CMS Response: When completing M2015, Patient/Caregiver Drug Education Intervention, at Transfer/Discharge, you are reporting whether or not the patient and/or caregiver was taught how to manage ALL their medications either at the time of the last OASIS assessment or since that time. If the patient was transferred to the hospital after one visit and you are completing the Transfer to Inpatient OASIS, the M2015 response would be based on whether or not the clinician was able to teach the patient how to effectively and safely manage all their medications at the SOC visit, which includes knowledge of effectiveness, potential side effects and drug reactions and when and how to report problems that may occur. If the clinician was not able to complete the teaching regarding all medications, “0-No” would be the appropriate response. NA is only selected if the patient is taking any medications by any route.

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This has proven to be one of the more confusing areas for clinicians.
When using two tools, one of which is not a validated tool, consider only the validated tool when answering M1910. However, note the discrepancy in your documentation and take appropriate measures to mitigate the risk. In the April, 2010 Q & A (question 20), CMS noted the following (see Q & A for full answer):
Since the validated standardized test (the Timed Up and Go or “TUG”) shows the patient is not at risk, they are considered to be not at risk. The OASIS-C Guidance Manual Chapter 3, M1910 Response Specific Instructions state you are to score based on the results of the standardized test [emphasis added]. ….If it were a matter of two validated, standardized tests being in conflict, an “at risk” score on either tool would indicate the presence of fall risk.

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In response to a similar question (Q 18; April, 2010) CMS reports:
No, it is not acceptable to use the PHQ-2 to screen for depression by asking the questions of a caregiver, or to respond to the two questions based on clinician observations. The PHQ-2 tool is a standardized, validated screening tool in which the patient is the source of report. The PHQ-2 instructions clearly define how the tool should be administered. The clinician is to ask the patient a specific question related to two problems. The information may also be self-reported, precluding the need for the interview. When evaluating the patient, the clinician must first assess whether the PHQ-2 is the appropriate depression screening tool. If the PHQ-2 is appropriate (the patient appears to be cognitively and physically able to respond), then the instrument may be used. If, however, the clinician is then unable to elicit responses to either of the PHQ-2 questions from the patient during the assessment, the clinician can report in M1730 that the PHQ-2 was administered (Response 1), and select N/A - unable to respond.
If the PHQ-2 is not appropriate due to limitations such as cognitive status or communication deficits, the clinician may choose to administer a different standardized depression screening tool with instructions that may allow for information to be gathered by observation and caregiver interview as well as self-report. In this case, the clinician would select Response 2 or 3 for M1730, depending on the outcome of the assessment. If the clinician chooses not to assess the patient (because there is no appropriate depression screening tool available or for any other reason), Response 0, “No” should be selected.

Note that patients who have been assessed as “unresponsive”, based on M1710, When Confused and/or M1720, When Anxious, will not be included in the process measure for depression screening.

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In 2000 the Prospective Payment System (PPS) said that the PPS would not recognize for payment purposes the discharge of a patient who was hospitalized. A provider was free to discharge a client but when it came to payment, Medicare did not recognize the discharge. If a patient needed more resources upon resumption of care, the agency could take advantage of a new Health Insurance Prospective Payment System (HIPPS) code and receive revenue.

However, effective July 1, 2010, this will no longer be an option for providers. New information in the Medicare Claims Processing Manual, CMS Publication 100-4, Chapter 10, reads,

“A beneficiary does not have to be discharged from home care because of an inpatient admission. If an agency chooses not to discharge and the patient returns to the agency in the same 60-day period, the same episode continues. However, if an agency chooses to discharge, based on an expectation that the beneficiary will not return, the agency should recognize that if the beneficiary does return to them in the same 60-day period, the discharge is not recognized for Medicare payment purposes. All the home health services provided in the complete 60-day episode, both before and after the inpatient stay, should be billed on one claim.”

