Top Home Health Survey Deficiencies and How to Avoid Them
When it comes to home health agency compliance, survey readiness requires year-round attention. Let’s breakdown of the top home health survey deficiencies and actionable tips to prevent them.
1. Patient Rights and Informed Consent
Deficiency: Failure to properly inform patients of their rights in a timely and documented manner.
What Surveyors Look For:
- Timely delivery and acknowledgment of patient rights.
- Clear documentation that patients understand their rights.
- Inclusion of advanced directives and complaint processes.
How to Avoid:
- Train staff to review and document patient rights during admission.
- Use a standardized checklist and obtain signatures.
- Regularly audit records to ensure compliance.
2. Comprehensive Assessments and Care Planning
Deficiency: Incomplete or inaccurate comprehensive assessments, or care plans that aren’t individualized or updated timely.
What Surveyors Look For:
- Timely completion of assessments (including OASIS).
- Person-centered, updated care plans.
- Coordination of care among disciplines.
How to Avoid:
- Ensure clinicians are well-trained in OASIS and care planning.
- Use electronic alerts to remind staff of reassessment deadlines.
- Hold weekly interdisciplinary case conferences.
3. Clinical Record Documentation
Deficiency: Missing, late, or inconsistent clinical documentation.
What Surveyors Look For:
- Signed and dated visit notes.
- Documentation that matches the care plan.
- Evidence of patient progress or lack thereof.
How to Avoid:
- Implement a documentation policy with clear timeframes.
- Perform routine chart audits.
- Provide ongoing education on documentation best practices.
4. Infection Control
Deficiency: Lack of a robust infection control program or inconsistent use of standard precautions.
What Surveyors Look For:
- Agency infection control policies.
- Evidence of staff training and adherence.
- Proper use and disposal of PPE.
How to Avoid:
- Update policies in line with CDC and CMS guidelines.
- Conduct annual training and random competency checks.
- Monitor infection trends and implement corrective actions.
5. Supervision of Home Health Aides
Deficiency: Inadequate or undocumented supervisory visits.
What Surveyors Look For:
- Supervisory visits at required intervals.
- Documentation that includes aide performance and patient response.
- Alignment with the aide care plan.
How to Avoid:
- Create a tracking system for supervisory visit due dates.
- Use standardized forms to document supervision.
- Incorporate supervision review into your QAPI program.
6. QAPI (Quality Assurance & Performance Improvement)
Deficiency: Lack of a data-driven, effective QAPI program.
What Surveyors Look For:
- Written QAPI plan.
- Evidence of performance improvement projects (PIPs).
- Use of data to identify and address problems.
How to Avoid:
- Assign a QAPI coordinator and/or team.
- Regularly analyze clinical, patient satisfaction, and adverse event data.
- Document and share progress on PIPs agency-wide.
Avoiding survey deficiencies isn’t just about passing your next audit—it’s about delivering high-quality care every day. Make compliance a part of your culture through proactive training, ongoing audits, and a strong QAPI program.
Next Steps:
Conduct a mock survey at least annually to identify vulnerabilities before surveyors do. Contact Proactive today to schedule your agency’s mock survey and ensure that you are prepared for your next survey!
Learn more about home health mock survey and survey management.
Written By:
Nichole McClain, RN
Principal Consultant of Home Health Services
Proactive Medical Review
Contact Proactive to learn more about Five-Star Improvement support services and develop a road map to Five-Star success in 2025.