Home Health & Hospice

Inside Scoop: Who Can Complete Data Collection

Homecare Insider, August 29, 2016

The following is an excerpt from The Handbook to Home Health Therapy Documentation, by Cindy Krafft, PT, MS, available as a 10-pack for your staff.

The ability to show the impact of care begins with an accurate assessment at the beginning of the episode. According to the Medicare Conditions of Participation (CoP 484.55), “A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status.” In cases that include nursing and therapy services, the registered nurse is required to complete the admission visit regardless of patient diagnosis or staffing availability. CoP 484.55 goes on to add, “When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional.”

For Medicare patients, the physical therapist or the speech-language pathologist can complete the initial assessment, inclusive of OASIS, when there are no nursing orders present. The need for occupational therapy alone does not meet the criteria for a qualifying service and means that occupational therapists may not admit a Medicare patient to home health. However, they may be able to do so with other payer sources, so each one should be verified independently with respect to coverage criteria. Nursing and any of the three therapies can complete a Discharge, Transfer, Resumption of Care, or Recertification
OASIS, and there is no hierarchy of which one can do it. Therapist assistants are not able to complete the document itself, but they can provide valuable insights into the patient’s abilities when they understand the importance of the tool.