Time for a policy update for your home health agency?

How Often Should Home Health Agencies Update Policies?

Regulatory agencies require home health agencies (HHAs) to maintain comprehensive written policies and procedures. Your agency’s policy and procedure (P&P) manual provides guidance, supports operations, and helps ensure patient safety. Since policies are so important, it’s essential to know how often your agency should update them.

Regarding Medicare-certified agencies, the CMS rules spell out some requirements. For the most part, however, it is up to each agency to update policies as needed.

Depending on your state, your HHA may receive a scheduled visit by a surveyor every 1–3 years. And, of course, an unannounced survey could happen anytime. During a survey inspection, surveyors will review your P&P manual for compliance. You want to make sure your policies are up to standards. Here are some considerations when it comes to how often you should update your Home Health Agency’s policies.

How often should agencies update Emergency Preparedness Policies?

Medicare-certified agencies must update their Emergency Preparedness Plans at a specified interval. According to the Conditions of Participation (CoPs) §484.102, HHAs must review and update their emergency preparedness program (EPP) every other year. The EPP must describe how the business will meet the safety, security, and health needs of patients and staff during an emergency or disaster.

At a minimum, the EPP must include:

  • Individual plans for each patient as part of the comprehensive patient assessment, which agencies must conduct according to the provisions at § 484.55.
  • The agency’s procedure for informing state and local officials about patients who need assistance with evacuation from their residences because of medical or psychiatric conditions
  • The procedures for agency follow-up with staff and patients in the event of a service interruption due to an emergency.
  • A plan for medical records that preserves documentation protects patient confidentiality and maintains the availability of records.
  • Emergency staffing strategies.

It is important to note that although the policy must be reviewed and updated every two years, agencies are required to test preparedness programs annually.

Action Steps

To make sure you are prepared for your next home health agency survey, you can take these action steps now:

  • Review your agency’s EPP to verify it contains all of the required elements listed in the CMS Manual Appendix Z.
  • Ensure that leadership has identified the hazards (e.g., natural, man-made, facility, geographic, etc.) that could affect your business in the agency’s risk assessment and that you have written plans to mitigate those risks.
  • Make sure to include documentation in your P&P of the review date.

How often should agencies update their Patient Rights and Privacy Policies?

As for patient rights and privacy practices, agencies do not need to update policies according to a particular timeline. However, the written policies must accurately describe how your HHA protects rights and privacy. Specifically, you must have written policies to show how the business uses and preserves protected health information (PHI) and complies with the privacy rules.

Tag G438 in the surveyor guidance manual outlines the three privacy rules HHAs must abide by, including:

  • The HIPAA Privacy Rule
  • The HIPAA Security Rule
  • The Breach Notification Rule

Home care businesses face unique concerns, such as workers transporting PHI with them as they travel in and out of patient homes for visits. Therefore, owners and supervisors must be vigilant about monitoring compliance with patient rights and privacy policies.

Action Steps

To make sure your patient rights and privacy policies are up-to-date, you can take these action steps now:

  • Review your agency’s policies related to confidential client records, use and disclosure of information, and staff training on HIPAA are up to date.
  • Look at your policies annually and update them as needed.
  • Make sure to include documentation in your P&P of the review date.

How often should agencies review other policies?

In some states, an annual agency evaluation is required for home health agencies. A yearly look at your HHA’s policies can be a good practice––even if your state does not expressly require it. To save time and be as efficient as possible, here is a basic list of policies to go over annually:

  • Admission Policy
  • Discharge Policy
  • Emergency Preparedness policies
  • Treatment policies
  • Documentation and Clinical Records Policies

Policies should be appropriate, effective, efficient, and sufficient.

Action Steps

Consider appointing a team of administrative and clinical personnel to meet for policy review, and then advise your leadership on care issues or any concerns with the current policy. Have someone in the group document meeting minutes and keep a record to include in quality improvement plans.


Your agency must ensure that policies are up to standards. You can look to state and federal rules and regulations for guidance. Still, in many cases, it will be up to your agency how frequently policy updates are necessary. You may also consider an annual evaluation of the most important policies that guide your day-to-day operations at a minimum.

We hope this article has helped you understand how often HHAs should update policies and given you practical steps for compliance.

Sources & Additional Reading

Code of Federal Regulations”. ecfr.gov. Accessed September 28, 2022.

Emergency Preparedness Guideline Fact Sheet”. cms.gov. Accessed September 28, 2022.

QSO-20-41-ALL”. cms.gov. Accessed September 28, 2022.

State Operations Manual: Surveyor Guidance”. cms.gov. Accessed September 28, 2022.

Alora provides agencies with the complete solution for home health agency workflow. Having the right home health software in place makes it easier to manage policy updates and implementation, and Alora’s streamlined efficiency and cloud based ease of use is designed to simplify workflow on both the administrative and clinical side.

Learn more about ALORA – request a demo.

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