One question that members needed clarified was whether DME providers need to follow the CMS vaccination mandate. MHCA reached out to MDH for clarification. QSO-22-07 for Home Health and Hospice includes a definition for staff that need to meet the mandate.

“Staff” refers to individuals who provide any care, treatment, or other services for the home health agency/hospice and/or its patients, including employees; licensed practitioners; adult students, trainees, and volunteers; and individuals who provide care, treatment, or other services for the home health agency/hospice and/or its patients, under contract or other arrangement. This also includes individuals under contract or arrangement with the home health agency/hospice, including hospice and dialysis staff, physical therapists, occupational therapists, mental health professionals, licensed practitioners, or adult students, trainees or volunteers. Staff would not include anyone who provides only telemedicine services or support services outside of the home health agency/hospice and who does not have any direct contact with patients and other staff specified in paragraph (d)(1).

There may be many infrequent services and tasks performed in or for a HHA that is conducted by “one-off” vendors, volunteers, and professionals. HHAs are not required to ensure the vaccination of individuals who very infrequently provide ad hoc non-healthcare services (such as annual elevator inspection), services that are performed exclusively off-site, not at or adjacent to any site of patient care (such as accounting services), but they may choose to extend COVID-19 vaccination requirements to them if feasible. HHAs should consider the frequency of presence, services provided, and proximity to patients and staff.

With taking that into consideration, MDH has stated that, in general, DME providers would NOT be considered staff if they do not have direct contact with patients. One exception to this would be in situations where the DME vendor is delivering supplies to the patient’s house, going inside, setting up the equipment, and providing education to the patient on how to use the equipment. MDH has stated that in these cases, an agency will need to have a process in place for how they will ensure contracted staff are complaint with the vaccination requirement.

Another agency shared the following items assessed during a State Survey the previous week:

• The surveyors focused on therapy for co-visits. They scheduled these with multiple therapists (PT/OT), and asked questions about how a therapist reconciles and reviews medications in the home and Assisted Living Facilities.
• Requested contracted staff employee files. They were specifically looking at background study, TB testing, and vaccination status.
• Reviewed records of discharged clients. When doing this, they looked for communication of a discharge summary to providers.
• Interviewed multiple staff members on HHA, OTA, PTA, and LPN supervision. They also looked at how this agency manages, trains, and collaborates with contracted staff such as therapy.
• They looked at their medication reconciliation process, how they handled noncompliance with medications, discrepancies, and interactions.
• When reviewing employee records, they wanted to look further into Home Health Aide records in comparison to other disciplines. They looked at competency evaluations of Home Exercise Programs, Alzheimer training certificates and records that the aides meet the annual training requirement. If an aide does not have a CNA certificate, they wanted to know how they were comped on all the requested competency evaluations.
• Vaccine Mandate- they requested policy and requirements for unvaccinated staff and requested the vaccination/exemption status of all employees. The surveyors asked to see proof of weekly testing (for those that had an exemption as required by this agencies policy) and/or vaccination information was requested for selected employee records.  They also wanted to know how the care team knows the vaccination status of clients.
• Evaluated how complaints and vulnerable adult issues are addressed.
• Other items they looked for compliance with include:
  • The COVID-19 screening/infection control process.
  • Manufacturer’s instructions for disinfection for equipment (for example, an INR machine).
  • Orders for all services provided.
  • Service agreements and ABN/NOMNC forms.

The CRR group plans to hold another meeting on Thursday 6/30 at 1pm. This is a free event, and all members are welcome to attend! Register here.

We can agree that each discipline has its own scope of expertise. There is no one discipline that can be the expert in all aspects of healthcare or be the expert in all of the areas of intervention that a patient may need. Given this, it is most advantageous to match each of our patient’s needs to the discipline that is the “expert” for that need. Having multiple disciplines involved with a patient’s care is an opportunity that we need to take advantage of in order to achieve the optimal outcomes for our patients.

