A 485 by definition is “ Home Health Care Agency to serve as a plan of care and certification or recertification in case the physician assumes oversight of patient care” 

A 485 consists of the SOC medications, functional status, evaluation verbiage, goals and frequency noted at SOC, as well as the evaluation findings for all disciplines involved. 

This is why it is imperative that all evaluations are completed within the 5 day window, in order to complete the 485 per the rules and regulations for home health!!!!!

The overseeing physician will sign and return the 485 in agreement with the POC. 

Similar to the ATS General Protocol, these are the basic CMS Rules & Regs:

BASIC CMS (Medicare) Rules

Timeline: An ATS Customer (Agency) will accept a patient referral for home health care. The Customer will input the referral into SOLI if they cannot staff internally. The referral is accepted by the ATS team and it is sent out to the SOLI app. The first clinician to say ‘I am interested’ will be assigned the referral; an assistant cannot be assigned without a supervising therapist. The clinician then calls the patient to schedule the Evaluation or SOC ASAP, representing the agency of the patient in SOLI (ex. I am a PT representing Alliant Home Health and I am calling to schedule your initial PT evaluation). Document your attempts to schedule in Communication Notes.

• SOCs must be completed within 48hrs of the written doctors order, or will need a delay order before proceeding. SOCs cannot be completed on the same day they were discharged from a hospital or inpatient rehab facility per CMS.

• Evaluations must be completed within 5 days of the SOC, or a delay order will be needed before proceeding.

• Delay Orders - A clinician (cannot be an assistant) must call the MD in SOLI, requesting a Verbal Order to Delay Care Initiation per patient request, and input the date, time of day and who they spoke with for a true Verbal Order. This is typically done by an MA for the MD via call back. Input the VO for the Delay order on the chart before evaluating or completing the SOC.

Nonadmits: Never non-admit the patient before calling the agency to see if they have been able to get in touch first. If the patient refuses therapy, call the agency first. Once the agency knows and is in agreement, then call the MD for a VO to refuse the discipline evaluation. Document the VO in the Physician Orders.

Scheduling: Try to schedule the patient for at least one evaluation to meet CMS rules, instead of completing a non-admit. We recommend scheduling each patient 1hr - 1.5hrs apart. For example, start at 8:30, with the next appointment at 10.

EVV (Electronic Visit Verification): Look in SOLI for the correct EVV platform and the protocol website for the agency you are representing; EVV is required for a billable/payable visit for all Medicaid patients.

Review Bag Technique: Before going to your first scheduled patients visit, make sure you review the bag technique, have your name tag available (once this is sent to you from ATS) for infection control. See Home Health 101 for video.

Documentation: Check SOLI and determine what agency you are going to see the patient for, documentation type/billing type will be listed in SOLI and details will be on the protocol website for each agency.

Billing/Payroll: If you are documenting in Alpine Kinnser (depending on the agency) you won’t have to bill the agency for your time. However, if you are documenting in an agency Kinnser such as Alliant Kinnser, you must bill for your visits in Alpine Kinnser using (*) timecards. ALL Billing and Documentation is due within 24hrs, and must be completed in full no later than Mondays at 9am.

Once you see the patient: introduce yourself representing the agency the patient is with, follow bag technique for infection control, obtain the signature in SOLI, capture EVV (time in and out) then document your evaluation/SOC, upload SOC consents when applicable, and call the Agency for the frequency approval, then obtain a Verbal Order to continue care. Make sure to input your frequency in SOLI!!!

• CALL the Agency for POC Approval First (Auth or PDGM approval)

• VERBAL ORDERS: (Only to be done by PT/OT/ST or MSW; cannot be done by a PTA or COTA) call the MD listed in SOLI and state for example ‘My name is Jayme, Home Health PT calling for Verbal Orders to continue care for patient John Doe, DOB 1/1/1955 for frequency of 1w1, 2w2.’ Document the VO on your evaluation or separate Physician Order. Notify the Assistant when applicable. Continue care per the frequency and VO you obtained at evaluation.

Frequency: once your frequency is approved by the agency for authorization, you must follow that frequency per your POC (plan of care). If you change frequency at re-evaluation or any time during the episode of care, you must call the agency first and then obtain a new VO/Physician order. If you sway from the POC, you have to notify the agency and then the MD. (If you put in a resign from a home health position, per CMS you are required to continue the POCs for your current patients, but the ATS staff can assist when possible in restaffing depending on availability. Care coordination is key in this situation)

• CMS will NOT allow “0w1” for example, instead they require 1w1 and a note on the Physician Order/VO stating ‘Patient does not want to be seen the week of 7/26/23’ and complete a missed visit, for example if you are going on vacation and the patient does not want an alternative therapist, or if the patient has multiple doctors appointments, etc.

