Essential Forms Every Home Health Agency Must Have to Stay Compliant

Operating a Medicare-certified home health agency requires strict adherence to the Home Health Conditions of Participation (42 CFR §484). One of the most critical aspects of compliance is maintaining accurate, complete, and timely documentation. Federal and state surveyors frequently cite agencies for missing or incomplete forms, outdated templates, inconsistencies between clinical documentation and the plan of care, and failure to maintain mandatory patient records.

This comprehensive guide outlines the essential forms every home health agency must have to meet Medicare CoPs, ensure clinical continuity, reduce claim denials, and maintain survey readiness at all times.

1. Patient Admission Forms

The admission packet establishes the foundation of the patient record. Missing or incomplete admission forms are among the top deficiencies cited during surveys and medical reviews.

a. Consent to Treat

Patients must provide written permission allowing clinicians to deliver skilled care. The form should include:

• Patient signature and date

• Explanation of services

• Risks and benefits

• HIPAA acknowledgment

• Emergency contact information

b. Notice of Rights & Responsibilities

Medicare requires agencies to provide and document patient receipt of their rights:

• Freedom from discrimination

• Participation in the plan of care

• Freedom from abuse

• Privacy and confidentiality

• Right to file complaints

Surveyors often check whether agencies documented that this information was explained verbally and provided in writing.

c. Advance Directives Inquiry Form

Home health agencies must ask whether the patient has:

• A living will

• Durable Power of Attorney for Healthcare

• POLST (if applicable in the state)

If the patient declines, this must also be documented.

d. Insurance & Financial Responsibility Form

This form outlines:

• Insurance coverage sources (Medicare, Medicaid, private pay)

• Explanation of potential out-of-pocket expenses

• Agency billing practices

e. HIPAA Notice of Privacy Practices

Medicare requires documentation that the patient received a copy of the HIPAA privacy notice.

2. OASIS Assessment and Related Documentation Forms

OASIS (Outcome and Assessment Information Set) is the backbone of home health eligibility and payment.

a. Initial OASIS Start of Care (SOC) Assessment

This standardized assessment must include:

• Clinical history

• Functional status

• Diagnosis coding

• Medication review

• Homebound status justification

Missing or incomplete OASIS documents can result in claim denials, payment recoupments, and survey deficiencies.

b. Recertification OASIS (Every 60 Days)

A recertification must include:

• Continued skilled need

• Clinical update

• Review of goals

• Physician’s recertification and face-to-face documentation

c. Transfer and Discharge OASIS Forms

Required when patients transfer to an inpatient facility or complete care.

3. Face-to-Face Encounter Documentation

One of the most common reasons for ADR denials and payment takebacks is non-compliant face-to-face (F2F) encounters.

CMS requires each home health patient to have:

• A timely F2F encounter (within 90 days before or 30 days after SOC)

• Documentation that supports the primary reason for home health

• Homebound status justification

• Skilled need description in the physician narrative

Agencies must have a standard F2F template to promote consistency and reduce compliance risk.

4. The Plan of Care (POC) – Form 485

Form 485 remains a foundational CMS document. Every patient must have a complete and individualized POC that includes:

• Diagnoses (ICD-10)

• Goals of care

• Visit frequencies (number and duration)

• Interventions and supplies

• Medications (dose, route, frequency, indication)

• Functional limitations

• Equipment and safety needs

• Risk assessment findings

• Orders for disciplines (RN, PT, OT, MSW, HHA)

Surveyors evaluate whether clinical notes match the POC.

Incomplete or outdated POC forms are among the top deficiencies under §484.60.

5. Skilled Nursing, Therapy, and Aide Visit Forms

Every discipline must have documentation tools that capture skilled services and meet CoP requirements.

a. Skilled Nursing Visit Notes

Should include:

• Comprehensive assessment

• Interventions performed

• Patient response

• Pain management documentation

• Teaching and education provided

• Homebound status support

• Clinician signature, credentials, and date/time

b. Physical, Occupational, and Speech Therapy Visit Notes

Must document:

• Skilled therapeutic interventions

• Exercises performed

• Patient progress toward goals

• Objective measurements (ROM, gait, balance, strength)

• Recommendations for POC updates

c. Home Health Aide (HHA) Visit Checklists

Must include:

• Personal care tasks performed

• Vital signs (if permitted)

• Meal prep and homemaking duties

• Safety concerns

Aide assignments must match the HHA Care Plan signed by an RN.

