Documentation Checklist

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 Updated requirements for OASIS Start of Care (SOC) Assessments have come  with the new Patient-Driven Groupings Model (PGDM) implemented by the Centers for Medicare and Medicaid Services (CMS).

Clinical staff must assess the patients needs and document a plan of care (POC) as soon as possible because the first 24-48 hours from the start of care (SOC) are critical to the agency.

The Request for Anticipated Payment Assessments (RAP), estimating the care a patient will receive over the course of a care "episode", must be completed within 5 days of admission.

The PDGM is designed to focus more heavily on clinical characteristics and other patient information to better align Medicare payments with patients' care needs. It removed the incentive to over-provide therapy. With the new 30-day periods of care under Patient  Driven Groupings Model,accurate, timely  completion and documentation of POC and supplemental order is critical.

An overview  of the PDGM model is listed below:Admission Source

• Community- a patient has had no HOSPITAL or  NURSING HOME stay within the 14 days prior to admission
• Institutional- patient has had an acute stay or post-acute care stay (nursing) within 14 days  prior to admission

"Episode" Timing: Early or Late

• Early- the first 30-day period in a sequence of home  health periods.
• Late - each subsequent 30-day period (second or later) in a sequence of 30 day are classified as late.
• Following 30-day periods continue as "Late" until there is a gap of at least 60 days between the end of services, and start of a new care period.

Clinical Grouping

• PDGM clinical  groupings are based on the principal diagnosis which provides information to describe the primary reason for which a patient is receiving home health services.
• The first 3 diagnoses MUST explain why we are in the home.
• If PT/OT are in the home, justifying diagnoses MUST be listed first.
• Each 30 day period is grouped into  one of twelve clinical groups based  on the patient's principle diagnosis as reported on home health  claims.
• This describes the primary  reason for which patients are receiving home health services

For more  information on updates implemented with PGDM,refer to the CMS Guide
Clinical Groups & Primary Reason For Home Health ServicesMusculoskeletal Rehab

• Therapy  (PT/OT/SD for a musculoskeletal condition

Neuro/Stroke Rehab

• Therapy(PT/OT/SD for a neurological condition or stroke

Wounds

• Assessment, treatment and evaluation of a surgical wound,non-surgical wounds, ulcers, burns,and other lesions

Behavioral Health

• Assessment, treatment & evaluation of psychiatric conditions including substance use disorder

Complex Nursing InterventionsAssessment, treatment, and evaluation of complex medical and/or surgical conditions.

MMTA: Assessment,evaluation, teaching, and medication management for a variety  of medical and surgical conditions not classified in one of the  above  listed groups.These subgroups represent common clinical conditions that require home  health services for medication management,teaching, and assessment.

• Surgical Aftercare
• Cardiac/Circulatory o Endocrine
• GI/GU
• ID/Neoplasms/Biood Diseases o Respiratory
• Other

Functional Impairment Level: Low/ Medium/ HighA functional impairment level is designated for each 30-day period based on the following eight OASIS assessment items: • Grooming• Current  ability  to dress upper  body safely• Current  ability  to dress lower body safely• Bathing• Toilet Transferring• Transferring• Ambulation and locomotion• Risk for hospitalization 

M1800

M1810

M1820

M1830

M1840

M1850

M1860

M1033 

CMS looks at the above OASIS assessment items and related  resource usage over a 30-day period and assigns a point value to each item.  Points reflect relative resource use; OASIS item  responses that indicate higher  functional impairment and a higher  risk of hospitalization are assigned higher  points.

Comorbidity AdjustmentPDGM includes  a Comorbidity Adjustment category based on a patient's secondary  diagnosis. A 30 day period may receive no comorbidity adjustment, a low comorbidity adjustment, or a high comorbidity adjustment. A 30 day period can have a low adjustment, or a high  adjustment, but not  both.

Low Comorbidity Adjustment

• Reported secondary  diagnosis that is associated with higher  resource use

High Comorbidity Adjustment

• Two or more secondary  diagnoses that are associated with higher  resource use when both are reported together, compared to if they were reported separately.  The two diagnoses may interact  with one another, resulting in higher resource use.

No Comorbidity Adjustment

• No secondary  diagnoses exist or none meet the criteria for a low or high comorbidity adjustment.

HHAs can report up to 24 secondary  diagnoses that may be eligible for additional payment under  PDGM

REMINDERS FOR ALL OASIS ASSESSMENTS Verification and Documentation of Patient Information

• Photo identification (state or federally issued)
• Phone number(s)
• Insurance types(s) & number(s) (ID, group, etc.)
• The name, address & phone# of current, Primary Care Physician
• Emergency contact information (name(s) & phone# (s).

Prepare a new "Individualized Emergency Plan", for each patient, for ALL SOC, ROC, or RC, if changes I updates are warranted.

Timely and Accurate Submission of Clinical Documentation

• (OASIS, HHA Plan of Care, Admission Consent, Patient Signature Visit Verification (PSWS), "ADD" Orders, etc.).
• OASIS must be completed in Allegheny within 48-hours of assessment and any paper documents be turned in by the following Monday.
• The OASIS needs to be completed in its entirety, not just the "M" questions.
• Diagnoses must reflect reason(s) for home care services!
• The PSWS is NOT to be turned in until the OASIS and/or Verification Assessment has been completed in Allegheny!
• It is critical to turn the OASIS assessments (and all other  visit documentation) in timely!
• Starting Januarv 2021  if the initial RAP is not submitted within 5 days of the SOC, the payment for the care period will be reduced!

IT IS IMPORTANT TO REMEMBER THAT A TOTAL BODY ASSESSMENT MUST BE PERFORMED FOR ALL ASSESSMENTS.

• If patient refuses, question skin condition to determine if there is skin breakdown.

• The OASIS is a separate document from the Visit Record which MUST also be completed.• Upon completion of the SOC, click the view button and check DOCUMENT COMPLETED button in the "verified" box above.