OASIS Alert

Do you know what types of adverse events or patient outcomes are likely to send up flares for surveyors? If not, you might as well stand on the runway alongside CMS and wave surveyors in.

The Centers for Medicare & Medicaid Services has issued a draft survey protocol that provides surveyors with a list of eight adverse events and 10 patient outcomes to focus on prior to initiating a survey or site visit.

Home health agencies must learn this draft protocol by heart to head off survey problems before they start, advises Ann Howard with the American Association for Homecare. "Agencies need to be totally familiar with the survey protocol and address any areas that could raise a red flag with surveyors, from Adverse Event Reports to OBQI reports to OASIS timeliness and errors," she warns.

Under the new draft protocol, surveyors will have to fill out a checklist to focus their efforts before undertaking a survey (see chart article #5 ). CMS has divided adverse events into "Tier 1" and "Tier 2" events. Tier 1 which comprises "Emergent Care for Injury Caused by Fall or Accident at Home" and "Emergent Care for Wound Infections, Deteriorating Wound Status" demands the most immediate attention from surveyors.

If an HHA has any patients who have experienced these events, CMS requires the surveyor to take a closer look through record reviews and home visits.

Listed next are the six Tier 2 AEs: 1) Emergent Care for Improper Medication Administration, Medication Side Effects; 2) Emergent Care for Hypo/ Hyperglycemia; 3) Substantial Decline in Three or More Activities of Daily Living; 4) Discharged to the Community Needing Wound Care or Medication Assistance; 5) Discharged to the Community Needing Toileting Assistance; and 6) Discharged to the Community with Behavioral Problems.

If any patients have experienced Tier 2 events, CMS instructs surveyors to compare the HHA's incidence of those events to the national reference. If the incidence is more than twice the national rate, it becomes an area of investigation. If not, the agency is in the clear, CMS instructs.

While CMS has honed in on falls and wound care as focal points, industry experts are quick to detect another significant trend within the AE outcomes list. "Clearly, this issue of emergent care must be something that's more important to [CMS]," notes Bob Wardwell, vice president of regulatory and public affairs for the Visiting Nurses Association of America and former CMS senior staffer.

Both Tier 1 outcomes, as well as two of the Tier 2 adverse events improper medication and hypo/hyperglycemia are emergent care issues. Should any of the four emergent care outcomes get checked as an "Area for Focus," surveyors must make home visits. None of the remaining (i.e., non-emergent care) AEs demands a similar action.

OBQI and Case Mix Join the Fray

Another aspect of the draft survey protocol that is sure to turn heads among HHAs is a section devoted to outcome-based quality improvement reports. Participation in the OBQI program, which was introduced by CMS this past February, has been billed as "voluntary," though its inclusion in the draft protocol may soon suggest otherwise (see related article # 1 ).

Surveyors' reliance on OBQI data means agencies must pay particular attention to the new protocol, insists Rachel Hammon of the Texas Association for Home Care. The draft's inclusion of OBQI outcomes, she suggests, signals a move toward eliminating the voluntary designation of the OBQI program.

In the meantime, the draft protocol instructs surveyors to consider a list of 10 OBQI outcomes during the pre-survey process. For this section, surveyors must first determine the outcome sample size, and can consider only categories with 30 or more patients. Surveyors can examine other outcomes if none of the 10 listed has at least 30 patients, but if an agency has no outcomes with at least 30 patients, surveyors must skip the OBQI section.

For outcomes with at least 30 patients, surveyors must determine if any are statistically significant (denoted by a * or ** on the OBQI report). Then, CMS tells surveyors to pick two outcomes that have a "large and unfavorable magnitude of difference from the reference sample" for investigation. It defines a "large and unfavorable magnitude" in four categories: