Chapter 20: OASIS Assessments

Overview

OASIS (Outcome and Assessment Information Set) assessments are federally-mandated clinical evaluations required by Medicare and many other payers for home health patients. These assessments determine patient eligibility, establish care plans, calculate payment rates, and measure quality outcomes. This chapter covers all OASIS assessment types, when to use each one, how to complete them, and what happens after approval.

What You'll Learn

• What OASIS is and why it's required
• All 7 OASIS assessment types and when to use each
• How to complete OASIS Start of Care (SOC) - most common first assessment
• How to complete OASIS Recertification - required every 60 days
• How to complete OASIS Resumption of Care (ROC) - after hospital transfer
• Brief overview of Transfer, Discharge, Transfer-Discharge, and Death assessments
• What happens after each OASIS type is approved
• Physician signature requirements
• OASIS submission to CMS workflow

---

20.1 What is OASIS?

Definition

OASIS stands for Outcome and Assessment Information Set. It's a standardized data collection tool developed by the Centers for Medicare & Medicaid Services (CMS) specifically for home health agencies.

Purpose

OASIS assessments serve multiple critical functions:

1. Patient Eligibility: Confirms patient meets criteria for home health services
2. Care Planning: Establishes the baseline for creating the Plan of Care
3. Payment Calculation: Used to calculate PDGM (Patient-Driven Groupings Model) payment rates
4. Quality Measurement: Tracks patient outcomes for CMS quality reporting
5. Regulatory Compliance: Required by law for Medicare-certified home health agencies

Who Completes OASIS

Only certain disciplines can complete OASIS assessments:

• RN (Registered Nurse) - Can complete ALL OASIS types
• PT (Physical Therapist) - Can complete SOC and Recert (if PT is primary discipline)
• SLP (Speech Language Pathologist) - Can complete SOC and Recert (if SLP is primary discipline)
• OT (Occupational Therapist) - Can complete SOC and Recert (if OT is primary discipline)

Important: LPNs, HHAs, and MSWs CANNOT complete OASIS assessments.

---

20.2 OASIS Assessment Types

There are 7 types of OASIS assessments, each used in specific circumstances:

1. Start of Care (SOC)

• When: Patient is admitted to home health for the first time or after a break in service
• Triggers: New Admission, New care order
• Creates: Initial Plan of Care, establishes baseline
• Physician Signature: Required

2. Recertification (Recert)

• When: Every 60 days to continue services into a new certification period
• Triggers: Approaching end of current 60-day episode
• Creates: New 60-day episode, updated Plan of Care
• Physician Signature: Required

3. Resumption of Care (ROC)

• When: Patient returns to home health after a hospital stay (following an approved Transfer OASIS)
• Triggers: After Transfer OASIS is approved and patient returns home
• Reactivates: Previously ON_HOLD care order
• Physician Signature: Required

4. Transfer

• When: Patient is transferred to a hospital, SNF, or another facility (but NOT permanently discharged from home health)
• Purpose: Pauses services while patient is away
• Effect: Puts care order ON_HOLD, cancels future visits
• Physician Signature: NOT Required

5. Discharge

• When: Patient no longer needs home health services and is being permanently discharged
• Purpose: Officially closes the episode of care
• Effect: Closes care order, cancels future visits, closes prior authorizations
• Physician Signature: NOT Required

6. Transfer-Discharge

• When: Patient is transferred to another facility AND permanently discharged from home health at the same time
• Purpose: Combines Transfer + Discharge into one assessment
• Effect: Closes ALL care orders, cancels ALL visits, updates patient to DISCHARGED
• Physician Signature: NOT Required

7. Death at Home

• When: Patient dies at home while receiving home health services
• Purpose: Documents circumstances of death for regulatory compliance
• Effect: Closes care order, cancels future visits, updates patient to DECEASED
• Physician Signature: NOT Required

---

20.3 OASIS Start of Care (SOC) - Detailed

When to Complete OASIS SOC

OASIS SOC is completed when a patient is:

• Newly admitted to your home health agency
• Starting their first episode of care
• Has a care order with reason "New Admission"

Accessing OASIS SOC

1. Navigate to Care Orders → Select the patient's care order
2. Click Schedules tab
3. Find the OASIS SOC visit (automatically created with the care order)
4. Click to open the visit
5. The OASIS E2 Start of Care Note form opens

OASIS SOC Layout

The form is organized into 6 major workflow groups with multiple sections:

Left Sidebar shows all sections with completion indicators:

• Green checkmark = Section complete
• Number badges = Number of items in that section

Main Content Area shows the current section's fields

Top Action Bar includes:

• Previous / Next buttons (navigate between sections)
• Save Section button (blue)
• D/T Review button (unique to SOC)
• ✓ HHA Care Plan Created button (if HHA frequency > 0)
• Check for Errors button (blue)

Unique Features of OASIS SOC

1. D/T Review Button

D/T stands for Discipline & Treatment Order Review. This button is unique to SOC (and Recert).

What It Does:

• Opens a modal showing a searchable list of all OASIS sections
• Shows completion counts (e.g., "4/4" means 4 out of 4 items completed)
• Clicking on any section scrolls directly to that section in the form
• Helps you quickly navigate large OASIS forms

When to Use It:

• When you need to find a specific section quickly
• When checking which sections are incomplete
• When returning to edit specific items

How It Works:

1. Click "D/T review" button
2. Modal opens with complete section list
3. Use search bar to find sections (e.g., type "respiratory")
4. Click section name or "Expand All" to see all subsections
5. Click "Apply Changes" to close modal

The modal also shows a Clinical care plan preview which displays:

• Diagnoses: 2 diagnoses from patient history
• Plan of Care: Summary of discipline orders
• Goals: Selected goals from the assessment
• Interventions: Selected interventions (9 of 9 shown in screenshot)

This preview helps you verify that key clinical information is captured before completing the assessment.

2. NO "Plan of Care Profile" Modal

OASIS SOC does NOT have a "Plan of Care Profile" button because:

• This is the first assessment for this care order
• There is no previous Plan of Care to reference
• The SOC creates the initial Plan of Care

Other OASIS types (Recert, ROC, Discharge) WILL have a "Plan of Care Profile" button to view/edit the existing Plan of Care.

3. HHA Care Plan Button

If HHA services are ordered (HHA frequency > 0), you'll see:

• "Create HHA Care Plan" button (red) - if no care plan exists
• "✓ HHA Care Plan Created" button (green) - if care plan already exists

Requirement: You MUST create the HHA Care Plan before completing the SOC if HHA frequency > 0.

OASIS SOC Sections Summary

The SOC form contains hundreds of items organized into these major groups:

1. Intake / Identity:

• Administrative Information (M0010-M0090)
• Patient Demographics
• Current Residence & Living Situation

2. Clinical History:

• Patient History and Diagnoses (M1000-M1051)
• Inpatient Facility Discharge
• Prognosis
• Supportive Assistance
• Respiratory Status
• Cardiac Status

3. Sensory / Cognitive / Functional:

• Sensory Status (Vision, Hearing, Speech)
• Behavioral, Cognitive, and Psychiatric Symptoms
• Prior Functioning (ADL/IADL) - M items
• GG Functional Abilities and Goals - GG codes

4. Skin / Integumentary:

• Skin Conditions
• Pressure Ulcer/Injury Risk Assessment
• Wounds (Number and Status)

5. Medications / Treatments:

• Drug Regimen Review (M2000-M2020)
• Medication Management
• Endocrine (if applicable)
• Supplies / DME

6. Summary of Care:

• Pain (M2200-M2250)
• Care Preferences
• Summary of Care - This is where you enter:
  • Discipline frequencies (SN, HHA, PT, OT, SLP, MSW)
  • Treatment frequencies
  • Problems/Diagnoses list
  • Goals
  • Interventions

Completing OASIS SOC Step-by-Step

1. Start with Section 1 (Administrative Information):

   • Most fields pre-fill from patient intake
   • Verify MRN, demographics, dates
   • Move through sections in order