We can and should utilize the expertise of each ordered discipline to assist with patient assessment. CMS recently made this clarification in the OASIS Guidance Manual that will be effective 1/11/18: “Although one clinician must take responsibility for the comprehensive assessment, collaboration with the patient, caregivers, and other health care personnel, including the physician, pharmacists, and /or other agency staff is appropriate. For items requiring patient assessment, the collaborating healthcare providers must have had direct contact with the patient”. Given that each discipline has their area of expertise, collaboration can more accurately score the OASIS items as each discipline sees the patient from a different perspective and focus. Physical therapists from a mobility standpoint, occupational therapists from the perspective of daily living activities, speech-language pathologists from a communication and cognitive view, and nurses from a medical understanding. After a clinician performs the Initial assessment, collaboration can and should take place to assure that a complete assessment is conducted and that accurate data is collected. Examples of this would be an occupational therapist collaborating with a nurse on medication management issues for a patient with cognitive impairments, or a nurse collaborating with a physical therapist to accurately score items related to mobility and locomotion.

To minimize barriers for collaboration, to maximize efficiency in accurate OASIS scoring, and to enable clinicians to share their expertise in a meaningful way, it is helpful to have processes in place that will support a team approach. There are a couple of processes that have been utilized in our home care agencies that we will provide for your consideration.

OASIS Collaboration Process #1: Co-SOC assessments. For patients who are referred for combined multi-disciplinary interventions, it can be beneficial to have 2 disciplines present and overlapping at the start of care assessment in order to put together a collaborative care plan, and to also obtain optimal scoring accuracy. Agencies may utilize this Co-SOC opportunity with a majority of their orthopedic referrals, scheduling with 2 disciplines, where the case managing nurse or PT arrives at the visit 30 minutes or more ahead of the secondary discipline in order to get the patient opened to services. These visits may end up combining a nurse and a therapist(s) or two therapy disciplines at the visit. Generally, after the history and medical status is gathered by both disciplines jointly, the assessment tasks can be divided for completion by the most appropriate clinician. Significant findings are shared and observed by both clinicians. Keeping this visit fluid and interactive is a team skill which can have the added benefit of selling the patient on the value of a having an agency team working on her behalf.

You may find that your more seasoned clinicians have an easier time putting all of the pieces together during an assessment visit. There are some scoring concepts that are standard so that only individualized nuances may need to be discussed between the clinicians when validating OASIS scores. For example, it is common that a patient who needs training in safe mobility will also require assistance for safe medication management. This overarching effect of functional safety in OASIS scoring will be threaded through the OASIS items. For your newer clinicians, nurses or therapists, some of these concepts may still need to be taught or reinforced. The Co-SOC is a perfect opportunity to utilize the skills of the seasoned clinician for ongoing field training. An agency may use a paper document that can be handed off to the primary clinician at the end of a visit, or that can be e-mailed, for the purpose of sharing scoring recommendations and rationale when that is helpful for the team members. Having a template on the form which includes the Functional OASIS scores would be appropriate for standardizing the information gathering and sharing process.

OASIS Collaboration Process #2: Evaluation Template for Functional OASIS Scoring Feedback. This process promotes team care planning by providing all secondarily involved disciplines an opportunity to report their findings and recommendations back to the SOC (or ROC) clinician/discipline.
For an agency lacking an internal software system with which to share scoring feedback, one may utilize an e-mail template in which the appropriate rehab professionals (PT/OT/SLP) provide feedback to the SOC clinician based on their evaluation findings. The only feedback to be provided would be those items in which a discrepancy is observed. In such cases, change recommendations are provided, and the SOC OASIS scoring may be modified at the discretion of the SOC clinician. If further assessment is warranted by the SOC clinician, and it is completed within the 5 day window of a SOC, a change of the M0090 item, Date Assessment Completed, would be appropriate, in order to align with the date of the updated score(s).

