O-13-902 Client Transfer Q&As

👤 RESPONSIBLE POSITION  |  ROLE

Clinical Supervisor

🎯 PURPOSE

Provides scenarios related to client hospitalization and transfers. This resource outlines actions Clinical Supervisors may take when making decisions related to action to take when a client is hospitalized.

These Q&As were developed related to OASIS Q&As which can be found here for reference:

CMS.gov OASIS Q&As

🔄 PROCESS

Scenario #1: Hospitalization Discovered After Return Home

Q: What should you do if you learn that a patient was hospitalized after they have already returned home?

A: First, determine whether the inpatient hospitalization was 24 hours or longer and was for a reason other than diagnostic testing.

• Inpatient less than 24 hours or diagnostic testing only: No special OASIS action is required. A follow-up change in condition may be appropriate to complete.
• Inpatient 24+ hours for other reasons: Complete the required Transfer to Inpatient Facility assessment using M0100 = 6, then complete the Resumption of Care (ROC) assessment.
  • Clinical Supervisor will add Transfer OASIS in back office
  • Clinician may use unexpected event to change subsequent visit to ROC OASIS
• The ROC must be completed within 2 days of learning the patient has returned home.
• M0090: Date the assessment is actually completed.
• M0032: Date of the first visit after the patient's return home.
• M0906: Actual date the patient transferred to the inpatient facility.

Scenario #2 : Hospitalization Before Recertification

Q: If a patient is transferred to the hospital on Day 58 before the Recertification assessment is completed, is a new SOC required when they return?

A: It depends on when the patient returns:

• Returns on Day 59 or 60, with ROC on before end of episode: Complete a ROC with RCT . This satisfies both the ROC and RCT requirements.
• Hospital stay extends beyond the end of the certification period, or ROC unable to be performed before the end of the cert period: Complete a new SOC when the patient returns and perform a paper discharge from the previous episode. No OASIS Discharge is required but a transfer OASIS is required for the transfer to their inpatient stay.

Scenario #3: Hospital Discharge on Day 60 or 61 following RCT

Q: If a patient goes to the hospital near the end of the certification period, after the RCT was completed, and returns home on Day 60 or 61, is a SOC or ROC completed?

A: Determine if ROC will be performed on the last day of the current cert period, or in the new period

• If ROC on Day 60, complete ROC.
• If services are to be resumed in the new episode, complete a Discharge/SOC

Scenario #4 : Hospitalization at Start of New Certification Period

Q: If a patient is recertified at the end of one episode, then hospitalized at the beginning of the new episode before receiving any home health visits, what is required?

A: Complete a Transfer assessment. TIF must be assigned and completed on the tablet. When the patient returns home, complete the appropriate SOC/ROC comprehensive assessment, depending on if there is a potential change in the HIPPS code:

• Evaluate if there is a change in Plan of Care, Primary Focus of Care, Services Ordered, etc.
  • HIPPS code stays the same: Episodes are considered continuous → complete a ROC
  • HIPPS code changes: Episodes are not continuous → complete the agency's discharge process and complete a new SOC, establishing a new episode/certification period.
• A Discharge OASIS is not required for the previous episode.
• If RFA 6 (Transfer without discharge) was completed and the HIPPS later changes, there is no need to correct the Transfer to RFA 7.

Scenario #5: Transfer to Hospital, No Return

Q: What OASIS assessment is required when a patient is transferred to a hospital and does not return to the agency?

A: No additional OASIS assessment is required. The Transfer OASIS data conclude the episode from the point of OASIS collection.

• No OASIS Discharge is required.
• Complete any necessary agency internal discharge process to close the case if the patient was not already discharged.

Scenario #6: Transfer to SNF/TCU from Hospital:

Q: What action should be taken if a client is hospitalized and then subsequently transferred to a SNF/TCU/Post Acute Facility?

A: CMS expects home health to discharge and complete a new SOC when patient returns home.

Scenario #7: Dual Eligible Client Hospitalized

Q: Should we do a ROC or a SOC for a MA client that was hospitalized and is dual-eligible (has both MDCR and Medicaid)?

A: If the client meets MDCR criteria when they return home, a SOC should be completed.

• The clinician cannot change a ROC to a SOC from the PointCare Device
  • They would need to restart the visit, send it back, and a new record would need to be created with a SOC
• If there is a change in the Plan of Care, increased services, new disciplines, noted decline, etc., then it is recommended to DC a Readmit so the clinician is prompted to evaluate for MDCR eligibility on the SOC

Scenario #8: Transfer vs Death at Home

Q: When is a Transfer completed vs. a Death at Home document?

A: Review multiple factors, including how many home health visits were performed and where they passed:

• Client receives only one visit and dies:
  • If the client dies after only one home health visit, the agency generally does not collect or submit a discharge OASIS solely because of the death
  • This is especially important for a single-visit episode.
  • Manually discharge the record after ensuring workflow from 485 is completed
• Client has more than one visit in a quality episode and goes to the hospital:
  • Dies en route to the hospital? —> Death at Home (88)
  • Dies in ER? —> Death at Home (88)
  • Admitted, but dies <24 hrs?—> Death at Home (88)
  • Qualifying inpatient stay 24 hrs or more? —> Transfer with DC (44)
  • Client returns home but dies during attempted ROC before resuming Home Health services? -> No additional OASIS is required. Manually discharge the record.

📅 Effective: 10/1/2026  | 🛠️ Revised:  |  ✅ Approved: JS/KD