Home Health Blogger

Does Your Annual Meeting Include These 11 (Required) Items?

Posted by Melissa Cott on Jul 10, 2023

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:

Download the Annual Meeting Form for Home Health Agencies
  • 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


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?


  • 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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