➾

Fill in Your Home Health Audit Template

The Home Health Audit form is a crucial tool used to evaluate the quality and compliance of home health care services. It ensures that all necessary documentation and procedures are in place for patient care, from admission to discharge. By systematically reviewing these elements, agencies can maintain high standards of care and meet regulatory requirements.

Table of Contents

The Home Health Audit form serves as a comprehensive tool designed to ensure that home health agencies comply with regulatory requirements and maintain high standards of patient care. This form encompasses various critical components that assess the quality and completeness of medical records. It includes sections for evaluating patient admission processes, such as the timely initiation of care and the completion of necessary documentation, like the Patient Referral Sheet and the Pre-Admit Physician Order. Additionally, the form requires auditors to verify that diagnoses are accurately recorded and supported by appropriate medical necessity. It emphasizes the importance of signed agreements, consent forms, and acknowledgment of patient rights. The audit also addresses the ongoing management of patient care, including documentation of skilled nursing visits, therapy evaluations, and medication profiles. Each element is designed to capture essential information that reflects compliance with agency policies and ensures that patient needs are met effectively. Moreover, the form incorporates measures for assessing care quality, such as pain assessments and fall risk evaluations, which are crucial for enhancing patient safety and outcomes. Ultimately, the Home Health Audit form is an essential instrument for maintaining accountability and improving the quality of home health services.

Sample - Home Health Audit Form

Home Health Medical Records Audit Form	(Updated for CY2013)
Auditor’s Name/Title: ________________________________________________________
Date: ___________________________

Yes

N/A MR #

Comments

Admission

1.Patient Referral Sheet Complete Timely Initiation of Care

Face to Face Encounter Within 90 Days To SOC

Face to Face Encounter Within 30 Days To SOC

History of Physical Present

2.Pre‐Admit Physician Order –

Signed, Dated or VO signed by RN + Physician

3.Primary DX M1020 Secondary M1022 M1022

M1022

Any Codes 401.1 Any Codes 401.9

All DX Supported & Sequenced Properly

4.Medication (N)ew and (C)hanged Interactions – Included Food/OTC

5.Admission consistent with Agency Admission Policies

6.Patient/Client Service Agreement – Signed, Dated & Complete

7.Insurance Screening Form – Signed & Complete

8.Medical Necessity Noted

9.Acknowledgement, Receipt & Explanation of the Items Below:

a.Home Care Patient Rights & Responsibilities

b.Privacy Act Statement‐Health Care Care Records

c.Complaint Procedure

d.Authorization for Use or Disclosure of Health Information (if applicable)

e.Statement of Patient Privacy Rights (OASIS)

f.Consent for Collection & Use of Information (OASIS)

Yes	No	N/A	MR #	Comments

g.Emergency Preparedness Plan/Safety Instructions

h.Advance Directives & HHABN

10. Complete Post Evaluation –

D/C Summary Report by RN/PT/OT/ST on:

a. Start of Care

b. Resumption of Care

c. Recertification

Plan of Care 485

11.Plan of Care Signed & Dated by Physician Within 30 Working Days or State Specific days‐ ________

12.Diagnoses Consistent with Care Ordered

13.Orders Current

14. Focus of Care Substantiated

15.Daily Skilled Nurse Visit Frequencies with Indication of End Point

16. Measurable Goals for Each Discipline

17. Tinetti or TUG Completed at SOC

18. Recertification Plan of Care Signed &

Dated Within 30 Days or State Required

Time

19.BiD Insulin Visits Documented with Vision, Musculoskeletal Need, Not Willing/Capable Caregiver. MSW Every Episode

20. Skilled Nurse Consult

Medication Profile Sheet

21.Medication Profile Consistent with the 4 485

22. Medication Profile Updated at

Recertification, ROC, SCIC, Initialed &

Dated

23.Medication Profile Complete with Pharmacy Information

Physician Orders/Change Verbal Orders

24. Change/Verbal Orders Include Disciplines, Goals, Frequencies, Reason for Change, Additional Supplies as Appropriate

25.Change Orders Signed & Dated by Physician Within 30 Working Days

OASIS Assessment Form

26. Complete, Signed & Dated by:

___________________________

27.M2200 Answer Meets the Threshold for a Medicare High Case Mix Group

28. M1020 & M1022 Diagnoses & ICD‐9 are Consistent with the Plan of Care

Yes	No	N/A	MR #	Comments

29.All OASIS Assessments Were Exported Within 30 Days

30. OASIS Recertifications Were Done

Within 5 Days of the End of the Episode

31.All OASIS Were Reviewed for Consistency in Coordination with the Discipline Who Completed the Form

Skilled Nursing Clinical Notes

32. Visit Frequencies & Duration are Consistent with Physician Orders

33.Orders Written for Visit Frequencies/ Treatment Change

34. Homebound Status Supported on Each Visit Note

35.Measurable Goals for Each Discipline with Specific Time Frames

36. Frequency of Visits Appropriate for Patient’s Needs & Interventions Provided

37. Appropriate Missed Visit (MV) Notes

38. Skilled Care Evident on Each Note

39. Evidence of Coordination of Care

40. Every Note Signed & Dated

41. Follows the Plan of Care (485)

42. Weekly Wound Reports are Completed

43. Missed Visit Reports are Completed

44. Pain Assessment Done Every Visit with Intervention (If Applicable)

45.Abnormal Vital Signs Reported to Physician & Case Managers

46. Evidence of Interventions with Abnormal Parameters/Findings

47.Skilled Nurse Discharge Summary/ Instructions Completed

48. LVN Supervisory Visit Every 30 Days by Registered Nurse

Certified Home Health Aide

49.Visit Frequencies & Duration Consistent with Physician Orders

50. Personal Care Instructions Documented,

Signed & Dated

51.Personal Care Instructions Modified as Appropriate

52. Notes Consistent with Personal Care Instructions Noted on the CHHA Assignment Sheet Completed by the RN/PT/ST/OT

53.Notes Reflect Supervisor Notification of Patient Complications or Changes

54. Visit Frequencies Appropriate for Patient Needs

Yes	No	N/A	MR #	Comments

55. Each Note Reflects Personal Care Given

56. Supervisory Visits at Least Every 14 Days by RN or PT

57. Every Note Signed & Dated

58. Assessment Includes Evaluation,

Care Plan & Visit Note

59.Evaluation Done Within 48 Hours of Referral Physician Order or Date Ordered

60. Visit Frequencies/Duration Consistent with Physician Orders

61.Evidence of Need for Therapy/Social Service

62. Appropriate Missed Visit (MV) Notes

63. Notes Consistent with Physician Orders

64. Evidence of Skilled Service(s) Provided

in Each Note

65.Treatment/Services Provided Consistent with Physician Orders & Care Plan

66. Notes Reflect Supervisor & Physician Notification of Patient Complications or Changes

67.Specific Evaluation & “TREAT” Orders Prior to Care

68. Verbal Orders for “TREAT” Orders Prior to Care

69.Homebound Status Validated in Each Visit Note

70. Notes Reflect Progress Toward Goals

71. Evidence of Discharge Planning

72. Evidence of Therapy Home Exercise

Program

73.Discharge/Transfer Summary Complete with Goals Met/Unmet

74. Assessment & Evaluation performed by Qualified Therapist Every 30 Days

75.Supervision of PTA/OTA at Least Every 2 Weeks

76. Qualified Therapy Visit 13th Visit (11, 12, 13)

77.Qualified Therapy Visit 19th Visit (17, 18, 19)

78. Every Visit Note Signed & Dated

SLP

79.Assessment Includes Evaluation, Care Plan & Visit Note

80. Evaluation Done Within 48 Hours of Referral Physician Order or Date Ordered

81.Visit Frequencies/Duration Consistent with Physician Orders

Yes	No	N/A	MR #	Comments

82. Evidence of Need for Therapy/Social Service

83. Appropriate Missed Visit (MV) Note

84. Notes Consistent with Physician Orders

85.Evidence of Skilled Service(s) Provided in Each Note

86. Treatment/Services Provided Consistent with Physician Orders & Care Plan

87.Notes Reflect Supervisor & Physician Notification of Patient Complications or Changes

88. Homebound Status Validated in Each Visit

Note

89. Notes Reflect Progress Toward Goals

90. Evidence of Discharge Planning

91.Evidence of Therapy Home Exercise Program

92. Discharge/Transfer Summary Complete with Goals Met/Unmet

93.Supervision of PTA/OTA at Least Every 2 Weeks

94. Every Visit Note Signed & Dated

Miscellaneous

95.Progress Summary Completed(30‐45Days) Each Episode Signed & Dated

96. Field Notes are Submitted & Complete

97. Chart in Chronological Order

98. Chart in Order per Agency Policy

99.Patient Name & Medical Records Number on Every Page

100. Physician Orders are Completed/ Updated for Clinical Tests Such as:

a. Coumadin: Protime/INR

b. Hemoglobin A1C

c. CBC, Metabolic Panel, CMP

d. Others: _______________________

101.Communication with Physician Regarding Test Results

Process Measures:

Timely Initiation of Care

Influenza Received

PPV Ever Received

Heart Failure

DM Foot Care & Education

Pain Assessment

Pain Intervention

Depression Assessment

Medication Education

Falls Risk Assessment

Pressure Ulcer Prevention

Pressure Ulcer Risk Assessment

Additional Comments/Recommendations ‐

__________________________________________________________________________________________________

THE FOLLOWING IS APPLICABLE FOR QUARTERLY MEDICAL REVIEW REPORT

REVIEWED AND SIGNED BY THE FOLLOWING DISCIPLINARY REPRESENTATIVE

______________________________________	______________________________________
Registered Nurse	Occupational Therapist (If Applicable)

______________________________________	______________________________________
Physical Therapist (If Applicable)	Speech Language Pathologist (If Applicable)

______________________________________	______________________________________
Medical Director	MSW (If Applicable)

MR # ______________________

↓ Home Health Audit PDF

File Specs

Fact Name	Details
Form Title	Home Health Medical Records Audit Form (Updated for CY2013)
Purpose	This form is used to evaluate compliance with home health care regulations and agency policies.
Key Components	The audit covers various aspects such as patient admission, medical necessity, care plans, and skilled nursing documentation.
Signature Requirements	Multiple sections require signatures and dates from healthcare professionals, including physicians and registered nurses.
State-Specific Regulations	Regulations may vary by state. For example, California requires the Plan of Care to be signed within 30 days.
Data Export Timeline	All OASIS assessments must be exported within 30 days of completion to ensure timely reporting and compliance.

Home Health Audit - Usage Guidelines

Filling out the Home Health Audit form is an essential step in ensuring compliance and maintaining high standards of care. By following the steps outlined below, you can complete the form accurately and efficiently.

Write the auditor's name and title at the top of the form.
Enter the date of the audit.
For each section, indicate "Yes," "No," or "N/A" as appropriate for each item listed.
Provide the medical record number (MR #) next to each item where applicable.
In the comments section, add any relevant notes or observations for each item.
Ensure that all required documents, such as the Patient Referral Sheet and Pre-Admit Physician Order, are signed and dated.
Review the patient's diagnoses and ensure they are consistent with the care ordered.
Check that the medication profile is complete and updated as needed.
Verify that all OASIS assessments are complete, signed, and dated.
Confirm that visit frequencies and durations are consistent with physician orders.
Make sure that each note reflects the personal care given and is signed and dated.
Complete the progress summary for each episode and ensure it is signed and dated.
Organize the chart in chronological order and ensure it follows agency policy.
Check that the patient's name and medical record number appear on every page of the documentation.
Submit the completed form and all supporting documents as required by agency policy.

Your Questions, Answered

What is the purpose of the Home Health Audit form?

The Home Health Audit form is designed to evaluate the quality and compliance of home health care services. It assesses various aspects of patient care, including documentation accuracy, adherence to care plans, and the timely execution of services. By using this form, agencies can ensure they meet regulatory requirements and provide high-quality care to their patients.

Who should complete the Home Health Audit form?

The Home Health Audit form should be completed by qualified auditors, typically individuals with experience in home health care operations. This may include registered nurses, compliance officers, or other healthcare professionals trained in auditing practices. Their expertise ensures that the audit is thorough and that any potential issues are identified and addressed.

