U.S. Department of Health and Human Services 
Office of Inspector General 
Home Health Agencies Failed 
To Report Over Half of Falls 
With Major Injury and 
Hospitalization Among Their 
Medicare Patients 
Ann Maxwell  
Deputy Inspector General 
 for Evaluation and Inspections 
September 2023, OEI-05-22-00290  U.S. Department of Health and Human Services 
 
Office of Inspector General 
Issue Brief 
September 2023, OEI-05-22-00290 
Why OIG Did This Review  Home Health Agencies Failed To Report Over 
Starting in 2019, home health 
Half of Falls With Major Injury and 
agencies (HHAs) were required to 
report that their patients  Hospitalization Among Their Medicare Patients 
experienced falls with major injury 
in patient Outcome Assessment  What OIG Found 
Information Set (OASIS)  Key Takeaway  Fifty-five percent of falls we 
assessments.  The Centers for 
Among Medicare home health  identified in Medicare claims were 
Medicare & Medicaid Services 
patients hospitalized for falls  not reported in associated OASIS 
(CMS) uses this HHA-reported 
with major injury, over half of  assessments as required.  Falls 
information to calculate major 
the falls were not reported on  reporting on OASIS assessments 
injury fall rates at the agency 
patient assessments by HHAs as  was worse among younger home 
level.  Beginning in 2022, CMS 
required.  These patient  health patients (compared to older 
included these fall rates as one of 
assessments are used by CMS  patients) and patients who 
the Care Compare websites 
to monitor and provide public  identified as Black, Hispanic, or 
quality measures, which provide 
information about home health  Asian (compared to White).  
consumers with information 
care quality.  Due to this high  Reporting was also lower among 
about HHA performance.  OIG 
rate of non-reporting, Care  for-profit HHAs as compared to 
and others have found problems 
Compare may not provide  nonprofit and government-owned 
with using provider-reported 
accurate information about the  agencies.  Notably, HHAs with the 
information to assess quality in 
incidence of these falls.  lowest Care Compare major injury 
the past.  We conducted this 
  fall rates reported falls less often 
study to determine the extent of 
than HHAs with higher Care Compare fall rates, indicating that Care 
falls reporting by HHAs and 
Compare does not provide the public with accurate information about 
implications for the accuracy of 
how often home health patients fell.  Finally, for many Medicare home 
the falls information on Care 
health patients who fell and were hospitalized, there was no OASIS 
Compare. 
assessment at all associated with the hospitalization, which raises 
additional concerns about potential noncompliance with data submission 
How OIG Did This Review 
requirements and its impact on the accuracy of information about falls 
We identified falls with major 
with major injury on Care Compare. 
injury in Medicare hospital claims 
for home health patients.   What OIG Recommends 
Whenever their patients are 
We recommend that CMS (1) take steps to ensure the completeness and 
hospitalized, HHAs must submit 
accuracy of the HHA-reported OASIS data used to calculate the falls with 
an OASIS assessment.  We 
major injury quality measure; (2) use data sources, in addition to OASIS 
checked whether the falls were 
assessments, to improve the accuracy of the quality measure related to 
reported in those OASIS 
falls with major injury; (3) ensure that HHAs submit required OASIS 
assessments as required.  We 
assessments when their patients are hospitalized; and (4) explore whether 
calculated non-reporting rates for 
improvements to the quality measure related to falls can also be used to 
these falls.  We also examined 
improve the accuracy of other home health measures.  CMS concurred 
whether reporting rates differed 
with all four recommendations.
by patient or HHA characteristics, 
including whether HHAs had low 
fall rates on Care Compare. 
   
TABLE OF CONTENTS 
 
 
BACKGROUND ................................................................................................................................................ 1 
LANDSCAPE..................................................................................................................................................... 7 
FINDINGS ......................................................................................................................................................... 8 
HHAs failed to report over half of falls with major injury and hospitalization among Medicare  
patients, as required, on their OASIS assessments ...................................................................................................... 8 
Lack of falls reporting on OASIS assessments leads to inaccurate HHA fall rates on Care Compare .... 10 
In many cases, HHAs did not submit required OASIS assessments when their Medicare patients  
were admitted to the hospital due to a fall .................................................................................................................. 11 
OASIS assessments were more often missing for patient falls resulting in major injury and 
hospitalization in Medicare Advantage as compared to Traditional Medicare .............................................. 12 
CONCLUSION AND RECOMMENDATIONS ........................................................................................... 14 
Take steps to ensure the completeness and accuracy of the HHA-reported OASIS data used to 
calculate the falls with major injury quality measure ................................................................................................ 14 
Use data sources, in addition to OASIS assessments, to improve the accuracy of the quality  
measure related to falls with major injury ..................................................................................................................... 15 
Ensure that HHAs submit required OASIS assessments when their patients are hospitalized ................. 15 
Explore whether improvements to the quality measure related to falls can also be used to improve 
the accuracy of other home health measures .............................................................................................................. 16 
AGENCY COMMENTS AND OIG RESPONSE ......................................................................................... 17 
DETAILED METHODOLOGY ....................................................................................................................... 18 
APPENDICES.................................................................................................................................................. 21 
Appendix A: Falls non-reporting rates by additional HHA-level and patient-level characteristics.......... 21 
Appendix B: Agency Comments ........................................................................................................................................ 23 
ACKNOWLEDGMENTS AND CONTACT ................................................................................................. 27 
ABOUT THE OFFICE OF INSPECTOR GENERAL .................................................................................... 28 
ENDNOTES ................................................................................................................................................... 29
   
 
BACKGROUND 
Falls among older adults, including home health patients, are costly, common, and 
often preventable.1  According to the Centers for Disease Control and Prevention, in 
2020, falls among older adults resulted in approximately 920,000 hospitalizations and 
$70 billion in medical costsmore than half of which was paid for by Medicare.2, 3  
Among home health patients, nearly 100,000 fall-related injuries required emergency 
care in 2015.4  Home health agencies (HHAs) may recommend interventions such as 
home modifications, exercise programs, and medication adjustments that can reduce 
the prevalence and severity of falls; improve quality of life for their patients; and 
reduce program costs. 
OASIS Assessments in Home Health Care 
HHAs conduct regularly scheduled Outcome Assessment Information Set (OASIS) 
assessments to capture patients clinical and demographic information (such as race, 
ethnicity, and age), as well as information about patient outcomes and how often 
HHAs follow best practices, and submit this information to the Centers for Medicare 
& Medicaid Services (CMS).  Home health providers conduct OASIS assessments at 
the start of care; at 60-day intervals; upon any significant change in a patients health 
status; and when patients are discharged from home health care, are transferred to an 
inpatient facility, or die at home.5  HHAs must submit OASIS assessments to CMSfor 
both Medicare and Medicaid patients as a requirement for participation in the 
Medicare program.6, 7  
Ensuring the completeness and accuracy of OASIS assessments is the responsibility of 
HHAs.  HHAs should have practices in place for monitoring the accuracy of OASIS 
data, such as clinical record audits, data entry audits, and reports based on electronic 
health records.  Through agreements between CMS and the States, State survey 
agencies (hereafter referred to as State agencies) conduct on-site surveys of HHAs 
before they enroll in Medicare, and every 36 months afterwards, to certify that HHAs 
comply with the minimum health and safety requirements outlined in the Medicare 
Conditions of Participation.8, 9  As part of these surveys, State agencies audit the 
accuracy of OASIS data for a small number of patients.10  While the survey process is 
intended to ensure the accuracy of the OASIS data, in past work OIG found that in 
practice few States take steps to ensure the datas completeness and accuracy.11  
Data derived from OASIS assessments are used to determine Medicare home health 
payment amounts and monitor the quality of home health care.  CMS uses OASIS 
assessments to determine the appropriate payment rate for each home health 
episode in Traditional (fee-for-service or FFS) Medicare.  When CMS cannot directly 
link an FFS home health claim to a start of care, resumption of care, or recertification 
OASIS assessment, it will not pay for the home health service.  State agencies also use 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Background | 1   
OASIS data to prepare for HHA surveys and to assess the quality of care provided to 
HHAs patients.  Finally, CMS uses OASIS data to calculate home health quality 
measures used to monitor and drive improvements in patient care. 