6. Medication Management Forms

Medication errors lead directly to survey deficiencies and increased patient risk.

a. Medication Reconciliation Form

Must be completed:

• At admission

• At recertification

• Every time a medication changes

b. Medication Profile / Medication List

Should include:

• All prescription medications

• OTC items

• Herbal supplements

• Indications

• Allergies and adverse reactions

c. High-Risk Medication Assessment

Required for drugs such as:

• Anticoagulants

• Opioids

• Insulin

d. Controlled Substance Tracking Forms

Particularly important for agencies serving patients with pain management needs.

7. Physician Order Forms

Physician engagement is essential for compliance and reimbursement.

a. Verbal Order (VO) Form

Must include:

• Date VO was received

• Time of call

• Name of the physician

• Detailed order

• Signature of clinician receiving order

• Physician signature within required timeframe

b. Plan of Care Addendum Orders

For changes in:

• Visit frequency

• Medications

• New disciplines

• Updated goals

c. Discharge Orders

Required before the patient is officially discharged.

8. Home Health Aide Supervision Forms

Regulators evaluate whether agencies maintain proper:

• Every 14-day supervisory visits for patients receiving HHA services by an RN or therapist

• In-home supervision documentation

• Corrective action documentation if an aide does not perform duties per care plan

Missing aide supervision forms result in deficiencies under §484.80(h).

9. Emergency Preparedness Forms

CMS requires agencies to maintain a complete emergency preparedness program.

Essential forms include:

• Hazard Vulnerability Assessment (HVA)

• Communication plan

• Staff emergency training logs

• Annual tabletop exercise documentation

• After-action reports

• Patient emergency info forms and evacuation status

• Emergency supply checklist

Surveyors specifically look for documentation of annual testing and full program participation.

10. Quality Assurance & Performance Improvement (QAPI) Forms

Every agency must show evidence of an active QAPI program under §484.65.

Required forms include:

• QAPI plan

• Quarterly QAPI meeting minutes

• Performance improvement project forms

• Data collection tracking logs

• Audit tools (clinical record audits, med audits, aide audits, POC audits)

• Corrective action plans

QAPI documentation must be consistent, measurable, and ongoing.

11. Infection Prevention & Control Forms

CMS requires agencies to maintain:

• Infection control risk assessment

• Standard precautions competency checklists

• Bag technique logs

• Staff vaccination records

• Annual infection control training documentation

• Incident tracking logs for infections or exposures

Surveyors confirm that agencies implement an agency-wide infection control program.

12. Incident, Complaint, and Grievance Forms

To remain compliant with §484.50, agencies must have:

a. Incident Report Form

Used for:

• Falls

• Medication errors

• Safety incidents

• Patient injury

• Equipment issues

b. Complaint/Grievance Form

Must document:

• Date complaint received

• Description of issue

• Investigation steps

• Resolution and response time

• Patient notification

Surveyors verify that grievances are resolved within the agency’s policy timeframe.

13. Discharge and Transfer Forms

Essential for patient continuity and compliance.

a. Discharge Summary

Must include:

• Skilled services provided

• Progress toward goals

• Reason for discharge

• Updated medication list

• Final patient status

b. Transfer Summary

Required when a patient transitions to:

• Hospital

• SNF

• Rehabilitation

• Hospice

Timely and complete documentation is essential to avoid penalties during claim reviews.

Conclusion

Home health agencies must maintain a comprehensive set of mandatory forms to remain fully compliant with the Medicare Conditions of Participation. These forms not only protect the agency legally but also ensure high-quality, consistent patient care, reduce survey risk, and support accurate billing. Agencies that implement standardized documentation systems and conduct regular audits significantly improve operational efficiency and survey outcomes.

If your agency needs help developing compliant forms, auditing documentation, or preparing for survey readiness, SummitRidge Consulting offers expert support in home health compliance, document development, mock surveys, and operational management.