Top 10 Survey Deficiencies in Home Health—and How to Stay in Compliance

Discover the most commonly cited home health survey deficiencies from Accreditation Standards and practical strategies your agency can implement to stay compliant with Medicare and accreditation standards.

6/20/20253 min read

Top 10 Survey Deficiencies in Home Health—and How to Stay in Compliance
Top 10 Survey Deficiencies in Home Health—and How to Stay in Compliance

Survey readiness is essential for maintaining certification and delivering high-quality care in the home health setting. Whether you're preparing for a routine survey or trying to strengthen your internal operations, understanding common areas of non-compliance can help your agency avoid citations, delayed payments, and reputational risk.

This guide outlines the top 10 most frequent deficiencies found during home health surveys—along with practical steps your team can take to stay compliant.

1. Incomplete or Inaccurate Medication Profiles

What Goes Wrong:

  • Missing dosage, route, frequency, or start/stop dates

  • Medications listed that the patient no longer takes

  • Lack of review for drug interactions or duplications

How to Stay in Compliance:

  • Reconcile medications during every visit

  • Review with both the patient and the plan of care

  • Clearly document changes, and flag discrepancies for follow-up

2. Missing or Incomplete Plan of Care

What Goes Wrong:

  • Therapy goals and visit frequency not included

  • Disciplines listed on orders but not documented in the plan

  • Measurable outcomes missing

How to Stay in Compliance:

  • Ensure every care plan includes frequency, interventions, measurable goals, DME, and medications

  • Update care plans promptly when a patient’s condition changes

  • Coordinate between nursing, therapy, and aide services

3. No Written Instructions Provided to Patients or Caregivers

What Goes Wrong:

  • Patients are unsure how to care for wounds or manage exercises

  • Visit frequency and staff contact information not communicated

  • Medication instructions are unclear or written in shorthand

How to Stay in Compliance:

  • Provide written care instructions at the start of care

  • Include frequency of visits, emergency contacts, and key interventions

  • Ensure patients and caregivers understand the materials (consider translation if needed)

4. Skilled Services Not Properly Documented

What Goes Wrong:

  • Missing progress notes or clinical details from visits

  • Patient education not documented

  • Services ordered but never documented as completed

How to Stay in Compliance:

  • Document every skill performed and how the patient tolerated it

  • Include education topics, responses, and follow-ups

  • Review documentation during interdisciplinary case conferences

5. Inadequate Transfer or Discharge Planning

What Goes Wrong:

  • Summaries are incomplete or delayed

  • The required notice of non-coverage isn’t issued

  • Receiving provider doesn’t receive documentation

How to Stay in Compliance:

  • Use a discharge or transfer checklist to ensure every element is addressed

  • Issue required notices at least 48 hours in advance

  • Send clinical summaries to the patient’s next provider within policy timeframes

6. Disorganized or Incomplete Patient Records

What Goes Wrong:

  • Clinician signatures missing or illegible

  • Visit times not documented

  • Progress toward goals not clearly described

How to Stay in Compliance:

  • Ensure every entry includes a full signature, credentials, and date

  • Document patient response and goal progression in every visit note

  • Conduct routine audits for documentation completeness

7. Services Not Delivered as Ordered

What Goes Wrong:

  • Aides or clinicians skip tasks or perform care not listed in the care plan

  • Inconsistent care delivery from visit to visit

  • Orders not followed or updated after changes in patient condition

How to Stay in Compliance:

  • Match each visit to the established plan of care

  • Update aide care plans whenever goals or interventions change

  • Educate staff on scope of practice and required documentation

8. Poor Infection Control Practices

What Goes Wrong:

  • Lapses in hand hygiene during home visits

  • Improper bag technique

  • Incorrect disinfectant use or exposure times

How to Stay in Compliance:

  • Provide refresher training on infection control quarterly

  • Audit staff in the field for handwashing and bag technique

  • Post disinfectant guidance in clinician kits and EMRs

9. Delays in Completing Initial Assessments

What Goes Wrong:

  • Assessments not completed within required timeframes

  • Patient strengths, preferences, or risk factors overlooked

  • Incomplete identification of necessary services

How to Stay in Compliance:

  • Complete the comprehensive assessment within 5 days of SOC

  • Include patient preferences, functional limitations, and psychosocial needs

  • Use alerts or EMR flags to track assessment deadlines

10. Care Plan Not Reviewed or Updated After Changes

What Goes Wrong:

  • Changes in patient status not reflected in updated care plan

  • No physician orders for modified goals or interventions

  • No evidence of interdisciplinary team collaboration

How to Stay in Compliance:

  • Reassess care plans after every hospitalization or condition change

  • Document physician communication for updated orders

  • Ensure all disciplines are aware of and working from the current plan

Final

Survey deficiencies are often the result of workflow gaps—not bad intentions. The good news is that each of these common issues can be corrected with strong policies, team training, and ongoing internal review.

At HealthBridge, we specialize in helping home health agencies prepare for surveys, correct deficiencies, and implement sustainable compliance programs. Whether you need mock surveys, documentation audits, or staff education, our team is here to help your agency succeed.