An Evaluation template in which specific OASIS items are listed for the rehab clinicians to attend to in their assessments would offer a helpful reminder and a convenient location in which feedback could be entered when it is indicated. It may equally be appropriate for a rehab clinician to support the SOC clinician’s functional scoring, and to enter this feedback on the same template. How reaffirming for the team members! The following data points are ones that may be ideal to place on the feedback list:

    M2020 Management of Oral Medications
    Clinical Severity
    M1242 Frequency of Pain*
    M1400 Dyspnea*
    M1740 Cognitive, Behavioral, Psychiatric Symptoms
    Functional Status
    M1810 Dressing, Upper Body
    M1820 Dressing, Lower Body
    M1830 Bathing*
    M1840 Toilet Transferring
    M1850 Transferring*
    M1860 Locomotion*
    GG0170C 1. SOC/ROC Performance
    GG0170C 2. Discharge Goal
    M2012 a-g. Types and Sources of Assistance
    Service Utilization
    M2200 Therapy Need
*Publicly reported STAR rating outcomes

Your agency may already have systems and processes in place to help support team care planning and related OASIS scoring accuracy. If you do not have something in place yet, the new CMS guidance which supports collaboration may be the prompt you were looking for to set this opportunity in motion as, referencing an article from the APTA’s Home Health Section, there are some initial studies showing an improvement in OASIS outcomes and a reduction in re-hospitalization with implementing a structured collaborating interprofessional team.

When collaboration is utilized, the assessing clinician is responsible for considering available input from these other sources, and selecting the appropriate OASIS item response(s), within the appropriate timeframe and consistent with data collection guidance. M0090 (Date Assessment Completed) will indicate the last day the assessing clinician gathered or received any input used to complete the comprehensive assessment document, which includes the OASIS items.
This is from Chapter one of the Oasis Guidance Manual 2018

13. Only one clinician may take responsibility for accurately completing a comprehensive assessment. However, for all OASIS data items integrated within the comprehensive assessment, collaboration with the patient, caregivers, and other health care personnel, including the physician, pharmacist, and/or other agency staff is appropriate and would not violate the one clinician convention. When collaboration is utilized, the assessing clinician is responsible for considering available input from these other sources and selecting the appropriate OASIS item response(s) within the appropriate timeframe and consistent with data collection guidance.

Oasis Q and A regarding the one clinician rule:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Downloads/Expansion-of-the-Home-Health-One-Clinician-Convention-August-2017.pdf

In the case of an unplanned or unexpected discharge (an end of home care where no in-home visit can be made), the last qualified clinician who saw the client may complete the discharge comprehensive assessment document based on information from his/her last visit. The assessing clinician may supplement the discharge assessment with information documented from client visits by other agency staff that occurred in the last 5 days that the client received visits from the agency prior to the unexpected discharge. The “last 5 days that the client received visits” are defined as the date of the last client visit, plus the four preceding days.

CMS has made changes in 2 areas of the form:

1. The expiration date at the bottom of the form has been changed to 3/2020

2. The form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.

The effective date for use of this revised ABN form is 6/21/2017. If you have paper copies of this form in your agency, it is recommended that you replace them with an ABN that includes these changes on or before 6-21-17.

Download the ABN in English and Spanish.

More information can be found at: https://www.cms.gov/MEDICARE/medicare-general-information/bni/abn.html

0 - No

1 - Yes

NA – Patient not taking any drugs

Interventions to Complete

• Instruct the patient/caregiver about how to manage medications effectively and safely.
• Drug education interventions should address ALL medications the patient is taking – prescribed and over-the-counter - by ANY route.
• Effective, safe management of medications includes knowledge of effectiveness, potential side effects and drug reactions, and when to contact the appropriate care provider.
• Timeframe for this item includes at the time of or at any time since the previous OASIS assessment.
• Other health care provider can include: pharmacist, physician, nurse practitioner, etc.

M2015 Drug Education Response Guide