OASIS Assessment Schedule: When to Complete SOC, ROC, Recert, Transfer, and Discharge

The OASIS assessment schedule is the set of CMS-mandated time points at which home health agencies must collect and submit Outcome and Assessment Information Set (OASIS) data. There are seven assessment categories -- Start of Care, Resumption of Care, Recertification, Other Follow-Up, Transfer, Discharge, and Death at Home -- each triggered by a specific clinical event and each with its own completion deadline.

If you have ever stared at M0100 (Reason for Assessment) wondering which RFA code to select, or been told a recert was "completed too early," this guide walks through every time point, the exact CMS windows, and the clinical scenarios where scheduling gets complicated.

The Seven OASIS Assessment Types

Every OASIS assessment begins with M0100, where you select the Reason for Assessment (RFA) code. The RFA code tells CMS why you are completing this particular assessment. Here is the full list:

RFA codes 01, 03, 04, and 05 determine PDGM payment groupings. RFA codes 06, 07, 08, and 09 capture end-of-episode or interruption-of-care data but do not generate new payment groupings.

Start of Care (SOC)

The SOC assessment is completed when a patient is newly admitted to your agency. The SOC date (M0030) is the date the first billable skilled service is provided. From that date, you have 5 calendar days to complete the OASIS -- the SOC date counts as Day 0.

Example: Your agency admits Mrs. Torres on Monday, April 6 (Day 0). The OT evaluation is Wednesday, April 8. The entire OASIS -- all disciplines' sections -- must be completed by Saturday, April 11 (Day 5).

If multiple disciplines are involved, each clinician completes their discipline-specific items, but the entire OASIS must be finalized within the 5-day window. Coordinate evaluation schedules upfront at admission -- do not let a single discipline's delay blow the window.

Resumption of Care (ROC)

An ROC assessment is required when a patient returns home after an inpatient facility stay of 24 hours or more (for reasons other than diagnostic testing) and the agency did not discharge the patient. The ROC date (M0032) is the date of the first home health visit after the patient returns.

The OASIS must be completed within 2 calendar days of the patient's return home, the agency learning the patient is home, or the physician-ordered ROC date -- whichever applies.

Example: Mr. Park was hospitalized on March 20, and the agency completed a Transfer OASIS (RFA 06). He is discharged from the hospital on March 28. The RN performs the ROC visit on March 29 (Day 0). The ROC OASIS must be completed by March 31 (Day 2).

Key overlap rule: If the ROC timing falls within the last 5 days of the current certification period, the ROC assessment satisfies both the ROC and the recertification requirements. Select RFA 03 -- you do not need two separate assessments.

Recertification

Home health certification periods run 60 days. CMS requires the recertification OASIS to be completed within the last 5 days of the current certification period -- days 56 through 60, counting from the SOC date.

Example: A patient's cert period runs from February 1 through April 1. The recertification OASIS window is March 28 through April 1. The assessment should be completed during a visit within those five days.

Completing the recert too early -- say, on day 40 -- means the assessment does not reflect the patient's status at the episode transition, leading to inaccurate PDGM grouping and a compliance flag. The recert window is always calculated from the SOC date, not from when the last recert was completed. If you miss the window, complete the assessment as soon as you discover the gap -- do not discharge and readmit the patient to reset the clock.

Other Follow-Up (AACR)

The Other Follow-Up assessment (RFA 05) -- sometimes called the AACR or SCIC (Significant Change in Condition) -- is the most misunderstood OASIS time point. Unlike every other assessment, the trigger for RFA 05 is defined by your agency's own policies, not by a universal CMS definition.

When Is It Required?

The Medicare Conditions of Participation (42 CFR 484.55(d)) require a comprehensive assessment, including OASIS, when there is a major decline or improvement in the patient's health status that was not anticipated in the original plan of care.

CMS does not define what constitutes "major." Each agency must establish written policies defining what qualifies, and staff must follow those policies consistently.

Common Triggers

Agencies typically define these as triggers for an RFA 05:

• A new diagnosis or medical event that significantly changes the plan of care (e.g., a new stroke or fall with fracture while on service)
• A sudden functional decline requiring a substantial increase in services
• A marked improvement that changes the patient's service needs or discharge timeline
• New onset of weakness, exhaustion, or deconditioning not present at admission and not related to physical exertion

Completion Window and Payment Impact

Once a clinician identifies a significant change, the assessment must be completed within 2 calendar days. Under PDGM, an RFA 05 cannot adjust payment for the current 30-day period -- it can only affect grouping for a subsequent 30-day period. The grouping can go up, down, or stay the same -- there is no guarantee of higher payment.

