When we’re reviewing your clinicians’ data, it may be helpful to know what we are looking for in order for us to verify to CMS that your data is accurate and complete. Measure 155 requires documentation that a patient with a history of falls has a plan of care for falls within 12 months.
This documentation may be found in the patient’s medical record and/or physician’s notes. The relevant document should be made available to the auditor for the patient requested.
What will the auditor be looking for in the plan of care?
The American Geriatric Society’s 2010 clinical practice guidelines recommend multifactorial/multicomponent interventions to address risks and prevent falls. Your auditor will be looking for elements from the following :
- A strategy to reduce the risk of falls should include a multifactorial assessment of known fall risk factors and management of the risk factors identified.
- The components most commonly included in efficacious interventions were:
- Adaptation or modification of home environment
- Withdrawal or minimization of psychoactive medications
- Withdrawal or minimization of other medications
- Management of postural hypotension
- Management of foot problems and footwear
- Exercise, particularly balance, strength, and gait training
- All older adults who are at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. Flexibility and endurance training should also be offered, but not as sole components of the program.
- Multifactorial/multicomponent intervention should include an education component complementing and addressing issues specific to the intervention being provided, tailored to individual cognitive function and language.
- The health professional or team conducting the fall risk assessment should directly implement the interventions or should assure that the interventions are carried out by other qualified healthcare professionals.