CMSs home health quality monitoring efforts 
CMS began collecting OASIS data for a new home health quality measurethe 
percentage of each HHAs patients that experienced a fall with major injuryas part 
of its Home Health Quality Reporting Program in 2019.  This quality measure helps 
HHAs assess their efforts at improving patient care and safety and provides 
information for patients and their families as they select an HHA.  However, an HHAs 
performance on the falls quality measure does not currently affect its overall quality 
rating or the payments it receives from CMS. 
Home Health Quality Reporting Program.  HHAs must participate in CMSs Home 
Health Quality Reporting Program.12  As part of this program, CMS calculates several 
quality measures reflecting patient care outcomes and processes for Medicare- and 
Medicaid-paid home health care.  CMS then provides each agency with its quality 
scores, which HHAs can use to gauge their impact in improving patient care and 
safety.  CMS operates similar quality reporting programs for other providers, including 
nursing homes.   
To calculate home health quality measures used in the Home Health Quality 
Reporting Program, CMS uses both OASIS data and Medicare claims.  CMS uses 
OASIS data to calculate many quality measures, including measures that reflect how 
often HHAs follow best practices to improve patient outcomes and how often home 
health patients general health and functional status improve.  For many of these 
measuressuch as how often patients get better at walking; moving around; or 
getting in and out of bedHHA-submitted OASIS data are the only available source 
of information.  CMS also uses Traditional Medicare claims to calculate a smaller 
number of quality measures based on health care utilization, such as how often home 
health patients need urgent, unplanned emergency care or are admitted to a 
hospital.13  CMS refines these quality measures over time and publishes updates in 
the annual Home Health Payment Rules. 
To calculate a new quality measure to capture the incidence of falls among home 
health patients, in 2019 CMS began requiring HHAs to report the number and severity 
of falls among their patients.14  Whenever a home health patient is transferred to an 
inpatient facility, is discharged from home health care, or dies at home, the home 
health care provider must complete an OASIS assessment and report the number of 
falls experienced by that patient for the entire episode of care.15, 16  The provider also 
reports the severity of these falls, indicating whether they resulted in a major injury, 
minor injury, or no injury.  CMS uses this information to calculate the percentage of 
each HHAs episodes of care in which the patient experienced a fall with major injury 
(defined as bone fracture, joint dislocation, closed head injury with altered 
consciousness, and/or subdural hematoma).17 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Background | 2   
Care Compare Website.  CMSs Care Compare website publicly reports a subset of 
these quality measures to help home health patients and their families make informed 
decisions when selecting an HHA.  The public can use Care Compare to review how 
HHAs perform on specific measures of quality related to managing daily activities, 
symptom treatment, harm prevention, and the prevention of unplanned hospital care.  
People can also view each HHAs five-star quality rating, an overall performance 
measure based on seven of the publicly reported quality measures. 
CMS began reporting information about falls among home health patients on Care 
Compare in April 2022.  CMS publishes the percentage of each HHAs patients that 
experienced a fall with major injury, as well as the national average rate of falls among 
home health patients, on the Care Compare website.18  According to this quality 
measure on Care Compare, as of April 2022, on average, 0.9 percent of episodes of 
care included a fall that resulted in a major injury.19  Currently, an HHAs performance 
on the falls quality measure does not affect its five-star quality rating. 
Payment Implications for HHAs.  CMS links HHAs payment to the OASIS 
assessment data used to calculate quality measures in two ways.  First, in response to 
OIG work that uncovered issues with the completeness and accuracy of OASIS data, 
CMS introduced a Pay for Reporting program in 2015.20  This program financially 
penalizes HHAs that do not submit the OASIS assessments CMS uses to assess quality 
episodes of care.21  Second, CMS uses quality measures derived from OASIS data to 
determine payments for HHAs participating in the CMS Innovation Center Home 
Health Value-Based Purchasing Model, which CMS plans to implement for all HHAs in 
Calendar Year 2025.22  As part of this model, HHAs will receive payment adjustments 
(both bonuses and penalties) based on their total Medicare FFS payments and their 
relative scores on a set of quality measures.  This set of quality measures does not, to 
date, include the falls quality measure. 
Previous work has identified concerns with quality and 
completeness of provider-reported assessment data 
Studies have shown that providers do not always accurately report patient assessment 
dataparticularly when it could result in lower quality scores and fewer prospective 
customerswhich raises concerns that HHAs may not report falls in OASIS 
assessments as required.  Academic researchers have found that nursing homes did 
not always report falls in patient assessments that were then used in a similar quality 
measure for nursing homes.23, 24  In addition, OIG found that nursing homes 
underreport the use of antipsychotic drugs and inappropriately exclude residents 
from the antipsychotic drug quality measure.25  Finally, as noted above, while State 
agencies are responsible for auditing home health OASIS data through the survey 
process, OIG found that few States take steps to ensure the datas completeness and 
accuracy.26  
 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Background | 3   
Exhibit 1. Because OASIS assessments are the sole source of information used by CMS to 
calculate fall rates among home health patients, HHAs failure to accurately report falls with 
major injury or complete OASIS assessments leads to inaccurate fall rates on Care Compare. 
 
Scope of Inspection 
For this study, we reviewed HHAs reporting of falls with major injury that resulted in 
hospitalization among Medicare home health patients on OASIS assessments 
completed between July 1, 2020, and June 30, 2021.  This was the same time period 
used by CMS to calculate the major injury fall rates that were first publicly posted to 
Care Compare in April 2022.  This study focused on the subset of home health patient 
falls that resulted in a hospital admission because (1) the HHA must submit an OASIS 
assessment and report any falls when the patient is admitted to the hospital; and (2) 
we can independently identify hospitalizations for falls in the Medicare claims data.  
While HHAs are also required to submit an OASIS assessment and report any falls 
upon patient discharge from home health care or death, even if there is no hospital 
admission, we did not assess HHA reporting of such falls in this study.  This study also 
did not assess HHA falls reporting for Medicaid home health patients.  Lastly, this 
study did not collect data on or analyze why HHAs did not report falls. 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Background | 4   
Methodology in Brief 
This study builds on past work on limitations of using assessment data for quality 
monitoring by examining the accuracy of the OASIS data used to calculate one 
specific home health quality measure: the percentage of patients experiencing falls 
with major injury. 
We linked OASIS assessments to information from a second data source, Medicare 
claims, to assess whether falls resulting in major injury were reported in OASIS 
assessments as required over the 1-year period July 1, 2020, through June 30, 2021.  
