CHANGING TIMES
REGULATIONS
PLAN OF CARE
DOCUMENTATION
MOO to YOU
100

This is the industry standard when orders should be signed by the physician or non-physician provider.

What is 30 days?


100

Physician orders, services rendered in a patient’s place of residence, Homebound, Skilled Intermittent Need and Reasonable and Necessary, are examples of these.

What are Medicare Coverage Criteria or Eligibility criteria?

100

These 2 items on the POC should correlate

What are medications and diagnoses?


100

MSW and HHA are considered to be this type of service

What are non-qualifying services?

100

These are the M0 items on a SOC OASIS that contribute to agency reimbursement

What are M1033 – Risk for Hospitalization

and the M1800s functional questions?

200

This is the frequency for performing HHA supervisory visits

What is at least every 2 weeks?


200

Observation and Assessment, Teaching and Training,     Performing Skilled Procedures and Management and Evaluation of the Plan of Care are examples of these

What are Skilled Nursing Services?


200

This item provides primary support for the most intensive service and justifies reasonable and necessary on the Plan of Care. It also is used for Clinical Groupings under PDGM

What is the Primary Diagnosis?

200

- Requires assistance of 2 to leave home

- Lives in second floor apartment without elevator   access and unable to navigate stairs,

- Experiences severe dyspnea upon ambulating 10 ft and must rest are examples of these

What are homebound status'?


200

Pt has a new Colostomy and is sent home for colostomy-related care. How should the nurse answer the OASIS question M1340 “Does the patient have a surgical wound?”

What is “No”?

300

This is the minimum suggested frequency in which length, width, depth and wound characteristics should be measured.

What is weekly?


300

The verbiage “No answer to locked door” is used when documenting these.



What are Attempted visits?

300

This section of the POC justifies homebound status and supports Aide and therapy services

What are Functional limitations and Activities Permitted?


300

RN, PT, ST are examples of these

What are skilled, qualifying disciplines?

300

This number represents a patient’s clinical profile, based on Timing, Referral source, Clinical Grouping, Functional Status and Co-Morbidities. It is used to calculate agency’s reimbursement.

What is the Case-Mix Weight?


400

This is the minimum time when a Notice of Medicare Non-Coverage (NOMNC) should be issued

What is at least 2 calendar days?

400

Sudden weight gain, increased blood pressure, changes in mental status, or a newly discovered decubitus are examples of these 

What are changes in condition?


400

This must be specific regarding your best guess as to how well the patient will achieve return to his previous level of function

What is rehab potential?


400

This is when the comprehensive assessment/OASIS must be completed when recertifying a patient

What are the last 5 days of the episode or days 55-59?

400

A patient is transferred to the hospital on day 38 of their episode and does not return back home. Which OASIS time point and other documentation needs to be completed?

What are an OASIS Transfer (TIF) and DC Summary?

500

This is how often the medication regimen must be reviewed

What is at least every 60 days or as often as a change occurs?

500

Case conferencing, HIPAA-secure texting, telephone calls to physicians and other providers are examples of these

What is Care Coordination?


500

This is the process of creating the most accurate, complete list of all medications a patient is taking and comparing it against current orders to ensure everything is correct, consistent, and safe.

What is Medication Reconciliation?

500

These are 4 items to include when writing a resume care order

What are:

  • Exacerbation or new diagnoses
  • Disciplines, frequency, duration
  • Any duties or treatments
  • Any changes or new medications and their parameters, if applicable


500

Pt had a Right total knee replacement 8 days ago. During the initial assessment, it is noted that the incision has 14 staples, is clean, dry, intact and open to air. How should M1342 “Status of Most Problematic   Surgical Wound” be completed?

0 –  New or worsening (increased in size, depth,               drainage, or new signs/symptoms of infection)
1 –  No observable signs/symptoms of infection;              clean, healing as expected
2 –  Early/partial granulation
3 –  Fully granulating
4 –  Not healing
NA – No observable surgical wound

What is:

 “1” No observable signs/symptoms of infection;        clean, healing as expected?


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