CMS Guidelines for Home Health: A Comprehensive Guide for Home Health Agencies

As the demand for home health services continues to rise, so does the complexity of regulations that agencies must follow to stay in compliance. Meeting these requirements is crucial for delivering high-quality care, maintaining patient trust, and securing Medicare reimbursements.

In 2021, there were 11,474 Medicare-certified home health agencies throughout the United States, with approximately 3 million Medicare Fee-for-Service (FFS) beneficiaries using home health care. For these agencies and those that followed, understanding and adhering to the guidelines set by the Centers for Medicare & Medicaid Services (CMS) is essential for compliance and providing top-notch care.

This article provides an overview of the CMS guidelines for home health care and Medicare coverage criteria, as well as strategies agencies can implement to uphold standards, navigate regulatory requirements, and enhance their quality of care.

Defining home health care

While home health professionals are familiar with the general concept of home health services, understanding the precise CMS definition is crucial for compliance and reimbursement. CMS defines home health care as healthcare that skilled professionals provide to patients in their homes, including nursing care, physical, occupational, and speech therapy, as well as medical social services.

Home health care, typically intermittent and part-time, helps patients manage their conditions independently for either short-term recovery or long-term maintenance. Services are guided by a comprehensive plan of care and treatment plan developed with the patient's doctor and home health staff. The doctor oversees and approves any changes to the plan as needed. 

The need for home health care is growing as medical technology allows treatments once restricted to hospitals to be delivered at home. Home health services are often more cost-effective and equally effective, with the added benefit of allowing patients to stay in a comfortable, familiar environment. 

Medicare coverage criteria for home health care

Medicare coverage for home health care services is governed by specific eligibility criteria. These criteria ensure that the services are appropriate and qualify for reimbursement. To be eligible for home health benefits under Medicare, the patient must:

• Be under a doctor’s care or qualified healthcare provider (such as a nurse practitioner, clinical nurse specialist, or physician assistant) who establishes and regularly reviews a personalized care plan.
• Have a certified need for skilled care: Have a healthcare provider certify that they require intermittent skilled nursing care (excluding blood draws), physical therapy, speech-language pathology, continued occupational therapy, or home health aide services.
• Receive care from a Medicare-certified home health agency in good standing.
• Meet homebound status: Have a provider certify that they are homebound, meaning they have difficulty leaving home without assistance (such as a cane, wheelchair, or help from another person) due to illness or injury, or leaving home is not recommended because of their condition.
• Have a documented face-to-face encounter: Have a doctor or qualified healthcare provider document a face-to-face encounter within the required timeframes related to the need for home health care.

In addition, it’s important to note that Medicare only covers "part-time or intermittent" care, defined as care needed less than seven days a week or daily for less than eight hours a day, for a maximum of 21 days. Patients requiring full-time or long-term skilled nursing care don’t qualify for home health benefits.

Covered services for home health

If a patient meets the eligibility requirements outlined above, they qualify for Medicare home health benefits. However, Medicare coverage extends only to specific services that meet particular criteria. The following are the core home health services Medicare covers:

• Skilled nursing care: Care provided by a nurse, such as administering IV drugs, injections, tube feedings, or wound care, that requires specialized skills and is given on a part-time or intermittent basis.
• Therapy services: Physical, occupational, and speech-language therapy provided by or under the supervision of a qualified therapist to restore or maintain function or prevent deterioration if they are safe and effective treatments.
• Home health aide services: Part-time or intermittent personal care services (like help with bathing or dressing), eligible when the patient also receives skilled care such as nursing or therapy services.
• Medical social services: Services ordered by a doctor to help with social or emotional concerns affecting recovery, provided only when the patient is also receiving skilled care.
• Medical supplies and equipment: Medicare covers most of the cost of supplies (like wound dressings) and certain medical equipment (like wheelchairs or walkers) if ordered by a doctor as part of the care plan.

Note that Medicare doesn’t cover services solely for personal care, such as bathing or dressing, if these are the only services required. Additionally, 24-hour care, meal delivery, and homemaker services (like shopping, cleaning, or laundry) are not covered unless part of a broader care plan.

CMS guidelines for home health: certification and operational standards

To qualify for Medicare and Medicaid reimbursement, home health agencies must meet foundational requirements set by CMS. These Conditions of Participation (CoP) establish the core health and safety standards agencies must meet to provide CMS’ definition of safe, high-quality care. Meeting these standards is crucial for maintaining certification and providing patients with consistent, compliant service.

Below are some key operational guidelines that home health agencies must follow to remain compliant with CMS requirements. (Note that this list is not exhaustive; please refer to the official CoP for complete requirements).