More specifically: 
  We identified falls with major injury that resulted in a hospitalization from 
Medicare inpatient hospital claims among home health patients. 
  For each of these hospitalizations due to a fall, we looked for the associated 
OASIS assessment.  When a patient is hospitalized for any reason, HHAs must 
submit a transfer or discharge OASIS assessment.  CMS requires HHAs to 
complete the assessment within 48 hours of learning that their patient was 
admitted to the hospital.  To allow for time for the HHA to learn about these 
hospital admissions, we included assessments that were completed up to 7 
days after the admission, or that indicated a discharge or transfer date within 4 
days of the admission. 
  In cases in which OASIS assessments were identified, we determined whether 
the fall was reported on the assessment as required. 
  We calculated falls non-reporting rates overall and by person-level and 
HHA-level characteristics, including fall rates on Care Compare. 
  We determined the extent to which we could not locate associated OASIS 
assessments. 
Refer to the Detailed Methodology section for additional details. 
Limitations 
This analysis may not have identified all falls with major injury that resulted in a 
hospitalization among Medicare home health patients.  For example, this analysis was 
based on diagnosis codes for falls and injuries in Medicare hospital claims; therefore, 
we may not have identified falls with major injury among home health patients if the 
inpatient hospital claims did not fully capture the cause and extent of patients 
injuries.  Additionally, OIG and others have found that Medicare Advantage encounter 
records are often less complete than Traditional Medicare claims.27, 28  As a result, we 
may not have identified all falls leading to hospitalization among people enrolled in 
Medicare Advantage.  However, for all falls that we identified in the claims and 
encounters and linked to OASIS assessments, we did evaluate whether those falls 
were reported in associated assessments as required. 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Background | 5   
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Background | 6   
LANDSCAPE 
We identified 39,900 falls with major injury and hospitalization among Medicare home health patients 
that had a matching OASIS assessment conducted between July 1, 2020, and June 30, 2021.   
Home health patients experienced the following major injuries because of these falls*: 
85% of falls resulted in a bone fracture. 
9% resulted in a subdural hematoma. 
11% resulted in a head injury with altered consciousness. 
1% resulted in a joint dislocation. 
*The total of these percentages is greater than 100 percent because some falls were associated with more than one injury type.  
Source: OIG analysis of Medicare claims and OASIS data, July 2020-June 2021.
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Landscape | 7   
 
FINDINGS 
HHAs failed to report over half of falls with major injury and 
hospitalization among Medicare patients, as required, on their 
OASIS assessments 
We found that many falls resulting in a major  55% 
injury and hospitalization among Medicare home 
health patients were not reported by HHAs in the 
OASIS assessments they submitted, as is required.  
of the 39,900 falls with 
Given that CMS requires HHAs to report the 
major injury and 
number and severity of falls in OASIS assessments, 
hospitalization went 
the high rate of non-reporting indicates poor 
unreported by HHAs on 
overall compliance among HHAs.  OASIS assessments. 
 
For-profit HHAs failed to report falls more 
often than other types of agencies.  HHAs owned by for-profit entities did not 
report 56 percent of falls, while HHAs owned by nonprofit and government-owned 
entities did not report 52 percent and 38 percent of falls, respectively.  Refer to 
Appendix A, Exhibit A-1, for falls non-reporting rates by additional HHA-level 
characteristics. 
Falls non-reporting rates were higher for Hispanic, Black, and Asian people and 
younger patients.  While most falls were among White home health patients, the 
percentage of falls not reported for White patients was lowest (54 percent not 
reported).  That is, a greater percentage of falls with major injury went unreported for 
patients who identified as Asian (66 percent not reported), Black (65 percent of falls 
not reported), or Hispanic (64 percent not reported) as compared to White patients.     
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Findings | 8   
Exhibit 2.  While HHAs failed to report falls for all groups of patients, HHAs 
failed to report falls for Asian, Hispanic, and Black patients at higher rates 
than for White patients; rates for these groups were even higher than the 
overall non-reporting rate. 
 
Source: OIG analysis of Medicare claims and OASIS data, July 2020-June 2021. 
Note: The number of falls here is less than the total number of falls in the study (39,900) because the exhibit excludes 
falls among patients in other race/ethnicity groups or with unknown race/ethnicity. 
 
Similarly, while most falls were among home health patients in older age groups, the 
percentage of falls not reported by HHAs was lowest among those 85 years of age 
and older (52 percent).  In contrast, falls non-reporting was highest among patients 
less than 65 years of age (64 percent).  Additionally, home health patients who 
qualified for Medicare due to disability (the majority of whom were under 65 years of 
age) were less likely to have their falls reported (64 percent not reported) than 
patients who qualified due to age (54 percent not reported).  
Refer to Appendix A, Exhibit A-2, for falls non-reporting rates by additional patient-
level characteristics.   
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Findings | 9   
Lack of falls reporting on OASIS assessments leads to inaccurate 
HHA fall rates on Care Compare 
The home health falls with major 
injury quality measure published 
on Care Compare provides the 
public with inaccurate 
information about how often 
people using home health 
services fell.  Currently, CMS 
calculates this measure using 
information about falls among 
Medicare and Medicaid home 
health patients collected as part 
of the OASIS assessment process.  
However, our finding that HHAs 
failed to report more than half of 
falls with major injury that 
resulted in a hospitalization 
among Medicare home health 
patients on OASIS assessments 
suggests that the falls quality 
measure may substantially 
underestimate how often home 
health patients actually fell.  In 
other words, a low fall rate on 
Care Compare may reflect an 
Source: OIG analysis of Medicare claims and OASIS data, 
HHAs lack of falls reporting, 
July 2020-June 2021. 
rather than a low incidence of 
falls among its patients.  
In fact, we found that HHAs with low falls with major injury rates on Care Compare 
were the most likely to not report falls among their patients enrolled in Medicare
suggesting that those HHAs low fall rates on Care Compare are driven by a failure to 
report patient falls, rather than an actual low incidence of falls.  After evenly splitting 
HHAs on Care Compare into three categoriesthose with low, medium, and high falls 
with major injury rateswe found that the HHAs in our study with low fall rates on 
Care Compare failed to report 78 percent of the falls we identified in the Medicare 
claims.  In contrast, the HHAs in our study with high fall rates on Care Compare failed 
to report 43 percent of the falls we identified in the Medicare claims.   
We cannot determine what the falls with major injury rates on Care Compare would 
have been if all falls we identified in the Medicare claims were reported as required.  
The falls with major injury rate on Care Compare factors in both Medicare and 
Medicaid patients and reflects HHA-reported falls with major injury that did not result 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Findings | 10   
in hospitalization.  The scope of this evaluation does not cover all of these aspects.  
However, the correlation between HHAs low fall rates on Care Compare and high 
non-reporting rates among hospitalized Medicare patients in our analysis calls into 
question the accuracy of the Care Compare measure. 
Exhibit 3. HHAs with the lowest falls with major injury rates on Care Compare had the 
highest rates of falls non-reporting among their patients. 
 
Source: OIG analysis of Medicare Inpatient and Home Health Claims and Encounters, OASIS assessments, and Care Compare data, July 
2020-June 2021. 
Note: Low Care Compare fall rates are those less than 0.4%; medium rates are 0.4% and <1.2%; high rates are 1.2%.  Falls 
among patients of HHAs without Care Compare fall rates are excluded from this calculation of falls non-reporting rates. 
