QA Nurse changing my Oasis answers!!

caliotter3 · Feb 25, 2007

I'm sensitive to all the ways we can get burned. I would not like this idea at all. As I read your post, I was telling myself, well it's ok, you did your part, if she wants to change things, as long as she signs it....then I saw where you have to sign the 485. No, don't like it. Anyhow, in my agencies, the Director of Clinical Services signed all 485's anyway. So she was ultimately responsible. Our field nurses have had it easy as far as paperwork is concerned.

Cattitude · Feb 25, 2007

hi, i've only been doing hh for 5 months now, and no one else at my agency seems to have a problem with this...
the field rn's complete the oasis, but cannot lock it, (we're almost completely computerized now). the qa nurse changes the answers as she sees fit, mainly mo questions, in order to get more $$$. in the computer system, the changes are automatically signed by her, because of her login, etc... and computer signature is required. however, when the 485 is sent, it has the field rn's name on it and she is required to sign it. the qa nurse does not sign it, and her name is not on it anywhere. changes are not sent to the field rn to review and authorize. does this sound right?
i feel very uneasy about this, but the fact that none of the other rn's mention it at all surprises me. is there something i don't know?
anyone have any comments or suggestions?

yes, if she's changing it, she should be signing it. i sometimes cannot believe the stuff we go through. my supvr. loves to tell me what to chart. recently i told her that i will chart how i want , i have been charting for 10 years and that it's my name going on the note. she left me alone.

[color=#483d8b]

DutchgirlRN, ASN, RN · Feb 25, 2007

Our oasis coordinator does this to everyone all the time. We lock our Oasis, on the computer, she goes in and changes it and then sends us an e-mail. MO #'s so and so have been changed, clinician notified. The DON signs the 485. I'm ok with the fact that there is written documentation in the chart that my oasis answers had been changed.

I'm beginning to understand the whole process better now that I'm with a reputable company and they take the time to explain all of these things. If a patient wears depend pads they are considered to be incontinent. Our definition of incontinent is completely different but within Medicare regulations this is their definition and yes the company does get more reimbursement if the patient is incontinent. It's perfectly legitimate so why not? Same with wounds. I would never consider a fully healed and granulated (years old) pacer site a wound but within Medicare regulations it is considered a wound. The company gets more reimbursement the more wounds that are present. I don't agree with these definitions but the important thing is that Medicare does. I'm not going to fight the Medicare system. I do get upset when they try to change the level of dyspnea. That is one of the few items they cannot change without my permission. I will stick with my original assessment and not let it be changed. Especially when I have seen with my own eyes a PT evaluation where the patient wasn't even ambulated.

runrn · Feb 27, 2007

Hi, I've only been doing HH for 5 months now, and no one else at my agency seems to have a problem with this...
The field RN's complete the oasis, but cannot lock it, (we're almost completely computerized now). The QA nurse changes the answers as she sees fit, mainly MO questions, in order to get more $$$. In the computer system, the changes are automatically signed by her, because of her login, etc... and computer signature is required. However, when the 485 is sent, it has the field RN's name on it and she is required to sign it. The QA nurse does not sign it, and her name is not on it anywhere. Changes are not sent to the field RN to review and authorize. Does this sound right?
I feel very uneasy about this, but the fact that none of the other RN's mention it at all surprises me. Is there something I don't know?
Anyone have any comments or suggestions?

