Common Home Health Survey Deficiencies and How to Fix Them Fast

Medicare-certified home health agencies operate under strict federal and state regulations. The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) require agencies to provide high-quality, coordinated, and safe care to patients in their homes. However, even the most experienced agencies can face survey deficiencies that threaten certification, delay reimbursements, and damage reputations.

This comprehensive guide explores the most frequent home health survey deficiencies and provides practical, fast-acting solutions to correct and prevent them. Whether you’re preparing for an upcoming survey or addressing a recent Statement of Deficiencies (Form CMS-2567), understanding these issues can mean the difference between compliance success and financial setbacks.

1. Deficiency in Comprehensive Assessment and OASIS Accuracy (§484.55)

The Issue

One of the most cited deficiencies during home health surveys is related to incomplete or inaccurate patient assessments. CMS requires that agencies conduct a comprehensive assessment that includes OASIS data, capturing the patient’s medical, functional, psychosocial, and environmental needs.

Surveyors often find:

• Missing initial or updated OASIS assessments.

• Assessments not completed within the required time frames.

• Inaccurate or inconsistent documentation between OASIS and clinical notes.
  

How to Fix It Fast

• Implement an internal audit tool: Review 100% of OASIS submissions before transmission.

• Cross-check data: Ensure the OASIS data matches physician orders and narrative documentation.

• Train clinicians: Reinforce the purpose and structure of each OASIS item through refresher courses.

• Use peer review: Assign experienced clinicians to review assessments for accuracy and completeness.

Agencies should also maintain a system to flag overdue or missing assessments automatically.

2. Plan of Care (POC) and Physician Orders Deficiencies (§484.60)

The Issue

Surveyors frequently cite agencies for missing or outdated physician orders. The plan of care must be individualized, reflect all current needs, and be signed and dated by the physician.

Common problems include:

• POC not updated with new interventions or medications.

• Lack of timely physician signatures.

• Care being provided outside the approved plan.
  

How to Fix It Fast

• Develop a POC checklist: Ensure each order includes frequency, duration, goals, and measurable outcomes.

• Monitor physician signature timelines: Create alerts for unsigned orders after 5 business days.

• Standardize order changes: Use a formal “Order Change Form” for any update to ensure documentation continuity.

• Review during case conferences: Include POC validation as part of interdisciplinary team (IDT) meetings.
  

By implementing clear workflows, agencies can avoid noncompliance and improve communication between field staff and physicians.

3. Skilled Services Documentation Deficiencies (§484.75 and §484.80)

The Issue

CMS expects home health agencies to demonstrate that all services provided are skilled, reasonable, and medically necessary. Documentation must support this requirement. Surveyors often identify issues such as:

• Vague or repetitive nursing notes.

• Missing justification for skilled need.

• Lack of measurable outcomes or progress updates.

• Inconsistent signatures or visit verification.
  

How to Fix It Fast

• Retrain on documentation standards: Educate field staff to write skilled interventions using measurable terms (e.g., “educated patient on fall precautions with return demonstration”).

• Establish internal audits: Randomly review at least 5 charts per clinician monthly.

• Create documentation templates: Align templates with CoPs and clinical best practices.

• Use “show, don’t tell” method: Document interventions that clearly demonstrate skilled nursing involvement rather than routine care.
  

Proper charting ensures medical necessity and supports reimbursement integrity.

4. Failure to Coordinate Care (§484.60(d))

The Issue

CMS mandates effective communication among all disciplines involved in patient care. Surveyors often cite agencies for inadequate coordination, such as:

• Lack of communication between nursing and therapy teams.

• Missed interdisciplinary meetings.

• Care plan inconsistencies among different providers.
  

How to Fix It Fast

• Hold regular IDT meetings: Require weekly or biweekly coordination reviews for all active patients.

• Centralize communication: Use EMR-based messaging or coordination notes.

• Implement handoff procedures: When one clinician discharges, ensure the next provider receives a full handoff summary.

• Document communication: Record all updates, calls, and interventions in the medical record.
  

Strong interdisciplinary communication enhances patient outcomes and demonstrates compliance with CoPs.

5. Medication Reconciliation Deficiencies (§484.55(c)(5))

The Issue

Medication errors are a leading cause of patient harm and survey deficiencies. CMS requires agencies to reconcile all medications the patient is taking, including over-the-counter and herbal products.

Surveyors often find:

• Outdated or incomplete medication lists.

• Missing documentation of physician notification for discrepancies.

• Lack of patient education about new or changed medications.
  

How to Fix It Fast

• Implement a Medication Reconciliation Form: Ensure it’s completed at SOC, recertification, and discharge.

• Create a “Call and Confirm” process: Nurses should contact the physician immediately for any discrepancies.

• Educate patients: Document medication teaching and patient understanding using return demonstration.

• Audit high-risk cases: Review medication lists for patients on anticoagulants, insulin, or opioids.
  