In many cases, HHAs did not submit required OASIS 
assessments when their Medicare patients were admitted to the 
hospital due to a fall 
In addition to failing to report falls on submitted OASIS assessments, HHAs failed to 
submit any OASIS assessment at all for a portion of hospitalizations due to falls.  We 
were unable to identify any transfer or discharge OASIS assessment completed 
around the time of the hospitalization for 5,757 falls (13 percent of the total falls we 
identified) that resulted in a major injury among home health patients.  While we 
excluded falls that could not be linked to OASIS transfer or discharge assessments 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Findings | 11   
from our non-reporting analysis, treating these falls as not reported would increase 
the overall non-reporting rate from 55 percent to 61 percent.  We were unable to find 
these assessments despite using a flexible approach to maximize our match rate.  For 
example, our approach allowed for matches on Medicare beneficiary identification 
numbers or social security numbers, as well as for assessments submitted well beyond 
the required timeframe.29  
Moreover, it is likely that these missing transfer or discharge assessments for 
Medicare home health patients who were admitted to the hospital after a fall also 
resulted in inappropriately lower fall rates on Care Compare.  If a patients fall is never 
reported by the HHA on an OASIS assessment, it will not be included in the fall rate 
on Care Compare.  It is possible that HHAs submitted OASIS assessments for some 
falls that we identified long enough after the fall occurred that they would not have 
been considered matches in our analysis but would have been included in the 
quarterly calculation of the Care Compare fall measure.  However, this is unlikely to be 
the case for all of the falls with missing transfer or discharge assessments in our 
analysis.30 
OASIS assessments were more often missing for patient falls 
resulting in major injury and hospitalization in Medicare 
Advantage as compared to Traditional Medicare 
We were more often able to link falls to OASIS assessments when the home health 
services were paid by Traditional (FFS) Medicare as compared to Medicare Advantage 
organizations.  Most falls occurred among FFS enrollees, and we were able to link to 
OASIS assessments for all but 8 percent of these falls; in contrast, for Medicare 
Advantage enrollees, we could not find OASIS assessments for 29 percent of falls. 
Exhibit 4. OASIS assessments for Medicare Advantage enrollees were more likely to 
be missing than OASIS assessments for FFS enrollees. 
 
 
Source: OIG analysis of Medicare claims and OASIS data, July 2020-June 2021. 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Findings | 12   
This difference in match rates between Medicare Advantage and Traditional Medicare 
may be related to differences in the oversight of HHAs OASIS submissions between 
the two programs.  For example, CMS checks for certain required OASIS assessments 
before paying home health claims in FFS Medicare; if CMS cannot link to those 
assessments, the HHA will not get paid.  While CMS does not link FFS claims to the 
specific transfer or discharge assessments in which falls should be reportedbecause 
those assessments are not required for paymentCMSs general focus on OASIS 
assessment submission in FFS may drive the higher rate of matches we found.  In 
contrast, CMS does not have a process to link any assessments with managed care 
encounters. 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients   
OEI-05-22-00290  Findings | 13   
CONCLUSION AND RECOMMENDATIONS 
Because falls are not accurately reported in OASIS data, CMSs falls with major injury 
quality measure does not provide reliable informationfor patients and their families 
in selecting an HHA, or for CMS and HHAs in their efforts to improve the safety and 
care of patients.  We found that over half (55 percent) of falls with major injury were 
not reported by HHAs in OASIS assessments as required.  In addition, we were unable 
to find any OASIS assessments submitted for a large number of these falls, particularly 
among home health patients enrolled in Medicare Advantage.  As a result, the actual 
incidence of falls resulting in major injury among home health patients is almost 
certainly higher than the rate CMS shares with HHAs and reports on Care Compare.  
Because an individual HHAs low fall rate on Care Compare can result from poor falls 
reportingrather than less frequent falls among the HHAs patientsthese rates may 
also provide misleading information about which HHAs have a lower incidence of 
patient falls with major injury than their peers.   
These findings contribute to a growing body of evidence that the use of provider-
reported information from patient assessments may provide a misleading 
representation of care quality.  Academic researchers have found that nursing homes 
did not always report falls in patient assessments, leading to potential inaccuracies in 
a similar falls quality measure for nursing homes.31, 32  After finding that nursing 
homes underreport the number of residents receiving antipsychotic drugs in patient 
assessments, OIG has also raised concerns about the accuracy of CMSs quality 
measure based on this provider-reported data.33 
CMS should work to improve falls reporting among HHAsas well as submission of 
the OASIS assessments that record these fallsand ensure that the quality 
information it shares with HHAs and the public is accurate.  While this study did not 
specifically evaluate the underlying cause of these low reporting rates or missing 
assessments, CMS could consider a number of approaches when determining the 
most effective way to address these issues and improve the falls with major injury 
quality measure.  CMS may also be able to apply lessons learned during this process 
to assess whether other existing or future quality measures based on HHAs OASIS 
data would be improved with additional data sources, oversight, or training. 
Therefore, we recommend that CMS:  
Take steps to ensure the completeness and accuracy of the 
HHA-reported OASIS data used to calculate the falls with major 
injury quality measure  
CMS should take steps to improve HHAs reporting of falls with major injury among 
their patients on OASIS assessments.  CMS could consider multiple approaches to  
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Conclusion and Recommendations | 14   
meet this objective.  For example, CMS could work with State agencies to provide 
home health providers with additional training and education about these relatively 
new falls reporting requirements.   
CMS could also use data analysis to identify, and then address, continued problems 
with HHAs reporting of falls.  For example, to identify continued gaps in HHA 
reporting of falls through audits, CMS could compare HHAs OASIS assessment 
responses with inpatient hospital claims dataas we did in this studyor with 
patients medical records.  Additionally, CMS could compare HHAs OASIS-based fall 
rates with claims-based fall rates to identify any patterns of underreporting.  Finally, 
CMS could encourage State agencies to focus on the accuracy of falls reporting, and 
other questions used to generate quality measures, when auditing OASIS assessments 
as part of the survey process.  CMS could then use this information to target OASIS 
falls data improvement efforts.   
Use data sources, in addition to OASIS assessments, to improve 
the accuracy of the quality measure related to falls with major 
injury  
As CMS evaluates the new home health falls with major injury quality measure, it 
should supplement falls data from OASIS assessments with additional data sources, 
such as Medicare claims.  For example, CMS could consider using a combination of 
Medicare claimswhich include the information necessary to identify falls with major 
injuryand provider-reported OASIS data to generate a more accurate measure of 
the rate of falls with major injury among people using home health services.  Given 
the low reporting rates found in this study, this could help CMS to estimate fall rates 
more accurately than the provider-reported assessment data alone.   
Ensure that HHAs submit required OASIS assessments when 
their patients are hospitalized 
CMS should do more to ensure that HHAs submit required discharge and transfer 
assessments when their patients are hospitalized.  We were unable to find the 
required OASIS transfer or discharge assessments for many falls among managed care 
home health patients in our study, as well as a smaller share of FFS patients.  CMS 
currently has two mechanisms in place to encourage HHAs to submit OASIS 
assessments as required.  First, CMS directly links some types of OASIS assessments to 
FFS claims to determine FFS payment amounts.  Second, following previous OIG work 
which found that few States take steps to ensure OASIS datas completeness and 
accuracy, CMS established the Pay for Reporting Performance Requirement, which 
penalizes HHAs that do not submit the patient assessments CMS uses to assess 
quality episodes of care.  However, neither of these mechanisms are designed to 
ensure that transfer and discharge assessments are submitted when patients are 
hospitalized.  As a result, even with these policies in place, we could not identify 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Conclusion and Recommendations | 15   
OASIS transfer or discharge assessments associated with 13 percent of 
hospitalizations for falls with major injury among Medicare home health patients.   
