Most Common Home Health Deficiencies Across ACHC, CHAP, & TJC in 2024

Every day thousands of home health agency owners like you and their staff are preparing for or recovering from a survey. Regardless of which accreditor your agency chooses, all three national accreditors survey for conditional deficiencies, as well as their own additional standards. 

Even when you think you’ve covered all the bases, a surveyor can still walk in and uncover a deficiency you didn’t see coming. It’s frustrating, especially when you feel like your team is already stretched thin trying to do everything right. You might be wondering, “What are we missing?”

At The Home Health Consultant, we work with agency owners every day to strengthen operations and prepare for survey success, regardless of their choice of accreditor. That’s exactly why we created this guide. With decades of combined experience in home health leadership, compliance, and accreditation readiness, our team knows what surveyors are really looking for.

In this article, we’ll break down:

• the most common home health deficiencies shared by CHAP, ACHC, and The Joint Commission,
• what these deficiencies can look like in practice, 
• …and most importantly, how to fix them before they cost you.

By the end of this article, you'll have a list of 10 common deficiencies to keep an eye out for and know how to proactively prevent them in your agency.

1. Incomplete or Poorly Individualized Plan of Care

What it looks like:
Plans of care lack patient-specific goals, are vague or generic, and don’t reflect the comprehensive assessment (e.g., “improve mobility” with no measurable goals).

How to address it:

• Ensure all plans are individualized based on the patient's assessment. Include specific assessment items and the exact patient status for those items.
• Use SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound).
• Include due dates for goals.
• Include starting status and exact goal status in the plan of care.

For example, let’s say a patient can initially walk 5 feet independently. In this case, an individualized goal may be to walk 15 feet independently. “Improve walking” is not an individualized goal.

• Verify inclusion of all ordered disciplines, services, medications, and visit frequencies.
• Educate staff on what a complete plan looks like 
• Include a section at the end of the care plan (often “Item 99”) to describe the patient and their living situation, medical history and specifics of their condition.

For example, “Patient is a 99 year old female, living at home with her husband and daughter, with a history of (list specific DX)...”. Include any details that add information for treating clinicians, that would individualize the care plan further.

2. Failure to Provide Timely or Complete Written Instructions to Patients

What it looks like:
Patients don’t receive complete visit schedules, medication instructions, or contact information at start of care (SOC) or throughout care.

How to address it:

• Standardize packets that include visit frequency, med/treatment instructions, and emergency contacts.
• Send a copy of the care plan to review with the patient. Also keep a copy of the care plan in the patients home folder. 
• Make sure the patient has a visual calendar of visit frequencies for all disciplines. This doesn’t have to match how the visits will ultimately fall, but should demonstrate how the overall schedule is structured.  
• Train all staff (including contractors) to review this in the home.
• Use supervisory visits to confirm compliance.
• Provide company approved teaching materials online. This makes it easier for clinicians to access and print what they need. They then provide these materials to the patient. 

3. Inadequate or Untimely Documentation in the Clinical Record

What it looks like:
Late documentation, missing visit notes, or incomplete records that don’t support the care provided.

How to address it:

• For staff with pending documentation, at payroll, print physical paychecks and require in-person pickup. This is a great way to get staff to drop off notes, discuss any missing or pending items, and address any pending documentation adjustments.
• Do not pay for visits with missing or incomplete documentation, until it is completed. The “job” is the visit plus the document.
• Give an “on-time” bonus to staff members. You can add $1-5 per timely submission.
• Use EMR alerts or checklists to ensure completeness (e.g., medication changes, allergies, interventions).
• Perform ongoing chart audits and give timely feedback.
• Dedicate a staff member to call and follow up daily on all pending documentation. Field staff often prioritize the agency that is persistent (even if it’s just to get you off their backs).
• If the field clinician is full time with your company, have them start every day from the office, with a required one hour of documentation. 

4. Missed or Delayed Start-of-Care Assessments

What it looks like:
Initial assessments are completed outside the required 48-hour window or outside as directed by the physician.

How to address it:

• Develop tracking systems to flag pending SOCs.
• Ensure scheduling and clinical staff are trained on assessment timelines.
• If visits are scheduled later than the allowed referral window, add MD orders to explain why. Make sure you include the decided upon date of the Start of Care (SOC). When a patient’s schedule/preferences are the reason for delay, include that in the order.
• Have a backup plan for weekends and holidays.