Providers will no longer be able to discharge and readmit a patient who is hospitalized if the hospitalization and return home are within the same 60-day episode. If a patient resumes services prior to the 60th day of the episode, the agency must resume services under the same HIPPS code established by the start of care assessment, regardless of the circumstances. If the patient does not resume services by the end of the 60th day, the agency can discharge him or her and start a new episode upon return home.

To read the details about this change, download Transmittal 1904 at http://www.cms.gov/transmittals/downloads/R1904CP.pdf .

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CMS Response: M1845
”Toileting Hygiene” assesses the patient’s ability on the day of the assessment to manage personal hygiene and clothing when toileting. If the patient has a colostomy, the hygiene would include cleaning (wiping) the perineal area after voiding and around the stoma when necessary. M1845 does not include the patient’s ability to manage the ostomy bag, stoma wafers, or other ostomy equipment. On the day of the assessment, if the patient has the ability to safely manage his or her clothing and perform the personal hygiene as described above, the appropriate score would be a “0.″ How often the appliance (equipment) is changed does not factor into the scoring of this item.

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I went out on day 57 and completed by recertification. My patient was then hospitalized on day 59. What OASIS assessments need to be completed?

A transfer assessment would be required if the patient was admitted to an inpatient facility for a period of 24 hours or longer for reasons other than diagnostic testing.

Additional OASIS assessment completion depends on when the patient resumes your services.

1. If the patient resumes services within the five-day recertification window (day 56 – 60), a resumption of care (ROC) assessment would be completed and the Health Insurance Prospective Payment System (HIPPS) code generated from the ROC assessment would be used to determine payment for the subsequent 60-day episode
2. If the patient is in the hospital at the end of the 60th day of the original episode and had a recertification assessment completed prior to the hospitalization, when the patient comes home determines whether a ROC or SOC assessment is completed.

1)      If the patient resumes services on the first day of the new episode (day 61), the episode would be considered a continuous care episode if the ROC assessment generated the same HIPPS code as the recertification assessment that was completed prior to hospitalization. The patient would not need to be readmitted.

2)      If the HIPPS code from the ROC assessment is different from the recertification assessment, or if the patient resumes services after the first day of the new episode, the episode would not be considered continuous and a new SOC would be necessary.

1. If a new SOC assessment is required because the patient is in the hospital at the end of day 60, a discharge assessment would not be required, since a discharge assessment should never follow a transfer assessment.
2. The agency must complete an internal agency discharge (no D/C OASIS required). A new episode and certification are established, requiring completion of all required admission paperwork.

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CMS Response: All medications, prescription and over the counter (OTC), must be listed on the drug regimen review. It is not necessary for the mediations to be listed in the actual comprehensive assessment form that includes OASIS. They can be listed on a separate medication form. This medication form can be used as part of the comprehensive assessment to document the review of meds as listed in 484.55(c). The documentation should include information indicating the drug regimen review was completed as part of the comprehensive assessment. It can include any notations related to drug interactions, side effects, etc.

NAHC Request for Clarification: The practice of many home health agencies is to use the plan of care and interim orders as the “list of medications.” These agencies do not use a “separate medication form.” The CoP and Interpretive Guidance at G337 language in the State Operations Manual do not include a requirement for a separate medication form or list outside of the plan of care. Does listing the medications on the plan of care meet the requirements?

CMS Response: ALL medications, both prescription and OTC must be listed on the plan of care signed by the physician. Our regulation does not specifically require a separate medication sheet. Surveyors would focus on compliance with 484.55 and 484.55(c).

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The connection between M0102, date of physician-ordered start of care (resumption of care), and M0104, date of referral (date the agency received the written or verbal referral for initiation of care) and the CoPs is:

According to the Conditions of Participation, §455(a), the start of care visit must be within 48 hours of referral or the patient’s return home, or on the physician-ordered start of care date. If the dates in either of these data elements combined with the date of the agency’s visit to start or resume care (date in M0090) do not demonstrate compliance with the CoPs, the agency may experience a survey citation. To avoid potential problems, consider the following:
1. If the referral information comes in over a period of days, designate the last day as the date of referral.
2. Change your intake/referral form to encourage accurate, detailed information. Add a space to the intake/referral form to record the physician-ordered date.
3. Audit inpatient discharge date (M1005) in comparison to M0102 and 104
4. If the SOC visit is not within 48 hours of referral or the patient’s return home, get a physician’s order for the SOC (assuming with the later order the client’s needs are still met).