• Vacations: plan ahead and write this in your original POC frequency as above.

Missed Visits: ALWAYS notify the MD, then notify the Agency for insurance reasons, when a missed visit has occurred, as it is a deviation from the POC. Even if you are an assistant, you must notify the MD and Agency when there is a missed visit. Please document your communication with who you spoke to for each on your missed visit note.

Noncompliance: If a patient misses 3 consecutive visits, please call the agency first before calling the MD to obtain a VO to discharge due to noncompliance. This has to be a case coordination decision, per CMS.

Re-Evaluations: Must be completed at least once every 30days. This does not have to wait for the 30 day mark! If you miss a 30 day re-eval, you must do a non-billable DC, obtain new orders for a new evaluation and start over, IF the agency is in agreement. Avoid missing a 30 day re-evaluation and plan ahead! Schedule a re-evaluation at the time of the evaluation.

Supervision: A PTA/COTA should be supervised every 30 days. Therefore, if you do a re-evaluation for a COTA or PTA, make sure you also add a supervision note as well. If you supervise a COTA or PTA, make sure you add a supervision note (*) to each of the PTA/COTA visits as well.

Discharges: Always call the agency to see if you are the last discipline in for discharge. If you are the last one to see the patient, you must obtain the NOMNC (specific to each agency) and complete the DC OASIS.

Transfers or Under Observation: If the patient goes to the hospital, you. may be asked to do a Transfer OASIS if the patient is admitted. If the patient was not admitted and only under observation at the hospital, no Transfer OASIS is needed.

Resumptions of Care: If a patient is admitted to the hospital and then discharged back to home health during an active episode, one clinician will need to complete a ROC (Resumption of Care). This must be completed within 48hrs of the patient going home, but cannot be on the same day as discharge from the hospital.

HEP: Home Exercise Programs must be on the chart at the time of DC. You can utilize HEP2go Link

HR Credentials in SOLI: Keep these updated at all times for survey purposes. Agencies/Customers of ATS are surveyed once a year, meaning ATS is surveyed 1-2x a week!!!! This is CRUCIAL!!!

Communication Notes must be entered in Alpine Kinnser for the following purposes:

• Scheduling attempts, i.e. ‘left VM for the patient on 7/1/26, 7/2/26 waiting for call back to schedule.

• Spoke to Agency about patient concerns related to add on MSW needs.

• Anytime you communicate between other disciplines, the patient or patient family members, document it as a comm note, otherwise ‘it never happened.’

Discharge with Visit

• ALWAYS check who will be the last out and who is responsible for DC OASIS!!

• Please review company protocols before completing the Discharge Visit for specifics. 

• Notice of Medicare non-coverage (NOMNC) form- SHOULD BE DATED 48 HOURS BEFORE DC and must be uploaded to the agency documentation system. Typically the therapist who completes the DC OASIS is the one who will upload the NOMNC. 

• HEP for every patient must be uploaded into the documentation system 

• Vitals are required at each visit, including the Discharge visit

• Goals must be reviewed at Discharge visit

• If an assistant treated the patient during the cert period, please also include a supervisory visit to the Discharge visit for compliance.

Non-Visit Discharge:

• A discharge without a visit or a “Non-Visit Discharge” is either done by a Nonbillable Discharge OASIS if you are the last clinician in, or “Discharge Summary” if you are discharging your discipline per patient request, due to authorization, etc.

Daily notes are documented after a skilled visit has been completed.

Definition of a Skilled Visit: at minimum 30 minutes of face to face skilled care with a patient. Documentation time should be added to your total time (i.e. Face to Face with the patient 30mins and document for 15mins = 45mins total).

A Daily Notes visit requires the following information:

• Time In & Time Out

• Date

• Confirmed patient identity (check off)

• Vitals

• Pain Levels

• Subjective Evaluation

• Objective Evaluation

• Teaching (check applicable boxes)

• Progress to Goals

• Intervention/Education provided

• Plan (must always check “discharge planning”)

• Sign & Date

DON’T FORGET Patient Signature in SOLI !

Start of Care (SOC) Scheduling: Must be completed in 48hrs of the order, or a delay order must be obtained (all delay orders must be written as a separate order BEFORE you evaluate, followed by another order AFTER you evaluate with your frequency and POC).

Documentation is due billed & signed within 48hrs of visit date.