2. Complete Clinical Sections (Sections 2-5):

   • Answer all required items (marked with red asterisks)
   • Use clinical judgment for assessments
   • Reference physician orders and intake data

3. Enter Summary of Care (Section 6):

   • Enter discipline frequencies (e.g., SN 2x/week for 8 weeks)
   • Enter treatment frequencies (e.g., Wound Care 3x/week)
   • Select primary diagnoses
   • Enter goals (e.g., "Improve mobility")
   • Select interventions (e.g., "Medication management")

4. Create HHA Care Plan (if HHA frequency > 0):

   • Click "Create HHA Care Plan" button
   • Add minimum 5 tasks
   • Set vital sign parameters (optional)
   • Save & Activate

5. Check for Errors:

   • Click "Check for Errors" button
   • System validates all required fields
   • Shows any CMS validation errors (Fatal, Warning, Info)
   • Shows soft alerts (clinical plausibility checks)
   • Fix any Fatal errors before proceeding

6. Complete Visit:

   • Click "Complete Visit" button
   • Enter password to sign
   • Visit is submitted to QA Center
   • Document status = "Pending Review"

What Happens After OASIS SOC is Approved

When QA approves the SOC:

1. Document Status → "Pending Physician Signature"
2. Plan of Care is Created with all discipline frequencies, goals, interventions
3. OASIS Submission Entry Created with status "READY_TO_SUBMIT"
4. Medication Snapshot Taken (frozen copy of medications at time of approval)
5. Care Order Awaits Physician Signature before becoming Active

After Physician Signs the Plan of Care

1. Care Order Status → "Active"
2. Patient Status → "ACTIVE"
3. HIPPS Code Calculated (for Medicare patients - determines payment)
4. Prior Authorizations Updated (remaining visits calculated)
5. Clinicians Can Complete Visits for this care order

---

20.4 OASIS Recertification (Recert) - Detailed

When to Complete OASIS Recertification

OASIS Recert is required to extend services into a new 60-day certification period.

Timing Requirements:

• Must be completed within 14 days BEFORE the current certification end date
• Must be completed at least 40 days AFTER the episode start date
• Initial episode OASIS must be complete and approved

Example:

• Episode 1: April 1 - May 30 (60 days)
• Recert Window: May 16 - May 30 (last 14 days)
• Must complete Recert during this window to avoid gap in services

Accessing OASIS Recertification

1. Navigate to Care Orders → Select the patient's care order
2. Click Actions dropdown (three dots)
3. Select "Recertification"
4. System creates a Recert visit
5. Open the Recert visit from Schedules tab
6. The OASIS E1 Recertification Note form opens

Key Differences from SOC

1. Has "Plan of Care Profile" Modal

This is the MAIN difference from SOC!

The "Plan of Care Profile" button allows you to:

• View the current active Plan of Care from the previous period
• Edit discipline frequencies for the new certification period
• Review the Discharge Summary if available
• See current discipline orders (e.g., "SN: 1 pr Week for 8 weeks")
• Refresh the POC to pull latest changes
• Add new orders (e.g., add PT if condition worsened)

Why This Exists:

• During Recert, you're continuing services into a new 60-day period
• You need to review the previous period's plan and adjust for the new period
• You can increase/decrease frequencies based on patient progress
• You can add/remove disciplines as needs change

How to Use It:

1. Click "Plan of Care Profile" button (in top action bar)
2. Modal opens showing current discipline orders
3. Click "Collapse All" or expand specific sections
4. Review Alteration in Glucose Metabolism, Alteration in Hematological Status, etc.
5. See all interventions and goals from previous period
6. Click "Save & Exit" when done reviewing

2. Has D/T Review Button

Same as SOC - helps navigate the form quickly.

