OASIS Alert

Joint RN/PT episodes require early coordination.

Question: In the November issue of OASIS Alert, you included a scenario about the order of visits in a new episode where there are physician's orders for both physical therapy and nursing.

The scenario involved a patient referred to a home health agency on a Monday for RN and PT visits. The nurse scheduled the admission visit for Tuesday morning, and PT scheduled a first visit for Tuesday afternoon.

The nurse called and rescheduled the admission visit for Wednesday, but the therapist still arrived at the patient's home on Tuesday afternoon. The question concerned whether the PT did the right thing by having the patient sign a consent form and then conducting the PT evaluation and initiating treatment. 

The answer to the scenario says that the PT must reschedule the Tuesday visit, even after arriving at the patient's home, if the RN has not yet provided the start of care assessment visit.

Could you please provide the references that explain why this answer is correct? Our agency has not been doing it this way, and I need to understand the reason for changing the process we use.

Answer: This scenario addresses who may do the initial assessment visit, according to OASIS expert Linda Krulish of Redmond, WA-based OASIS Answers, who presented the scenario at the National Association for Home Care & Hospice's October annual conference in Baltimore.

The initial assessment is not the same as the comprehensive assessment, although they can be done at the same visit, explained Pat Sevast with the Centers for Medicare & Medicaid Services, speaking at the same session. The comprehensive assessment containing the OASIS items must be completed "in a timely manner," CMS says. But the clinician has up to five days to complete that assessment. The rules about the initial assessment for a patient being admitted to home health care are found in the Code of Federal Regulations (CFR), Sevast said.

Requirement: In 42 CFR 484.55(a)(1), the regulation says, "A registered nurse must conduct the initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine the eligibility for the Medicare home health benefit, including homebound status." The only exception to this requirement is when a rehabilitation service is the only service ordered by the physician.

Surveyor expectation: Another source agencies should be familiar with is the State Operations Manual, Sevast said. This is the manual surveyors use, she explained. In section 2202.1 of this manual, which defines OASIS terms, the initial assessment is defined as the agency's first visit to the patient after the referral. Besides reviewing the regulations about when the first visit must occur, section 2202.1 says, "In accordance with the regulations, the initial visit must be made by a registered nurse or, for therapy-only cases, a qualified therapist."  

Note: The State Operations Manual is at www.cms.hhs.gov/manuals/downloads/som107c02.pdf. The Code of Federal Regulations is at www.access.gpo.gov/nara/cfr/waisidx_04/42cfr484_04.html.