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Be diligent in efforts to prevent OASIS errors
Chart audits, education, reference books helpful
Everyone makes mistakes; but when mistakes are made routinely by home care nurses gathering information for the Outcomes and Assessment Information Set (OASIS), your agency’s bottom line is affected.
"Nurses are not coding specialists, so we have to provide the education that they need to accurately complete OASIS forms," says Jewel L. Walker, RN, CNA, MSA, quality improvement and compliance manager for University Home Care Services in Worthington, OH. "Not only should agencies have a mechanism in place to catch errors, but the nurses’ education should demonstrate the effect answers on the OASIS have on reimbursement levels," she says.
Walker’s agency has coding specialists look at both the OASIS information and the nursing chart within 24 hours of admission and before the information is submitted to Medicare. "We want to make sure the diagnosis is accurate," she says. For example, a diagnosis of senile degenerative brain function, also known as confusion, pays less than a diagnosis of dementia, she says.
"We tell nurses that we don’t want them to upgrade a diagnosis if unwarranted, but we do want the nurse to accurately input the diagnosis of dementia if the physician agrees that the patient’s condition is more serious than confusion," Walker adds.
In addition to ensuring accurate reimbursement, an accurate diagnosis also ensures that your outcomes are based on realistic expectations, points out Lisanne Bright, RN, BSN, MA, process improvement and clinical supervisor for Alliance (OH) Visiting Nurse Association and Hospice.
"Look at the transfer OASIS data," she suggests. "If the patient was admitted to the hospital because of a fall, find out if the fall was the result of a stroke." A patient recovering from a broken hip will have a far different outcome than a patient recovering from both a broken hip and a stroke, Bright adds.
Another problem that Bright’s agency has addressed is inconsistency between nurses. "We realized that two different nurses could look at the same wound; and one would classify it a wound, and the other would classify it a lesion," she says.
To standardize how clinicians answered questions, her agency developed an OASIS booklet that contains the most commonly used codes, along with detailed descriptions of how to apply those codes, Bright says.
"We also require that nurses have their supervisors review their charts at the start of care, resumption of care, and recertification." These checkpoints ensure that inaccurate data are corrected in a timely manner so reimbursement will not be affected adversely, she adds.
Another inconsistency can show up in the same chart, Bright points out. "When reviewing charts, we may see that a patient does not require assistance, but then further down on the form, we see that the patient uses a walker."
Discharge audits are performed regularly to identify recurring errors, she says. In one audit, Bright discovered that the same employee committed half of the 60 OASIS errors committed by one team in a six-week period.
"She was a new employee and thought she was completing the form correctly," she says. After identifying the problem, the supervisor worked with the employee to make sure she knew how to complete the form correctly, and the error rate for that team dropped.
The most common errors found in the audits are omissions where questions are skipped and inaccurate therapy information, says Bright.
"You don’t want your nurse guessing how many physical therapy visits are needed," says Walker. "Under PPS [the prospective payment system], 10 or more physical therapy visits mean an additional $2,000, but a nurse may not be able to accurately judge the number needed."
Because her physical therapists are required to see the patient between 24 and 48 hours after admission, Walker suggests that her nurses hold their charts until they’ve consulted with the therapist.
"During our chart review, we also compare the nurse’s information with the physical therapist’s notes. If the therapist changes the number of visits during treatment or if the therapist’s notes conflict with the nurse’s notes, we contact the nurse and submit a corrected bill," she adds.
"We usually find that the physical therapist finds a higher acuity level than our nurses because the therapist actually observes the patient," says Joanne Rogers, RN, BSN, MA, director of coordinated care for University Hospital Home Care in Warrensville Heights, OH.
"Many times, a nurse will ask patients how well they get around and take their word for it," she adds. For this reason, University Home Care’s performance improvement department completes the therapy section of OASIS after consulting with the physical therapist, she explains.
Now that the Centers for Medicare & Medicaid (CMS) will be posting certain home health agency outcomes, it is more important than ever to accurately document the patient’s prior condition and current condition, says Walker. (See "Public to get access to home health quality information thanks to CMS," Hospital Home Health, February 2003, p. 13.)
For example, if you are admitting a patient that has been in the hospital after a cerebrovascular accident, you have to be specific about the patient’s condition prior to the home care admission, she says.
Don’t just ask the family how the patient was prior to the illness, be specific and focus on the 14-day time frame that CMS defines as "prior to," and ask questions about walking unassisted, bathing with no assistance, and handling activities of daily living, she says.
If you incorrectly take the family’s assurance that "everything was fine" without probing for specifics, you are setting yourself up for a less-than-desirable outcome, she adds.
Ongoing education important
At University Hospital Home Care, OASIS education for nurses is ongoing. "As we conduct random chart reviews, we talk one on one with nurses about their errors," says Rogers.
"We also offer regular programs on new information about OASIS as well as programs that address the errors we most frequently observe," she points out.
Because attending an inservice program not always is convenient for nurses, the home care agency offers continuing education credits as an incentive for everyone to attend programs that are mandatory, she explains. "We also conduct the program at lunchtime to make it easier."
Although OASIS is addressed in orientation, Rogers points out that new nurses may need some extra supervision.
"A lot of times, new nurses don’t take the time to read the entire question or find out exactly what is meant. They try to interpret the intent for themselves," she adds.
In addition to quarterly, active chart reviews in which the nurse brings in charts of active patients to review along with a performance improvement specialist, University Home Care also offers telephone consultation to nurses in the field who encounter questions about which they are unsure.
"Nurses are appreciative of our efforts to teach them individually with the active chart reviews, and we always get calls from nurses in the field," says Rogers. "We’re glad we can provide the extra support they need to prevent errors and ensure accurate documentation."
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