OASIS-Central

Q: I believe that when answering M2400, the clinician only looks at interventions since the last OASIS. This  includes the recertification OASIS. We have many long-term stable patients under Medicaid that we are seeing monthly or sometimes more often (e.g., med prefills). In these cases, many of the interventions were done months or even years before. Do you think we should include these interventions on every recertified plan of care, such as “reinforce prevention of decubitus ulcers” even though the teaching has already been done and the patient and caregiver are competent?

A: No. The plan of care should always be accurate for the time frame that it covers. If there is no current need for an intervention, there is no reason to include it on the plan of care. There are many reasons why an agency might not respond “yes” to implementation of a process, and there is no requirement that an agency implement all processes. Nothing has changed in terms of an agency basing care decisions on patient assessment of need. What’s important is that clinicians document their decision making and that the assessment data represents each individual’s status. Additionally, since you’re referring to a specific Medicaid supported program (mediplanner prefills), it would be a good idea to check with your state resources regarding what to include within the care plans for such patients. Including “orders” for additional types of assessment on these plan of cares may bring up other coverage issues.