3. Has HHA Care Plan Button

If HHA services continue in the new period:

• Button appears to view/edit the HHA Care Plan
• Can update tasks, vital sign parameters, etc.
• Creates new version of care plan for new period

Recert Sections Summary

Recertification includes similar sections to SOC but with some differences:

• Clinical items focus on CHANGES since the last assessment
• Functional items compare current status to admission status
• Goals and Interventions are carried forward but can be updated
• New diagnoses can be added if patient's condition changed

Completing OASIS Recertification Step-by-Step

1. Review Previous Plan of Care:

   • Click "Plan of Care Profile" to see current orders
   • Note discipline frequencies, goals, interventions

2. Complete All Sections:

   • Work through sections 1-6 in order
   • Update clinical status based on current assessment
   • Compare functional status to admission baseline

3. Update Summary of Care:

   • Enter new discipline frequencies for the next 60 days
   • Adjust frequencies based on patient progress
   • Update goals if previous goals were met
   • Add/remove interventions as needed

4. Update HHA Care Plan (if applicable):

   • Click "✓ HHA Care Plan Created" button
   • Review and update tasks
   • Save & Activate new version

5. Check for Errors and Complete:

   • Click "Check for Errors"
   • Fix any Fatal errors
   • Acknowledge/resolve soft alerts
   • Click "Complete Visit"
   • Sign and submit to QA

What Happens After OASIS Recert is Approved

When QA approves the Recert:

1. Document Status → "Pending Physician Signature"
2. NEW 60-Day Episode is Created:
   • Old episode end date = Day before new start date
   • Old care order status → "Discharged"
   • New care order created with status "Pending Physician Signature"
3. New Plan of Care Created with updated frequencies
4. OASIS Submission Entry Created for the new episode
5. Medication Snapshot Taken
6. Awaits Physician Signature

After Physician Signs the Recert Plan of Care

1. New Care Order Status → "Active"
2. Patient Continues as "ACTIVE"
3. HIPPS Code Recalculated for new episode
4. Prior Authorizations Updated with new frequencies
5. Services Continue seamlessly into new 60-day period

---

20.5 OASIS Resumption of Care (ROC) - Detailed

When to Complete OASIS ROC

ROC is used when a patient returns home after being temporarily transferred to a hospital or facility.

Prerequisites:

• A Transfer OASIS must have been approved previously
• Patient status must be "TRANSFERRED"
• Care order status must be "ON_HOLD"

Example Scenario:

1. Patient receiving home health services
2. Falls and is hospitalized for 5 days
3. You complete and approve Transfer OASIS (puts care on hold)
4. Patient is discharged from hospital and returns home
5. You complete ROC (Resumption of Care) to restart services

Similarities to SOC/Recert

ROC form structure is very similar to SOC and Recert:

• Same section organization (Intake, Clinical History, Functional, etc.)
• Has "Plan of Care Profile" button (like Recert)
• Has "D/T Review" button
• Has "HHA Care Plan" button (if HHA services continue)

Key Differences

1. Clinical Assessment Focus:

   • ROC focuses on post-hospital condition
   • Documents any changes from the hospitalization
   • May show decline or improvement in function

2. Timing:

   • Must be completed within timeframe after patient returns
   • Check with your agency's clinical manager for specific policies

3. Plan of Care Updates:

   • Can adjust discipline frequencies based on post-hospital needs
   • May add new disciplines (e.g., add PT if patient is now weaker)
   • May remove disciplines if no longer needed

What Happens After OASIS ROC is Approved

When QA approves the ROC:

1. Patient Status → "ACTIVE" (reactivated)
2. Care Order Status → "Pending Physician Signature"
3. HHA Care Plan Updated (if tasks were modified in ROC)
4. OASIS Submission Entry Created
5. Awaits Physician Signature

After Physician Signs the ROC Plan of Care

1. Care Order Status → "Active" (services resume)
2. HIPPS Code Recalculated (using post-hospital ROC data)
3. Prior Authorizations Updated with remaining visits
4. Visits Can Be Scheduled and completed again

---

20.6 OASIS Transfer - Brief Overview

When to Use Transfer

Use Transfer OASIS when a patient is:

• Going to the hospital for acute care
• Moving to a SNF (Skilled Nursing Facility) temporarily
• Moving to inpatient rehab temporarily
• NOT permanently discharged - expected to return

Do NOT use Transfer if:

• Patient is permanently leaving home health
• Patient is going to long-term care with no plan to return
• Patient is being discharged entirely

(In those cases, use Discharge or Transfer-Discharge instead)

Transfer Form Structure

Transfer form is similar to other OASIS forms with these sections:

• Patient Demographics
• Transfer Information (M0906 Transfer Date - Required)
• Clinical status at time of transfer
• Discharge planning items

No D/T Review button - Transfer is a simpler form focused on discharge items.

What Happens After Transfer is Approved

Immediate Effects (this is called the "Safety Sweep"):

1. Patient Status → "TRANSFERRED"
2. Current Care Order → "ON_HOLD" (services paused)
3. Future Care Orders → "CANCELLED" (if any exist)
4. Future Visits Cancelled (all visits scheduled after transfer date)
5. Prior Authorizations Remain Open (not closed - patient may return)
6. Document Status → "Approved" (NO physician signature required)

Result: Services are paused. Patient is expected to return and will need ROC to resume.

---

20.7 OASIS Discharge - Brief Overview

When to Use Discharge

Use Discharge OASIS when a patient is:

• Goals met - no longer needs home health
• Max benefit achieved - not progressing further
• Moving to long-term care permanently
• No longer homebound
• Refusing services

Discharge Form Structure

Discharge form includes:

• Discharge Date (M0906 - Required)
• Discharge Disposition (where patient is going)
• Clinical status at discharge
• Discharge planning items
• Emergency department use
• Hospitalizations since SOC or last assessment

What Happens After Discharge is Approved

Immediate Effects:

1. Patient Status → "DISCHARGED"
2. Care Order Status → "Discharged" (permanently closed)
3. Future Visits Cancelled (all visits after discharge date)
4. Prior Authorizations Closed (status → "closed")
5. Compliance Tasks Cancelled
6. Document Status → "Approved" (NO physician signature required)

Result: Episode is permanently closed. Patient is no longer active in home health.

---

20.8 OASIS Transfer-Discharge - Brief Overview

When to Use Transfer-Discharge

Use Transfer-Discharge when:

• Patient is transferring to another facility AND
• Will NOT be returning to home health

Example:

• Patient moves to nursing home permanently
• Patient moves to hospice care
• Patient transfers to another home health agency

What Happens After Transfer-Discharge is Approved

Immediate Effects (even more comprehensive than regular Discharge):

1. Patient Status → "DISCHARGED"
2. ALL Care Orders → "Discharged" (not just current - ALL episodes)
3. ALL Future Visits Cancelled (across all care orders)
4. ALL Prior Authorizations Closed
5. ALL Compliance Tasks Cancelled
6. Document Status → "Approved" (NO physician signature required)

Result: Complete closure of patient from home health. Most final OASIS type.

---

20.9 OASIS Death at Home - Brief Overview

When to Use Death OASIS

Use Death at Home OASIS when:

• Patient dies at home while receiving home health services
• Patient dies in home setting (not in hospital or facility)

Do NOT use Death OASIS if:

• Patient died in hospital
• Patient died in SNF or other facility

(In those cases, use regular Discharge OASIS)

Death OASIS Form Structure

Death form includes:

• Date of Death (Required)
• Clinical status prior to death
• Circumstances of death
• Hospice election (if applicable)
• Discharge planning items

What Happens After Death OASIS is Approved

Immediate Effects:

1. Patient Status → "DECEASED"
2. Care Order Status → "Discharged"
3. Future Visits Cancelled
4. Prior Authorizations Closed
5. Compliance Tasks Cancelled
6. Document Status → "Approved" (NO physician signature required)

Result: Episode is closed. Patient record is marked as deceased for compliance.

---

20.10 Physician Signature Requirements

Which OASIS Types Require Physician Signature?

