Medicare's Conditions of Participation (CoP) requires an HHA's Governing Body to regularly evaluate the policies and procedures that regulate the Agency's:

• Agency-wide risk management
• Patient-specific risk management
• Emergency Preparedness
• Employee Management: continuing education, evaluations, health-status requirements, license & education verification, reference verification
• Ethics
• Infection Surveillance and Identification
• Leadership
• Patient care
• Patient complaints
• Patient surveys - CAHPS
• Supervision of nursing and therapy assistants

Agency-wide Risk Management

Are your policies and procedures effective at controlling:

• workplace injuries resulting from musculoskeletal disorders secondary to lifting/lowering, and pushing/pulling, and carrying of patients?
• needlesticks? 
• management of hazardous waste? fire and utility safety?
• infection exposure & personal protective equipment?

Patient-specific Risk Management

Do your patient education materials include: home safety? infection control? medications, oxygen, and home medical equipment?

• Do you verify license, reference and education on all field staff?
• Do you have clinical policies and procedures readily available to field staff?
• How often are are patient education materials reviewed?

Emergency Preparedness

• annual update of risk assessment and risk types for the agency secondary to its location
• types of patients served and emergency preparedness for each patient type served
• how patients are prioritized for care
• communication system during emergency
• employee training on emergency preparedness

Employee Management

Are the following verified for all new employees?

• education verification
• experience verification
• license verification
• references and experience verification

How frequently are the following monitored and/or performed during employment?

• health status and vaccinations
• evaluations
• continuing education
• non-proficiency evaluations

Ethics

Any incidences and corrective actions regarding the following?

• Patient rights violations
• Patient confidentiality violations
• Patient care provided according to professional standards
• Patient education regarding advance directives
• Patient liability for payment
• Policies and procedures regarding application of restraints
• Policies and procedures regarding patient non-compliance

Infection surveillance and identification

• How do you monitor for infections in your patient population?
• What training is provided to staff?
• What steps are taken with a suspected infection of a patient? of an employee?
• What steps are taken with an active infection of a patient? of an employee?

Leadership

• How do you solicit feedback from field clinicians and office staff?
• What do you do with feedback from field clinicians and office staff?
• How does your organization solicit your ideas and views about issues like daily operations, educational needs, information management, and so on?
• Describe the budgeting process and its relationship to your organization's planning process.
• Who is involved in budget development?

Patient Care

• What reports do you use to evaluate your HHA's quality of care?
• How often are those reports reviewed?
• Can you provide documentation of the reports and corrective actions?
• What training do you provide on patient care protocols?

Patient Complaints

• What patient complaints were received and what was the corrective action?
• What employee training was provided?

Patient Surveys

• What are the results of the Consumer Assessment of Healthcare Providers and Systems surveys (CAHPS) from the prior reporting period?
• Were corrective actions indicated?
• If yes - were they performed?

Supervision of nursing and therapy assistants

• Documentation of required supervision

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