OASIS Alert

Question: Our clinician reported an ostomy as a surgical wound in the OASIS M1340, Surgical Wound item. This clinician no longer works for our agency, so we cannot contact her about the error. Can this OASIS change be made by the director of nursing without speaking to the clinician?

Answer: Two factors are important to point out in a scenario like this, said Annette Lee, RN, MS, HCS-D, COS-C, with Redmond. Wash.-based OASIS Answers during the July OCCB Quarterly OASIS Update audioconference. First, this situation describes a true OASIS scoring error -- not a situation where someone is questioning what was reported. Second, the assessment was complete.

There's no disputing the fact that the patient had an ostomy, based on the medical record. But, for some reason the assessing clinician incorrectly reported it as a surgical wound in M1340 despite OASIS guidance which indicates that ostomies aren't considered surgical wounds for this item.

This is a situation in which you'll need to refer back to your agency's correction policy, Lee said. But before you can do that you'll need to make sure that your agency has a correction policy and that the policy follows the regulations set out by the Centers for Medicare & Medicaid Services.

"Normally, if an error is identified through audit or review, the individual who made the original entry into the patient's record would, whenever possible, make the necessary correction by following agency policy," CMS says in the July 2011 Quarterly CMS OCCB Q&As.

But your correction policy could allow the auditor to contact the clinician who made the entry to discuss the discrepancy and make the correction. If your correction policy allows this method of making a correction, be sure to document who discovered the error and the date and time of the discussion with the assessing clinician who agrees that it was an error, CMS instructs.

Tip: Corrections such as the one discussed in this scenario do not impact M0090 -- Date assessment completed.

In this situation, the assessing clinician is no longer available, so the clinical supervisor or quality staff can make the correction. They should follow agency correction policy and document why the original assessing clinician isn't available to make the correction as well as how the error was discovered and validated, CMS says.

Remember: When you make corrections to assessments that have been submitted to the state, consider the impact on the plan of care, HHRG, plan of treatment, and RAP.

Make corrections to those documents and billing as appropriate, CMS says.

For guidance on establishing a correction policy, see www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/scletter01-12.pdf.

To read the July 2011 Quarterly CMS OCCB Q&As, visit www.oasisanswers.com/downloads/CMS-OCCB-2nd-Qtr-2011-QAs-07-20-11.pdf.