SECTION Q: PARTICIPATION IN ASSESSMENT AND GOAL SETTING

Chapter 3 Chapter 3

Section Q: Participation in Assessment and Goal Setting SECTION Q: PARTICIPATION IN ASSESSMENT AND GOAL SETTING Introduction

This section includes one item to identify interventions that were included in the physician-ordered plan of care and implemented.

M2401: Intervention Synopsis

M2401. Intervention Synopsis

At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? (Mark only one box in each row.)

Plan/Intervention

b. Falls prevention interventions

No Yes

↓Check only one box in each row↓ ↓

0 1 NA

c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment

d. Intervention(s) to monitor and mitigate pain

e. Intervention(s) to prevent pressure ulcers

f. Pressure ulcer treatment based on principles of moist wound healing

Item Intent

0 1

0 1

0 1

0 1 NA

NA

NA

NA

Not Applicable

Every standardized, validated multi-factor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls. Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used. Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain. Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers. Patient has no pressure ulcers OR has no pressure ulcers for which moist wound healing is indicated.

Identifies if specific interventions were both included on the physician-ordered home health Plan of Care AND implemented as part of care provided at the time of or at any time since the most recent SOC/ROC assessment.

Time Points Item(s) Completed

Transfer

Discharge from agency

Response-Specific Instructions

• First, review the physician’s orders and the Plan of Care to identify if the specific interventions are included. • Then, determine if the interventions were implemented by reviewing the clinical record, including but not limited to the clinical assessments, and communication notes.

OASIS-E Guidance Manual Effective 1/1/2023 Centers for Medicare & Medicaid Services

Chapter 2 Chapter 3

Section Q: Participation in Assessment and Goal Setting

• Consider interventions implemented any time during the quality episode (at the time of, or at any time since the most recent SOC/ROC assessment, to the time the Discharge or Transfer assessment is completed).

• The problem-specific interventions referenced in this item may or may not directly correlate with stated requirements in the Conditions of Participation. • Interventions provided by home health agency staff, including the assessing clinician, may be reported in this item. o For example, if the RN finds a patient to be at risk for falls, and the physical therapist implements fall prevention interventions included on the Plan of Care prior to the end of the quality episode, the RN may Code “Yes” for row b: Falls prevention interventions. The M0090 - Date Assessment Completed should report the date the last information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed. • For row d, BOTH of the interventions (monitor and mitigate pain) must be both on the physician-ordered

Plan of Care AND implemented for “Yes” to be selected.

Coding Instructions

Enter one Code (Yes, No or Not Applicable) for each row: b, c, d, e and f.

• Code Yes, if the physician-ordered Plan of Care includes the specified best practice interventions listed in each row, AND there is evidence of implementation in the clinical record, by the time the Discharge or

Transfer assessment was completed. o Code "Yes" to M2401 b - e, if the specified clinical interventions were included in the physician ordered Plan of Care and implemented at the time of or at any time since the most recent SOC/ROC assessment whether or not a formal assessment was performed. • Code No, if the interventions are not on the Plan of Care OR if the interventions are on the Plan of Care but the interventions were not implemented by the time the Discharge or Transfer assessment was completed, unless “NA” applies. • Code NA, according to the instructions in the last column of the item, for each row. • Dash is not a valid response for this item.

OASIS-E Guidance Manual Effective 1/1/2023 Centers for Medicare & Medicaid Services

Chapter 2 Chapter 3 Coding Tips

• Falls prevention interventions (Row b) may include, but are not limited to environmental modifications, strengthening exercises, and consultation with the physician regarding medication concerns. • Interventions for depression (Row c) may include but are not limited to new medications, adjustments to already-prescribed medications, psychotherapy or referrals to agency resources (for example, social worker). If the patient is already under physician care for a diagnosis of depression, interventions may include monitoring medication effectiveness, teaching regarding the need to take prescribed medications, etc. • Interventions to monitor and mitigate pain (Row d) may include but are not limited to medication, massage, visualization, and biofeedback. • Interventions to prevent pressure ulcers (Row e) may include but are not limited to teaching on frequent position changes, proper positioning to relieve pressure, careful skin assessment and hygiene, use of pressure-relieving devices such as enhanced mattresses, etc. • Pressure ulcer treatments based on principles of moist wound healing (Row f) may include but are not limited to moisture retentive dressings.

OASIS-E Guidance Manual Effective 1/1/2023 Centers for Medicare & Medicaid Services