Pressure Ulcers Quality Measure OASIS-C2 Covariates: M1028, M1060, and M1620

Pressure Ulcers Quality Measure OASIS-C2 Covariates: M1028, M1060, and M1620

»» Okay. Good morning again, everyone. Are we all awake? Everybody’s had enough coffee, right? Okay. And you’re all full of those terrific crab
cakes and you had a great dinner last night, and a good sleep. And my loud printed jacket is going to keep
your eyes open. That’s why I wore it today because you’re
unfortunately stuck with me for an hour this morning. And I won’t even tell you how long this afternoon. But I’ll try to at least make this information
entertaining so that it will stick with you. This morning my task is to talk about the
covariates that will affect the Percentage of Patients with Pressure Ulcers that are
New or are Worsened. So that we’re going to have that conversation
today. Our objectives for this morning are to demonstrate
a working knowledge of three specific M questions. M1028, the Active Diagnosis Comorbidities and
Coexisting Conditions. M1060, Height and Weight. M1620, Bowel Incontinence and Frequency. We’re going to be able to describe the intent,
what is the reason behind M1028, M1060 and M1620? We will be comfortable interpreting the response
options for M1028, M1060 and M1620. Using that knowledge, you’ll be able to apply
the instructions to accurately respond to our practice scenarios. Then we’ll discuss how we’re going to identify
and resolve the common stumbling blocks so that everyone will be able to code these answers
correctly. Just as we said yesterday, there are a variety
of acronyms in this presentation. As I said yesterday, for those of us in this
room who are not newbies, we’re not new to home care. We toss these acronyms around on a regular
basis. But there are people in your office, in your
staff, whether they’re new to home care, whether they just haven’t perhaps heard that particular
abbreviation. They’re new to them. So please be sensitive to that. And be sure that when you use these acronyms
as we used them this morning, that your staff are equally comfortable with these specific
definitions so that they are not only using them, but they’re also understanding them
correctly. So take a look at them as we go through the
ASAP Assessment Submission and Processing, BMI, CMS we all know, diabetes, DM, discharge,
follow-up, the OASIS form, HHA for home health agency and so on. You want to be sure that you’re comfortable
with these, that you know the difference between QIES and QTSO. Throughout these two days we have used the
term “code” or “coding.” When we use it during this training, we are
referring to the action of responding to or scoring the OASIS assessment items. We don’t want you to confuse that with the
act of applying an ICD-10 code to a diagnoses. I know when I first started preparing to do
this class back in the summer last year, I kept tripping over that. I kept saying, why do I have to say coding? I’m not coding. I don’t do coding. It’s too complicated. But that is the verb that we are using. That’s the way we’re using it. So please don’t get confused by that. I want to have a little flashback to yesterday. What is a covariate? If you remember yesterday we talked about
the three different factors, the three different types of risk adjustment. And we defined a covariate. A covariate is a factor that affects the risk
level for your patient to develop a new pressure ulcer or to have an existing one exacerbated
or made worse. These four items are the risk-adjustment covariates
that affect the Percentage of Residents or Patients with Pressure Ulcers that are New
or Worsened. This quality measure is directly impacted
by these four factors. M1028 Active Diagnoses Comorbidities and Coexisting
Conditions. That’s the one we’re going to talk about first. M1060 Height and Weight is the one we will
speak to next. M1620 Bowel Incontinence Frequency is not new. But it’s used as a covariate. And we’re going to talk about why and how. And last, GG0170C Lying to Sitting on the
side of the Bed. Ann is going to go through that one very carefully
and in detail. Because this is a critical factor. So as I said, M1028 and M1060 are new to the
OASIS-C2 as of January 1 of 2017. You can see these two on your slide. The active diagnoses comorbidities and coexisting
conditions, this is done at the timepoints of SOC and ROC. M1060, height and weight is
also done at SOC and ROC. These are not done at recertification. When we look at 1628, Bowel Incontinence Frequency,
this item is done at SOC, ROC, follow-up and discharge, but only discharge not to an inpatient
facility. Okay. So you want to make sure that you are doing
this correctly, and only at the assigned timepoints. Let’s take a look at M1028 in a little more
detail. This is how the item appears on your screen
or on your paper form. It reads as Active Diagnoses Comorbidities
and Coexisting Conditions. Check all that apply. See your guidance manual for a complete list
of the relevant ICD-10 codes. Item number one says Peripheral Vascular Disease,
(PVD) or Peripheral Arterial Disease (PAD). Item two says Diabetes. The intention here is that you should be identifying
whether these diagnoses are present and active. That’s a very important distinction that you
need to be making. These diagnoses are very particular in that
they influence a patient’s functional outcomes and they increase their risk for developing
a new pressure ulcer or having an existing one clearly become worse. Note that although the slide says two specific
diagnoses, there are actually three. Because in the first box you have PVD and
PAD, and in the second you have diabetes. We know that these disease processes can have
