Are Deficiencies Dogging Your Home Health Agency?

For a home health agency (HHA) to operate, it must be in compliance with the Medicare Conditions of Participation (CoPs).  Of course, it is difficult for agencies to comply with many of the new home health CoPs; therefore, to ensure compliance, a home health agency is subjected to unannounced on-site agency surveys.  These surveys determine if the HHA meets the minimum health and safety standards, delivers patients services, and achieves positive patient outcomes.  After the survey, the HHA receives a summary of findings (SOF) and/or statement of deficiencies (SOD) requiring a Plan of Correction (POC).  This first blog in our series on “How to Write a POC”, we will explore the different classes and types of deficiencies a HHA may experience.

Classifications of Deficiencies

In today’s home health industry, it is almost unheard of that no deficiencies are cited after a survey.  However, the seriousness of the different deficiencies varies quite a bit.  Below are details about the three classifications of home health deficiencies:

  • Standard-Level Deficiency means noncompliance with one or more of the standards that make up each Condition of Participation for HHAs. Some common deficiencies include:
      • Aide not following the Aide Care Plan
      • Not following physician orders
      • Breaking infection control technique on a home visit
      • No medication reconciliation

While writing the POC, keep in mind that the date of compliance will be typically within 30 – 60 days from the date the HHA received the summary of findings/statement of deficiencies.  The Plan of Correction must be approved by the regulatory body citing the standard level deficiency.  Most of the time, there is no follow up survey for Standard-Level Deficiencies.

  • Condition-Level Deficiency is a more serious type of deficiency cited, and is issued if a surveyor determines that a HHA is not in compliance with a Condition, such as not having a formal agency wide QAPI program. A Condition-Level Deficiency may be cited if a HHA receives two – three (or more) Standard-Level Deficiencies.  An example of this is if under the Aide Condition.  For example, the aide does not follow the Aide Care Plan, the Aide Care Plan is not completed specifically, and/or the aide supervisory visits are not timely.  The date of compliance must typically be within 10 calendar days from the date the agency received the summary of findings/statement of deficiencies.  A return survey visit will be made by Day 45 from the last day of the survey, and the agency must show that they are in substantial compliance.

If a Condition-Level Deficiency is not cleared, this could affect the agency’s Medicare certification, as this may indicate that the provider is not able to furnish adequate care or adversely affects the health or safety of patients.

  • Immediate Jeopardy (IJ) is defined by CMS as “a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient.” Once a HHA receives an IJ rating, a follow up survey will typically be conducted within 7-21 days, and the POC survey will have to provide evidence that the deficient findings have been corrected.  The Plan of Correction must also be completed after the survey report is received.  However, often the return survey is occurring concurrently due to the short time period.  Keep in mind that an IJ can be and often is cited for potential harm to a patient.  We have seen recently where an IJ was cited due to adverse conditions or changes assessed in patients in which the clinicians did not notify the physician (i.e. high blood glucose readings, low blood pressure, increasing wound drainage).  If the surveyor does not see this immediate compliance in the HHA, which many times involves policy/process changes, education, performance improvement projects, etc., CMS can terminate the HHA’s Medicare certification.


Both monetary and non-monetary sanctions may be given to a HHA for Condition-Level Deficiencies and will be given for Immediate Jeopardy situations.  Non-monetary can include temporary management, directed Plan of Correction and/or education.  A monetary sanction can range from $500- $21,000 per day, which is fined until the deficiencies have been cleared.  In addition, there is a suspension of payments for new admissions.  This, of course, is a tremendous burden for home health agencies.

When an agency receives a Condition-Level Deficiency or IJ, they may not competency their home health aides for two years.  This is not related to solely Aide Deficiencies, but for any Condition-Level Deficiency; therefore, the HHA must contract outside to have their aides competencied.

It is of course critical for agencies to be in continual survey readiness so that they are not vulnerable to receiving Condition Level-Deficiencies, and particularly Immediate Jeopardy.  The stress and financial burden to an agency are excruciating.  So be prepared!  Mock surveys are the best method to ensure that an agency is not vulnerable.  These should be done annually.  An agency can conduct their own annual self-assessments and then have an objective expert, such as 5 Star Consultants, perform a mock survey every three years at minimum.  This mock survey should always be performed at least six months prior to its next scheduled survey so that areas found can be fixed in a realistic timeframe.

Next Steps

When an HHA has been cited with deficiencies, then a POC is the next step.  However, you may ask what is involved with a Plan of Correction?  Our next blog will provide details about this important document.  However, if you have an immediate need, please contact us today [email protected] or 866-428-4040. The 5 Star team of experts can help your team through the critical POC step now!

Southern Web SupportAre Deficiencies Dogging Your Home Health Agency?
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