To address this issue, CMS could consider a number of approaches.  For example, 
CMS could evaluate whether automated checks to identify inpatient hospital claims 
and encounters among home health patients and alert HHAs if the required OASIS 
assessments are not submitted in a timely manner would be an effective way to 
improve OASIS completion rates.  CMS could also encourage State agencies to check 
for completion of assessments when home health patients are hospitalized as part of 
the survey process.  CMS could provide additional training and/or guidance to HHAs 
about when transfer and discharge assessments are required.  Finally, given our 
finding that there is a higher rate of missing assessments for home health care paid 
via managed care, CMS should target efforts aimed at improving compliance with 
OASIS submission requirements for hospitalized patients to HHAs managed care 
patients. 
Explore whether improvements to the quality measure related 
to falls can also be used to improve the accuracy of other home 
health measures 
Given the inaccuracies of provider-reported assessment data identified by this and 
other studies, CMS should consider opportunities to improve additional home health 
quality measures that are based solely on OASIS assessment data.  In doing so, CMS 
should determine whether the approaches it takes to improve the falls with major 
injury quality measure could also be used to improve such measures.  For example, if 
CMS determines that incorporating claims data allows it to more accurately measure 
falls with major injury rates for HHAs, CMS could consider using a similar approach as 
it develops and revises other quality measures.  Similarly, if CMS finds that additional 
training for home health providers or having State agencies conduct targeted follow-
up through the survey process improves the accuracy of OASIS falls reporting, it could 
apply the same approaches to improve other types of OASIS reporting from which 
quality measures are derived.     
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Conclusion and Recommendations | 16   
AGENCY COMMENTS AND OIG RESPONSE 
CMS concurred with all four of our recommendations. 
In response to our first recommendationthat CMS should ensure the completeness 
and accuracy of the HHA-reported OASIS data used to calculate the falls with major 
injury quality measureCMS stated that it would explore opportunities to promote 
the completeness and accuracy of the data, including additional OASIS outreach and 
educational opportunities. 
In response to our second recommendationfor CMS to use data sources, in addition 
to OASIS assessments, to improve the accuracy of the quality measure related to falls 
with major injuryCMS stated that it would explore opportunities to use additional 
data sources to improve the accuracy of the quality measure.  OIG acknowledges that 
changing a quality measure specification to incorporate new data sources requires 
significant time and effort due to established procedures such as soliciting public 
comment and validation.  We look forward to seeing the specific steps CMS plans to 
take to address this recommendation in its Final Management Decision. 
In response to our third recommendationfor CMS to ensure that HHAs submit 
required OASIS assessments when their patients are hospitalizedCMS stated that it 
will explore opportunities to help ensure that these assessments are submitted.  OIG 
notes that because we found a higher rate of missing assessments for home health 
care paid via managed care as compared to fee-for-service, our recommendation 
specifies that CMS should target efforts to improve compliance with OASIS 
submission requirements to managed care patients. 
In response to our final recommendationfor CMS to explore whether improvements 
to the major injury falls quality measure could also be used to improve the accuracy 
of other home health measuresCMS stated that it will consider this 
recommendation when evaluating other home health measures.  
For the full text of CMSs comments, see Appendix B.     
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Agency Comments and OIG Response | 17   
DETAILED METHODOLOGY 
Data Sources 
Medicare Inpatient and Home Health Claims and Encounters.  We used both 
Traditional Medicare claims and Medicare Advantage encounters (hereafter referred 
to as claims) to identify falls among home health patients to include in our analysis.  
We used inpatient claims to identify hospital admissions for falls with major injury 
with admission dates between June 27, 2020, and June 30, 2021.34  Then, we used 
home health claims to identify the subset of falls that occurred among home health 
patients. 
OASIS assessments.  We analyzed OASIS assessments with assessment completion 
dates between July 1, 2020, and June 30, 2021, to determine whether the falls 
identified in the claims were reported.35  We also used OASIS assessments to identify 
characteristics of the home health patients who fell and characteristics of the HHAs 
that served them. 
Medicare Enrollment Database (EDB).  We used the Medicare EDB from Calendar 
Years 2020-2021 to identify additional patient-level characteristics. 
Care Compare Provider file.  We used CMSs public Home Health Services Provider 
file from April 2022 to identify additional HHA characteristics. 
Data Analysis 
Identifying falls with major injury among home health patients.  We used 
external cause of injury codes from the inpatient claims to identify inpatient hospital 
admissions due to falls.  We then used diagnosis codes to identify which of those 
hospitalizations met CMSs criteria for major injuries: bone fractures, joint dislocations, 
closed head injuries with altered consciousness, and subdural hematomas.  For each 
admission, we noted the Medicare identification numbers of the person who was 
hospitalized and the date of the hospital admission.   
Next, we determined which hospitalizations due to falls with major injury were among 
people who were receiving home health services at the time of the fall.  To do this, we 
used Medicare identification numbers to link to home health claims.  Specifically, we 
considered a person to have been using home health services at the time of the fall if 
they had a home health claim with dates of service that included the admission date 
or had a home health claim that ended the day prior to the admission date. 
In results not included in the report, we also explored falls reporting where the home 
health claim ended in the 2 to 7 days prior to the hospital admission date, rather than 
the same day or 1 day prior.  While many falls meeting these criteria were reported 
(non-reporting rates were still greater than 50 percent with this set of falls), we 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Detailed Methodology | 18   
decided to exclude these falls from the study inclusion criteria because responsibility 
for reporting is less clear when more time accrued between the end of the home 
health claim and the admission date as compared to the shorter time window we 
used. 
We also used the home health claims to classify falls into two groups based on 
program structure: managed care (i.e., Medicare Advantage) and FFS.  If the home 
health claim associated with the hospital admission was a managed care encounter 
record per the claim type code, we assigned that fall as managed care; if the home 
health claim was an FFS claim, we assigned the fall as FFS. 
Matching to the associated OASIS assessments.  For each hospitalization of a home 
health patient for a fall with major injury, we attempted to identify the associated 
OASIS transfer or discharge assessment.  We used Medicare identifiers, the hospital 
admission dates, and dates from the OASIS assessments to match between the two 
data sources.  We considered the fall to have a match to an OASIS assessment if there 
was a match on Medicare identifiers36 and either (1) the assessment completion date 
(OASIS item M0090) was the same day or in the 7 days after the hospital admission 
date or (2) the assessment discharge/transfer/death date (OASIS item M0906) was 
within 4 days of the hospital admission date.37 
We used this set of inpatient hospitalizations for home health patients to calculate the 
total number of falls resulting in major injury and hospitalization among home health 
patients.  We also calculated the number of unique patients who experienced one of 
these falls.  We determined the number and percentage of these falls for which we 
were able to identify an associated OASIS transfer or discharge assessment in which 
the fall should have been reported.  We also calculated the match rate for falls 
classified as managed care and FFS separately.  Finally, for falls with linked OASIS 
assessments, we described the characteristics of the patients who fell and the HHAs 
that served them. 
