California Department of Public Health: Must-Have Documents Before the State Walks In

A Home Health Agency’s Guide to Survey Preparedness Based on CMS Protocols

When the California Department of Public Health (CDPH) or any CMS-authorized entity walks into your home health agency (HHA) unannounced, it’s not the time to begin organizing your documentation—it’s the time to shine. The survey process is rigorous, patient-focused, and outcome-driven, designed to evaluate whether your agency is in compliance with Medicare’s Conditions of Participation (CoPs) as outlined in CMS’s State Operations Manual (SOM) Appendix B.

To ensure a smooth, efficient survey and avoid deficiencies—or worse, condition-level citations—it is crucial that your agency has the essential documents ready and accessible before surveyors arrive.

Why Being Prepared Matters

A survey can result in a range of outcomes, from full certification to termination, depending on your agency’s level of compliance. CDPH uses survey protocols that mirror CMS’s guidance, focusing on both documentation and direct care to assess whether your agency delivers safe, effective, and coordinated services.

Noncompliance—especially at the condition level—can have serious consequences including mandatory corrective action plans, monetary penalties, or revocation of Medicare certification.

The Top Must-Have Documents—No Exceptions

1. Organizational and Administrative Readiness

• Current organizational chart and administrator designation

• Updated Form CMS-1572, Home Health Agency Survey Report

• List of all parent and branch locations, including services offered

2. Personnel and Staffing

• Roster of all direct and contracted staff, including:

  • Job titles and responsibilities

  • Dates of hire and licensure verification

  • Home health aide competency evaluations and in-service training logs

• Documentation of staff assigned to clinical supervision and emergency roles

3. Clinical Records and Patient Care

• Complete, current clinical records for active and recently discharged patients (last 6 months), including:

  • Comprehensive assessments

  • Plan of care

  • Medication profiles

  • Progress and visit notes

• Schedule of home visits during the week of survey

• A list of patients receiving specialized services (e.g., wound care, IV therapy)

4. Emergency Preparedness Documentation

• Emergency Preparedness Plan

• Staff training records on emergency protocols

• Drill documentation and corrective actions taken

5. Quality Assurance and Performance Improvement (QAPI)

• Documentation of QAPI activities and improvement projects

• Infection prevention and control reports, including staff education logs

6. Complaint and Abuse Logs

• Complete and updated complaint log

• Abuse tracking log (even if no incidents have occurred)

• Policies on abuse reporting and staff training documentation

7. Patient Rights and Disclosures

• Admission packet given to patients, including:

  • Patient rights and responsibilities

  • Notice of privacy practices

  • Information on service limitations and financial responsibility

What Surveyors Look for

Surveyors don’t just look at documentation—they triangulate findings from:

• Clinical record reviews

• Observations during home visits

• Interviews with staff, patients, and caregivers

They assess how well your written policies translate into actual practice. Therefore, alignment between documentation and field practice is non-negotiable.

Survey Types to Expect

CDPH may conduct different types of surveys, each with specific documentation needs:

• Initial Certification Survey
  Verifies compliance with all CoPs before enrollment.

• Recertification Survey
  Conducted every 36 months to renew certification.

• Complaint Investigation
  Triggered by external complaints; documentation supporting investigation and resolution is essential.

• Post-Survey Revisit
  Evaluates correction of prior deficiencies; keep corrective action plans and supporting evidence ready.

• Extended Survey
  Initiated when substandard care is identified. All CoPs may be reviewed.

Special Notes for California Agencies

California-specific considerations include:

• Maintaining compliance with state licensing regulations in addition to federal CoPs

• Ensuring branch locations are approved and listed correctly on Form CMS-1572

• Being transparent during surveys, but avoid providing extraneous materials unless requested

Final Thoughts: Your Pre-Survey Strategy

Preparation is ongoing. Agencies should:

• Perform internal audits and mock surveys regularly

• Maintain updated documentation binders

• Designate a survey readiness team responsible for document collection and coordination during surveys

• Practice real-time compliance—not just "paper compliance"

Conclusion

A surprise visit from the California Department of Public Health doesn’t have to be a nightmare. With the right documents in place and a culture of continuous readiness, your home health agency can confidently demonstrate compliance, protect your Medicare certification, and—most importantly—prove your commitment to high-quality patient care.