• OASIS/Initial Evaluations
  Scheduling: Must be completed within the 5 day window of the SOC, or a delay order must be obtained
  Documentation is due billed & signed within 48hrs of visit date.

• Add-On Evaluations (evals added during an episode of care) - Must be completed within the 2 day window, or a delay order must be obtained

• Daily Visit Notes
  Scheduling: Must be completed weekly as written in frequency statement (ie: 1w3 = once a week for 3 weeks).
  Documentation is due billed & signed within 24hrs of visit date.

• Discharge w/ Visit is due billed & signed within 24hrs of visit date.

• Discharge w/out Visit is due billed & signed within 24hrs of visit date.

Evaluation Assessment Tools - click on links below for assessments and templates:

OT: Berg Balance, DGI, FIM

PT: Tinetti, TUG

SLP: SLUMS

PT Evaluation Template

OT Evaluation Template

OT Eval Example (Kinnser)

Evaluation & SOC Checklists: click on each link below for a helpful quick guide to use for initial evaluations or SOCs.

Checklists

• Evaluation Checklist

• First Visit Checklist

• Daily Note Checklist

Therapy Evaluation (NON-OASIS EVALS)

MAKE SURE SN/PT SOC VISIT HAS BEEN COMPLETED BEFORE GOING OUT TO SEE THE PATIENT

Steps:

1. Call to schedule patient. Always say you're with the agency! Agency is listed in SOLI on patient chart.

   Timeframe for scheduling SOC visit:  Initial Eval within 5 days after SOC/ ROC / Re-cert for all secondary disciplines 

   NOTE: If you are unable to schedule the pt within the 5 day window OR the visit needs to be replotted to the following Medicare week, notify the physician of the delay, complete a communication note, and complete an order stating reason for the delay, and that the Physician was notified and agreeable to the delay.

2. Complete therapy visit – make sure to get patient signature in SOLI app, write down vitals in pt’s folder if available, write down next visit on pt’s calendar

3. Call physician’s office for verbal orders – make sure to take note of who you talked to, date, and time; you must have a VO before returning to the patient after evaluation is complete. 

4. Enter a communication note with every attempt made in communicating/scheduling with the patient 

5. Enter frequency into SOLI app. Visits in ATS Kinnser will be plotted when frequency is approved.

6. Complete documentation within 24hrs. 

Therapy Re-Evaluation (NON-OASIS EVALS)

MAKE SURE TO DOCUMENT AND EMPHASIZE SKILLED NEED DURING RE-EVALUATION! Make sure you are showing skilled need and changes (progression/regression) each visit and your documentation includes the following:

1. A written statement regarding the comparison of current measurements to previous measurements (just listing current measurements is not enough) 

2. A written statement regarding the therapist’s determination of the effectiveness of therapy or lack thereof. 

Without these two statements the re-evaluation is considered incomplete and will be denied along with all visits made after the re-evaluation

Please review each company protocol for re-evaluation guidelines. Per the general rules and regulations for Colorado, a patient must be re-evaluated at least once every 30 days. 

NOTE: If you know you want to change your discharge visit to a Re-evaluation visit, please do the following 1 week or more prior to re-evaluation visit to make sure your visit type is changed.

• Call physician’s office for verbal orders – make sure to take note of who you talked to, date, and time

• Enter a new ORDER  – utilize the following template:

  • “Request to change D/C visit to Re-Evaluation and request to continue [discipline] intervention at [frequency] effective [date] to address [deficits]. Verbal Orders received from [name, title] at [MD name] office at [time, date].

If you are unable to schedule the pt for re-evaluation within the 30 day window, please call the agency to discuss possible nonbillable DC. If the re-evaluation is within the 30 days, and needs to be replotted to the following Medicare week, call physician for verbal orders to cover your additional visit, complete a communication note, and complete an order for 1w1 (for example) to cover re-evaluation visit stating reason and Physician was agreeable to the delay. 

Go by cert dates in the documentation system – if you notice it is different than SOLI, notify the office

A Home Health LUPA (Medicare patients only) is when a patient has been seen < 5x by therapy (specifically PT, OT, ST combined) in the first 30 days of a home health episode. This means the agency will not be reimbursed for the entire episode of care and patient would be discharged. To avoid this, it is recommended to front load all Medicare patients to make sure the patient is obtaining the services they need to progress towards goals set at initial evaluation.

LUPA Info

Missed visits occur for a myriad of reasons and are sometimes unavoidable, such as if you arrive at the patients home and they are not there, or do not answer the door. Before entering a missed visit please try and reschedule your visit for later in the week or consider changing your POC to avoid entering a missed visit. If you update your POC and physician order and VO are required. 