Home health care agency provider certification

To become a certified Home Health Provider, agencies must meet the CoP, including providing skilled nursing and therapeutic services, maintaining clinical records, and ensuring supervision by a physician or registered nurse. Agencies must also comply with state licensing requirements, develop a comprehensive plan and budget, and adhere to federal standards for patient health and safety to qualify for federal reimbursement.

Patient rights and responsibilities

Home health agencies are required to protect and promote patient rights by providing information about rights in an accessible format and language, maintaining privacy and confidentiality, and allowing participation in care planning. Patients have the right to choose their home health agency, be treated with respect and dignity, receive information about their care in a way they understand, and file complaints or appeals if needed.

Infection control

Home health agencies must implement a comprehensive Infection Control Program to ensure a safe environment and prevent the transmission of diseases. This program should include the surveillance, investigation, and management of infections, standard and transmission-based precautions, proper hand hygiene practices, and the safe handling of medical waste and linens. Agencies must also provide regular education and training to staff, patients, and caregivers on infection control practices.

Emergency preparedness

Home health agencies must establish a comprehensive emergency preparedness program to ensure patient and staff safety during emergencies. The plan should include an all-hazards risk assessment, coordination with local, state, and federal emergency services, and policies for patient care continuity. Agencies must maintain a communication plan, provide regular training, and conduct testing exercises at least every two years to ensure readiness and compliance.

Clinical record-keeping

Home health agencies must maintain accurate and comprehensive clinical records for each patient, including assessments, care plans, services provided, and patient progress. Records must be legible, authenticated, and retained for at least five years. They must be safeguarded against loss or unauthorized use and accessible to patients upon request, in compliance with CMS and HIPAA regulations.

CMS guidelines for home health: key programs for quality assessment and improvement

Alongside the foundational certification and operational standards, CMS requires home health agencies to participate in certain programs to monitor compliance and maintain quality. Some programs are mandatory under the CoP, while others promote ongoing quality improvement and transparency.

The following programs are central to evaluating and supporting high-quality care in home health agencies:

Home health care agency providers

To become a certified home health provider for Medicare and/or Medicaid, agencies must comply with the CoP. This involves maintaining a proper organizational structure, respecting patient rights, and meeting established care standards. Agencies are required to have an effective administrative framework that supports quality care delivery, clear communication, and adequate staffing.

In addition, compliance with all relevant federal, state, and local laws — especially those related to health and safety, patient privacy, and billing practices — is essential. Certification under these guidelines ensures agencies provide consistent, high-quality care and are eligible for Medicare and Medicaid reimbursement. By adhering to these standards, agencies affirm their commitment to patient safety, effective care, and regulatory accountability.

Home health quality reporting program

The Home Health Quality Reporting Program (HHQRP) is designed to ensure high standards of care by requiring home health agencies to submit data on specific quality measures. 

The HHQRP reporting requirements focus on the Outcome and Assessment Information Set (OASIS), a standardized tool for assessing patients' health status at different points during their care. OASIS data helps CMS evaluate the effectiveness of the patient’s care and monitor agency compliance with federal requirements.

To determine compliance with OASIS requirements, complete data is needed from the entire "quality episode" or course of care for each patient, including assessments at the following points:

• Start of Care (SOC)
• Resumption of Care (ROC)
• End of Care (EOC) 

To maintain certification, agencies must achieve a compliance rate of at least 90 percent, calculated using Quality Assurance and Performance Improvement (QAPI) metrics. Failing to meet this rate can affect the agency's eligibility for Medicare reimbursement.

Home health quality measures

As part of its review of HHQRP reports, CMS evaluates home health agencies on three categories of home health measures:

• Outcome measures: These measures focus on care results, such as improvement in patients' mobility, self-care abilities, or reduced hospitalizations, providing insight into how well the agency achieves desired health outcomes.
• Process measures: These evaluate whether agencies follow best practices and protocols during care delivery, including metrics like timely initiation of care, adherence to clinical guidelines, and effective management of patient symptoms.
• Patient-reported outcomes: These measures capture feedback directly from patients about their care experiences, satisfaction, and overall perception of the quality of care provided, and help gauge the effectiveness of patient engagement and communication strategies.

By analyzing these measures, CMS ensures that agencies provide consistent, high-quality care and identifies areas for improvement.

Home health star ratings

The Home Health Star Rating system rates agencies from one to five stars based on their performance on various quality metrics, with five stars indicating the highest level of quality. These ratings are publicly accessible on Medicare’s Care Compare website, allowing patients to compare agencies and make informed decisions.

Home health agencies can use their star ratings to identify specific areas for improvement, such as patient care processes or communication practices. Focusing on areas that impact their rankings — like enhancing patient outcomes, improving adherence to care protocols, and increasing patient satisfaction — can help agencies boost their star rating and attract more clients.