significant adverse effect on the person’s health status and their quality of life. We need to know if these diagnoses are active
and are they associated with the home health episode of care? Do they have an impact on the plan that your
nurse is developing for this patient? We do this as I said at SOC, at ROC, but not
at recertification or transfer/discharge. Your process begins with identifying whether
or not the diagnoses is present. And that’s actually more complicated than
it sounds at times. And we’ll talk a little more about why that
is. Your second step is going to be to determine
whether or not it’s active. As I said, active means, does it relate to
the current plan of care? How would you go about identifying the diagnoses? Let’s think a little bit about the referral
when you receive it. What is it that you have in your hand? The referral came to you from a number of
different sources. Let’s say it came from a rehab or long-term
care facility, a skilled nursing facility. What did they send you? You got an electronic referral, an electronic
referral document has diagnoses listed, meds, activity levels, perhaps a paragraph of a
summary. It came from a long-term care or rehab facility. It’s going to have summaries from all the
different disciplines that saw that person. If they came to that facility from an acute-care
hospital, you should always be asking for that discharge summary as well. And you want more than just the simple summary. You want the course of care documents. Because that will give you everything you
need to know. So you can look through those documents to
see what was written in that record, in that referral document package by any of the physicians
who saw that patient. Nurse practitioners, physician assistants,
clinicians, nurses, therapists. You may have in your state, because there
are many states represented here, you may have other levels of licensed personnel who
are allowed to add information into that document. So you need to know according to your state
regulations who’s allowed to write information in there. And you need to scan through that and identify
all the diagnoses that are listed. First find them. Then we’ll look at whether or not they’re
active and impacting your plan of care. What if the referral came from the community? From a physician’s office or a family member? Now you don’t have all these lovely documents
to look at. Where are you going to get your diagnoses? Physicians offices are required to be up on
an EMR. Ask for the last two office visits and possibly
a clinical summary if they have a summary document in the file. It will give you all the history documents,
all the historical diagnoses. And it will tell you what the physician has
been focusing on in the last two visits. And you’ll be able to read it, if it’s electronic
any way. So these are the different sources that we’ve
just been talking about, all those transfer documents, progress notes, HMPs, discharge
summaries, med sheets, all the consults. That’s why you’re asking for the course of
care summary. It’s all those consults that were made that
are going to give you clues as to what other diagnoses are lurking in the bushes. It’s critical information that you really
need. And lastly, when you go out and do the admission
assessment, your assessment itself may indicate symptoms that are associated with one of the
listed conditions, but the documented diagnosis may not be spelled out in the available records
that you have. If that’s the case, clinicians should contact
the physician immediately so that they can ask for confirmation that the patient has
that diagnosis. Once it’s been identified, then you can move
on to determine if it’s active and related to the plan of care. When we talk about asking the physician to
confirm it, a perfect example is the patient that’s on a no added sweets or no concentrated
sweets diet. That’s what comes from the referral source. Does not say that they’re a diabetic of any
kind. There’s no insulin, no hypoglycemics on the
med profile. No concentrated sweets is the diet. So in the assessment, your nurse, who obviously
knows how to do an excellent history conversation is asking, so why is it that mom doesn’t eat
candy or she’s supposed to stay away from a lot of sugar? Well you know, a long time ago they told her
she might be a diabetic. And of course at that point mom pops right
up and says, I’m not! (Laughter) Am not! I should know. That’s exactly what my mother did. When she came off the insulin as far as she
was concerned she was cured. That was the end of that. Not a diabetic anymore, thank you very much. She paid no attention to the fact that we
monitored and kept her on a no concentrated sweets, very careful diet. But she told everybody that would listen she
as cured and she was not a diabetic. And she most certainly was. But you can take that history and then have
your clinician contact the physician office, send an interim order over. Please confirm diagnosis of — And you put
in the diagnosis. And then you want to be sure whether or not
they are actively treating it. You can put down a second question, is this
an active treatment diagnosis? Let them answer the question, put their John
Hancock on the interim order. And now you have in your file the confirmation
in writing you need in order to answer this question correctly. So now you have obtained the documentation
that’s defined here. You have the information, the past history. You’ve talked to the family, you’ve sent the
order out to the physician in order to validate that this is a diagnosis that is present,
and it is or is not an active part. Anything you get verbally you should always
be sending an interim order to have written confirmation. You need a signature on a piece of paper in
