From CMS Q&As …
Question: Our clinician reported an ostomy as a surgical wound in the OASIS M1340, Surgical Wound item. The clinician no longer works for the agency, so we cannot contact her about the error. Can this OASIS change be made by the DON without speaking to the clinician?
CMS Answer: You have described a situation where a true OASIS scoring error was discovered during the audit process. The assessment was complete. The patient had an ostomy, a clear, non-disputable fact based on the entire clinical record. The assessing clinician responsible for completing the assessment misunderstood, wasn’t aware, or made an error based on the OASIS scoring guidance, which states all ostomies are excluded as surgical wounds in M1340.
HHAs should have a policy and procedure for correcting errors that involves the assessing clinician. The policy should follow established clinical record professional practice standards and guidance found in relevant CMS regulations and guidance. Normally, if an error is identified through audit or review, the individual who made the original entry into the patient’s record would, whenever possible, make the necessary correction by following agency policy. A correction policy may allow the auditor who found the error to contact the clinician, discuss the discrepancy in the medical record and make the correction following your policy including information such as who discovered the error, and the date and time of communication with the assessing clinician who agrees that it was an error. Correction of an error will not impact the M0090, Date Assessment Completed.
In a case where, as you have described, the original documenter is not available, the clinical supervisor or quality staff may make the correction to the documentation following the correction policy. The supervisor must document why the original assessing clinician is not available to make the correction and how the error was identified and validated as a true error. When corrections are made to assessments submitted to state, you must determine the impact of the correction on the POC, HHRG, the Plan of Treatment, RAP and make corrections to those documents and billing, as applicable.
When the comprehensive assessment is corrected, the HHA must maintain the original as well as subsequent corrected assessments in the patient’s clinical record per requirements at 42 CFR 484.48.
CMS urges HHAs to make corrections and/or submit inactivations as quickly as possible after errors are identified so the state system will be as current and accurate as possible, as the data is used to generate OBQM, OBQI, PBQI, Patient-Related Characteristics Report and HHRG.
Follow the guidance found in CMS Survey & Cert Letter 01-12 New Outcome and Assessment Information Set (OASIS) Correction Policy for Home Health Agencies (HHAs)—ACTION and INFORMATION.
