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afety assessment has a different focus in home care than it does in facilities. In a facility, the ability to change structure or hazards (eg, rugs) is within the staff’s control. In home care, this control rests completely with the patient. In this article, we will discuss some of the important safety factors to consider. With the Outcome and Assessment Information Set (OASIS), one place this assessment starts is the following question.

(M0300) Current Residence:
1 - Patient’s owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)
2 - Family member’s residence
3 - Boarding home or rented room
4 - Board and care or assisted living facility (ALF)
5 - Other (specify)

       The focus of this question is to identify where the patient will be receiving home care services for this episode. The level of intervention and education that will need to be provided may differ based on the response to this question.
       Risk of falls is one of the safety issues receiving a lot of attention today. The OASIS assessment can help provide guidance in identifying patients at risk for falls. There are several areas that should be evaluated. These include level of consciousness and mental status. OASIS Question M0560 (Cognitive Functioning) can provide a summary of mental functioning. The patient’s balance and gait status is also a factor to consider, and question M0700 (Ambulation/Locomotion) describes the level of assistance needed to safely ambulate. Consider any equipment being used both for ambulation and to support health status (eg, oxygen). It is also important to assess the patient’s balance while standing, changing positions, and ambulating. Orthostatic hypotension can also impact fall risk.
       Other areas to also consider are elimination (see question M0520: Urinary Incontinence or Urinary Catheter Presence) and vision (see question M0390: Vision with corrective lenses if the patient usually wears them). Current medications can also have an impact, especially anesthetics, antihistamines, cathartics, diuretics, antihypertensives, antiseizure medications, benzodiazepines, hypoglycemics, psychotropics, and sedative/hypnotics. Other predisposing diseases (see questions M0230/240: Diagnosis), such as osteoarthritis, diabetes, and stroke, should also be considered. Having a complete picture of fall risk can assist in the planning and teaching of fall prevention.
       Disaster preparedness is another area of safety planning and education that needs to occur in home care. The goal is for the patient to be in a safe environment in the event of a disaster where critical needs can be met. Be sure the patient and/or caregiver are knowledgeable in various areas of disaster preparedness. Evacuation needs affect all patients. Where will they go if evacuation is needed? Perhaps that is out of the home in case of a fire or out of the county in case of a hurricane. Special shelter availability is more critical for areas prone to hurricanes, earthquakes, and tornadoes. What transportation will the patient need to complete his or her evacuation plan? A social worker can provide information to assist the patient in contacting local authorities and identifying resources. Other important areas of safety assessment include:
• Anticoagulant use
• Need for oxygen precautions
• Medication storage and administration
• Transfer and ambulation safety
• Seizure precautions
• Infection control and needle or lancet disposal
• Proper positioning during meals
• Side rails for bed bound patients.
       Areas of education may include:
• Safe utilities management
• Mobility safety
• Durable medical equipment (DME) and electrical safety
• Biohazard waste disposal
• Fire safety.
       Safety is a consideration in home care that should be initiated at the start of a care visit and built upon throughout the episode of care. This will also support the primary goal of most patients: being able to live safely in their own homes.

Questions and Answers

       Question: During the home healthcare admission, it is determined that the patient is incontinent of urine. After implementing clinical interventions (eg, pelvic floor strengthening exercises, biofeedback, and medication therapy), the episodes of incontinence stop. At the time of discharge, the patient has not experienced incontinence since the establishment of the incontinence program. At discharge, can the patient be considered continent of urine for the scoring of M0520 to reflect improvement in status?
       Answer: Assuming that there has been ongoing assessment of the patient’s response to the interventions to control the incontinence, yes, this patient would be considered continent. For M0520, “0” (no incontinence or catheter) is an appropriate answer. Timed voiding was not specifically mentioned as an intervention utilized to defer incontinence. If, at discharge, the patient was dependent on a timed-voiding program to defer incontinence, the appropriate answer to M0520 is “1” (patient is incontinent), followed by a response of “0” (timed voiding defers incontinence) to M0530 (When does Urinary Incontinence occur?).
       Question: What are some assessment strategies for answering M0560 (Cognitive Functioning)?
       Answer: The patient’s description of current illness, past health history, and ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) allows the clinician to assess cognitive functioning through observation. If the patient is having trouble remembering questions, ask if this is common or because a stranger is asking a lot of questions. Does the patient have trouble remembering friends’ and/or relatives’ names? Does the patient forget to eat or bathe or get disoriented when walking or traveling (in a car) around the neighborhood or city? If there is a caregiver in the home, gather information from that person also.
       Question:Should all unscheduled physician visits be considered emergent care for purposes of responding to M0830 (Emergent Care)? Or do only those which the clinician judges to represent a physician visit being utilized in lieu of an emergency room visit? For instance, if the clinician calls the physician with patient reports of marked calf pain, tenderness, and acute shortness of breath and the physician wants the patient to come into his or her office, would that be considered emergent care? If the clinician calls the physician to report that the patient’s knee range of motion is not progressing as rapidly as expected and the doctor tells the patient to move up the appointment by a few days and come in today, would that be considered emergent care?
       Answer: Question M0830 is trying to determine if the patient received emergent medical care for an illness or injury since the last time an assessment was completed. “Emergent/ unscheduled (within 24 hours)” is the definition that we are using and following. CMS has not changed the definition of M0830. It remains the same as it is in the current manual. The clinician needs to use the information for any necessary care planning changes; for example, was there a change or addition in medications or treatments? The item does not justify why the patient sought emergent care, only that emergent care occurred (or not). The 24-hour timeframe is a guideline to see whether the need for the physician visit was emergent. If a patient is listed on an adverse event report, then the agency needs to investigate the event to determine whether the care for this patient was problematic.

       Author’s note: The source of the previous questions is the Centers for Medicare & Medicaid Services (CMS) OASIS implementation manual, Chapter 8, from June 2005.