Falls reporting.  For the hospitalizations with matched OASIS assessments, we then 
determined whether the fall was reported in the OASIS assessment as required.  We 
reviewed the OASIS items that ask (1) whether the patient has had any falls since the 
last assessment and (2) how many falls with major injury the patient experienced.  If 
the OASIS assessment did not record that the patient had experienced at least one fall 
with major injury, the fall was considered to be unreported by the HHA.  We then 
determined the total number of these falls that were not reported in OASIS as 
required.    
To evaluate the extent to which HHAs reported these falls among their patients, we 
calculated the percentage of unreported falls with major injury (hereafter referred to 
as falls). First, we divided the total number of falls not reported in the OASIS 
assessments by the total number of falls identified in the hospital claims and matched 
to OASIS assessments.  We also calculated the percentage of unreported falls for each 
HHA by dividing the number of falls not reported by the HHA in its OASIS 
assessments by the number of falls identified in the review of hospitalizations and 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Detailed Methodology | 19   
matched to OASIS assessments for the HHAs patients services.  We analyzed the 
number and percentage of unreported falls across HHAs to identify any HHAs with 
concerning patterns of falls non-reporting.  
Patient-level characteristics.  We calculated the percentage of unreported falls for 
different groups of patients to identify potential disparities in falls reporting.  Using 
information from OASIS, we determined the percentage of unreported falls by age, 
sex, race/ethnicity, rural versus non-rural ZIP code, and whether the patient lived 
alone during the home health care episode.38  Using information from the Medicare 
enrollment file, we also compared the percentages of unreported falls for home 
health patients covered by Medicare only versus Medicare and Medicaid (i.e., 
dual-eligibles) and by reason for Medicare entitlement (age versus disability and/or 
end-stage renal disease).  
Patient race and ethnicity data are collected during OASIS assessments.  The home 
health patient (or their caregiver) is given the following options and instructed to 
mark all that apply: American Indian or Alaska Native; Asian; Black or African 
American; Hispanic or Latino; Native Hawaiian or Pacific Islander; and White.  We then 
coded these responses into the following mutually exclusive groups: White (single 
race) non-Hispanic; Black non-Hispanic; American Indian Alaska Native (AIAN) 
non-Hispanic; Asian non-Hispanic; Native Hawaiian/Pacific Islander non-Hispanic; 
more than one race non-Hispanic; and Hispanic.  
HHA characteristics.  We also calculated the percentage of unreported falls for 
different groups of HHAs to determine if there are differences in falls reporting by 
HHA characteristics.  Using CMSs Home Health Agency Care Compare data, we 
determined the percentage of unreported falls by ownership type (for-profit, 
nonprofit, or government-owned), Care Compare patient quality of care star rating, 
and major injury fall rate.  Using OASIS data, we also calculated falls non-reporting 
rates by agency size (number of patients), percentage of Medicaid-paid patients, and 
percentage of patients identifying as a race/ethnicity other than White.
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Detailed Methodology | 20  APPENDICES 
Appendix A: Falls non-reporting rates by additional HHA-level 
and patient-level characteristics 
Exhibit A-1: Falls non-reporting by HHA-level characteristics 
Characteristic of HHA  Percentage of 
Falls Not 
Reported 
Size (Number  Small (fewer than 30  51.1% 
of Patients)  patients) 
Medium (30-97 patients)  51.8% 
Large (98+ patients)  55.5% 
Percent   Low (0%)  55.1% 
Medicaid-Paid   Medium (0.1%  7.4%)  55.5% 
Patients   High (>7.4%)  54.0% 
Percent   Low (<19.4%)  52.0% 
Patients of   Medium (19.4  53.2%)  56.9% 
Color   High (53.3%+)  63.4% 
Care Compare  1 star (lowest rating)  55.7% 
5-Star Quality 2 stars  50.3% 
Rating 3 stars  54.3% 
4 stars  56.8% 
5 stars (highest rating)  60.4% 
Source: OIG analysis of Medicare claims, OASIS, and Home Health Services Provider file, July 2020-June 2021. 
Note: Falls among patients of HHAs that are missing information about each characteristic are excluded from the 
calculation of the percentage of falls not reported.  For example, falls among patients served by agencies with no 
5-star quality rating are excluded from the calculation of percentage of falls not reported by 5-star quality rating.
Home Health Agencies Failed To Report Over Half of Falls With Major Injury 
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Appendices | 21  Exhibit A-2: Falls non-reporting rates by patient-level characteristics 
Characteristic of Patient Who Fell  Percentage of Falls 
Not Reported 
Sex  Male  57.8% 
Female  53.3% 
Age  Less than 65 years  64.1% 
65-74 years 58.0% 
75-84 years 54.7% 
85 years and older  51.8% 
Insurance  Medicare only  53.7% 
Coverage  Medicare and  58.4% 
Medicaid 
Location  Rural ZIP code  48.2% 
Non-rural ZIP code  56.9% 
Living  Lives alone  55.4% 
Arrangement  Lives with others  54.8% 
Source: OIG analysis of Medicare claims and OASIS data, July 2020-June 2021. 
Note: Falls among patients who are missing information about each characteristic are excluded from the 
calculation of the percentage of falls not reported.  For example, falls among patients with no information on living 
arrangement are excluded from the calculation of percentage of falls not reported by living arrangement.
Home Health Agencies Failed To Report Over Half of Falls With Major Injury 
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Appendices | 22  Appendix B: Agency Comments 
Following this page are the official comments from CMS. 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury 
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Appendices | 23  DATE:  August 04, 2023 
TO:  Ann Maxwell 
Deputy Inspector General for Evaluation and Inspections 
Office of Inspector General 
FROM:  Chiquita Brooks-LaSure 
Administrator 
Centers for Medicare & Medicaid Services 
SUBJECT:  Office of Inspector General (OIG) Draft Report: Home Health Agencies Failed 
To Report Over Half of Falls With Major Injury and Hospitalization Among Their 
Medicare Patients (OEI-05-22-00290) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report.  
As the nations largest payer and a trusted partner of the health care system, CMS has been 
committed to ensuring the highest quality care and best health outcomes for all individuals. CMS 
has leveraged a number of approaches to achieve quality goals, including quality measurement; 
public reporting; value-based payment programs and models; establishing and enforcing health 
and safety standards; and providing quality improvement technical assistance.  
Home health is a covered service under the Part A Medicare benefit. It consists of part-time, 
medically necessary, skilled care (nursing, physical therapy, occupational therapy, and speech-
language therapy) that is ordered by a physician. Home health agencies collect a group of 
standard data elements, referred to as the Outcome and Assessment Information Set (OASIS), as 
part of their comprehensive assessment to collect and report quality data to CMS. Since 1999, 
CMS has required Medicare-certified home health agencies to collect and transmit OASIS data 
for all adult patients whose care is reimbursed by Medicare and Medicaid with the following 
exceptions: patients under the age of 18, patients receiving maternity services, and patients 
receiving only chore or housekeeping services. OASIS data are used for multiple purposes 
including calculating several types of quality reports which are provided to home health agencies 
to help guide quality and performance improvement efforts. 
