OASIS Manual · For admins & DONs

OASIS Assessment Schedule (SOC, ROC, Recert, Discharge)

When each OASIS assessment is required, the CMS timepoints involved, and how the 60-day certification period anchors the whole schedule from admission to discharge.

By Reza Djangi, OTR/L·8 min read·Aligned with OASIS-E2 v1.00.0

CMS source

OASIS-E2 Guidance Manual · Verified 2026-10-16

TL;DR

OASIS isn't a one-and-done form. CMS lists six time points: Start of Care, Resumption of Care, Follow-up (Recertification or Other), Transfer, Death at Home, and Discharge. Each one has its own clock.
The 60-day cert period is the spine. The SOC date anchors it, and recert lands in days 56–60 of every 60-day period, counted from the SOC date.
Pick the wrong time point and the record carries the wrong RFA. CMS warns that the submission logic accepts or rejects data based on that one answer. The ten minutes you spend on the schedule before scoring saves three hours of cleanup later.

Timeline

Standard 60-day cert period

Day 0 · RFA 01
Start of Care
OASIS comprehensive assessment must be completed within 5 days after the SOC date.
Day 14 · RFA 03
Resumption of Care window
If the patient returns from a 24+ hour inpatient stay, complete within 2 calendar days.
Day 30 · RFA 06 or 07
Transfer event window
Transfer assessment within 2 calendar days of learning of the transfer.
Day 56 · RFA 04
Recertification window — day 56
Recert OASIS may be completed during the last 5 days of the cert (days 56–60).
Day 60 · RFA 04 or 09
Recert due — day 60
Recert must be completed by day 60 if care continues. A patient who is not continuing is discharged with RFA 09.

Start of Care (SOC)

Specifies the start of care date, which is the date that the first reimbursable service is delivered. [...] The Start of Care date is the date of the first reimbursable service and is maintained as the start of care date until the patient is discharged.

Source: OASIS-E2 Guidance Manual — Ch. 3, Section A, M0030, p. 25 · Verified 2026-10-16

The assessment time point completed on or within 5 calendar days after the SOC date.

Source: OASIS-E2 Guidance Manual — App. A, Glossary, Start of Care, p. 265 · Verified 2026-10-16

Resumption of Care (ROC)

Code 3, Resumption of care, when the patient: [...] Resumes care following an inpatient stay of 24 hours or longer for reasons other than diagnostic tests.

Source: OASIS-E2 Guidance Manual — Ch. 3, Section A, M0100, p. 43 · Verified 2026-10-16

The assessment time point completed within 2 calendar days of the facility discharge date, or knowledge of patient's return home, or the physician-ordered ROC date.

Source: OASIS-E2 Guidance Manual — App. A, Glossary, Resumption of Care, p. 265 · Verified 2026-10-16

From the field

ROC is the time point people get wrong most often, in both directions. Some agencies do an ROC for any hospital touch. An ER visit and home the same day is not an ROC. CMS is explicit that time in the ER or a short observation stay, however long, doesn't count as a transfer to an inpatient facility. Other agencies skip the ROC because the patient "seemed fine." But if the patient went in on an RFA 06, stayed 24 hours or more, and comes back during the cert, you owe the ROC. If you sent an RFA 07 and discharged them, the return is a new SOC instead.

I've reviewed hundreds of charts where agencies put RFA 03 on what should have been an RFA 01. The tell is the discharge. If the patient was discharged from your agency and came back later, that's a new SOC, not an ROC. The same goes for a Medicare patient whose inpatient stay ran past the end of the 60-day period: CMS says that return needs a new start of care assessment. ROC is for an interruption during the cert, not for re-establishing care.

Recertification

All patients who remain on service into a subsequent certification period require a follow-up comprehensive assessment (including OASIS) during the last 5 days of each 60-day period (days 56-60, counting from the start of care date) until discharged. [...] Unless the patient has been discharged, the due dates for Follow-Up (recertification) assessments are calculated from the original Start of Care date rather than from the Resumption of Care date.

Source: OASIS-E2 Guidance Manual — Ch. 3, Section A, M0100, p. 45 · Verified 2026-10-16

Transfer to Inpatient

Code 6, Transferred to an Inpatient Facility- patient not discharged from agency, if the patient is admitted to an inpatient facility for 24 hours or longer (for reasons other than diagnostic tests), with the expectation that home health care will be resumed following inpatient discharge. The patient is not discharged from the agency. [...] Code 7, Transferred to an Inpatient Facility- patient discharged from agency, if the patient is admitted to an inpatient facility for 24 hours or longer (for reasons other than diagnostic tests), and the agency does NOT anticipate the patient will be returning to care. The patient is discharged from the agency.

Source: OASIS-E2 Guidance Manual — Ch. 3, Section A, M0100, p. 44 · Verified 2026-10-16

Discharge from Agency

Code 9, Discharge from agency, when the patient is discharged from the agency for any reason other than transfer to an inpatient facility or death at home. [...] This response includes transfer and discharge to another home health agency or an in-home hospice. [...] When a patient is discharged after only one visit (a single visit quality episode), a Discharge OASIS should not be collected or submitted.

Source: OASIS-E2 Guidance Manual — Ch. 3, Section A, M0100, p. 44 · Verified 2026-10-16

From the field

Discharge OASIS is the time point clinicians most want to skip. Goals are met, you're done, on to the next case. But the discharge OASIS closes the quality episode, and outcome measures compare it with the SOC or ROC. Improvement in ambulation, improvement in bathing, the measures families see on Care Compare. If you don't do it, your agency's numbers get hurt by your own paperwork. It's due within 2 calendar days of the discharge date.

Death at home is RFA 08, not RFA 09. Transfer with discharge is RFA 07, not RFA 09. RFA 09 is the everything-else bucket: goals met, patient moved, patient refused services, lost contact, payer cut off, or the patient went to another home health agency or to hospice at home. The one exception is a patient discharged after a single visit. CMS says no Discharge OASIS for that one.

Common errors

RFA Codes (01–09) — which RFA code maps to each assessment type
M0090, Completion Windows, and Transmission Deadlines — the dates that must be met for each assessment