order to use that and to answer the question. So now I have this diagnosis. I’ve got a signature on an interim order. Now what? How do I know if it’s active or just historical? An active diagnosis is one that has a direct
relationship to the patient’s current functional, cognitive, mood or behavior status. It relates to treatments or orders for the
nurse that she is currently monitoring or assessing. It may be a factor in the risk of death or
change in condition at the time of your assessment. If the condition has been completely resolved
and there is no assessment, monitoring of any kind going on during your nurse’s plan
of care, then you would say it’s inactive or resolved. But tread carefully there and look closely
at the orders and the assessment plan that your nurse has created. Because if it’s relating to it, you need to
be sure that you are documenting it correctly. And again, you’re going to look at all those
same documents. What is it that the physician, the PA, the
nurse practitioner is referring this patient to you to do? If the family is saying, well she’s always
followed that no concentrated sweets diet. They used to say she was a diabetic, but they
don’t say that anymore, they just say for her to follow the diet. Sure, they don’t say that because mom didn’t
like it and she was fighting them. But if they don’t discuss it and they just
have her follow the diet, she behaves better. So they don’t use the word. Makes a big difference. But you need to be sure. If you’re checking blood sugars, if you’re
interviewing for symptomology, for low blood sugar events, then you are assessing for diabetes. And that’s an active diagnosis. If it’s an active diagnosis, it’s going to
exacerbate the risk of a developing pressure ulcer, or an exacerbating pressure ulcer. So that’s the reason for looking very carefully
at what you are documenting when you answer this question. Is the diagnosis active? If there’s any form of assessment going on,
any potential impact, then absolutely, it is an active diagnosis. So here’s a question for you. We have that lovely 5-day window to get the
assessment done, right. It’s not always easy to call the physician’s
office and get an answer back, is it? Wouldn’t life be wonderful if they actually
came to the phone, or if they responded to you within the two or three days you have
left of the five. What if information to define whether that
diagnosis is in fact active or resolved is learned after the assessment completed date? Now what do you do? The OASIS Data Set should not be revised to
reflect the new information. If your assessment completed date is entered
in, come and gone, done, you can not go back and open that document and change it at that
point in time. The OASIS Data Set that you completed for
SOC/ROC within the required timeframe should reflect what was known and documented at the
time of the assessment. But what if you discover that a documented
active diagnosis was not on there and it does exist, and it is creating an impact? What are you going to do? The data set is revised in accordance with
the instructions in the Memo No. 15-18 Outcome and Assessment Information Set Transition
ASAP and the OASIS Correction Policy. You need to go there. Read the instructions and follow them so that
the information can get into the system, but you are doing it correctly according to the
rules. So let’s take a look at the question itself. Now that we’ve looked at all the background
factors that might influence how you’re going to answer it. You would select box number 1 Peripheral Vascular
Disease (PVD), or Peripheral Arterial Disease, (PAD) if you’ve determined that the patient
has an active diagnosis of PVD or PAD, you would check off box number 1. That diagnosis, those diagnoses are indicated
by any of the following codes that start with those first four characters. There’s a completed list in your manual. PVD or PAD is indicated by the diagnosis code
that may start with the first three characters of 173-Other Peripheral Vascular Disease. For box number 2, Diabetes, you would select
this if they have an active diagnosis of diabetes. That uses codes that begin with E0 then 9-13. It also does include the combination codes. If the assessment is completed and it’s determined
that the patient does not have a diagnosis of PVD, PAD or diabetes, you leave both boxes
unchecked. So now you have a pickle, don’t you. You’re out there, you’re supervisors, quality
managers, you’re reviewing charts, you’re reviewing OASIS documentation before your
OASIS submission is locked and loaded and submitted. Two boxes are not checked. Did the nurse just miss that question? Did she forget to answer it? Did she answer it correctly? None of these diagnoses apply. It’s the responsibility of the agency, your
responsibility to develop an auditing strategy to ensure that this item is completed correctly
based on the data that you have obtained. You need to find a process so that when you
review and you find it like this, you are positive that the intent was correct and the
information is correct, and both boxes should not be checked. The dash value is a valid response for this
item. I don’t want you to be confused between leaving
the boxes blank and using the dash. The dash value indicates that no information
is available, or it could not be assessed. You most often use this when the patient is
unexpectedly transferred, discharged or dies before the assessment of the item could be
completed. Obviously CMS expects this to be a rare occurrence. We have for start of care the 5-day window. For resumption, you have a shorter window. You would use the dash if you had not gotten
any confirmation back from the physician but you had to transfer the patient back to the
