Home health and home care agencies: what an audit looks like

State survey agencies for Medicare-participating home health (CMS)

Recertification, complaint and revisit surveys against 42 CFR Part 484, guided by State Operations Manual Appendix B. A standard survey reviews the Level 1 standards through clinical record review, observational home visits, and patient and staff interviews.

How often. Each agency must be surveyed no later than 36 months after the last day of its previous standard survey. The surveys are unannounced.

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CMS-approved accrediting organizations (ACHC, CHAP and others)

Agencies that choose accreditation are surveyed by the accreditor, and CHAP states its deeming authority lets its surveys substitute for federal and state inspections.

How often. ACHC's accreditation period is three years, and its deemed-status surveys are unannounced.

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Medicare claims reviewers (CERT contractor)

CERT reviews a random sample of Medicare claims for coverage, coding and documentation, and home health claims are part of that sample.

How often. The improper payment rate is measured annually, and a CERT documentation request allows 45 calendar days to respond.

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Admission, census and visit schedule lists

At the entrance conference surveyors ask for unduplicated skilled admissions for the prior 12 months across all locations, and a list of active skilled patients with certification dates, diagnoses, services by discipline and complex treatments. They also ask for the home visit schedule and a list of every patient discharged in the past six months.

SOM Appendix B, Task 2 Entrance Conference (Rev. 245)Source ↗

Staff, organization and complaint records

Requests include a list of direct and contracted employees with job titles and hire dates, the organizational chart, the admission packet, the complaint log, and an abuse tracking log if one exists.

SOM Appendix B, Task 2 Entrance ConferenceSource ↗

Aide, QAPI and emergency records for an extended survey

An extended survey adds home health aide training and competency records and in-service training, written authority for the person acting for the administrator, and the CLIA certificate of waiver. It also adds QAPI activities and performance improvement projects including infection control, and the emergency preparedness plan.

SOM Appendix B, Task 2 Entrance ConferenceSource ↗

Clinical records

Surveyors ask to be oriented to the comprehensive assessment, plan of care, physician orders, progress and visit notes, supervisory visits, case conferences, medication lists and medication administration records. Clinical records are retained 5 years after discharge unless state law sets a longer period.

SOM Appendix B, Task 2; 42 CFR 484.110(c)Source ↗

A patient sample sized by skilled admissions

With fewer than 300 unduplicated skilled admissions the minimum is 7 patients: 2 closed records, 3 active patients with a home visit and 2 active record reviews. The minimum rises to 10, 13 and 17 patients at 301 to 500, 501 to 700 and 701 or more admissions.

Closed records picked from OASIS outcome reports

Surveyors use the Potentially Avoidable Event reports from iQIES and select closed records for outcomes where the agency exceeds the national observation.

Home visits, patients and staff

Active patients in the sample are visited so surveyors can observe care and interview patients and caregivers, and staff are interviewed as findings indicate.

Records and home visits on complaint and licensing surveys

Complaint and revisit surveys select at least 3 records. A Texas licensing survey includes at least three home visits.

Plan of care content and visit schedules

Ranked 1st of CHAP's top 10 in each of CY 2023, 2024 and 2025 CY 2025

CHAP ranks content of the individualized plan of care first among its most cited home health deficiencies, ahead of written visit schedule instructions and transfer or discharge summaries in the clinical record. The same top two held in CY 2023 and CY 2024.

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Provision of care and record management documentation

Top eight deficiencies averaged 32% frequency, down from 41% in 2022 Reported October 28, 2025

All five of ACHC's top home health accreditation deficiencies come from its Section 5, Provision of Care and Record Management. ACHC attributes this to standards that need many elements documented by several team members.

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Medicare claim documentation

6.9% improper payment rate; 13.3% of claims with errors FY 2025 (claims July 2023 to June 2024)

CMS's CERT review put the home health improper payment rate at 6.9%, about $1.07 billion. Of those payments 49.4% were for insufficient documentation and 30.4% for medical necessity, and 163 of 1,224 reviewed claims contained errors.

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Notice of rights signed by the patient

The agency must give the written notice of rights and responsibilities, plus its transfer and discharge policies, at the initial evaluation visit before care starts. It must obtain the patient's or representative's signature confirming receipt.

Acceptance-to-service policy and public service information

The policy must be reviewed annually and cover the patient's anticipated needs, agency caseload and case mix, staffing levels, and staff skills. Public service information must be reviewed whenever services change and at least annually, and CMS issued surveyor guidance on both requirements on August 5, 2026.

Staff training, supervision and policy acknowledgment

Home health aides need at least 12 hours of documented in-service training per 12 months, and a skilled professional must complete a supervisory assessment at least every 14 days for aides on skilled cases. Texas requires direct care staff to sign a statement that they have read, understand and will comply with agency policies.

Emergency preparedness plan and training

The emergency plan and the training and testing program must be reviewed and updated at least every 2 years. Staff are trained when they join, at least every 2 years and after significant policy updates, with documentation kept, and the plan is tested with exercises at least annually.