Require Signature (3 types):

1. Start of Care (SOC) - Establishes initial Plan of Care
2. Recertification (Recert) - Establishes new 60-day Plan of Care
3. Resumption of Care (ROC) - Updates Plan of Care after hospital return

Do NOT Require Signature (4 types): 4. Transfer - Just pauses services 5. Discharge - Closes episode 6. Transfer-Discharge - Closes all episodes 7. Death at Home - Documents death

What Happens While Waiting for Signature

Document Status: "Pending Physician Signature" Care Order Status: "Pending Physician Signature"

During This Time:

• Visits cannot be scheduled for the new episode (for Recert)
• Services cannot resume (for ROC)
• Patient cannot access care until signature is obtained

How Long It Takes:

• Depends on physician responsiveness
• Most agencies get signatures within 24-72 hours
• Some use electronic signature systems for faster turnaround

Getting the Physician Signature

The typical workflow:

1. RN prints or emails the Plan of Care to the physician
2. Physician reviews and signs the Plan of Care
3. Agency uploads signed POC or marks as signed in system
4. Care Order is activated
5. Services begin

---

20.11 QA Review and Approval Workflow

From Clinician to QA

1. Clinician Completes OASIS:

   • Fills out all sections
   • Checks for errors
   • Signs and submits
   • Document status → "Pending Review"

2. Document Appears in QA Center:

   • QA reviewer sees it in their queue
   • Can filter by document type, clinician, date
   • Opens document for review

3. QA Reviews Document:

   • Checks for completeness
   • Validates clinical accuracy
   • Reviews soft alerts
   • Verifies consistency with patient condition

4. QA Takes Action:

   • Approve: Document moves to next step (signature or final approval)
   • Return for Correction: Sends back to clinician with notes
   • Can add review notes for either action

Three Possible Outcomes

Outcome 1: Approved (Requires Physician Signature)

• For SOC, Recert, ROC
• Status → "Pending Physician Signature"
• Awaits physician signature on Plan of Care
• After signature → Care Order becomes "Active"

Outcome 2: Approved (No Signature Required)

• For Transfer, Discharge, Transfer-Discharge, Death
• Status → "Approved" (final)
• Immediate effects take place (patient status updates, visits cancelled, etc.)

Outcome 3: Returned for Correction

• Status → "Returned for Correction"
• Clinician sees it in their queue with QA notes
• Clinician makes corrections
• Resubmits to QA
• QA reviews again

---

20.12 OASIS Submission to CMS

After OASIS assessments are approved (and signed if required), they must be submitted to CMS.

OASIS Submission Statuses

1. READY_TO_SUBMIT:

   • OASIS is approved and signed (if required)
   • Ready to be exported and submitted to CMS
   • Appears in "Ready to Submit" tab

2. SUBMITTED:

   • Agency has exported the OASIS XML
   • Agency has submitted to CMS via their clearinghouse
   • Waiting for CMS response

3. ACCEPTED:

   • CMS has accepted the OASIS submission
   • Care Order becomes "Active" (if it was Pending Physician Signature)
   • This is the final step before billing can proceed

4. REJECTED:

   • CMS found errors in the OASIS data
   • Agency must correct and resubmit
   • Common reasons: Invalid dates, missing required items, logic errors

5. PENDING_CORRECTION:

   • CMS notified agency of needed corrections
   • Agency is working on fixes
   • Will resubmit after corrections

OASIS Submissions Page

Navigate to OASIS Submissions in the sidebar to:

• View all OASIS submissions across all tabs
• Export OASIS XML files
• Mark submissions as "Submitted" after sending to CMS
• Mark as "Accepted" or "Rejected" based on CMS response
• Track submission history

Sandbox Restriction: Export and "Mark Submitted" buttons are disabled in sandbox mode. Go Live agencies can export and submit to CMS.