hospital suddenly. They had an unexpected MI during the night
and died on day three. You hadn’t received a phone call back. You don’t know if the diagnosis is in fact
active. It hasn’t been confirmed as present. So you’re going to enter the dash and then
submit your OASIS. Those are the circumstances when you would
use it correctly. But again as I said before, creating an auditing
strategy so that you know whether or not this is in fact, there is no active diagnosis or
oops, I forgot to answer that question. You need to be able to determine that. And the auditing strategy itself, that’s process. And that is our responsibility as providers. It is not the responsibility of CMS to tell
you how to go about doing that. As I said before, you have to have specific
documentation in the record by a physician, a nurse practitioner, a PA, a licensed person
who has it within their scope of practice according to your state regulations that they
are allowed to confirm the presence of the disease and whether or not it is currently
considered an active diagnoses. You only look at the documented active diagnosis
to answer this question. You can not infer it based on your own technical
knowledge without getting the written confirmation from an appropriate person entering it into
the record. In other words, you can not check off diabetes
because the patient and the family member tells you that mom is always drinking water,
always running to the bathroom, sometimes she smells like she’s been eating honey for
lunch. Yeah that does sound like a diabetic, in trouble
too. But you can’t do that. You can not check off that box because that’s
not within your purview. You don’t diagnose. So you would need to get it confirmed in writing
by an appropriately licensed person. Okay. Enough said. Let’s play. Time to practice our scenarios. Who’s got the clickers on these tables? Got it in your hands? Let’s take a look at our first scenario. Okay. In our first scenario, our patient Mr. J has
been admitted to home care services after surgery for a left total knee replacement. I hope his went better than mine. His medical record documents current active
diagnoses of asthma and arthritis. The admitting clinician completes M1028 Active
Diagnoses as noted below. Okay, look at your slide. There’s nothing checked there. The clinician completed M1028 with a valid
coding response. Do you agree? Is that true or false? Look at that. Aren’t we all smart? That’s true. And why? You leave M1028 unchecked if the patient does
not have any of the listed diagnoses. Let’s talk to Mr. B. Mr. B has Type 2 Diabetes,
he takes metformin and glipizide every day. His regimen includes regular blood glucose
monitoring, exercise and a diabetic diet. The physician progress note that you received
documents an active diagnoses of both diabetes with peripheral neuropathy and peripheral
vascular disease or PVD. How would you respond to M1028? Will you check off box number one? Will you check box number two? Will you check both of them? 1 PVD/PAD? And 2 diabetes? Or will you enter a dash? Put down your answer on your clicker and we’ll
see how we do. I’m checking to see if you’re awake if I put
you to sleep yet, in which case we might have to stop for coffee early. And there we go, 100%. And the correct answer is to check both. Because based on the physician’s progress
note, it clearly documents that this patient has diabetes with peripheral neuropathy and
PVD. The patient has an active treatment regimen
that includes specific tasks related to treating his diabetes. And for that reason, your M1028 should look
like that at the bottom with both boxes checked. Let’s try a different one. Mrs. K underwent a below-the-knee amputation
due to gangrene associated with PVD. She requires dressing changes to the stump
and monitoring for wound healing. In addition, peripheral pulse monitoring is
ordered. The nurse practitioner’s progress note documents
the PVD, and the left BKA. So how would you respond to M1028 this time? Will you check off number 1, PVD/PAD? Diabetes, number two? Would you check both? Or would you put a dash? You got your clickers? Pick one of those. These are easy this morning. You’ve all been paying attention. You must have been reading your slides last
night. Look at that. 100% on the correct answer. You guys are really good today. Okay. This would be correct, the PVD/PAD would be
an active diagnosis because the nurse practitioner’s note documents the diagnosis, includes as
part of the treatment plan the peripheral pulse monitoring, the below-the-knee amputation
dressing changes and wound status monitoring. So those are all related to the diagnosis
making it present and active. Okay, let’s move on to M1060. Gets a little warm up here. Okay, Height and Weight. First of all, this is a touchy little subject,
right. The majority of your patients tend to be women. And who’s got the guts to sit down with another
woman and say, so tell me, how much do you weigh? Think you’re going to get an honest answer
to that one? Don’t be asking me. This is what your box looks like, height and
weight. It clearly tells you, while measuring, if
the number is between 0.1 and 0.4 that you need to round down. Between 0.5 and 0.9 you round up. This is known as mathematical rounding. It’s an understood rule. Height and weight are here and there are no
decimal points between the boxes. They are giving you some direction in terms
of the weight. And I want you to read that carefully because
there’s language in here that has been confusing. And we’re going to go through the wording
itself very carefully to be sure that we can eliminate as much confusion as possible. It says the base weight on the most recent
