OASIS Alert

Reconsider assessment assumptions to keep unobserved wounds from hurting your agency.

Question: A large percentage of our cases are opened by weekend or per diem staff who do not revisit the client. On occasion we will have a client with a wound that is not observed by that start of care clinician within the 5 day window allowable for OASIS assessment completion. This usually occurs due to non-removable or occlusive dressing, cast, incomplete history from the patient, or sometimes client refusal until he/she is more comfortable with the clinician.

We've considered claiming a significant change in condition or modifying the OASIS with the opening nurse's permission. What actions can we take to obtain the points on that wound assessment that we deserve?

Answer: You can approach this problem in at least two ways, says senior clinical consultant Judy Adams with Charlotte, NC-based LarsonAllen Health Care Group.

Try this: Re-evaluate your weekend admission process. Remember that the Medicare Conditions of Participation establish a two-part assessment process. If the weekend nurse cannot observe the wound and is not available to revisit the patient within five days, defer the comprehensive assessment for a regular full-time nurse who can continue to visit the patient.

Step 1. Only the initial assessment requires a visit within the 48 hours of referral, return home or on the date ordered by the physician, Adams explains. The initial assessment determines if the patient meets Medicare requirements for home health and is appropriate for home care. It also establishes the patient's immediate needs. The initial assessment can serve as the start of care date if you provide a skilled service on that date and the patient reviews and signs the consents, etc.

Step 2. You must complete the second part of the assessment - the comprehensive assessment that includes the most current OASIS requirements - within 5 days of the start of care date. Only one clinician can complete the comprehensive assessment, so the first clinician to start the assessment must complete it. Although most home health agencies complete both assessments on the same visit, you can split them, Adams advises.

Another way: Each agency must develop its own policy for which changes in condition require the clinician to complete another OASIS assessment, Adams says.  If this wound issue is a major concern for your agency, you might choose to include the ability to visualize a wound that could not be observed earlier as one criteria for completing an "other" comprehensive assessment, she recommends.
 
If your agency also receives orders for care of this wound, you could process a SCIC and follow the billing guidelines for submitting it. Specifically, one would expect the home health resource group (HHRG) to increase with the presence of a wound that the clinician previously could not visualize, and the agency then has the option to file the SCIC.