How to implement CMS guidelines for home health care

To meet CMS guidelines and deliver exceptional home health care, agencies must go beyond basic compliance. By focusing on continuous improvement, transparent communication, and specialized care, agencies can enhance service quality, ensure patient satisfaction, and maintain a strong community reputation.

Below are several key strategies to help your agency achieve these goals.

Strengthen your infection control program

A thorough infection control plan that aligns with CMS requirements is essential for effectively managing and preventing infections. Such a program not only ensures compliance but also protects both patients and staff, reinforcing your agency’s commitment to safety and quality care.

Action steps:

• Establish comprehensive protocols for hand hygiene, PPE use, and medical equipment disinfection. Regularly update these protocols to reflect the latest CDC guidelines.
• Incorporate routine infection surveillance and reporting into your Quality Assurance and Performance Improvement (QAPI) program to quickly identify and respond to potential outbreaks.
• Educate staff, patients, and caregivers on infection prevention. Infection control training should be consistent, meet compliance standards, and be developed by experts like registered nurses or infection control professionals.

Build a solid emergency preparedness plan

An effective emergency preparedness plan is essential for protecting patients and staff during emergencies. Not only does it meet CMS requirements, but it also demonstrates your agency’s readiness to handle crises and strengthens your credibility.

Action steps:

• Conduct regular risk assessments to identify potential hazards and update your emergency plan based on the findings.
• Develop detailed policies for maintaining operations, patient care continuity, and communication with local emergency services. Ensure your plan covers different scenarios, such as natural disasters or pandemics.
• Train all staff on emergency procedures and conduct regular drills. Continuously review and revise the plan to incorporate lessons learned from drills or actual emergencies.

Enhance patient rights and communication practices

Promoting patient rights and effective communication is fundamental to delivering high-quality home health care. Clear communication fosters trust and satisfaction, aligns with CMS standards, and strengthens relationships with patients and their families.

Action steps:

• Create clear, accessible protocols for informing patients about their rights, such as the right to choose their home health agency, privacy, and participation in their care. Ensure information is available in formats and languages patients understand.
• Implement training programs that enhance staff communication skills, focusing on engaging patients in care planning and decision-making. Regularly update these programs to maintain high standards.

Optimize your quality reporting and improvement efforts

Providing exceptional care and maintaining compliance requires continuous quality improvement. Effective and timely quality reporting helps agencies maintain certification, enhance patient outcomes, and stay competitive.

Action steps:

• Use tools like OASIS to monitor performance on quality measures such as patient outcomes, care processes, and patient satisfaction. Identify areas for improvement and set specific, measurable goals.
• Regularly analyze quality data to track progress and refine care practices as needed to meet CMS standards.
• Engage staff in the quality improvement process by providing training on data collection and analysis and reinforcing the importance of continuous improvement.

Maximize your home health star ratings

High star ratings can be a powerful tool for attracting new clients and demonstrating quality. They serve as a benchmark for your agency's performance and build trust with prospective clients, helping to establish your agency as a leader in quality care.

Action steps:

• Regularly monitor your agency’s star ratings on Medicare’s Care Compare website and include them in marketing materials to showcase your commitment to quality.
• Identify key areas that affect your star rating, such as patient care processes or communication practices, and focus on targeted improvements.
• Use patient feedback from the HHCAHPS survey to identify areas for enhancement, like communication and care coordination, to increase overall satisfaction.

Ensure high-quality caregiver training and accreditation

Accreditation and ongoing education for caregivers are critical for maintaining high standards of care. Proper HHA training helps caregivers deliver safe, effective care, meet regulatory requirements, and enhance patient satisfaction and trust.

Action steps:

• Use training programs developed by industry experts, such as registered nurses, to ensure they meet compliance standards and reflect current best practices. Incorporate a mix of online and in-person sessions.
• Emphasize critical HHA skills and compliance areas like infection control, patient rights, and emergency preparedness, and offer specialized training for managing specific conditions like dementia or diabetes.
• Conduct regular evaluations and refresher courses to ensure caregivers consistently meet high standards and are prepared to address patient needs effectively.

CareAcademy: your partner in CMS compliance and high-quality home health care

Selecting a top-tier home health agency is vital to ensuring safe, effective care that meets CMS guidelines. CareAcademy supports home health agencies by providing continuous caregiver education that enhances care quality and keeps staff current on the latest industry practices and regulatory requirements.

With CareAcademy’s comprehensive training platform, agencies can confidently meet federal and state compliance standards while fostering improved patient outcomes and maintaining their reputation for excellence.

Ready to equip your team with the tools they need for success? Call our resident experts today to learn more about how our training solutions can help your agency stay compliant and deliver the highest quality care.