairfast patients," said consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. in a response to Rosenblum's blog.

Because current CMS guidance on answering M1910 is vague, home health agencies have been approaching this question in a variety of ways.

Some have been unable to find a validated falls risk assessment for non-ambulatory, community dwelling patients and so have decided to always answer 0 -- No multi-factor falls risk assessment conducted for these patients. These agencies use a test like the TUG (Timed Up and Go) or Tinetti which require the patient to be ambulatory. As a result, these agencies will have poor Home Health Compare scores for this measure.

Other agencies may opt to report one of the "Yes" answers for bedfast or chairfast patients. "The argument being that the question isn't applicable to the non-ambulatory and the TUG and Missouri aren't validated for these patients, so why should the agency be penalized?" Rosenblum said. While this reasoning contradicts CMS guidance on this OASIS item, these agencies will show much more favorable Home Health Compare scores for this area.

Resources: The Connecticut Collaboration for Fall Prevention has been working on a falls risk assessment tool that would meet the standardized tool requirements for non-ambulatory patients. You can read more about it here: www.fallprevention.org/index.htm. Researchers at Vanderbilt University have also been studying fall risk for community dwelling elders and you can read their findings here: www.tandfonline.com/doi/abs/10.1300/J027v25n03_01.

Editor's note: Read Rosenblum's letter and blog on the M1910 controversy here: www.shpdata.com/blog/barbara/default.aspx.