A client just received their certification report and it was good but not deficiency free as they had been in the past. The reason? Although the risk factors for hospitalization were pulled from the OASIS assessment, they were not identified on the Plan of Care as risk factors for hospitalization. The interventions were similarly not tied to the risk factors even though they did address them. The DON reported that she talked to a friend at another agency and learned that the other agency had received the very same tag. Coincidence or survey trend? Time will tell. For now, smart agencies will go with ‘survey trend’ as their final answer.
The Condition of Participation is §484.60(a)(2). It reads:
(2) The individualized plan of care must include the following:
- All pertinent diagnoses;
- The patient’s mental, psychosocial, and cognitive status;
- The types of services, supplies, and equipment required;
- The frequency and duration of visits to be made;
- Rehabilitation potential;
- Functional limitations;
- Activities permitted;
- Nutritional requirements;
- All medications and treatments;
- Safety measures to protect against injury;
- A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
- Patient and caregiver education and training to facilitate timely discharge;
- Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
- Information related to any advanced directives; and
- Any additional items the HHA or physician may choose to include.
This is a new requirement included in the 2018 Conditions of Participation. It’s something that (hopefully) has been done by agencies in the past but risk factors haven’t always been labeled. The requirement is consistent with the CMS goal of avoiding unnecessary admissions.
There are no instructions on how to do this. Prior to the final regulations, the proposed regs suggested stratifying patients as high, medium or low risk. That was omitted from the final rule. From the 2018 CoPs:
While there may be benefits to establishing more inter-HHA consistency in the application of this requirement, we do not believe that those benefits would outweigh the cost of reducing HHA flexibility and innovation to determine the best possible way to achieve the overall goal of reducing unnecessary emergent care visits and hospital admissions.
The OASIS question that examines risk factors for hospitalization is M1033 reads:
(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)
- History of falls (2 or more falls – or any fall with an injury – in the past 12 months)
- Unintentional weight loss of a total of 10 pounds or more in the past 12 months
- Multiple hospitalizations (2 or more) in the past 6 months
- Multiple emergency department visits (2 or more) in the past 6 months
- Decline in mental, emotional, or behavioral status in the past 3 months
- Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months
- Currently taking 5 or more medications
- Currently reports exhaustion
- Other risk(s) not listed in 1–8
- None of the above
Additionally, M1036 looks at smoking, obesity, alcohol dependency and drug dependency. There is a falls risk assessment which may score high in patients who have not fallen in the last 12 months such as those who had a recent hip replacement. Depression is assessed and is known to impair recovery in most illnesses and conditions but is not included in the question specific for risk factors unless it has an onset within 3 months.
Some of the most dangerous risks to our patients are not captured by OASIS at all.
- Elderly patients living alone in a rural area
- Patients unable to afford or prepare food; may have frequent interruptions in utilities due to financial limitations.
- Transportation or willing caregiver to pick up medications.
- Functionally illiterate patients
It is possible that drawing in some information from OASIS might meet the condition, but it may not serve the patient. On the other hand, it is highly unlikely that you would be hit with a survey deficiency if you included risk factors that were based on a full assessment even if they are not included in the OASIS assessment.
You won’t find many interventions to address isolation, depression and lower socioeconomic status in care pathways for other conditions, but they are equally as important for some patients as falls precautions which are ordered for pretty much everyone. It may cost a little more but in the long run, lower hospitalization rates will correspond with higher margins.
The CoP’s mandate that care plans include patient risks for hospitalizations and Emergency Room visits and corresponding interventions to mitigate the risks. Since you must do it, make it meaningful.
Contact us if you need help setting up a system for this or if you would have us review your careplans for you.