12 high-frequency Conditions of Participation areas CMS surveyors focus on during HHA audits.
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The 12-Point Checklist
Answer Yes, No, or Skip for each item.
Built by Tiffany Simpson — Respiratory Therapist & CPD-Certified AI Consultant, Luminous AI Consulting
Patient Rights
Written patient rights & responsibilities notice provided at the initial evaluation visit, in advance of furnishing care — per 42 CFR §484.50(a)(1)
Patient rights notice in a language/manner the patient understands
OASIS & Assessment
OASIS completed within the 5-day SOC window
OASIS data transmitted to the state within 30 calendar days
Care Planning
Individualized plan of care within 5 days of SOC
Plan of care signed by physician before billing
Plan of care reviewed/updated every 60 days
Infection Prevention
Written infection prevention & control program on file
PPE accessible to all field staff
Home Health Aides
75-hour training + 16 hours clinical supervision documented
Aide supervisory assessment every 14 days when the patient is receiving skilled services (every 60 days for non-skilled cases) — per 42 CFR §484.80(h)
Behavior — The One Nobody Checks
Every staff member can recite the protocol if a CMS surveyor arrives unannounced today
"I worked bedside as a respiratory therapist before building Luminous. I've watched good agencies get caught flat-footed by surveyors on the same 12 items. This checklist is how we stop that."
— Tiffany Simpson, Founder