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n the first article, we mentioned that starting in 2001 the data from the Outcome and Assessment Information Set (OASIS) assessments would be used by the Centers for Medicare and Medicaid Services (CMS) to generate agency-specific reports, including the adverse events report and the case mix report. Agencies are expected to use them to guide their own quality improvement activities. In 2003, CMS will begin to use the information for other purposes, as well. In this article, we will review an important new use of the OASIS data summarized in these reports, which is to guide the survey process.
       The next time a surveyor visits your agency he or she will be armed with a lot more information than in the past--he or she will have specific information on how your agency is performing in key areas identified on these reports. CMS has issued new instructions and worksheets for the survey process. The first step of the new process has the surveyor doing "homework" to guide the survey direction. They will use your agency's adverse events and outcome reports generated as part of the OASIS process to focus the survey on areas of potential weakness.

Adverse Event Reports (Outcome-Based Quality Management or OBQM)
       The surveyor will obtain the reports for your agency for the past quarter or more to reach the minimum patient threshold of 60 prior to your survey. They will focus on the following events.
       From the adverse events, the surveyor will be looking at a pair of Tier 1 (considered more severe) items:
* Emergent Care for Injury Caused by Fall or Accident at Home
* Emergent Care for Wound Infections, Deteriorating Wound Status.
       If one or more patients are listed on your report for either of these events, this will require the surveyor to make a home visit, and he or she will review the chart of the indicated patient(s). Patients with similar characteristics can also be reviewed.
       Additionally, six other events (Tier 2) will be evaluated:
* Emergent Care for Improper Medication Administration, Medication Side Effects
* Emergent Care for Hypo-Hyperglycemia
* Substantial Decline in Three or More Activities of Daily Living
* Discharge to the Community Needing Wound Care or Medication Assistance
* Discharge to the Community Needing Toileting Assistance
* Discharge to the Community with Behavioral Problems.
       For these events, the surveyor will evaluate if your agency's incidence is more than twice the results of all agencies in the US, also known as the reference sample. If so, this will be another survey focus and will also drive the home visit selection.

Outcome Reports (Outcome-Based Quality Improvement or OBQI)
       For this set of measures, the surveyor will be evaluating only if your agency has 30 or more patients in the designated reports and if there is an unfavorable difference between your agency's results and the reference sample. The outcomes with the percent difference are listed in Table 1.

Case Mix Report
       At the same time, the surveyors will use your case mix report to focus on up to three acute conditions and home care diagnoses that are statistically significant and are at least 15-percent higher than the rate for the reference sample. This will drive record review and potentially home visit selection. If there are not any statistically significant areas, this will not be a focus on the survey.
       Additional reports for OASIS transmission will also be evaluated to determine if the agency is compliant with the collection, encoding, and transmission requirements. Less than monthly transmission and specific errors will result in further surveyor evaluation.
       What are the implications for your agency? In order to focus your quality improvement efforts and to prepare for your next survey, know your results! Each quarter, pull the reports for your agency and be sure to evaluate the records of patients listed in your potential problem areas. If you identify real problems, you should, of course, implement efforts to correct them. If what you find are not really problems but simply variances in the data, then notes on your review would explain this. Either way, you're engaging in OBQI and are ready for the surveyor! Remember, adverse events are only potential events, so this may have already been evaluated and determined not to be an area of concern. Knowing your patients and measures will indicate you are on top of the performance improvement process.

Frequently Asked Questions
       Question: In your last article (ECPN 2003;86:36-39), you indicated infusion therapy does not have to be provided by the home health agency in order to answer M0250 with response 1, 2, or 3. What if the patient is receiving outpatient infusion therapy?
       Answer: In this situation, the therapy is administered by another professional and would not be considered in the home. Response number 4 would be the appropriate answer.
       Question: Is a peripherally inserted central catheter (PICC) line considered a wound or lesion for M0440? Is a PICC line considered a surgical wound for M0482?
       Answer: M0440 would be answered yes, because a PICC is considered a wound or lesion. But M0482 would be answered no, because PICC lines are not considered surgical wounds because they are peripheral lines.
       Question: As a physical therapist, I am asked to perform OASIS assessments. However, I am not comfortable evaluating medications. Is it reasonable for the agency to require I perform OASIS assessments?
       Answer: This is a very common question. Most state regulations allow physical therapists to perform initial assessments, and when nursing is not ordered, it is also allowed by the OASIS guidelines. In order to complete a comprehensive assessment, the therapist needs to make a list of medications, observe for side effects, and review for contraindications. This can be performed safely by the physical therapist if they are provided with some initial support from the nursing clinical team. The medication list is the easy part. Observation is part of the therapist's assessment. Depending on their comfort level, the therapist may need to consult with the nursing clinician after the assessment to determine if any abnormalities observed are a result of one of the medications. Contraindications can be verified after the assessment is complete. Shortly you will be independent with medication evaluations.
       Question: When do I do OASIS on a current patient that turns 18?
       Answer: Perform an OASIS at the next appropriate time point after his or her 18th birthday. For example, if he or she goes into the hospital, you would complete a Resumption of Care OASIS upon returning to home care services. Or, if he or she is recertified and is now 18 years old, complete a Reassessment OASIS.
       Question: What if you admit a patient with a diagnosis of pressure ulcer and during the 60-day episode she or he goes into the hospital for a myocutaneous flap procedure to the pressure ulcer. The flap fails to heal completely due to infection, and the patient comes home on antibiotics with an open wound in the area. Is the primary diagnosis now an infected surgical wound or a pressure ulcer?
       Answer: As long as a muscle flap was done, it should be coded as a surgical wound. According to CMS, if a pressure ulcer is closed with a muscle flap, the new tissue completely replaces the pressure ulcer. In this scenario, the pressure ulcer is replaced by a surgical wound. If the muscle flap heals completely but then begins to break down due to pressure, it would be considered a new pressure ulcer.
       Call Renee Olszewski, Managing Editor, at (800) 237-7285, extension 209, with your question, or e-mail it to rolszewski@hmpcommunications.com and we will address it in a future issue.