Table 3: When do Patients Need an OASIS Assessment? Included
Excluded
Start of Care (SOC)
Patient admitted for skilled home care services. SOC visit is only visit patient will receive; when this happens, an OASIS is not mandated, but it can be completed, which will provide payment for the one visit.
Transfer
Patient transferred and admitted to any type of inpatient facility for 24 hours or more.
Patient stay in facility is less than 24 hours or patient was admitted for “observation only” or only for diagnostic reasons.
Resumption of Care (ROC)
Patient returns to agency within the certification period. Patient has completed one 60-day certification period but continues to need home care services. Patient experiences a significant change in condition during an episode of care. Patient discharged from the agency due to “goals met” or for other reasons.
Recertification
If patient returns to care following a hospitalization within the last 5 days of a certification, a ROC OASIS should be completed instead of a Recert OASIS.
Other Follow-Up
Discharge
Do not complete a Discharge OASIS if only discharging from nursing services but rehabilitation therapists are continuing to provide care. Patient died after being admitted to an ED or inpatient facility.
Death
Patient died at home or anywhere else other than in an emergency department (ED) or inpatient facility.
Note . Adapted from Centers for Medicare and Medicaid Services. (2019). Outcome and assessment information set OASIS-D guidance manual . Effective January 1, 2019. Retrieved from https://www.cms.gov/Medicare Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/ Downloads/OASIS-D-Guidance-Manual-final.pdf Other follow-up
Death If the patient dies during a certification period anywhere other than in an emergency department or an inpatient facility, a qualified clinician needs to complete a Death at Home (DAH) OASIS , frequently called a Death OASIS . For instance, if the patient dies at home, during a visit to the doctor’s office, or in an ambulance on the way to the emergency department, a Death OASIS should be completed. If the patient dies in the emergency department or in an inpatient bed, a Transfer OASIS should be completed to close the patient’s current certification period. a bill has been introduced to permanently change this rule (Medicare Home Health Flexibility Act; information available at https://www.congress.gov/bill/116th-congress/senate-bill/1725). However, due to the CMS COVID-19 emergency declaration, this rule has been temporarily lifted and is not in effect as of this writing (CMS, 2020c). Occupational therapists and other home health practitioners must remain updated on this status as the situation is very fluid. For all the other OASIS assessments, including Transfer, ROC, Recert, Other Follow-Up, or Discharge OASIS assessments, any of the qualified disciplines can perform and complete the OASIS assessment. Who actually does these assessments is usually determined during case conferences based on patient needs or clinician availability. The Discharge OASIS is typically performed at the last patient visit, by whatever qualified discipline that performs the last visit. must initiate care of the patient within 48 hours of referral, but the SOC OASIS itself does not need to be initiated within 48 hours. If after accepting the referral the agency is not able to visit the patient within 48 hours, the agency should alert the referral source, the physician, and the patient of the delay. The delay in care will be captured in either OASIS M0102 (Date of Physician-Ordered SOC) or OASIS M0104 (Date of Referral) and
Occasionally an additional OASIS is obtained when a patient’s condition or service needs change dramatically from those identified during the patient’s SOC OASIS assessment. Under PDGM, this OASIS must be submitted at the 30 day payment period to capture any necessary changes that may affect reimbursement or outcomes. Discharge When the patient is discharged from an agency, the last qualified clinician to see the patient performs the OASIS assessment during the last visit to the patient. This OASIS assessment provides the data that will be compared with the data obtained at admission, determining the outcomes of the patient’s care. Who can perform an OASIS assessment? Registered nurses and rehabilitation therapists (physical therapists, speech-language pathologists, and occupational therapists) can perform OASIS assessments. Licensed practical nurses, social workers, and therapy assistants cannot perform OASIS assessments. These assessments are always completed during a registered nurse’s or therapist’s in-person assessment of a patient. For SOC OASIS assessments, there are special restrictions requiring nurses to perform the initial evaluation of the patient, including performing the SOC OASIS, unless the patient is a “therapy only” case. If the physician orders only therapy services without ordering any nursing services, such as for patients who require balance and strengthening exercises and gait training with an assistive device for frequent falls, then a physical therapist or speech- language pathologist can perform the SOC assessment. Occupational therapists normally cannot perform a SOC OASIS because they are prohibited from qualifying the patient for Medicare home health services, though
What time frame regulations govern completing OASIS assessments? The OASIS regulations require clinicians to pay attention to certain time frames related to how quickly each OASIS assessment must be initiated and completed (see Table 4). Start of care OASIS assessment
Once a patient referral is made to an agency, a clinician must admit the patient and initiate the SOC assessment within 48 hours. Simply stated, this means that the home care agency
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