measure in the last 30 days. Measure the weight consistently according
to standard agency practice. For example, in the a.m., after voiding, before
meals, with shoes off, et cetera. There’s a lot of information in that sentence,
isn’t there? What is the intent behind collecting this
new information, trying to pry out of your patient their height and weight? This supports the calculation of the patient’s
Body Mass Index, their BMI. And that BMI is a direct influencing factor
on their risk for pressure ulcers. We know, we’ve seen enough home care patients. We’ve seen enough patients in hospitals and
nursing homes. We know what the BMI is going to do to their
risk for developing a pressure area. We know that if there’s a large amount of
body mass pressing on a joint area, a bony prominence, and the person’s not being turned,
they’re not moving around, they’re going to breakdown. This is a very high risk factor. And so that’s why it is one of the covariates
determining the patient’s risk for developing a pressure ulcer. It also is going to impact your nurse’s plan
of care for nutrition and hydration, so that you can keep the weight stable, and improve
the BMI to its optimum point. Weight measurement is also a very consistent
common parameter for monitoring and controlling heart failure. We complete this item at SOC and ROC. Let’s talk about the assessment process, the
“how” that you’re going to use to get the actual height of your patient. The guidance says measure height in accordance
with the agency’s policies and procedures, which should reflect current standards of
practice. Measure and record the height in inches, whole
numbers. And when you are reporting the height for
a patient with a bilateral lower extremity amputation, measure and record the current
height after the bilateral amputation. And you would use the longer of the two extremities. Because it’s rare for them to be identical
in length. Let’s look at that first sentence again, in
accordance with agency policy and procedure. So you have a policy and a procedure back
home in the office in your procedure manual for how you want to get to this person’s actual
height and actual weight. Consider how you will answer the question
when someone comes to you and says, and what is your validated source for that policy and
for that process? What are you basing that on? It is not going to be acceptable to say well,
that’s what I think we should be doing. Because you’re not necessarily a validated
resource, are you? You need to have some kind of a validated
technical resource that you are using for your process for obtaining this height. You’re going to complete this particular assessment
only if M0100 equals 1 start of care, or 3 resumption. You record the height to the nearest whole
inch using mathematical rounding and entering the numbers you obtain in those boxes just
as it’s shown right there. Weights should be measured in accordance with
the policy and procedure which should reflect current standards of practice. Again, what is your validated resource? Are you using the VNAA’s Procedures Manual? Are you using Robyn Rice? Are you using some other particular research
manual? You need to have a validated resource that
you’re citing as the footnote in your policy. Measure and record the patient’s weight in
pounds. And understand if the patient can not be weighed
because of extreme pain, immobility, the risk of pathological fracture, then you may use
the dash value and document the rationale in the medical record. You can not do one without the other. If you use the dash, then your nurse’s admission
assessment narrative for the SOC or ROC must have a valid reason noted. The patient has a very high risk of pathological
fracture secondary to — the patient suffers from extreme pain from this diagnosis AEB
as evidenced by whatever. You need to have that sentence in there. You’re going to complete this again, if your
M0100 equals start of care or resumption of care 1 or 3, use mathematical rounding, whole
numbers and entering them in this box as is shown on this slide. Again the dash value is valid, but only when
no information is available, and you are unable to assess this item because the patient has
been again, unexpectedly transferred, discharged or died before you could actually do this. As always, in all of the items we talk about
today, the dash is expected to be a very rare occurrence. So let’s take a look at a couple of practice
scenarios. Mrs. G has congestive heart failure and advanced
osteoporosis. She is at risk for pathological fractures. She is pain-free at rest but experiences severe
pain when she moves. Daily weights have been discontinued as part
of her prescribed medical care due to pain management. So how will you respond to 1060B, the question
of this patient’s weight? Will you enter a dash here? Or will you leave this blank? Use your clickers. Select A or B and we’ll see how we did. All done everybody? Make sure you click either A or B. Very good. 100% said they were going to enter a dash
here. And you’re all correct. And the reason being, she can not be weighed
because of the extreme pain caused by motion, the high risk of pathological fractures. So therefore, you’re using the default response
correctly. Let’s try again. As part of the Start of Care Comprehensive
Assessment your nurse needs to obtain a weight for Mr. B. Mr. B has had bilateral lower extremity
amputations due to complications from diabetes. His legs are now uneven in length. Using a tape measure, the R.N. measures the
patient’s current height while the patient is lying in bed. She obtains two measurements, 64.4 inches
and 60.8 inches. As we said, it’s very rare for the two remaining
to be identical or even close. How would you respond to 1060A the height
