Free OpenClaw Skill for Home Health Agencies: OASIS, PDGM, EVV Coordinator (Download)

What this skill does for your home health agencies

• Pulls every OASIS-E assessment (SOC, ROC, follow-up, transfer, discharge) from HCHB, MatrixCare, or Axxess into a QA queue with the high-impact items (M1033 risk for hospitalization, M1800-1860 ADLs, M2020-2030 medication) flagged for clinical QA review.
• Tracks the PDGM 30-day periods so the agency can see clinical grouping (early/late, community/institutional, MMTA-Respiratory etc.), comorbidity adjustment, and LUPA threshold by episode in one view.
• Reconciles EVV vendor visit data (HHAeXchange, Sandata, CareBridge) against the schedule and flags missed clock-in, late clock-in, and visit-not-documented before payroll runs.
• Owns the 60-day recertification cadence: clinical case manager prompts at day 50, recert visit scheduling, and the recert OASIS routed through QA.
• Routes every patient-facing message through the case manager or office for approval by default; flips to autonomous after a two-week validation on rails you define.

What's inside this OpenClaw skill

The full file you download, indexed below for search engines and for operators who want to read before they install.

---
name: home-health-oasis-pdgm
description: OASIS-E QA, PDGM episode tracking, EVV reconciliation, 60-day recertification, and HHCAHPS coordinator for home health agencies. Integrates with HCHB, MatrixCare, Axxess, HHAeXchange, Sandata, CareBridge.
version: 1.0.0
author: OpenClaw Consult (Adhiraj Hangal)
license: MIT
url: https://openclawconsult.com/skills/home-health-agencies
---

# OpenClaw Skill: Home Health Agency OASIS and PDGM Coordinator

## Overview

This skill turns the OpenClaw agent into the back-office coordinator for a
home health agency. It owns the OASIS-E QA triage queue, the PDGM 30-day
period tracking with LUPA-risk surfacing, the EVV vendor visit reconciliation,
the 60-day recertification cadence, and the HHCAHPS pre-survey orchestration.

It is designed for Medicare-certified home health agencies running Homecare
Homebase (HCHB), MatrixCare Home Health, Axxess, WellSky CareInsights, or
Kinnser, with an EVV aggregator (HHAeXchange, Sandata, CareBridge, Tellus)
required by the 21st Century Cures Act.

## What this skill does

1. OASIS-E QA triage with high-impact items (M1033 risk for hospitalization, M1800-1860 ADLs, M2020-2030 medication) surfaced for clinical review
2. PDGM 30-day period tracking with clinical grouping (MMTA-Respiratory, MMTA-Other, Wounds, etc.), timing (early/late), and LUPA threshold visibility
3. EVV reconciliation against schedule, flagging missed clock-in, late clock-in, visit-not-documented before payroll closes
4. 60-day recertification cadence: day 50 case manager prompt, recert visit scheduling, recert OASIS routed through QA
5. HHCAHPS pre-survey patient outreach so the patient expects the vendor call and response rate climbs
6. Discharge to community-based provider handoff: care plan, medication list, follow-up appointment

## Triggers

```yaml
triggers:
  - type: heartbeat
    schedule: "0 7 * * 1"          # Mondays 7am
    action: oasis_qa_queue_triage

  - type: heartbeat
    schedule: "0 9 * * 1"          # Mondays 9am
    action: pdgm_lupa_risk_audit

  - type: heartbeat
    schedule: "0 8 * * 5"          # Fridays 8am
    action: evv_reconciliation_before_payroll

  - type: heartbeat
    schedule: "0 9 * * *"          # Daily 9am
    action: sixty_day_recert_pass

  - type: on_event
    event: emr.oasis_assessment_submitted
    action: enter_qa_queue

  - type: on_event
    event: emr.episode_discharged
    action: schedule_hhcahps_pre_survey_outreach
```

## Workflow: OASIS-E QA queue

The skill pulls every OASIS-E assessment (Start of Care, Resumption of Care, Follow-up, Transfer, Discharge) into a triage queue. For each assessment the agent:

1. Reads the M-items against agency-defined consistency rules
2. Flags assessments where M1033 (risk for hospitalization) does not align with the visit narrative
3. Flags assessments where M1800-1860 ADL scoring is inconsistent with therapy notes
4. Flags M2020-2030 medication management items where the medication reconciliation log does not back the scoring
5. Surfaces M-items with the agency-specific impact weight (some agencies weight wound items higher, others weight functional items)
6. Routes the flagged assessments to the clinical QA reviewer

The non-flagged majority moves through automatically. The QA reviewer spends time on the assessments that actually need a clinical decision.

