Clinician Home Health Documentation Ownership

What is OASIS

What is OASIS

What is OASIS?

Whether a person has worked in the home health industry for 10 days or 10 years, it is likely that they know OASIS is the main star of the universe that everything else revolves around. It can be very intimidating for clinicians to navigate OASIS documentation.

OASIS is an acronym for Outcome and Assessment Information Set. This documentation is collected at select times across the care timeline. It is not feasible for CMS to personally go visit every patient themselves, so they utilize data gathered from the OASIS to do this job for them.  The OASIS encompasses a mass variety of data that CMS uses to determine and track key patient metrics including patient condition, acuity level, and outcome trends. It is imperative that the OASIS paints an accurate clinical picture of the patient at the time the assessment was conducted.

Who is responsible for collecting the OASIS data?

When authoring the best documentation, it is important to know who is responsible for collecting that data. Collaboration across disciplines makes it possible to develop a picture from multiple angles. Prior to January 2018, the responsibility of completing the OASIS fell solely on the assessing clinician. Realizing the magnitude of that burden, CMS expanded the One Clinician Convention, and the cheers were heard far and wide. That expansion allowed assessing clinicians to elicit input from the patient caregiver as well as other healthcare personnel to assist them in accurately scoring the OASIS M-items included in the comprehensive assessment document.

Are there limitations to who can contribute information?

The expansion still dictates specific limitations, so not just anyone with information regarding the patient can provide input to complete the OASIS, but collaboration is not just confined to the nurses and therapist that visit the patient’s home. For example, the assessing clinician can take actions such as calling the patient’s pharmacist to verify medications dispensed and confirm dosing directions. MD documentation as well as verbal communication with the MD can help determine the diagnoses and conditions that impact the patient’s rehab potential and what the focus of care will be for the services that have been ordered. Demographic information such as patient name, DOB, and Medicare number may be completed by clerical staff as part of the intake process.   Whatever information is collected, CMS is very clear about one thing:  “For OASIS items requiring a patient assessment, the collaborating healthcare providers (e.g., other agency staff: LPN/LVN, PTA, COTA, MSW, HHA) should have had direct in-person contact with the patient, or have had some other means of gathering information to contribute to the OASIS data collection (healthcare monitoring devices, video streaming, review of photographs, phone calls, etc.)  Of course, in their collaborative efforts, all staff, including professional assistants and non-clinical staff, are expected to function within the scope of their practice and state licensure.”

How do home health agencies stay in compliance?

Many home health agencies outsource the responsibility of OASIS reviewing to third party companies with in-depth expertise in OASIS guidance.  The clinicians/reviewers employed by the third party have not had direct contact with the patient, so they do not qualify as collaborating clinicians regardless of how many years of home health experience they may have or what positions they have held in the past. Their review is a portion of the overall OASIS process and focuses on assessing the documentation authored by the collaborating clinicians, to identify inconsistencies and make recommendations to improve accuracy and compliance.

How do reviewers determine their recommendations?

Recommendations made by third party clinicians/reviewers are made based on assessing a “paper patient”. Per guidance, “The assessing clinician is expected to consider available input from other sources and select the appropriate OASIS items response(s), within the appropriate timeframe and consistent with data collection guidance.

Clinicians may find themselves struggling to interpret OASIS timeframes, and the data collection guidance that CMS offers often reads like a foreign language. The third-party clinician/reviewer’s job is basically to help interpret all the guidelines, make sense of the confusing stuff, and help the clinician apply it to their assessment.

Are there legal concerns?

While we are not able to give legal advice, we are aware that the home health industry is not immune to legal concerns. When it comes to the care of a patient, a lot is at stake. All the patient’s needs must be identified on the OASIS.  Failure to document care that was rendered, or an explanation for care that was needed but not addressed can cause agencies and staff members to face legal liability for substandard care. If a need is identified and not sufficiently addressed, resulting in patient injury or damage, this could signal lawsuit or charges for negligent liability.

The consequences of legal woes are wide ranging, including but not limited to:

  •       Decertification from Medicare and Medicaid participation
  •       Perception of engaging in fraudulent conduct
  •       Disciplinary action by state licensure boards for individual clinicians involved in the OASIS discrepancies.

With this in mind, it is vital that all assessing clinicians are aware that they ultimately own their assessments, so it is perfectly acceptable to not automatically agree with recommended modifications to the OASIS.

How should clinicians respond?

Clinicians must be aware that the OASIS is a legal binding document that becomes part of the permanent medical record at that agency.  When the clinician signs off on an assessment, it serves as their attestation that to the best of their knowledge, the document, including the OASIS responses, reflect the patient status as assessed, documented and/or supported in the patient’s clinical record. The assessing clinician has the final say as to what goes on that document—not the person who reviewed the assessment for accuracy, not the MD, not their coworkers, not even the person who signs their paycheck. Read that again! It is crucial that clinicians review any recommendations and approve any modifications of the OASIS.

Solutions for agencies

Steps can be taken by agency leadership to protect clinicians.  Agencies must follow practices in accordance with provider policies and procedures related to staff communication and patient information to track and/or identify those staff members contributing to the patient assessment information. Many EMRs have embedded audit trails to keep documentation checked and balanced as well. Agency protection only goes so far. The clinician really needs to know the importance of owning and protecting their documentation to avoid putting their livelihood at risk.

(Part II—Owning and Authoring the Plan of Care)

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