When I read your post I hate to admit this but I was relieved. Relieved because the same thing is happening to me....and has been for a while. I voiced my opinion a while back and I was made to feel like I was a trouble maker. I am per visit and over the next few weeks my amount of scheduled visits dwindled--I suppose in an effort to punish me. Things eventually went back to normal as far as visits. I didnt notice them making any changes without consulting me for the next few months....but today I found several that were changed without so much as asking my opinion. Needless to say this time I'm not going to wimp out on them. I have made copies of everything and read over the medicare guidelines and information regarding fraud. To be quite honest it hacks me off to no end that someone would blatantly alter my assessment of a patient in order to get a higher rate of pay. It disgusts me when a nurse or anyone else that is granted the utmost trust by our medicare program abuses that trust and does it in the name of 'the company'. Not that it matters because it doesn't but these same nurses don't get one penny more for committing these fraudulent acts. They come off sounding as though they have been brainwashed the way they disregard their own felonious ways in support of milking the system. They sound retarded when they say things like "well now we aren't breaking any laws here...I mean the answers are the answers it just depends on how you look at them and who does the judging". I want to say "exactly you wench, when I sign on the dotted line it is my judgement that is represented here and not yours....and by the way oasis is not a group effort".

Cattitude · Feb 27, 2007

[quote=dutchgirlrn;2084596
. if a patient wears depend pads they are considered to be incontinent. our definition of incontinent is completely different but within medicare regulations this is their definition and yes the company does get more reimbursement if the patient is incontinent. it's perfectly legitimate so why not? same with wounds. i would never consider a fully healed and granulated (years old) pacer site a wound but within medicare regulations it is considered a wound..

ok, some i agree with and some i don't. i get the incontinent issue. pt. is inc. even if it's stress inc. and it's only occasionally. that seems ok. but an old pacer site is a wound?? really, i don't make my pt's strip naked on assessment anyway. they could technically have several lesions i know nothing about.

[color=#483d8b]it's frustrating. we have supvr's on our back's yet i don't feel comfortable with creative charting. and think about it, it is our tax money. my program deals with both medicare and medicaid and i do budgets so i have to look at costs.

they sound retarded when they say things like "well now we aren't breaking any laws here...i mean the answers are the answers it just depends on how you look at them and who does the judging". i want to say "exactly you wench, when i sign on the dotted line it is my judgement that is represented here and not yours....and by the way oasis is not a group effort".

i like the way you think. yes i know agencies do need money to stay afloat, sometimes every penny does count. but really, it is very bothersome to have one's assessment and judgement overturned. it's offensive even.

PCUSheryl · Feb 28, 2007

I'm wondering if I will be covered if Medicare decides to audit and finds a discrepancy on one of "my" 485's? Our computer system will show who put what data in and when, etc. But will Medicare give a darn about what's in our computer system, or simply what is on the 485?

Is that a legitimate concern, or am I worrying for nothing?

Home Health Columnist / Guide · Feb 28, 2007

correction of clinical records

the hha is encouraged to create policies and procedures that govern correction of

clinical records. it is prudent for the hha to include latitude for correction of records in the event of staff turnover or staff schedules. for example, a clinical supervisor may be permitted by agency policy to make corrections when the original clinician is no longer available due to staff turnover.

when a comprehensive assessment is corrected, the hha must maintain the original assessment record as well as all subsequent corrected assessments in the patient’s clinical record for five years, or longer, in accordance with the clinical record requirements at 42 cfr 484.48. if maintained electronically, the hha must be capable of retrieving and reproducing a hard copy of these assessments upon request. it is acceptable to have multiple corrected assessments for an oasis assessment, as long as the oasis and the clinical record are documented in accordance with the requirements

at 42 cfr 484.48, clinical records.

clinical implications of corrected assessment records

when corrections are made to an assessment already submitted to the state system, the hha must determine if there is an impact on the patient’s current care plan. if there is an impact, in addition to the correction made to the assessment, the hha must make corresponding changes to the current plan of care. if there are any other records where the correction has an impact, for example, the home health resource group, the plan of treatment, or the request for anticipated payment, the agency should make corresponding changes to that record, as applicable. the agency should establish a procedure to review the impact of any corrections made to assessment records and make corresponding changes to other records that are affected.”

some agencies use a manual corrections form for one or more oasis items that can be acceptable after confirming the correction with the original clinician or as described in the agency’s policies and procedures. as long as the correction form clearly identifies the item or items of the specific assessment and remain with the original assessment as part of the permanent record in order to have a complete picture of the entire assessment; these suggestions are consistent with cms’s overall guidelines for maintaining clinical records in accordance with accepted professional standards.