5. Medication Regimen Review Deficiencies

What it looks like:
To recieve this deficiecncy, medication profiles may be missing:

• Physical Medication
• Required details of medication
• PRN indicators
  • Acronym Alert: PRN: ‘pro re nata’ → a Latin phrase commonly used in the healthcare industry which means “as needed.”
• Discrepancies not reported to the physician.

How to address it:

• Perform medication reconciliation during each home visit.
• Ensure therapists submit medication lists in therapy-only cases.
• Include all kinds of medications, not just prescriptions. Make sure to include over the counter medications, eye drops, creams, supplements, injections, topicals and anything else the patient is taking or using. 
• For each medication, make sure you record:

• Medication full name as written on the bottle
• Dosage
• Route
• Frequency
• Start date
• End date (if applicable)
• Any special instructions (for example: take with food)

6. Noncompliance with Following Physician Orders

What it looks like:
Services are provided without signed orders, missed visits are not communicated, or staff deviates from prescribed care.

How to address it:

• Check that each visit fits the frequency.
• Coordinate with and make MD orders for all weeks with missed visits. 
• Train staff to let the office know if they feel like they will have missed visits.

• Match visits against orders regularly.

• Ensure staff understand they must wait for signed orders before initiating care.
• Create a visit plan for addressing each order and goal in the care plan, and add it to the care plan. 
• Ensure there is a copy of the care plan in the patient’s home folder, so clinicians can reference it, even if they didn’t bring one.
• Check half way through the episode to make sure orders and goals are tracking for completion. Create a plan for anything that feels like it will be missed or left out. Or, update the care plan to reflect the realistic status of the patient and their anticipated care.

7. Lack of Timely Transfer or Discharge Summaries

What it looks like:
No evidence summaries were sent to the physician or they're sent late, without necessary details.

How to address it:

• Implement a tracking system to monitor transfer/discharge dates against summary sent dates.
• Use templates to streamline summary content and ensure compliance.
• Educate clinicians on timeliness expectations (Must be sent to the physician within 5 days of transfer or discharge).
• Document the sent date on transfer and discharge summaries.

8. Poor Infection Control Practices

What it looks like:
Staff fail to follow hand hygiene protocols or improperly use bag technique, increasing infection risks.

How to address it:

• Conduct regular training on standard precautions.
• Observe staff in the field during for compliance (e.g., hand hygiene, PPE, clean bag technique).
• Reinforce policy during orientation and annual competency checks.
• Flag staff that needed multiple tries to pass their hand hygiene checks. Place these staff members on the next round of hand hygiene checks.
• Conduct surprise hand hygiene and bag technique observations whenever field staff come into the office, for any reason.
• Review bag technique at hire and at least annually.

9. Inadequate Supervision of Home Health Aides

What it looks like:
Aides not properly supervised or documentation fails to reflect whether assigned tasks were completed according to the plan of care.

How to address it:

• Schedule and document supervisory visits regularly (At least every 14 days for every CHHA, as required by law)

• Provide aides with clear, task-specific written instructions—no “PRN” or vague directions.
• Ensure refusals of care are documented and reported appropriately.
• Review the first CHHA notes that are submitted for every patient. Make sure these notes adhere to the care plan.
• Create or source templates in which the CHHA care plan and CHHA notes have corresponding fields. This will make sure following the care plan and documenting the note are easier. 

10. Failure to Notify Physicians of Changes in Patient Condition

What it looks like:
Clinicians fail to report significant changes, delaying necessary updates to the plan of care.

How to address it:

• Train staff to recognize, report and document all reportable changes in patient's condition.
• Educate staff on the importance of reporting to the physician managing care and the office.
• Ask your EMR provider if there are alerts for red flags (e.g., falls, weight loss, uncontrolled pain).
• Designate someone in your office to read notes being submitted by clinicians.
• Keep an open line of communication between your patients and the office. This encourages patients to contact the office with any significant events or changes (like a fall or disease exacerbation).

How to Prevent Common Home Health Deficiencies Before Your Next Survey

It’s clear that the most common deficiencies aren’t just about missing documentation or technical errors. They’re often rooted in broken processes, lack of training, or unclear expectations across teams.

So what should you do now? Review your current processes, and use this list to proactively address any blind spots before they become a compliance issue.

And remember: staying ahead of deficiencies doesn’t happen by chance. It happens by design.

At The Home Health Consultant, we built our Administrative Compliance Program specifically for agencies that want to prevent deficiencies before they pop up during survey. If you're tired of reacting and ready to build systems that work, we're here to help.

Explore our proven process below to learn how we get, and keep, your agency survey-ready.