---

20.13 Summary Table: All OASIS Types

OASIS Type	When to Use	Physician Signature Required	Patient Status After Approval	Care Order Status After Approval	Future Visits
SOC	New admission	✅ Yes	ACTIVE (after signature)	Pending Physician Signature → Active	Scheduled after activation
Recert	Every 60 days	✅ Yes	ACTIVE (after signature)	New episode: Pending Physician Signature → Active	New episode visits scheduled
ROC	Return after transfer	✅ Yes	ACTIVE (after signature)	Pending Physician Signature → Active	Scheduled after reactivation
Transfer	To hospital/facility (temporary)	❌ No	TRANSFERRED	ON_HOLD	Cancelled (after transfer date)
Discharge	Permanently leaving home health	❌ No	DISCHARGED	Discharged	Cancelled (after discharge date)
Transfer-Discharge	Transfer + permanent discharge	❌ No	DISCHARGED	Discharged (ALL orders)	Cancelled (ALL visits)
Death at Home	Patient dies at home	❌ No	DECEASED	Discharged	Cancelled

---

20.14 Best Practices for OASIS Completion

Timing

1. SOC: Complete within 5 days of start of care (or per agency policy)
2. Recert: Complete within 14-day window before cert end date (don't wait until last day!)
3. ROC: Complete promptly after patient returns home (same day or next day)
4. Transfer/Discharge/Death: Complete as soon as event occurs or is known

Accuracy

1. Use Objective Measures: Base answers on actual observations and measurements
2. Be Consistent: Answers should align with clinical notes and patient condition
3. Don't Skip Items: All required items must be completed
4. Review Before Submitting: Use D/T Review to double-check sections

Documentation

1. Support Your Answers: Clinical notes should support OASIS responses
2. Explain Declines: If function worsened, document why (e.g., hospitalization, new diagnosis)
3. Document Improvements: If function improved, document interventions that helped
4. Note Barriers: Document any barriers to care or goal achievement

Communication

1. Coordinate with Team: Discuss patient status with all disciplines before completing
2. Review with Physician: Confirm diagnoses and orders match OASIS
3. Notify QA: Alert QA if rush approval needed (e.g., patient needs urgent services)
4. Plan Ahead: For Recerts, don't wait until the last minute - plan 2-3 weeks in advance

---

20.15 Common Scenarios

Scenario 1: New Patient Admission (SOC)

Situation: Patient referred from hospital. Discharged 2 days ago. Needs wound care and PT.

Steps:

1. Complete patient intake
2. Create care order (reason: "New Admission")
3. Open OASIS SOC visit
4. Complete all sections (may take 45-90 minutes)
5. Enter Summary of Care:
   • SN: 3x/week for 8 weeks (wound care)
   • PT: 3x/week for 6 weeks (gait training)
6. Check for errors
7. Submit to QA
8. QA approves → Status: "Pending Physician Signature"
9. Get physician signature
10. Care order becomes "Active"
11. Submit OASIS to CMS
12. CMS accepts → Ready to bill

Timeline: 3-7 days from admission to active status

---

Scenario 2: Continuing Services (Recert)

Situation: Patient's 60-day episode ends May 30. Patient still needs home health.

Steps:

1. Around May 16 (14 days before end), initiate Recertification from care order
2. Open OASIS Recert visit
3. Click "Plan of Care Profile" to review current orders
4. Complete all sections (reassess patient)
5. Update Summary of Care for new period:
   • SN: 2x/week for 8 weeks (reduced from 3x - patient improving)
   • PT: Discharge (goals met)
   • Add HHA: 3x/week for 8 weeks (patient now needs personal care assistance)
6. Create HHA Care Plan (since adding HHA services)
7. Check for errors
8. Submit to QA
9. QA approves → New episode created
10. Get physician signature
11. New 60-day period starts June 1

Result: Seamless transition from episode 1 to episode 2.

---

Scenario 3: Hospital Transfer and Return (Transfer → ROC)

Situation: Patient falls, hospitalized for 3 days, then returns home.