## Workflow: PDGM 30-day period tracking

PDGM (Patient-Driven Groupings Model) reimburses home health in 30-day periods. For each active period the skill maintains:

- Clinical grouping (one of 12: MMTA-Surgical, MMTA-Respiratory, MMTA-Cardiac, MMTA-Endocrine, MMTA-GI/GU, MMTA-Infectious, MMTA-Neuro Rehab, MMTA-Other, Wounds, Musculoskeletal Rehab, Behavioral Health, Complex Nursing Interventions)
- Timing category (early = first 30-day period, late = subsequent periods)
- Admission source (community or institutional)
- Functional impairment level (low, medium, high) derived from OASIS items
- Comorbidity adjustment level (none, low, high)
- LUPA threshold for the specific case mix and the visit count to date

The Monday LUPA audit flags every episode at or near the LUPA threshold with the recoverable-vs-not call. Recoverable episodes get case manager outreach drafted.

## Workflow: EVV reconciliation

The 21st Century Cures Act requires Electronic Visit Verification for Medicaid personal care and home health services. The agency uses HHAeXchange, Sandata, CareBridge, or Tellus (or a state-mandated aggregator). Every Friday at 8am the agent:

1. Pulls the scheduled visits for the week
2. Pulls the EVV clock-in/clock-out records
3. Reconciles the two
4. Flags: missed clock-in (no EVV record for a scheduled visit), late clock-in (more than 15 minutes after scheduled start), visit-not-documented (EVV in but no documentation note), patient signature missing where state requires
5. Routes the exceptions to the scheduler before payroll closes Monday

Payroll runs on bad EVV data when there is no Friday reconciliation. The skill catches the gaps before they become reimbursement problems.

## Workflow: 60-day recertification cadence

The Medicare home health benefit is built around 60-day episodes with recertification at the end of each if continued care is needed. The skill:

- Day 45: clinical case manager prompt to assess continued need
- Day 50: recert visit scheduling outreach
- Day 55-60: recert OASIS submitted and routed through QA
- Day 60: new episode opens, prior episode billing closes

## Message templates

```yaml
templates:
  oasis_qa_clinical_flag:
    channel: internal_slack
    body: |
      OASIS QA FLAG
      Patient: {patient_first_name} {patient_last_name}
      Episode: {episode_id} ({oasis_type})
      Flag: {qa_flag_reason}
      Submitted by: {clinician_name}
      Specific M-items: {flagged_m_items}
      Action: clinical QA review before lock

  pdgm_lupa_recoverable:
    channel: internal_slack
    body: |
      PDGM LUPA RISK RECOVERABLE
      Patient: {patient_first_name} {patient_last_name}
      Period: {pdgm_period_id} ({clinical_grouping}, {timing})
      Visits to date: {visits_completed} of {lupa_threshold} threshold
      Days remaining: {days_remaining}
      Suggested action: schedule case manager + remaining therapy visits

  evv_missed_clockin:
    channel: internal_slack
    body: |
      EVV MISSED CLOCK-IN
      Caregiver: {caregiver_name}
      Patient: {patient_first_name} {patient_last_name}
      Scheduled visit: {scheduled_start} to {scheduled_end}
      EVV record: NONE
      Action: confirm with caregiver, document reason before payroll runs Monday

  sixty_day_recert_day_50:
    channel: patient_sms
    body: |
      Hi {patient_first_name},

      We are reaching the end of your current home health episode. The
      next step is a visit from {case_manager_first_name} to evaluate
      continued need. Open slots:

      {open_slots}

      {scheduler_first_name}

  hhcahps_pre_survey_notice:
    channel: patient_sms
    body: |
      Hi {patient_first_name},

      Now that your home health episode with us has wrapped up, you may
      get a phone call from a survey company asking about your experience.
      That is Home Health CAHPS, run by Medicare. Your feedback helps us
      improve. Honest answers are the most useful kind.

      Thank you for trusting us with your care.

      {agency_name}
```

## Memory keys

```yaml
memory:
  - key: hh.oasis_ledger[{episode_id}]
    description: OASIS-E assessments and QA state per episode
    schema: { soc: object, roc: object, follow_up: object, transfer: object, discharge: object, qa_state: string }

  - key: hh.pdgm_ledger[{period_id}]
    description: PDGM 30-day period grouping and LUPA tracking
    schema: { clinical_grouping: string, timing: string, admission_source: string, functional_level: string, comorbidity: string, lupa_threshold: int, visits_to_date: int }

  - key: hh.evv_reconciliation[{caregiver_id_week}]
    description: Weekly EVV vs schedule reconciliation
    schema: { scheduled_count: int, evv_confirmed: int, missed: int, late: int, undocumented: int }

  - key: hh.recert_ledger[{patient_id}]
    description: 60-day recertification cadence state
    schema: { current_episode_start: date, next_recert_due: date, recert_visit_scheduled: date, recert_oasis_status: string }

  - key: hh.hhcahps_window[{episode_id}]
    description: HHCAHPS-eligible discharge tracking
    schema: { discharge_date: date, hhcahps_eligible: bool, pre_survey_sent: bool }
```