Initial Evaluations or SOC cannot be marked as “Missed Visits”. NOTE: Never delete a visit instead of missing a visit; the frequency must match the initial POC Verbal Orders

ATS does not provide any payment or reimbursement for no show visits, BUT some agencies do! Check the important notes in SOLI for each agency or contact the ATS Admin team for clarification.

• A “missed visit” is when a patient declines to be seen per POC set at evaluation after being admitted

• it is recommended this visit is rescheduled! If a missed visit is reschedule during the same work week, a new updated VO is not required from the doctor. If the missed visit is rescheduled for a future work week, a new updated VO is required from the doctor.

• Never mark SOCs, Evals, Re-Evals, or DCs as “missed” on Kinnser! Please ask our QA team to delete and input a nonbillable visit or delete the SOC if its a non-admit and input a communication note

• Vacation Planning: Plan Ahead! For scheduled vacations, suggest 1w1 for frequency the week you will be out. On the missed visit note, “Patient requested not to be seen this week” (assuming they do not want to be seen by another therapist). Documentation “missed visit” note can be completed prior to vacation.

OASIS documentation is required to be completed by the first clinician in the home. It is a comprehensive list of questions and data which ensures agencies meet Medicare requirements.

OASIS GUIDELINES

OASIS GUIDANCE MANUAL

SOC GG Information

SOC M1800s Information

Section GG: Functional Abilities and Goals

Understanding OASIS M GG Coding

Start of Care OASIS:

Check SOLI to determine if the SOC has been completed, or needs to be done by you or another clinicians. RN, PT, and ST’s are primarily the clinicians who complete an SOC. In 2020, OTs were also able to do SOCs during the COVID pandemic. For documentation, please look at the protocol website and/or in the SOLI app. The SOLI app will tell you what agency you are representing, as well as the documentation type. 

SOC (Start of Care) marks the first day of the home health episode = 60 days. 

• Make sure you have SOC folder for that particular agency. If you do not have the appropriate folder, please contact the ATS task force (CEO, COO or CMO)

• Call patient to schedule- always say you're with the agency listed in SOLI. 

• Time Frame for scheduling SOC visit:  

  • SOC/ROC within 24 hrs if patient is discharged from an inpatient facility 

  • SOC/ROC within 48 hrs if patient is discharged from an outpatient facility 

NOTE: If you are unable to schedule the pt within this timeframe OR the visit needs to be replotted to the following Medicare week, please Notify the physician of the delay, complete a communication note, and complete an order stating reason for the delay, and that the Physician was notified and agreeable to the delay.

• Complete therapy visit – make sure to get patient signature in SOLI app, write down vitals in pt’s folder if available, write down next visit on pt’s calendar

Paperwork needed for SOC

• Fill-out and/or have Patient Sign the following forms (which may vary depending on Agency): Authorization for Service, Patient Triage/Risk Emergency/Disaster Evaluation or Patient Emergency Plan, Advance Directives form, Medical Insurance Benefits, and Medication List ***Please review the company protocol before completing the SOC paperwork

• White copy to office, yellow to patient if applicable

• Copies of SOC forms must be uploaded to the agency documentation system

• Home folder w/copies is given to patient.  Instruct how to call agency and State of CO for questions or complaints.

• Use of calendar for visit appointments is required in the state of CO – use the patients calendar or the calendar in the SOC book 

• Write down V/S every visit if Vital Sign sheet is available in the folder, must be documented in your notes as well

• Medication list is reconciled/coded

• Upon admission, if another discipline is indicated, but not included in the initial doctor’s order referral, pls call MD to get authorization and then add a physican order for the new discipline. ***Please review the agency protocol before completing an add on order.

After you have completed your visit:

• Call the MD for VO to continue (have your frequency, the patient info available to report to the MA/NP)

  • Frequency of visits for yourself (refer to the frequency tool guide and agency protocols)

  • Enter frequency into SOLI app

  • Disciplines needed. If you are requesting disciplines that are not ordered on the referral, it will be your responsibility to get the appropriate order(s) from the physician. 

  • If you are completing the SOC visitonly and another clinician will follow, please indicate this to the ATS Task Force. 

  • Please communicate to the agency with a synopsis of your POC and findings; location of this communication is listed on each company protocol.

NOTE: Visits on the ATS Kinnser will be added when frequency is approved for either documentation or billing, depending on the agency.

• Complete documentation within 48hrs

  • Complete OASIS with Medication Reconciliation

  • Run OASIS check/ correct any errors

  • Go by cert dates in the documentation system – if you notice it is different than SOLI, notify the office

• Scan SOC paperwork and upload to the documentation system

• Upload HEP  to the agency documentation system 

• Schedule with patient once VO has been received and POC has been approved. 