______________________________________________________________________

pg. 75

http://www.cms.hhs.gov/guidanceforlawsandregulations/downloads/som107ap_b_hha.pdf

see also coding guidelines:

https://www.cahabagba.com/part_a/edu...als/hh_sup.pdf

we developed a coding change sheet to document that clinician aware of and agreeable to recomendations from coder

dx coded as _______ changed due to _____________

patient on oxygen in assessment. mo... changed to reflect o2 use.

reviewed with ___________ rn rationale for above changes

signed: coder suzzy nurse date 2/27/07

i agree with the above oasis changes. staff:home health queen 2/28/07

Pearl1 · Mar 2, 2007

I recently worked for a HHA where the QA nurses required that the RN's falsify answers such as if the pt is incontinent, impaired decision-making, memory deficit, require asst to bathroom, etc. Many of these pt's aren't even homebound. I wonder if this is something I should report to the OIG-MEDICARE FRAUD HOTLINE and if so would they investigate it? Has anybody had any experience with this sort of thing? Please respond. :nurse:

PCUSheryl · Mar 2, 2007

NRSKarenRN- Thanks for the good info and the links. That helps me alot.

The agency I work for is really pushing for PT and OT right now. They want EVERYBODY to have one or the other, preferably both. We have to document why the pt did not get one of them if their scores say they qualify, I mean give a detailed description of why they aren't getting it. And it's not because they want to help the pt. They want to help the corporate pocketbooks. I can understand to a certain extent. Everyone likes getting paid, and getting bonuses -- from the least in the company to the greatest. But it makes me feel like a used car salesman....they've given us a script to help us talk the pt's into therapy. They don't want us to take 1 "no" as an answer, tjhey want us to apply a little pressure. At this point, I no longer feel like a nurse, I am no longer an advocate for the pt. I just don't like it.

Thanks everyone for your responses....I had a feeling I wasn't the only one facing these kinds of issues.

CardioTrans, BSN, RN · Mar 3, 2007

About some of the OASIS questions:

Wounds: old pacer site: According to the Chapter 8 in the OASIS manual, yes an old surgical scar is a wound. The question asks "Does the patient have any open wounds or skin lesions?" A scar is a lesion. You mark yes to 440, then on surgical wounds, you mark fully granulating, or mark none and document to the side that it is scar from X yrs ago.

Follow WOCN guidelines for staging of pressure ulcers too........ you cant reverse stage a wound......... if you admit a pt with a Stage IV.......... it is ALWAYS a stage IV, even if it heals. It is fully granulated.

Also remember: say for example..............a patient has a Stage III or IV decubitus................... it heals to the point that a flap is done to close it.......... it is then no longer considered a decubitus/pressure ulcer....... it then becomes a surgical wound.

When 440 was placed on the OASIS, Medicare knew that 99% of the time that it would be marked yes. Its how you mark the others that count on the wounds. A mole is a skin lesion, scars, birthmarks, the old tetorifice injections that left the circular scar......discolorations of the skin.... such as "age spots".....all are skin lesions.

Incontinence: according to Medicare, if the person coughs and "leaks urine", they are considered "incontinent" per medicare. ie; stress incontinence. Yes I know, that makes 90% of us women who have had kids "incontinent" in the eyes of Medicare.

Hope that helps!

medicrnohio, RN · Mar 14, 2007

I've been through this and it was one of the many reasons I left home care. The QA nurses would call nearly everyday questioning my answers on OASIS. They would change the answers to whatever they wanted. My opinion...if they are not there to assess the patient then they have no business changing the answers. We did not have to sign our own 485's but we did have to sign our OASIS assessments. I would actually check them and if I saw they changed an answer without my permission I would refuse to sign.