Effective medication reconciliation safeguards patients and aligns with CMS’s quality improvement focus.

6. Infection Control and Surveillance Deficiencies (§484.70)

The Issue

Post-COVID, infection prevention has become a key focus in home health surveys. Common citations include:

• Lack of a written infection control program.

• Failure to document hand hygiene or PPE use.

• Missing infection logs and follow-up documentation.
  

How to Fix It Fast

• Review and update the Infection Control Policy annually.

• Train all field staff on standard precautions: Conduct competency evaluations annually.

• Maintain infection logs: Track all infections, identify trends, and include them in QAPI.

• Designate an infection control nurse: Assign oversight for surveillance and staff education.

Demonstrating a proactive infection control program shows CMS that your agency is serious about patient safety.

7. Quality Assessment and Performance Improvement (QAPI) Deficiencies (§484.65)

The Issue

Surveyors often find agencies lacking an effective, data-driven QAPI program. CMS expects agencies to measure, analyze, and improve performance using objective indicators.

Common findings include:

• QAPI activities not ongoing or documented.

• Lack of measurable goals or corrective actions.

• Governing body not involved in reviewing QAPI data.
  

How to Fix It Fast

• Develop a QAPI calendar: Schedule quarterly performance reviews with action plans.

• Select key performance indicators (KPIs): Include infection rates, hospitalization rates, and timeliness of visits.

• Involve leadership: The administrator and clinical director must review and sign QAPI reports.

• Document follow-up: Each identified issue should include a corrective action, implementation date, and re-evaluation.
  

A strong QAPI program not only ensures survey compliance but also drives agency growth and patient satisfaction.

8. Personnel File and Competency Deficiencies (§484.105 and §484.80)

The Issue

Surveyors often identify incomplete employee files or missing competency validations. CMS requires agencies to verify qualifications, licensure, background checks, and ongoing competency for all staff.

Common errors include:

• Missing annual evaluations or TB tests.

• Expired licenses or CPR certifications.

• Incomplete orientation and skills checklists.

How to Fix It Fast

• Create a personnel file checklist: Ensure every file includes required documents per CoPs.

• Track expirations: Use a compliance calendar to monitor license and training renewals.

• Conduct annual competencies: Document return demonstrations and written tests for each discipline.

• Centralize HR files: Store scanned documents in your EMR or secure digital folder for easy retrieval.
  

Well-organized personnel files demonstrate agency professionalism and readiness for survey review.

9. Emergency Preparedness Deficiencies (§484.102)

The Issue

CMS requires every home health agency to have a comprehensive emergency preparedness plan addressing risk assessment, communication, policies, and training.

Surveyors cite agencies for:

• Outdated or missing emergency plans.

• Lack of staff training or documentation of drills.

• No evidence of coordination with local authorities.
  

How to Fix It Fast

• Review your all-hazards risk assessment annually.

• Conduct at least two emergency drills per year and document lessons learned.

• Coordinate with local police, fire, and emergency services: Maintain MOUs or contact records.

• Update emergency contact lists quarterly.

Proper preparedness demonstrates your agency’s ability to protect patients and staff during crises.

10. Patient Rights and Complaint Handling Deficiencies (§484.50)

The Issue

CMS emphasizes protecting patient rights and ensuring access to complaint procedures. Deficiencies typically arise when:

• Patients are not informed of their rights upon admission.

• The complaint process is unclear or undocumented.

• Agencies fail to follow up or log complaints properly.

How to Fix It Fast

• Review admission packets: Ensure the Patient Rights and Responsibilities form is signed and dated.

• Maintain a Complaint Log: Include date, issue, action taken, and resolution.

• Train staff on grievance procedures: Ensure all employees can explain how patients can file complaints.

• Post patient rights visibly: In both the office and patient information materials.
  

A transparent and well-documented complaint process is not only a regulatory requirement but also an indicator of ethical care.

Final Thoughts: Stay Ahead of Deficiencies Before They Happen

Most home health survey deficiencies can be prevented through proactive management, staff education, and regular internal audits. Agencies that implement structured systems for monitoring compliance, documentation, and quality improvement experience fewer citations and better patient outcomes.

Consistency is key. When each discipline—from nursing to administration—understands its role in compliance, the agency operates more efficiently, minimizes risk, and sustains long-term growth under CMS regulations.

Partner with SummitRidge Consulting for Expert Compliance Solutions

If your home health agency has received survey deficiencies—or if you want to prevent them before the next inspection—SummitRidge Consulting can help. Our expert consultants specialize in Medicare Conditions of Participation, survey readiness, policy implementation, and performance improvement. We provide corrective action planning, mock surveys, and documentation support to help agencies maintain compliance and succeed under CMS standards.

Contact SummitRidge Consulting today to strengthen your agency’s operations, prevent costly citations, and build a culture of quality and accountability.