Re-Cert/ROC OASIS:

MAKE SURE TO DOCUMENT AND EMPHASIZE SKILLED NEED DURING RE-CERT!! Please make sure the agency is in agreement with recert per the company protocols. 

Time Frame for planning Re-Certification:  

• If you know you want to Re-Cert a patient, please do the following 2 WEEKS or more before your re-cert visit

• Call physician’s office for verbal orders – make sure to take note of who you talked to, date, and time

• Required: Call Agency to discuss your plan

  • If the agency approves: Enter a new ORDER (in the agency documentation system) – utilizing the Template: RECERT ORDER or ROC ORDER. Fill out the form completely

• Re-cert vists and re-evaluations must be completed within the last 5 day window of the end of the cert period. Questions, please ask the ATS Task Force. 

Time Frame for scheduling ROC visit:  

• ROC within 24 hrs if patient is discharged from an inpatient facility 

• ROC within 48 hrs if patient is discharged from an outpatient facility 

NOTE: If you are unable to schedule the pt within this timeframe OR the visit needs to be replotted to the following Medicare week, please Notify the physician of the delay, complete a communication note, and complete an order stating reason for the delay, and that the Physician was notified and agreeable to the delay.

Discharge OASIS

• ALWAYS check who should be doing the DC OASIS – it is always the last clinician seeing the patient. Please review each company protocol before completing a DC OASIS. 

• HEP for every patient – upload to the agency documentation system at Discharge for discharge instruction rules and regulations. 

• Notice of Medicare non-coverage (NOMNC)  form- SHOULD BE DATED 48 HOURS BEFORE DC and must be uploaded with DC OASIS 

• Run the OASIS check to ensure all questions are answered, any corrections are completed before final submission. 

• Timeline to complete DC OASIS = 24hrs. 

Timing: At minimum 30mins of face to face skilled care with a patient, documentation time should be added to your total time (i.e. Face to Face with the patient 30mins and document for 15mins = 45mins total)

Skill: Documentation must show a skill taught during the session to include but not limited to education, functional mobility, activities of daily living etc to match a goal set at initial evaluation.

Definition Here

VO is required after every SOC or Evaluation for every discipline to continue skilled therapy services. Refer to the Helpful Tools page on tips to obtain a Verbal Order (VO).

VO’s must contain the following and must be written in an MD order or Evaluation section of the note under communication – other. This is a requirement to obtain prior to seeing the patient for follow up visits. 

• Date

• Time 

• Who you spoke too 

• Frequency and POC 

  Example – “VO from Mary, MA on 8/1/18 at 2:00pm for Dr. Smith to continue skilled PT 1w1, 2w3 for strength, balance and gait training.”

• VO for Delay of Eval/SOC - Can be combined with VO frequency order. Templates are available for verbiage under the orders section in Kinnser. An example: VO for delay of evaluation per patient request for scheduling, and POC approval for Skilled PT 1w1, 2w3 from Sarah Smith, RN for Dr. John on 7/1/26 @4:00pm.”

• VO for early DC - If a POC is not followed due to lack of insurance auth, or early DC per patient request, you must call the MD and obtain a VO for early DC. **TIP: You can call and leave a VM to notify the MD of early DC, but it needs to be written as “Dr Smith notified of early DC due to authorization on 7/1/26 @4:30pm.”

Vitals are required we record vitals at EVERY patient visit for Home Health.

A patient has the right to decline vitals in home health. If this occurs, simply write in Vital Sign Comments: “Patient declined vitals at this visit.”

The vital signs you need to take each visit include: Blood Pressure, Respiration, Heart Rate/Pulse, Oxygen (spO2), Temperature 

• B/P: Normal 180 / 20
  High: SBP>160 / DBP >90
  Low: SBP<90 / DBP <60 

• Respiration: Normal 12-20

  High: >28
  Low: <12 

• Pulse: Normal 60-100
  High: >120
  Low: <50   
  *Unless on Digoxin, then report <60 

• O2: Normal 88 - 100%
  High: no parameter
  Low: < 88%
  Normal: > 88% at high elevations (if they use O2, it is >88% with O2) 

• Blood Sugar:
  High: FSBS >200 / RBS >300 Low: FSBS <50 / BS <80 

• Temperature: Normal 97.8-99 F
  High: >101.5 F
  Low: <96 F

If you do not have your equipment with you or it is not working properly, you can still manually record respiration rate, and heart rate.