How often should the Home Health Audit form be used?

What are the key components assessed in the Home Health Audit form?

Key components assessed in the Home Health Audit form include patient admission procedures, physician orders, medication management, and documentation of skilled nursing visits. The form evaluates whether all required signatures are present, if care plans are updated, and if patient rights and responsibilities are communicated effectively. Each section is crucial for ensuring that care is delivered safely and in accordance with established guidelines.

Common mistakes

Failing to complete the patient referral sheet accurately. This is a crucial document that sets the stage for the entire care process.
Not signing or dating the pre-admit physician order. This oversight can lead to significant delays in care initiation.
Inadequate documentation of medication interactions. It’s essential to include all relevant interactions, including food and over-the-counter medications.
Neglecting to ensure that the patient/client service agreement is signed and complete. This document is vital for establishing clear expectations between the agency and the patient.
Overlooking the acknowledgment of patient rights and responsibilities. Patients must be informed of their rights to ensure they receive appropriate care.
Failing to document skilled nurse visit frequencies accurately. This information is necessary to ensure that care meets the patient’s needs.
Not providing measurable goals for each discipline. Goals must be specific to track progress effectively and adjust care as needed.
Forgetting to include patient name and medical record number on every page of the audit form. This simple step is crucial for maintaining accurate and organized records.

Documents used along the form

In the realm of home health care, various forms and documents are essential for ensuring compliance, quality of care, and proper documentation. These documents work in conjunction with the Home Health Audit form to provide a comprehensive overview of patient care and agency practices. Below are several key forms that are commonly utilized alongside the Home Health Audit form.

OASIS Assessment Form: This form is critical for assessing patient needs and outcomes. It includes data on clinical status, functional status, and service utilization. The information gathered is vital for Medicare reimbursement and quality improvement initiatives.
Patient Service Agreement: This document outlines the terms and conditions of services provided to the patient. It ensures that patients understand their rights and responsibilities while receiving home health care, promoting transparency and trust between the agency and the patient.
Insurance Screening Form: This form verifies the patient’s eligibility for coverage under their insurance plan. It is essential for determining the financial aspects of care and ensuring that services are billed correctly to the appropriate payer.
Physician Orders: These are written instructions from the physician detailing the specific care and treatment required for the patient. They must be signed and dated, ensuring that all healthcare providers are on the same page regarding the patient’s care plan.
Skilled Nursing Clinical Notes: These notes document each visit made by nursing staff. They include details about the patient's condition, interventions performed, and any changes in care. This documentation is crucial for continuity of care and accountability.
Discharge Summary: This document summarizes the patient’s care and progress during their time with the agency. It includes information on goals met, ongoing needs, and any follow-up care required. A thorough discharge summary aids in ensuring a smooth transition for the patient post-care.

Each of these documents plays a vital role in the home health care process, contributing to effective communication, quality assurance, and compliance with regulatory requirements. By maintaining accurate and comprehensive documentation, agencies can enhance patient outcomes and foster a culture of accountability and excellence in care.

Similar forms

The Home Health Medical Records Audit Form shares similarities with the Patient Care Plan. Both documents focus on documenting the care provided to patients and ensuring that all necessary steps are taken to meet their needs. The Patient Care Plan outlines specific goals, interventions, and the responsibilities of healthcare providers, just like the Home Health Audit form emphasizes the importance of compliance with care protocols and documentation requirements. Both forms aim to ensure that patients receive consistent and high-quality care throughout their treatment.

Another document that aligns closely with the Home Health Audit form is the Quality Assurance Performance Improvement (QAPI) Plan. This plan is designed to monitor and improve the quality of care provided in home health settings. Similar to the Home Health Audit form, the QAPI Plan includes measures for evaluating patient outcomes, adherence to protocols, and staff performance. Both documents emphasize the importance of continuous improvement and accountability in delivering home health services.

The Plan of Care document is also comparable to the Home Health Audit form. The Plan of Care outlines the specific treatments and services a patient will receive, ensuring that all healthcare providers are on the same page. Both documents require signatures and dates from healthcare professionals to confirm that the care plan is understood and agreed upon. This ensures that all actions taken align with the patient's needs and the overall goals of their treatment.

