Home health personnel file checklist: what a surveyor looks for

A home health survey is largely a records survey. The surveyor samples patients, then pulls the files of the people who touched those patients and checks that each one was qualified, trained, supervised and screened on the dates the visits happened. A missing date is a deficiency even when the person was fully qualified. This is what the file has to show.

1. Qualification for the role

The Medicare Conditions of Participation (CoPs) set personnel qualifications in 42 CFR 484.115: the administrator, the clinical manager, each skilled discipline and the home health aide must meet the listed standard. For licensed roles that means a current license or certification in the state where care is delivered, verified against the licensing board, with the verification dated. For aides it means the training and competency requirements of 484.80.

In the file: a copy of the license or certificate, the primary-source verification with its date, and the expiration date tracked somewhere the office actually looks.

2. Aide training and competency

484.80 is the condition surveyors cite most. ACHC reports it as its most commonly cited condition-level deficiency, with G-tags G798, G800 and G808 recurring. The file needs the aide's training program completion, the competency evaluation before unsupervised care (observed skills signed by the RN), and documentation that each requirement in the standard was met. The regulation says so directly: the agency must maintain documentation that demonstrates the requirements of this standard have been met.

In the file: training certificate, the signed competency checklist with the date and the evaluator, and the state registry or certificate verification.

3. Twelve hours of in-service every 12 months

484.80(d): a home health aide must receive at least 12 hours of in-service training during each 12-month period. The 12-month clock is per aide, running from their own anniversary, not the calendar year. Agencies get cited for two reasons: the hours fall short, or the hours exist but the sign-in sheet doesn't say which aide, which topic, how long, or who supervised.

In the file: a running in-service log per aide with date, topic, hours and the supervising RN, and the total for the current 12-month window.

4. Supervision

484.80(h) sets aide supervision: when the patient receives skilled services, an RN or other appropriate skilled professional completes a supervisory assessment of the aide's services at least every 14 days (the aide need not be present, and since 2021 the rule allows a limited number of these to be done virtually); when the patient receives aide services only, the interval is longer, with an on-site observation of each aide at least once a year. Read the current text of 484.80(h) for the exact intervals. These are patient-record entries, but the surveyor cross-references them to the aide's file, so the aide's competency and supervision history should reconcile.

5. Health screening

Federal CoPs defer health screening to state law. In California, Title 22 section 74723 requires a written health assessment for employees with direct patient contact, performed within six months before or 15 days after starting, and the Department of Public Health requires annual TB screening unless the local health officer approves a longer interval in writing. Other states set their own intervals.

In the file: the initial health assessment, each TB screening result with its date, and the next due date.

6. Background and exclusion checks

State law governs criminal background checks (California requires fingerprint clearance as part of home health aide certification). Separately, OIG's 2013 Special Advisory Bulletin recommends screening every employee and contractor against the List of Excluded Individuals and Entities monthly and keeping proof of each search. The exclusion check is the item most often missing from otherwise complete files, because nobody owns the monthly repeat.

In the file: the background clearance, and a dated record of each exclusion check with the list version it ran against.

7. The agency's own requirements

Your policies create obligations the surveyor will hold you to. If the policy says CPR, a driver's license and auto insurance for anyone who drives to visits, or an annual evaluation, then those documents and dates are part of the file. Write the policy to match what you track, not the other way round.

How to keep this current without a binder week

Every item above has a date and a renewal period. The failure mode is the same every time: the document exists, the date passed, nobody noticed until survey week. Agencies that pass cleanly treat the personnel file as a live list of items with expiration dates, reviewed weekly, with the employee reminded before anything lapses. That is the job Benson HR does: each compliance item per job title, the dates on one grid, reminders sent to the person with a private upload link, and the document filed when it comes back. The compliance tracking page shows the grid.