question? Take your clicker. Select a number. 61? 64? 65? Or a dash? What do you think is the correct answer for
Mr. B’s remaining height? Remember to round according to the mathematical
rounding principles. Oh, we have a little bit of a spread now. Let’s see what happened. The correct answer is 64. Because you use mathematical rounding and
you use the longer limb. The rationale is that when you are reporting
height for a patient with bilateral lower amputations, you measure the current height,
the residual, after the amputations. Because they are uneven, you have to go with
the longer limb. And the mathematical rounding brings it to
the nearest whole number. Okay. Last scenario. During the start of care home visit the nurse
completes the assessment. The agency’s policy says the patient’s weight
is to be obtained with footwear removed. The nurse assists the patient to remove his
shoes and obtains his weight. The weight is recorded as 126.8. How would you respond to 1060B? A dash? 126? 127? Or 130? Select your number. And I have 100% on 127 which is correct because
we rounded to 127 and the nurse removed the shoes to be in compliance the agency’s policy,
which brings us back again to what is your validated resource for your policy and how
you are going about doing this? I want to move to that 30-day piece of the
assessment question. Because there’s been a great deal of confusion
about it. On day 20 of a home health episode Mr. Y is
transferred to acute care and is hospitalized for 3 days. On day 24 his services resume. During the resumption assessment, the clinician
attempts to weigh Mr. Y, but he’s unable to stand on the scale due to shortness of breath. The clinician locates the following information,
from the most recent start of care assessment 24 days ago Mr. Y has a documented weight
of 175. The weight was obtained by a different clinician
from the same agency. The hospital medical records from his recent
admission indicates his most recent weight to be 177. So now what weight are you going to use? Bearing in mind how the question was framed
when you were asked. Is his weight 175? 177? Do we use a dash because he couldn’t stand
on the scale? Or do we leave it blank? Select a number. And we will see how you are interpreting the
30-day window. Is it 175? Or 177? Is it a dash or is it blank? I see some conversations going on this time. This one’s not so easy is it? And look at that. Okay. We have a pretty even split here, don’t we. Okay. Let’s talk about what the correct answer actually
is. The correct answer is 175. Okay. Now we need to understand the why so that
you can be sure that when you go back to your agencies that you are training your staff
properly and actually getting the correct information. You would enter the weight as 175. This patient is unable to be weighed on day
24 due to shortness of breath. In this instance, we can use a previously
documented weight for the following reasons. The weight was obtained by the same agency
on the start of care. The weight was obtained within the 30-day
window because the resumption of care occurred on day 24. What you can not do is use a weight that was
obtained in the hospital. What you can not do when you go out to the
house to do a start of care, holding the physician office weight in your hand that was done within
the last 30 days, you can not use that weight. You need to do the assessment according to
your validated resource on your policy, you do the assessment. If the patient symptomatically can not be
weighed, you can not use that weight because it was not obtained by your agency within
the preceding 30 days. It doesn’t have to be the same clinician but
it has to have been obtained by your agency. And this height and weight issue, predominantly
the weight question, does bring up a significant number of questions for providers. Am I buying every clinician a scale? Am I buying scales just for my admission team? Am I buying them only for the cardiac rehab
nurse? Do I buy every patient who doesn’t have one
a scale? How do I know his scale is accurate? These are all valid concerns, but you need
again, go back to your validated resource for how you write your policy. Make sure that you have very clear guidelines
for yourselves, and then operate within them. But know that the information you use to answer
the question must be gathered by you. You can not use data from another source,
from a hospital, a long-term care, a rehab, a physician office, even if it’s within the
30-day window. So that has been a source of confusion for
awhile. And people were thinking that they could use
data from that referral source because it was within the 30 days. But we all know when you’re assessing congestive
failure especially, the actual number itself is less critical than the difference between
the weight two days ago and the weight today. And if the weight two days ago was on a different
scale that’s calibrated differently and is obtained differently perhaps on a seat scale
as opposed to you making the patient stand up, it’s not going to be the same. It’s not going to be a valid reference. And that’s why this question and its rules
are setup the way they are. Okay. That brings us to M1620. This is such a lovely topic for this time
of morning. (Laughter) I apologize. Okay. Bowel Incontinence Frequency. This is not a new question that we’re asking
but it certainly is as delicate a question to approach with your patients as asking them
what they weigh is. When your nurses are taking a health history
as part of their assessment, they need to be asking these questions. In my “spare time” — I have a short attention
span so I like to the a lot of different things. I have done some teaching with nursing students. One of my favorite occupations with the first