CMS posts a subset of OASIS-based quality performance information on the Care 
Compare website.1 These publicly reported measures include outcome measures, which indicate 
how well home health agencies assist their patients in regaining or maintaining their ability to 
function, and process measures, which evaluate the rate at which home health agencies use 
specific evidence-based processes of care. CMS also reports information on Medicare fee-for-
service claims-based measures and Home Health CAHPS (Consumer Assessment of 
Healthcare Providers and Systems) measures on Care Compare. For example, CMS reports on 
how often patients experienced one or more falls with a major injury on the Care Compare 
1 The Care Compare website is available at https://www.medicare.gov/care-compare. 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury
 and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290                       Appendices | 24 website. The information provided includes the percentage of each home health agencys 
patients that experienced a fall with major injury, as well as the national average rate of falls 
among home health patients.  
In 2022, the agency launched the CMS National Quality Strategy, an ambitious long-term 
initiative that aims to promote the highest quality outcomes and safest care for all individuals. 
The CMS National Quality Strategy builds on previous efforts to improve quality across the 
health care system, incorporates lessons learned from the COVID-19 Public Health Emergency, 
and addresses the urgent need for transformative action to advance towards a more equitable, 
safe, and outcomes-based health care system for all individuals. 
CMS is dedicated to empowering consumers, their families, and their caregivers by giving them 
the resources they need to make informed decisions regarding their care. As such, CMS 
understands the importance of providing accurate quality information to home health agencies 
and the public. CMS is consistently looking for ways to improve the quality of care, including 
the completeness and accuracy of the information used to assess quality. CMS appreciates the 
OIGs work on this area and looks forward to working collaboratively on this and other issues in 
the future.  
The OIGs recommendations and CMS responses are below. 
OIG Recommendation  
The OIG recommends that CMS take steps to ensure the completeness and accuracy of the 
HHA-reported OASIS data used to calculate the falls with major injury quality measure.  
CMS Response  
CMS concurs with this recommendation. CMS will explore opportunities to help promote the 
completeness and accuracy of the home health agency reported OASIS data used to calculate the 
falls with major injury quality measure, including additional OASIS outreach and educational 
opportunities.  
OIG Recommendation  
The OIG recommends that CMS use data sources in addition to OASIS assessments, to improve 
the accuracy of the quality measure related to falls with major injury.  
CMS Response 
CMS concurs with this recommendation. CMS will explore opportunities to use additional data 
sources in addition to OASIS assessments to improve the accuracy of the falls with major injury 
quality measure.  
OIG Recommendation  
The OIG recommends that CMS ensure that HHAs submit required OASIS assessments when 
their patients are hospitalized.  
CMS Response 
CMS concurs with this recommendation. CMS will explore opportunities to help ensure that 
home health agencies submit required OASIS assessments when their patients are hospitalized. 
OIG Recommendation 
The OIG recommends that CMS explore whether improvements to the quality measure related to 
falls can also be used to improve the accuracy of other home health measures.  
Home Health Agencies Failed To Report Over Half of Falls With Major Injury
 and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290                      Appendices | 25 CMS Response 
CMS concurs with this recommendation. CMS will consider this recommendation when 
evaluating other home health measures.  
Home Health Agencies Failed To Report Over Half of Falls With Major Injury
 and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290                      Appendices | 26  
ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Rebecca Gorges served as the team leader for this study, and Sarah Vogel served as 
the lead analyst.  Others in the Office of Evaluation and Inspections who conducted 
the study include Gabriella Herter.  Office of Evaluation and Inspections headquarters 
staff who provided support include Joe Chiarenzelli and Robert Gibbons. 
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including Rodney Brown and Michael Joseph. 
This report was prepared under the direction of Laura Kordish, Regional Inspector 
General for Evaluation and Inspections in the Chicago regional office; Adam Freeman, 
Deputy Regional Inspector General; and Hilary Slover, Assistant Regional Inspector 
General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Acknowledgments and Contact | 27   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 
95-452, as amended, is to protect the integrity of the Department of Health and 
Human Services (HHS) programs, as well as the health and welfare of beneficiaries 
served by those programs.  This statutory mission is carried out through a nationwide 
network of audits, investigations, and inspections conducted by the following 
operating components: 
The Office of Audit Services (OAS) provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work 
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI) conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs.  To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.  With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides 
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.
Home Health Agencies Failed To Report Over Half of Falls With Major Injury  
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  About the Office of Inspector General | 28   
ENDNOTES 
 
1 Abt Associates, Development of the Percent of Residents Experiencing One or More Falls with Major Injury During a Home 
Health Episode Measure, August 31, 2016.  Accessed at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-
instruments/mms/downloads/impact_-falls-with-major-injury-measure_public-comment.pdf on May 10, 2022. 
2 The Centers for Disease Control (CDC), WISQARS Injury Data.  Accessed at WISQARS (Web-based Injury Statistics Query and 
Reporting System)|Injury Center|CDC on June 7, 2023.  
3 CDC, Cost of Older Adult Falls, July 9, 2020.  Accessed at https://www.cdc.gov/falls/data/fall-cost.html on August 5, 2022. 
4 Abt Associates, Development of the Percent of Residents Experiencing One or More Falls with Major Injury During a Home 
Health Episode Measure, August 31, 2016.  Accessed at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-
instruments/mms/downloads/impact_-falls-with-major-injury-measure_public-comment.pdf on May 10, 2022. 
5 42 CFR  484.55(b) and (d); CMS, Outcome and Assessment Information Set OASIS-D Guidance Manual, ch. 1, pp. 3-4, 
January 1, 2019.   
6 OASIS data are collected for Medicare and Medicaid patients 18 years and older receiving skilled services, with the 
exception of patients receiving services for pre- or postnatal conditions.  Those receiving only personal care, homemaker, or 
chore services are excluded since these are not considered skilled services.  CMS, Outcome and Assessment Information Set 
OASIS-D Guidance Manual, ch. 1, p. 3, January 1, 2019.   
7 42 CFR  484.55 and 484.45(a). 
8 For a fee, HHAs can opt to have their surveys conducted by a CMS-approved accrediting organization instead of a State 
agency.  42 CFR  488.4; CMS, State Operations Manual, ch. 2, Section 2003C, revised March 11, 2022. 
9 42 CFR  488.730 and Part 484. 
10 42 CFR  488.68(c) and 488.710.   
11 OIG, Limited Oversight of Home Health Agency OASIS Data, OEI-01-10-00460, February 2012. 
12 42 CFR  484.245. 
13 CMS, Process of Care and Outcome of Care Quality Measures.  Accessed at https://data.cms.gov/provider-
data/topics/home-health-services/process-care-outcome-care-quality-measures on June 9, 2022. 
14 Abt Associates, Development of the Percent of Residents Experiencing One or More Falls with Major Injury During a Home 
Health Episode Measure, August 31, 2016.  Accessed at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-
instruments/mms/downloads/impact_-falls-with-major-injury-measure_public-comment.pdf on May 10, 2022. 
15 CMS, Outcome and Assessment Information Set OASIS-D Guidance Manual, ch. 1, p. 3, January 1, 2019. 
16 This includes falls that occur when home health personnel are not providing care.  HHAs are required to report any 
witnessed or unwitnessed falls on the basis of review of home health clinical reports; incident reports; any other relevant 
clinical documentation; and interviews with patients and/or caregivers about the occurrence of falls. 
