in OASIS M0030 (Start of Care Date). Such delays may indicate noncompliance with the Medicare CoPs and should be avoided. Additional documentation in the patient’s record should explain Table 4: Regulations Governing Completing OASIS Assessments Clinicians Who Can Perform OASIS
the delay. For instance, the delay could be related to a patient request or difficulty locating the patient.
Requirements for Initiating Assessment
Requirements for Completing Assessment
Start of Care (SOC)
Registered nurse (RN) unless therapy only; if therapy only, physical therapist (PT) or speech- language pathologist (SLP)
Visit within 48 hours post referral. Complete within 5 days of initiating SOC assessment.
Transfer
RN, PT, SLP, occupational therapist (OT)
Initiate on discovering patient was transferred to inpatient facility. Visit within 48 hours post hospital discharge. Visit on Day 56-Day 60 of the ending episode. Last visit by last discipline seeing patient. Initiate on discovering patient died.
Complete within 48 hours of discovering patient transferred. Complete within 48 hours of making the ROC visit. Complete on or before Day 60. Complete within 48 hours of discharge. Complete within 48 hours of discovering patient has died.
Resumption of Care (ROC)
RN, PT, SLP, OT
Recertification
RN, PT, SLP, OT
Discharge
Discipline making last visit
Death
RN, PT, SLP, OT
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/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/ Downloads/OASIS-D-Guidance-Manual-final.pdf
In some instances, there are appropriate exceptions to the 48-hour rule. For example, the physician may forward a referral with a request that the agency start care in 1 week to remove postoperative staples. In this case, the reason for the delay in care will be identified with the response to M0102 (Date of Physician-Ordered Start of Care). Once the SOC visit is initiated, the agency has the following 5 days to complete the OASIS. The CMS recognizes that the multiple subassessments needed to complete a SOC OASIS – physical, functional, and psychosocial assessments, with some requiring specialized tools for comprehensive pain, depression, fall risk, and caregiver abilities assessments – might overwhelm patients, let alone the therapists, if therapists felt compelled to complete them in one visit. Therefore, the CMS allows time for the therapist to assess the patient over several visits if necessary, so the therapist can carefully and accurately complete the SOC OASIS. The OASIS assessment is supposed to be a snapshot of the patient’s status at the beginning of the episode. Agencies ideally would like to capture the patient’s status on the first day of care, as this is the period in which the patient is likely to be most clinically and functionally acute, thus providing the best starting data against which to compare the discharge data. The comparison will reflect the best outcomes and maximize reimbursement. One way to achieve both of these goals – a snapshot of the patient at the patient’s most acute status and a careful assessment facilitated by two or more visits – is to perform the physical and functional assessments on the first visit. The therapist is supposed to identify the patient’s status on an OASIS item by determining the patient’s usual status on that item on the day the item is assessed. By performing the physical and functional assessments on the first visit, the therapist is likely to accurately capture the patient at the most acute stage. Other parts of the OASIS assessment, such as information about the patient’s history or assessments of psychosocial status, depression, fall risk, and caregiver’s abilities, can be performed on the following days as necessary to complete them accurately. Transfer OASIS Whenever a patient is transferred to a hospital for more than 24 hours, the agency is required to complete a Transfer OASIS. The Transfer OASIS is an exception to the rule that all OASIS assessments must be performed during a visit. This is because many if not most hospitalizations occur unexpectedly when the patient suddenly develops the need for emergency services. It
is not uncommon for the agency to be unaware that the patient was transferred to an inpatient facility until several days after the transfer has occurred. For some, the first notification that the patient was hospitalized occurs when the agency is notified that the patient will be returning home and services should resume. When this scenario occurs, the agency must nevertheless complete the Transfer OASIS within 48 hours of discovering the event, and also the ROC OASIS, so that the OASIS documents accurately reflect the sequence of events even though the Ordinarily, if the patient has been hospitalized, the agency will be informed by the hospital discharge planner that the patient will be returning home, and an order to resume home care services will be made. A clinician must make a visit and initiate a ROC OASIS within 48 hours of the referral. The therapist must then complete the OASIS within 48 hours of the assessment visit. Occasionally, therapists discover that a patient has been patient has already returned home. Resumption of Care (ROC) OASIS transferred into the hospital and returned home, all between the last visit and the therapist’s present visit. For instance, during the course of a regular follow-up visit, a therapist may discover that, since her last weekly visit, the patient was transferred into the hospital, spent 2 days there, and has returned home 2 days ago. When situations like this occur, the therapist needs to initiate both a Transfer OASIS and ROC OASIS at the visit. The ROC OASIS, which is very similar to the SOC OASIS, requires that the therapist perform a complete reassessment of the patient. Both the Transfer OASIS and the ROC OASIS need to be completed within 48 hours of that visit. Recertification OASIS As a patient draws close to the end of the 60-day certification period, the therapist and the patient, in collaboration with team members, need to review the goals of care to determine whether the patient’s stay in home care should be extended into another certification period. Theoretically, there is no limit to the number of 60-day episodes that a patient can stay in home care as long as the patient’s condition meets payer criteria. However, the therapist and the agency should be mindful that goals of care should be achieved as efficiently as possible. If it is determined that the patient does need another certification period, the OASIS regulations require the agency to reassess the patient before the beginning of the next episode of care. This recertification visit must be made during the last days of the ending certification period before the next certification
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