A report by the Office of Inspector General (OIG) last year revealed that home health agencies failed to properly document and report a significant number of fall incidents with major injuries among Medicare patients.
Stricter scrutiny is expected for HHAs for timely completion of OASIS and accurate completion of the OASIS assessments for falls. Documenting falls accurately is crucial as it is one of leading the causes of rehospitalization and mortality in patients. However, there are various factors to consider in order to accurately respond to OASIS items associated with falls.
We collect information about falls at the end of the home care quality episode at Transfer, Discharge, and Death at Home with OASIS items J1800 and J1900. Now, let’s review the guidelines for accurate documentation of falls in these OASIS items.
J1800- Any Falls Since SOC/ROC
When answering J1800, note that both ‘witnessed’ and ‘reported’ falls should be accounted for. Capture any falls that occurred since the last SOC/ROC, regardless of where the fall incident occurred.
To accurately collect this data, we need to revisit the definition of a fall for the purposes of J1800. A fall is defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed chair or bedside mat). This includes situations where the patient falls due to a broken sitting surface or chair, as it aligns with the definition of unintentional falls.
In cases of intercepted falls, which happen when a patient would have fallen if they hadn’t caught themselves or been caught by someone else, they are also classified as falls for J1800. These incidence might be harder to document accurately and may require a thorough review of the clinical record, interviews with the patient and caregivers, and examination of any incident reports or fall logs.
Excluded from the definition of falls are instances such as an expected loss of balance during a supervised therapeutic intervention or a fall resulting from an external force beyond the individual’s control (e.g., a patient pushing another patient).
J1900- Number of Falls since SOC/ROC
In J1900, we record the total number of falls and the highest level of injury sustained during those falls identified in J1800. Each fall is coded only once in J1900, even if multiple injuries occurred, using the highest level of injury for coding.
Below describes the levels of injury applied when scoring each fall in J1900
- No injury means there is no evidence of any injury on assessment.
- Injury (except major) includes things like skin tears, abrasions, lacerations, superficial bruises, and sprains.
- Major injury has a specific definition of only including bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas.
When ensuring accuracy with OASIS item J1900, it’s important to address any corrections needed when more accurate information arises. Errors should be corrected according to your agency’s policy, which may involve situations where injuries become apparent later or the level of injury is determined after the OASIS assessment is completed, such as when a patient is admitted to a hospital with a fall-related injury after being transported to an emergency department.
Recording falls is crucial for home health, aiding in risk identification, personalized care planning, and preventive measures for patient safety. This documentation also ensures regulatory compliance, quality assessment, and ongoing care improvement. Falls assessments are used by the CMS to monitor and provide public information about home health care quality.