Top 10 Policies Required to Open a Home Health Agency

Opening a home health agency is an exciting opportunity—but it is also a highly regulated process that requires strict alignment with federal and state rules, particularly the Medicare Conditions of Participation (CoPs) at 42 CFR 484. Whether you plan to become Medicare-certified or offer private-duty services, establishing strong, compliant foundational policies is the most critical step in achieving survey readiness, operational excellence, and long-term success.

The following guide outlines the top 10 policies every home health agency must have in place before opening its doors. These are the core documents surveyors expect to review, and they form the backbone of safe, ethical, and compliant home health care operations.

1. Admission, Discharge & Transfer (ADT) Policy

A comprehensive ADT policy is mandatory for demonstrating how your agency determines patient eligibility, admission criteria, ongoing appropriateness for services, and safe discharge planning. Under 42 CFR 484.55 and 484.60, agencies must ensure patients are admitted only when they meet skilled need criteria and can benefit from home health services.

Your ADT policy must include:

• Eligibility guidelines (homebound status, skilled need, physician oversight)

• Requirements for face-to-face documentation (F2F)

• Patient onboarding steps (consents, rights, assessments)

• Discharge criteria and safe transition processes

• Steps for handling unsafe or inappropriate referrals

Surveyors expect to see a consistent process that protects patients and prevents fraudulent admissions.

2. Patient Rights & Responsibilities Policy

Medicare CoPs §484.50 require agencies to provide all patients with clear, accessible information about their rights. This is one of the first items surveyors review.

Your policy should emphasize:

• The patient’s right to participate in their care

• Freedom from abuse, neglect, exploitation, and discrimination

• Privacy and confidentiality (HIPAA-compliant)

• The complaint/ grievance process and timelines for resolution

• Rights regarding advance directives and pain management

Every staff member must be trained to implement this policy, and proof of patient receipt must be in the clinical record.

3. Comprehensive Assessment & OASIS Policy

Under §484.55, home health agencies must complete a timely, accurate, and patient-specific comprehensive assessment that integrates OASIS when required.

Your policy must define:

• Assessment timeframes (start of care, resumption of care, recertification, discharge)

• Use of standardized OASIS-E data sets

• RN responsibility for the initial assessment and comprehensive assessment

• How the agency ensures accuracy, coding compliance, and quality data reporting

• How changes in patient condition are addressed and communicated

CMS places heavy emphasis on assessment accuracy because OASIS directly impacts patient safety, quality measures, and reimbursement under the Home Health Value-Based Purchasing (HHVBP) and PDGM.

4. Plan of Care (POC) Development & Review Policy

The plan of care is the center of all home health services. Under §484.60, your policy must outline how individualized POCs are created, approved, updated, and communicated.

Strong POC policies include:

• Physician oversight and signing requirements

• How disciplines collaborate to create a unified care plan

• Timeframes for POC updates when patient condition changes

• Interdisciplinary coordination processes

• Frequency of visits, interventions, measurable goals, and discharge planning

Surveyors closely audit POCs to ensure continuity, coordination, and medical necessity.

5. Infection Prevention & Control Policy

Every home health startup must have a robust infection control program under §484.70 that meets CDC and CMS requirements.

Your infection control policy should address:

• Standard and transmission-based precautions

• Staff competency in infection prevention

• Management of exposure to bloodborne pathogens

• PPE use and availability

• Environmental cleaning and bag technique

• Reporting of communicable diseases to public health authorities

This policy also supports your Emergency Preparedness Program, as infection control is closely tied to pandemic readiness.

6. Emergency Preparedness (EP) Policy & Program

Under §484.102, home health agencies must develop a fully compliant Emergency Preparedness Program, including policies for:

• Hazard vulnerability assessment (HVA)

• Evacuation, relocation, and shelter-in-place procedures

• Patient tracking and communication systems

• Backup power, water, and medical supply plans

• Staff roles during emergencies

• Annual testing of the EP plan:

  • One full-scale (or community-based) exercise

  • One tabletop exercise

Surveyors expect documented evidence of EP training and drills.

7. Personnel Qualifications, Training & Competency Policy

CMS requires agencies to verify staff qualifications under §484.80, including licensure, certifications, and background checks.

This policy must cover:

• Hiring standards for each discipline (RN, LVN, PT, OT, SLP, MSW, HHA)

• Skills competency evaluations (initial & annual)

• Orientation requirements

• Supervisory visit schedules (RN supervision of HHAs every 14 days)

• Ongoing education and professional development

• TB screening and health requirements

Your HR file audit process should also be integrated into this policy.

8. Clinical Documentation & Record Management Policy

Compliance with §484.110 requires agencies to maintain complete, accurate, and timely medical records. This policy is essential for preventing denials and supporting quality care.

Documentation policies should address:

• Timeframes for documentation completion (usually 24–48 hours)

• Signature requirements (electronic and manual)

• Requirements for visit notes, care coordination, and communication documentation

• Storage, privacy, and HIPAA compliance

• Coding and billing documentation requirements

CMS surveyors and auditors rely heavily on documentation to assess compliance.

9. Quality Assurance & Performance Improvement (QAPI) Policy

Every home health agency must have a fully operational QAPI Program under §484.65.

This policy must clearly outline:

• Performance improvement projects (PIPs)

• Indicators the agency will measure (e.g., OASIS outcomes, adverse events)

• Data collection and analysis methods

• Governing body involvement and approval

• Annual evaluation and reporting structure

• How the agency uses QAPI to improve patient care and reduce risk

Surveyors often cite agencies for poorly developed or inactive QAPI programs.

10. Medication Management Policy

Even if your agency does not administer medications, you must demonstrate safe processes for:

• Medication reconciliation

• Patient/caregiver medication teaching

• Monitoring for adverse reactions

• Handling high-risk medications

• Communication with prescribers regarding discrepancies

CMS focuses heavily on medication safety because medication-related incidents are one of the most common causes of avoidable hospitalizations.

Additional Policies Recommended for Strong Compliance

While not part of the top 10, the following policies significantly increase survey readiness and operational safety:

• Abuse, Neglect & Exploitation Prevention Policy

• HIPAA Privacy & Security Policy

• Clinical Supervision Policy

• Incident & Accident Reporting Policy

• Corporate Compliance & Ethics Program

• Financial & Billing Compliance Policy

• Telehealth/Remote Care Policy (if applicable)

• Advance Directives Policy

• Bag Technique Policy

• Hazard Communication/OSHA Safety Policy

Agencies with a complete, well-organized policy library have a much higher success rate during surveys and Medicare certification.

Why These Policies Matter

Opening a home health agency requires more than simply hiring clinicians and seeing patients. Surveyors will review all required policies before licensing, and Medicare accreditation cannot move forward without complete, compliant documents.

These policies:

• Ensure patient safety

• Reduce liability

• Allow your agency to pass state and federal surveys

• Provide consistent standards for staff

• Support operational stability

• Protect against fraud, waste, and abuse

• Lay the foundation for Medicare certification and reimbursement

The difference between a compliant agency and a non-compliant one begins with the strength of these core policies.

Conclusion

Developing the required policies to open a home health agency is a complex, detail-driven process that must align with the Medicare Conditions of Participation and state regulations. Agencies that invest in high-quality policies experience smoother surveys, stronger clinical outcomes, and long-term operational success.

If you need fully customized, Medicare-compliant policies, operational manuals, or survey-ready documentation:

SummitRidge Consulting

provides end-to-end policy development, licensing support, Medicare certification preparation, QAPI program setup, HR compliance, and ongoing operational management solutions.