clinical experience is to pair them off with another student they don’t know at all. I make them draw names out of a hat. You should try this in a staff meeting. Put every clinician’s name in a hat. Make them draw the names so they’re not partnering
up with their best friend. Then have them take a thorough health history
on this other person and actually write it up. See how they answer the questions. See if they actually ask the questions. It can be a very entertaining exercise. And you will learn a great deal about what
your staff can and cannot do in taking an appropriate complete health history. And I can almost guarantee you, they’re going
to skip right on over this question when they’re talking to their peers. And they shouldn’t be. You need to know how often does this patient
experience bowel incontinence and to what degree. It refers to the frequency of the symptom,
not to the etiology or cause. It’s not addressing the treatment of incontinence,
or constipation, i.e. the development of a bowel regimen. We do this assessment at SOC, ROC, follow-up
and discharge, but not to an inpatient facility. You have a long list of possible responses
for this question. They range from very rarely or never, less
than once a week, one to three time as week, daily, more often than daily, or they have
an ostomy. They do give you the unknown option, but not
for follow-up and discharge. By then they expect you to have an answer. How are you going to go about this? We’ve mentioned lightheartedly that health
assessment interview. But you do need to address bowel elimination
patterns when you’re taking a health history. When you’re having your patient take you on
that OASIS walk around the house, make sure you get them in the bathroom. How else are you going to ask them how they’re
going to get on and off the toilet. That gives you the opportunity to look around
the bathroom. Look for cleanliness. It’s going to tell you whether or not they’re
having accidents or incontinence. Look for the visible evidence of soiled clothing. Ask them outright, do they have difficulty
controlling their bowel? Do they have problems with soiling? Uncontrollable diarrhea? If there’s an aide present, private aide,
aide from your agency, ask the aide, preferably privately so as not to embarrass the patient
about what evidence have they seen of bowel incontinence. Because this can then be addressed with the
patient carefully to improve your plan of care and to give you the data you need to
answer the question. So we’ve talked about these covariates, the
quality measure for Pressure Ulcers New or Worsened has four covariates. That’s what we’ve talked about so far, three
of the four, M1028 the Active Diagnoses, M1060 Height and Weight, M1620 the Bowel Incontinence
Frequency. And shortly Ann’s going to come up and talk
about GG, Lying to Sitting on the Side of the Bed. M1028 and M1060 that we’ve already
discussed and GG which is coming after the break are new to the OASIS-C2. They will require some teaching and reinforcement
with your staff. There are no changes to M1620. But the importance of it is what we want you
to take away from this morning. We want you to think about how that impacts
pressure ulcers and how you’re going to educate your staff so that they will ask these questions
appropriately. Earlier this morning Ann talked about developing
Action Plans. We need you to go back and look at your policies
and your procedures. Policies are the rules for what your nurses
are and are not allowed to do. Procedures are how they go about doing it. Make sure you have validated resources for
the how-to. Develop an education plan. Please use the scenarios in this presentation. The versions that will be posted will have
the answers that you can then pull out. Use this as a testing or a competency for
your clinical staff. Consider what process you’re going to use
for your OASIS review to make sure that the data they’re collecting is accurate, and reflected
appropriately in the forms. We’ve given you some resources here that you
can use to get additional information. They’re all hyperlinked so that when you have
this presentation back in your office, you can click on these active links and they will
take you to these different sites. Okay. Questions? Am I going to get off easy? Nobody’s got questions about height and weight,
right? Everybody’s cool with that one, yes? Am I really going to be that lucky? Usually I’m bombarded with the weight one. No? Well I’ve either put you sound asleep — Ah,
there we go. »» I do have a question. So if the patient is hospitalized on day 20,
this is about the weight, and three days later the home health presumes — so what weight
do you use if the patient is unable to stand because of shortness of breath and the patient
has CHF, leave it blank or put a dash? »» If you already had the patient, you obtained
a weight on start of care, then you’re going to use that weight if it’s within the 30-day
window. »» Even with CHF? »» Because you would need to be monitoring
the CHF from other parameters as well. You’re going to have lower extremity edema,
you’ll have ascites. If they’re an amputee you might be using upper-arm
circumference and abdominal girth to measure the congestive failure. Because you’re always going to have to have
these multiple parameters. Weight is the most reliable, we know that. But if you can’t do it, you can’t do it. Patient safety always has to come first. Okay. In the scenario, it says you use the weight
you obtained on start of care. If you could not weigh the patient on start
of care, and they went to the hospital and came home and you did a resumption inside