Similarly, the OASIS Assessment Form is another document that shares a common purpose with the Home Health Audit form. OASIS assessments collect essential data about a patient's health status and care needs. Like the Home Health Audit form, OASIS assessments require timely completion and accuracy to ensure that care is appropriate and effective. Both documents are vital for compliance with regulations and for maintaining high standards of care.

The Skilled Nursing Clinical Notes are also akin to the Home Health Audit form. These notes provide detailed accounts of the services delivered during each visit, similar to how the audit form tracks compliance and care delivery. Both documents require documentation of patient interactions, interventions, and any changes in the patient's condition. This ensures that all care provided is recorded and can be reviewed for quality assurance purposes.

Another document that bears resemblance to the Home Health Audit form is the Patient Rights and Responsibilities document. This document outlines the rights of patients receiving home health care, ensuring they are informed and protected. Both the Patient Rights document and the Home Health Audit form aim to uphold patient dignity and safety while providing care. They serve as reminders of the ethical obligations healthcare providers have toward their patients.

Finally, the Discharge Summary is similar to the Home Health Audit form in that it documents the patient's progress and the outcomes of their care. The Discharge Summary includes information about the patient's condition at the time of discharge and any follow-up care needed. Like the Home Health Audit form, it emphasizes the importance of thorough documentation and communication among healthcare providers to ensure continuity of care as patients transition out of home health services.

Dos and Don'ts

When filling out the Home Health Audit form, consider the following guidelines:

Do ensure all sections are completed accurately.
Do double-check that all signatures and dates are present.
Do keep the patient's medical records organized and in chronological order.
Do verify that all diagnoses align with the care ordered.
Do include clear comments for any "N/A" responses.
Don't leave any section blank unless it is truly not applicable.
Don't forget to update medication profiles regularly.
Don't use abbreviations that may confuse the reader.
Don't submit the form without reviewing it for accuracy.

Misconceptions

Misconception 1: The Home Health Audit form is only for billing purposes.

This form serves a broader purpose. It ensures compliance with care standards, evaluates the quality of services, and helps maintain patient safety.
Misconception 2: All items on the form must be completed for every patient.

Not every section applies to all patients. Some items may be marked as N/A (not applicable) depending on individual circumstances.
Misconception 3: The form is only relevant for initial admissions.

The Home Health Audit form is used throughout the patient's care, including recertifications and discharges, ensuring ongoing compliance and quality.
Misconception 4: Completing the form is a one-time task.

Regular updates are necessary. The form must be revisited and updated as patient needs change or as new information becomes available.
Misconception 5: Only nurses need to complete the Home Health Audit form.

While nurses play a significant role, other healthcare professionals, such as therapists and social workers, also contribute to the audit process.
Misconception 6: The audit form is not important for patient care.

This form directly impacts patient care quality. It identifies areas for improvement, ensuring that patients receive the best possible services.
Misconception 7: The Home Health Audit form is the same across all agencies.

Different agencies may have unique requirements. While the core elements remain similar, specific items can vary based on agency policies and state regulations.

Key takeaways

When using the Home Health Audit form, several key points should be kept in mind to ensure accuracy and compliance. Here are the essential takeaways:

Complete Information: Ensure that all sections of the form are filled out completely, including the auditor’s name and date.
Timeliness: Pay attention to timelines, such as the face-to-face encounter requirements and the timeframes for signing the plan of care.
Documentation: Document all patient interactions and ensure that each note is signed and dated to maintain accountability.
Consistency: Verify that diagnoses and medication profiles are consistent with the plan of care and that any changes are properly documented.
Patient Rights: Ensure that patients receive and acknowledge their rights and responsibilities as outlined in the audit form.
Compliance with Policies: Confirm that all admissions and services align with agency policies and insurance requirements.
Coordination of Care: Evidence of coordination among healthcare providers should be documented to ensure comprehensive patient care.
Regular Reviews: Conduct regular reviews of OASIS assessments and care plans to ensure compliance with all regulatory requirements.