When You Do NOT Need an RFA 05

• A diagnosis change between 30-day billing periods. You can update diagnosis codes on the claim without completing a new OASIS.
• Minor fluctuations in patient status expected as part of the normal recovery trajectory.
• Changes already anticipated in the plan of care. If the plan accounted for the possibility, it may not qualify as a "significant change" under your agency's policy.

Transfer and Discharge

All transfer and discharge time points share the same 2-calendar-day completion window. The critical distinction is the trigger and whether the patient stays on your caseload.

RFA 06 -- Transfer, kept on service. The patient is admitted to a facility for 24+ hours (not for diagnostic testing), and the agency plans to resume care or the return status is uncertain. Use RFA 06 when in doubt. After the patient returns, you complete an ROC (RFA 03). Most transfer OASIS items can be completed via phone or chart review -- no in-person visit is required.

RFA 07 -- Transfer, discharged from agency. Same qualifying event, but the agency does not expect the patient to return (e.g., long-term SNF placement). If uncertain, default to RFA 06 -- choosing RFA 07 prematurely means readmission requires a full new SOC, resetting the episode.

RFA 09 -- Discharge from agency. A planned discharge: the patient met their goals or no longer needs skilled services. The clinician may use information from the last five days the agency provided visits to complete this assessment. Unlike transfers, the discharge OASIS requires an in-person encounter.

RFA 08 -- Death at home. The patient expires at home or anywhere other than during an inpatient stay. This is a limited data set -- you complete clinical record items and a few specific OASIS items, not the full functional assessment. The 2-day window still applies.

Common Scheduling Mistakes

Completing the recert OASIS too early. CMS requires days 56-60. Completing it on day 40 is a scheduling convenience that creates a real compliance risk.

Missing the 2-day transfer window. Two calendar days means calendar days, not business days. A Friday evening hospitalization means the transfer OASIS is due by Sunday, not Tuesday.

Using RFA 07 when the patient might return. If the return is uncertain, use RFA 06 (kept on service). You can always discharge later. RFA 07 closes the episode permanently.

Confusing ROC with SOC after a long hospitalization. If a patient's inpatient stay extends beyond the end of their current 60-day cert period, the assessment upon return is a new SOC (RFA 01), not an ROC. The previous episode ended while the patient was in the facility.

Completing an RFA 05 without agency policy support. If an auditor asks why you triggered an Other Follow-Up and there is no written policy defining "significant change," you have a compliance gap.

Missing the 30-day transmission deadline. Every OASIS must be transmitted to CMS within 30 days of M0090 (Date Assessment Completed). This applies to all time points. Late submissions can trigger penalties.

Frequently Asked Questions

Can the same visit satisfy both an ROC and a recert OASIS? Yes. If the ROC visit falls within the last 5 days of the current certification period, the ROC assessment satisfies both the ROC and recertification requirements. Select RFA 03 (ROC) -- not RFA 04.

What if the patient goes to the ER but is not admitted for 24 hours? No transfer OASIS is required. The 24-hour inpatient stay threshold is what triggers the transfer assessment. An ER visit with same-day discharge is not a qualifying event. Document the ER visit in your clinical notes.

Who can complete the OASIS? Only qualified clinicians -- RNs, PTs, OTs, and SLPs. LPNs/LVNs and therapy assistants (PTAs, COTAs) cannot complete OASIS assessments. Therapy assistants can provide observational data that the supervising therapist uses to complete their items.

What happens if I miss the completion window? Complete the assessment as soon as possible and document the reason for the delay. Late OASIS assessments are a compliance issue and may be flagged during agency surveys. The assessment is still required -- the window is a deadline, not a permission slip.

Does a diagnosis change require an RFA 05? Not automatically. You can update diagnosis codes on the claim between 30-day periods without a new OASIS. An RFA 05 is only required if the change represents a significant decline or improvement as defined by your agency's written policy.

Sources

• CMS OASIS-E2 Guidance Manual, Chapter 1: Time Point Requirements
• CMS OASIS Q&As, Category 2: Comprehensive Assessment (February 2026)
• CMS OASIS Q&As, Category 3: Follow-Up Assessments (February 2026)
• CMS OASIS Assessment Reference Sheet -- RFA codes and time points
• 42 CFR 484.55 -- Conditions of Participation: Comprehensive Assessment of Patients
• CMS OASIS Data Sets & Instruments