the 30-day window and you still can not weigh them, then you’re going to leave it blank
because you can’t. You use the dash if the patient was transferred
back to the hospital or died, okay. But you just can’t use the information from
the hospital. They have access to a seat scale, or to a
bed scale. I know some of the larger agencies, especially
if they have a cardiac rehab program have invested in a seat scale. Now those can be pricey, but it is certainly
an option. Yes? Can you come up to mic for me please. »» It’s about the weight. If a patient is discharged, and then readmitted
in the 30-day window, can we still use the weight from the previous episode of care? »» So that last weight falls within the
30-day window. That’s a question I’ve not been asked before. And if you don’t mind, I’m going to hold and
consult with CMS and then I will get back to you after lunch. Yes. Can you come up to the mic? »» What if our patient is diagnosed only
with prediabetes. How would we answer M1028? »» I’m sorry. You’ll have to repeat that. »» If our patient is only diagnosed with
prediabetes, how would we answer M1028? NEW SPEAKER: I’m sorry it’s me. Come up closer. It’s not you, it’s me. »» Oh, Oh. They’re prediabetic? Oh, okay. Is there — you’re going to have to look for
a diagnosis, an actual written diagnosis. Prediabetic would tend to be a term that someone
might use. But you’re going to have to get a hold of the
physician or his or her designee and get an exact answer. They are either going to be treating them
as a diabetic or they’re not. Most likely if they’ve actually written prediabetic,
they’re going to consider diabetes an active diagnosis and commit to that on an interim
order so you can then use it. But you’re going to need to get them to commit
one way or another. That helps you to code correctly as well. Okay. Anyone else? »» I have a quick question. We’ve encountered patients when we get to
M1028 about the active diagnoses that they say they have in their record that they are
diabetic from the hospital, from the physician’s office. And they say, well, I am not a diabetic. They don’t have medications. They don’t check their blood sugar. What we have done is we contact the physician’s
office and ask them to confirm and then we have them write and sign an order. »» Exactly. Because then the physician is confirming it. And that gives you the presence of the diagnosis. But then you’re going to need to look at what
the clinician and the physician want in the plan of care before you can determine if it’s
active. Anyone else? »» Good morning. Can you tell me the citation for the 30-day
window information so that I can cite it when I talk with my staff? »» It makes its to much easier when you
can wave that citation under their nose. »» Yes, it does. »» Okay. What I will need to do is to look that up. I don’t have it here. And I prefer to be able to give you the exact
information. So we will add that to the Q&A list and we
will get back to you with that. And someone up here had a question also. I did see a hand. Yes ma’am. (Audience Question) That’s up to you. You’ll need to decide what your policy is
going to be and what your procedure is going to be. Given that you can purchase a significant
number of them at the $8-10 dollar range in your local Target, it really is not a huge
issue. (Audience Comment)
»» You need to have a policy. I can’t tell you what your policy should be. But you do need to decide with the support
of your professional advisory committee what you believe your policy should be and then
act accordingly. »» Right here. »» So I just want to be clear. Are we allowed to ask the patient for their
weight? Because in the OASIS it has actual and stated. Are we not allowed to use the stated weight
from the patient? »» No. The weight has to be collected. »» Can we take it off the OASIS then? If it’s there, not everyone has gone to this
training. They might think it’s okay to put a stated
weight from the patient? »» No, the way the question is worded, right
on the screen, you have to obtain the actual weight. If you could accept a stated weight then you
would be able to accept the weight from the emergency room from before, on the referral. And we are not allowed to do that. You have to actually obtain the weight. »» Okay, so is there any circumstances — because
they’re on the OASIS. Is there any circumstance under which they
can delete that? If there’s no circumstance, why is it there? I just want to know. »» We will get you the citation. »» New speaker: Okay. Thank you.Anyone else? »» Yes, Ma’am. See I knew this weight question would do it. (laughter_
»» I just wondered if you could give us some of those resources you mentioned that
are validated, that would give us some validated citations. You mentioned the VNAA, I didn’t get all of
them. »» There a variety of different procedure
manuals out there, textbooks. It’s not appropriate for me to make a recommendation
of any particular one. That would be considered an endorsement and
I’m not permitted. But you certainly should do the research. Look at different accrediting bodies. Look at universities. Those are where you’re going to find the different
validated resources. Look at who’s vouching for them. And then I would definitely run it by your
physician on your professional advisory committee so that you have something to back it up. »» All right. Thank you. »» You’re welcome. Okay. We have about 2 minutes left before coffee
time. And I know not to get between people and the
coffee. So any other questions? No. Okay. I will be here the rest of the day and unfortunately
you’re stuck with me again this afternoon. So have your coffee. We’ll see you back here in 15 minutes. Thank you.

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