Steps:

Part 1: Transfer OASIS

1. Patient goes to hospital on May 10
2. Complete OASIS Transfer
3. Enter Transfer Date: May 10
4. Submit to QA
5. QA approves → Patient status: "TRANSFERRED", Care order: "ON_HOLD"
6. All visits after May 10 are cancelled

Part 2: ROC OASIS 7. Patient discharged from hospital May 13 8. Patient returns home May 13 9. Complete OASIS ROC 10. Assess post-hospital condition 11. Update Plan of Care if needed (may need more SN visits now) 12. Submit to QA 13. QA approves → Status: "Pending Physician Signature" 14. Get physician signature 15. Care order status: "Active" (services resumed)

Timeline: Services paused May 10-13, resumed May 14+

---

Scenario 4: Patient Discharge (Discharge)

Situation: Patient's goals met. MD agrees to discharge. Patient no longer needs home health.

Steps:

1. From care order, click Actions → "Discharge"
2. Complete OASIS Discharge
3. Enter Discharge Date (e.g., May 20)
4. Document reason (e.g., "Goals achieved, patient independent")
5. Complete discharge planning items
6. Submit to QA
7. QA approves → Immediate effects:
   • Patient status: "DISCHARGED"
   • Care order: "Discharged"
   • Future visits cancelled
   • Prior authorizations closed
8. Submit OASIS to CMS

Result: Episode permanently closed. Patient successfully discharged.

---

20.16 Troubleshooting

Problem: Cannot Complete OASIS SOC - "Must Create HHA Care Plan"

Error: "HHA services are ordered. You must create the HHA Care Plan before finalizing this assessment."

Cause: You entered HHA frequency > 0 but haven't created the care plan.

Solution:

1. Check Summary of Care section - confirm HHA frequency is > 0
2. Click the red "Create HHA Care Plan" button
3. Add at least 5 tasks
4. Save & Activate
5. Button turns green: "✓ HHA Care Plan Created"
6. Now you can complete the assessment

---

Problem: Cannot Submit OASIS - Fatal CMS Errors

Error: "1 Fatal error(s) found. Please fix before completing."

Cause: CMS validation found errors that BLOCK completion.

Solution:

1. Click "Check for Errors" to see full error list
2. Errors show:
   • Item Number (e.g., M1800)
   • Description of the error
   • Severity (Fatal = must fix)
3. Click on error to navigate to that item
4. Fix the issue (e.g., enter missing value, fix invalid date)
5. Run "Check for Errors" again
6. Repeat until no Fatal errors remain

---

Problem: OASIS Recert Window Missed

Situation: It's now June 3. Certification ended May 30. You forgot to do Recert.

Cause: Recert must be completed BEFORE cert end date (within last 14 days).

Solution:

• If gap is small (1-5 days):

  • Contact your clinical manager or agency administrator
  • May be able to backdate the Recert visit date (check agency policy)
  • Complete Recert with visit date within the window

• If gap is large (>5 days):

  • Patient may need to be discharged and re-admitted
  • Complete Discharge OASIS for old episode
  • Complete new SOC for new episode
  • This is a compliance issue - document reason for late documentation

Prevention: Set up compliance tasks or calendar reminders 21 days before cert end.

---

Problem: Transfer OASIS Already Approved, But Patient Didn't Actually Transfer

Situation: You completed Transfer OASIS, but patient's hospital stay was cancelled or they refused to go.

Issue: Care order is now ON_HOLD and visits are cancelled.

Solution:

1. Contact your agency administrator or clinical manager
2. This requires manual database fix (system doesn't have "undo transfer" feature)
3. Alternative: Complete ROC immediately to reactivate services
4. Document the situation thoroughly in activity log

Prevention: Only complete Transfer OASIS AFTER patient has actually transferred (not before).

---

Problem: QA Returned OASIS for Correction

Status: "Returned for Correction"

What to Do:

1. Open the OASIS visit from your task list or My Day
2. Read QA's review notes (displayed at top of form or in modal)
3. Make the requested corrections
4. Click "Save Section" for each section you edit
5. Click "Complete Visit" to resubmit
6. Sign again
7. Document goes back to QA queue

Note: You can communicate with QA via the Communication Center if you have questions about their feedback.

---