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Home Care Look
The following highlights are health care reform changes that directly affect home health care.
 Fraud crackdown – increased oversight activity for home care already started
 Home care expansion through FMAP
 Community Free Choice Option – encouraging states to use home and community based services; loosening of red tape for states to offer waiver programs
 Extension of “Money Follows the Person” demo
 CLASS Act – Federal LTC insurance program – expected to help private pay home care and may also be used to supplement Medicare and Medicaid
 Medicare cuts – payment reduction $39.7 BILLION
 Rural add on - 3% from 2010 to 2015 for episodes on or after April 1, 2010 and before January 1, 2016
 Closes the Medicare drug coverage “donut hole”
 Several demonstration projects related to home care
 Physician certification; participating physicians only; face-to-face encounter (patient/physician) must occur within 6 months of certification for home care
o Could be NP/PA
o Could be via telehealth
o Expected to take place January 2011 (subject to change)
 Establishes national centers for excellence for depression to engage in activities related to the treatment of depressive disorders
 Personalizes Prevention Plan – through Medicare plans, beneficiaries would have access to health risk assessment based on guidelines developed by the Secretary in consultation with relevant groups and entities.

Big Picture Look
Below are a few of the highlights that affect health care from a “big picture” perspective. At this time we are assuming they affect all long-term care settings but that too bears watching. Some of the requirements in the bill are already being done in Minnesota so we may experience less “bill shock” than will some states.

 Individual insurance mandates
 Increased tax credit for insurance premiums
 Insurance reform – e.g. pre-existing illness
 Efforts Related To Transparency
1. Disclosure of Ownership- each member of the Governing Body; each Officer, Director, Member, Partner, Trustee, or Managing Employee, and Organizational Structure
 Report must be in standardized format
2. Notice of Facility Closure
3. Standardized Complaint Form
 Complaint Resolution Process includes:
 Procedures to assure accurate tracking of complaints (including notification to complainant)
 Procedures to determine likely severity of a complaint, and investigation of complaint
 Deadlines for responding to complaint & notifying complainant of the outcome.
 Efforts R/T Accountability
1. Operate a compliance and ethics program
2. Criminal Background Checks: Builds on Previous Background Check program conducted under a CMS pilot
 Discretionary for a State (MN already has)
 Efforts R/T Enforcement
1. Civil Money Penalties
2. Background Checks
 Efforts R/T Training
1. Dementia & Abuse Prevention Training - Amends Statute to include dementia management training and abuse prevention training
2. National Nurse Aide Registry - Conduct a Study on Establishing a National Nurse Aide Registry
3. Culture Change & Use of Information Technology
 Requires States to Post Consumer-Oriented Website with Plan of correction & Complaints
 Develop & Provide Independent Informal Dispute Resolution Process
 Notice Requirements for Facility Closure
 $39 billion in Medicare home health payment reductions slated to take place over the next ten years
 Rebasing of home health payment rates scheduled to be phased in over four years beginning in 2014
 CMS plans to cut home health payment rates by 2.71 percent in 2011 continue
 Bolster the existing Medicare prescription-drug benefit by addressing part of its “doughnut hole” problem
 Medicare will begin to pick up the tab for annual wellness visits
 Focus from an acute care-based, institutionally oriented health system to one that focuses on disease prevention and home and community-based care
 Seeks to move toward payment parity for traditional fee-for-service Medicare and Medicare Advantage (MA) programs
 Expansion of health insurance coverage to an estimated 32 million Americans

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