What happens at a start of care visit?
The short answer
Your first visit on a new case is called the initial assessment visit, and you'll usually have 48 hours to get there. Before you do anything hands-on, the patient gets a notice of their rights and signs to say they got it. You also figure out what they need right now. If you give any hands-on care, that visit becomes the start of care, or SOC. You have five calendar days after the start of care to finish the full assessment, and later deadlines count from that date.
New referral, new name on your schedule, and a 48-hour clock.
Before you go
You've usually got 48 hours from the referral, or from when the patient gets home. If the doctor ordered a specific start date, you go that day instead. It sounds tight, but in CMS's national numbers for October 2024 to September 2025, care started on time in 96.5% of home health episodes.
Most of the time a registered nurse makes this visit. If the patient is only getting therapy, a physical therapist or speech therapist can go instead. Chapter 3 covers who can do what.
Fine print
The rule's three options are within 48 hours of the referral, within 48 hours of the patient's return home, or on the start of care date the physician or other allowed practitioner ordered. If the agency can't make it, it may not ask the doctor for a different date to stay compliant or for its own convenience. If the patient asks to delay, the agency contacts the doctor to request the change and documents it. An occupational therapist can also make the visit, but for a Medicare patient only when OT is ordered along with physical therapy or speech-language pathology. The 96.5% is CMS's timely start measure for October 2024 to September 2025: care started on the ordered date or, with no date ordered, within two days of the referral or hospital discharge.
Papers before care
Before you start anything hands-on, hand over the paperwork. The patient gets a written notice of their rights and responsibilities, the administrator's contact details in case they ever want to complain, and the OASIS privacy notice. They, or their legal representative, sign to say they got the rights notice. They can say yes or no to care, and they get information about advance directives before any care starts.
Fine print
The rights notice includes the agency's transfer and discharge policies, and the contact details are the administrator's name, business address and phone number. Some written instructions come later: the visit schedule, medication and treatment instructions, other instructions that apply to the patient, and the clinical manager's contact details are due no later than the next visit after the doctor or other practitioner approves the plan of care.
What they need today
The other half of the visit is the assessment. Start with what this person needs right now. That can include medication, something to help them move around safely, a nursing treatment, or help with fall risk or nutrition. If they're on Medicare, you're also confirming they qualify for home health, including that they're homebound.
When it becomes the start of care
If you give any hands-on care or treatment at this visit, it's the start of care, or SOC. If you only assess, it isn't. The start of care is the first visit where hands-on care happens. Note the date, because the deadlines at the end of this chapter all count from it.
The medication check
Every medication the patient uses goes on your list: prescriptions, over-the-counter products, vitamins, supplements, herbal remedies. You're checking for anything that could hurt them, like serious side effects, drugs that clash, two drugs doing the same job, or ones they aren't taking as prescribed.
Don't be surprised if the list you were given doesn't match what they're actually taking. In two small studies of patients going from hospital to home, more than 9 in 10 had at least one mismatch.
If something is serious enough to call the doctor about, OASIS asks whether the doctor was reached and their recommendations carried out by midnight the next day.
Fine print
The rule asks for a review of all medications the patient is currently using, to identify potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. CMS counts homeopathic products and any route of administration. Surveyors compare what the patient says they take with what the record shows. OASIS's wording is contact with the physician and completion of the recommended actions, to the extent possible, by midnight of the next calendar day. The studies: 70 patients just home from the hospital, 94% with at least one difference and a median of five (2015); 101 patients going from hospital to home, 94% with at least one discrepancy (2010).
Looking around the home
The assessment rules don't require a specific safety form, but keep your eyes open the whole visit. Who lives here? Who can help? Have they fallen before? Those questions are in OASIS, and the plan of care has to list safety measures. If you'd like something to walk the house with, the CDC has a free room-by-room fall prevention checklist covering stairs, floors, bedrooms and bathrooms.
The rest of the assessment
You don't have to finish the full assessment at this visit. The full assessment, which the rules call the comprehensive assessment, is due within five calendar days of the start of care, sooner if the patient's needs call for it. It's what the plan of care is built from, and at a minimum it covers their health, how they manage day to day, what they want, and who helps them. The OASIS questions are part of it, and chapter 8 walks you through those.
How long do the OASIS questions take? CMS once estimated just under an hour at a start of care.
Fine print
At a minimum the comprehensive assessment covers current health status; psychosocial, functional and cognitive status; strengths, goals and care preferences; continuing need for home care; medical, nursing, rehabilitative, social and discharge planning needs; a review of all medications; primary caregivers, if any, and other available supports, including their willingness and ability to help and when they're available; the patient's representative, if any; and the OASIS items. CMS's estimate was 57.3 minutes, on its 2022 start of care form (now expired), covering reading the instructions, gathering the data and completing the items.
After you leave
Back in the car, you'll usually have three things in progress: finishing the assessment, any orders your visit turned up, and the plan of care. You can only give care that's been ordered, so if you found something the referral didn't cover, it needs a new order; chapter 9 explains how orders get written and signed. The plan of care is drafted from your assessment and sent to the doctor to sign.
The agency also has to send Medicare a notice of admission within five calendar days of the start of care, and it can't send it until your visit has happened.
Fine print
If the notice of admission is late, the payment for that 30-day period is reduced by 1/30th for each day from the start of care until it's filed.
The dates to remember
All of these count from the start of care:
- Within five calendar days after the start of care: the full assessment and the notice of admission are due.
- The last five days of every 60-day period: update the full assessment. It also gets updated whenever the patient's condition changes significantly.
- At least every 60 days: the plan of care is reviewed, and if care continues, the patient is recertified.
Fine print
The day 56 to 60 update applies to every 60-day period counted from the start of care, unless the patient elects a transfer, has a significant change in condition, or is discharged and returns to the same agency during the period. The plan of care review is "at least" every 60 days.