17 CMS defines major injury in the OASIS questionnaire.  The specific OASIS items are: 
J1800 Has the patient had any falls during the episode of care?  If yes, then the agency reports the number of falls in each of 
the following three categories: 
J1900A No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no 
complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall 
 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury 
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Endnotes | 29   
 
J1900B Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related 
injury that causes the patient to complain of pain 
J1900C Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma 
18 While the new falls quality measure was publicly reported beginning in April 2022, it is not currently used to calculate the 
HHAs star rating that appears on CMSs Care Compare website.  Of the 17 CMS Home Health Quality Reporting Measures 
that currently appear on Care Compare, 7 are used to generate the Quality of Patient Care star rating.  CMS regularly makes 
changes to the HHA star rating system, so CMS may consider using the new falls measure in the star rating system in the 
future. 
19 Downloaded from the CMS Home Health Services Data Archive, 2022 Annual Files, April 2022 version.  Accessed at 
https://data.cms.gov/provider-data/archived-data/home-health-services on April 27, 2022. 
20 80 Fed. Reg. 68624, 68703-68706 (Nov. 5, 2015). 
21 An example of a non-quality assessment would be a Start of Care assessment for a patient that is not followed by a later 
End of Care assessment indicating the later discharge from care.  Source: CMS, Home Health Quality Reporting Requirements 
website.  Accessed at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-
instruments/homehealthqualityinits/home-health-quality-reporting-requirements on January 10, 2023. 
22 CMS, Expanded Home Health Value-Based Purchasing Model, May 8, 2023.  Accessed at 
https://innovation.cms.gov/innovation-models/expanded-home-health-value-based-purchasing-model on May 11, 2023. 
23 Prachi Sanghavi, Shengyuan Pan, and Daryl Caudry, Assessment of Nursing Home Reporting Of Major Injury Falls for 
Quality Measurement on Nursing Home Compare, Health Services Research, Vol. 55, 2020, pp. 201-210. 
24 Jessica Silver-Greenberg and Robert Gebeloff, Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes 
Mislead the Public, New York Times, March 13, 2021.  Accessed at https://www.nytimes.com/2021/03/13/business/nursing-
homes-ratings-medicare-covid.html on May 13, 2022. 
25 OIG, CMS Could Improve the Data It Uses to Monitor Antipsychotic Drugs in Nursing Homes, OEI-07-19-00490, May 2021. 
26 OIG, Limited Oversight of Home Health Agency OASIS Data, OEI-01-10-00460, February 2012. 
27 OIG, CMSs Encounter Data Lack Essential Information That Medicare Advantage Organizations Have the Ability to Collect, 
OEI-03-19-00430, August 2020.  
28 Health Affairs, The Promise and Pitfalls of Medicare Advantage Encounter Data, February 25, 2019.  Accessed at 
https://www.healthaffairs.org/do/10.1377/forefront.20190221.696651/full/ on May 23, 2022. 
29 CMS, Outcome and Assessment Information Set OASIS-D Guidance Manual, ch. 1, p. 4.  HHAs have 48 hours from the time 
they learn of a significant change in condition, transfer, discharge, or death date to complete the transfer/discharge/death at 
home assessment.  It may take HHAs longer to learn about and report a fall with major injury, particularly if a hospitalized 
patient decides to end their home health care without notifying the HHA of the fall.  To allow time for the HHA to learn about 
the fall and admission, we used a wider window when identifying OASIS transfer or discharge assessments.  Specifically, we 
looked for assessments with (1) an assessment completed date up to 7 days after the inpatient admission date or (2) a 
transfer or discharge date within 4 days of the hospital admission date. 
30 HHAs should report the fall at the transfer/discharge/death assessment that follows the fall.  If the HHA submitted the next 
transfer/discharge/death assessment more than 7 days after the hospital admission date and reported the fall on that 
assessment, it would not have been identified as a match in this study, but it would be counted as a fall for CMSs calculation 
of the major injury fall rate. 
31 Prachi Sanghavi, Shengyuan Pan, and Daryl Caudry, Assessment of Nursing Home Reporting Of Major Injury Falls for 
Quality Measurement on Nursing Home Compare, Health Services Research, Vol. 55, 2020, pp. 201-210. 
32 Jessica Silver-Greenberg and Robert Gebeloff, Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes 
Mislead the Public, New York Times, March 13, 2021.  Accessed at https://www.nytimes.com/2021/03/13/business/nursing-
homes-ratings-medicare-covid.html on May 13, 2022. 
 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury 
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Endnotes | 30   
 
33 OIG, CMS Could Improve the Data It Uses to Monitor Antipsychotic Drugs in Nursing Homes, OEI-07-19-00490, May 2021. 
34 Because OASIS transfer and discharge assessments can be completed after a patient is hospitalized, we also looked at falls 
that occurred up to 4 days before July 1, 2020.  This allowed us to determine whether falls were reported on the OASIS 
assessments submitted at the beginning of our study period. 
35 To ensure that we only examined falls reporting on OASIS assessments completed in our study period, we only analyzed 
falls with a matching OASIS assessment completed between July 1, 2020, and June 30, 2021.  We excluded falls that occurred 
at the end of our study period but had a matching OASIS assessment completed after June 30, 2021.  When we could not 
match a fall at the end of our study period to any OASIS assessment, we included it in the count of falls missing an OASIS 
assessment. 
36 We used several Medicare identifiers to match between the Medicare data and the OASIS records.  Specifically, we looked 
for matches between the following fields in the two data sources: 
Medicare beneficiary identification number (MBI in EDB and item M0063 in OASIS) 
Social security number (SSN in EDB and item M0064 in OASIS) 
Home health patient IDs (Patient medical record number in the home health claim and item M0020 in OASIS) 
National Provider Identifiers (NPIs) (Header attending or rendering NPI or line rendering NPI from the home health claim and 
item M0018 in OASIS) 
For each record that matched using at least one of the above Medicare identifiers, we further required that at least two of the 
following fields match between the Medicare EDB and OASIS: first name, last name, date of birth, and sex. 
37 In supplemental analyses, we explored whether falls non-reporting rates were much different for cases with exact matches 
on these dates as compared to cases with more flexible matches on dates (i.e., allowing for these small differences in dates 
between Medicare claims and the OASIS assessment we linked to).  Non-reporting rates were 52 percent when dates 
matched exactly and 59 percent when dates were more flexible, giving us confidence that the flexible date matching 
approach did not drive the high rates of falls non-reporting that we find overall. 
38 Where possible, we used OASIS, rather than Medicare enrollment data, to identify the characteristics of patients who fell 
because OASIS assessments contain patients self-reported demographic information that is considered more accurate than 
the demographic information, especially on race and ethnicity, contained in the Medicare enrollment files.  See OIG, 
Inaccuracies in Medicare's Race and Ethnicity Data Hinder the Ability to Assess Health Disparities, OEI-02-21-00100, June 2022.  
See also Olga Jarrin et al., Validity of Race and Ethnicity Codes in Medicare Administrative Data Compared With 
Gold-Standard Self-Reported Race Collected During Routine Home Health Care Visits, Medical Care, Vol. 58, No. 1, January 
2020, pp. e1-e8.  Accessed at https://journals.lww.com/lww-
medicalcare/Fulltext/2020/01000/Validity_of_Race_and_Ethnicity_Codes_in_Medicare.16.aspx on May 23, 2022. 
Home Health Agencies Failed To Report Over Half of Falls With Major Injury 
and Hospitalization Among Their Medicare Patients 
OEI-05-22-00290  Endnotes | 31