## Required integrations

| Integration               | Purpose                                          | Read | Write |
|---------------------------|--------------------------------------------------|------|-------|
| Homecare Homebase (HCHB)  | OASIS, schedule, patient data                    | yes  | optional |
| MatrixCare Home Health    | OASIS, schedule, patient data via REST           | yes  | optional |
| Axxess                    | OASIS, schedule, patient data via API            | yes  | optional |
| WellSky CareInsights      | OASIS, schedule via WellSky API                  | yes  | optional |
| HHAeXchange               | EVV aggregator feed                              | yes  | no    |
| Sandata                   | EVV aggregator feed                              | yes  | no    |
| CareBridge                | EVV aggregator feed                              | yes  | no    |
| Twilio (or similar)       | Outbound SMS                                     | no   | yes   |
| Slack                     | Internal QA and EVV alerts                       | no   | yes   |
| OpenClaw Memory           | Cross-run state                                  | yes  | yes   |
| OpenClaw Heartbeat        | Scheduled cadence triggers                       | yes  | yes   |

Write-back to the EMR starts disabled. The clinical QA reviewer and the scheduler commit all changes manually for the first two weeks. After validation, write access can be flipped on for low-risk fields (recall stamps, communication log entries, scheduling stamps).

## Compliance notes

HIPAA: home health is PHI-heavy by nature. The skill operates within the BAA-covered environment you configure. Outbound SMS and email contain no clinical detail by default. For tighter PHI handling, set phi_mode to identifier_only.

EVV: the skill performs reconciliation only. The actual EVV submission to the state aggregator continues to flow through the agency's standard EVV vendor pipeline. The skill exists to catch reconciliation gaps before they become claim problems.

PDGM: the skill surfaces grouping and LUPA risk. It does not optimize ICD-10 coding for reimbursement. Coding stays with licensed coders.

HHCAHPS: the skill drafts patient-facing pre-survey messaging. The actual HHCAHPS survey continues to be administered by the agency's CMS-approved vendor.

Confirm your BAA covers the cloud AI provider you point OpenClaw at.

## Configuration

```yaml
config:
  agency_name: "Your Home Health Agency"
  emr: "hchb"                               # or "matrixcare", "axxess", "wellsky"
  evv_vendor: "hhaexchange"                 # or "sandata", "carebridge", "tellus"
  approval_mode: clinical_qa_approves_all   # or "autonomous_after_2_weeks_low_risk"
  phi_mode: standard                        # or "identifier_only"
  oasis_qa:
    high_impact_items: [M1033, M1800, M1810, M1820, M1830, M1840, M1850, M1860, M2020, M2030]
    consistency_rule_set: agency_v1
  pdgm:
    lupa_audit_day: monday
    flag_visits_to_threshold: 2
  evv:
    reconciliation_day: friday
    late_clockin_minutes: 15
  recert:
    day_50_prompt: true
    day_60_lock: true
  hhcahps:
    pre_survey_window_days: 14
    approved_cms_vendor: "Press Ganey"        # or your contracted vendor
  medicare_mac: "Palmetto GBA"
```

## Quick install

```bash
mkdir -p ~/.claude/skills
mv home-health-agencies.md ~/.claude/skills/home-health-oasis-pdgm.md
# Edit the config block to match your agency
```

Launch OpenClaw and the skill is live. Run `triage oasis qa` or `audit pdgm lupa risk` or `reconcile evv` on demand, or wait for Heartbeat to fire on the configured schedule.

## Want it wired to your stack?

This SKILL.md is the starting point. If you want it plugged into your specific EMR, your EVV aggregator, your state Medicaid quirks, and your agency's QA philosophy, on a fixed-price two-week clock with the founder writing every line of the build, the door is at
https://www.adhirajhangal.com/work

Install in 60 seconds

1. 1

   Drop the file into your OpenClaw skills directory

   Save the downloaded home-health-agencies.md as ~/.claude/skills/home-health-oasis-pdgm.md (or your project-level .claude/skills/). OpenClaw picks up new skill files on next agent launch.

2. 2

   Connect your EMR and EVV vendor

   Edit the integrations block to point at HCHB, MatrixCare, or Axxess plus your EVV aggregator (HHAeXchange, Sandata, CareBridge). Read-only access is enough to start. The skill ships the prompts to translate the OASIS-E export, the PDGM grouping output, and the EVV visit feed into the agent's working memory.

3. 3

   Launch in QA-review mode, validate, then flip to autonomous

   Start with the clinical QA reviewer approving every OASIS flag and the office approving every outbound message for the first two weeks. Defaults route any clinical OASIS item, any LUPA-risk episode, and any missed-visit reconciliation to a human. After validation, flip the routine recall and HHCAHPS outreach to autonomous.

Example conversation

Common questions

Related free skills