home_health_visit_operations v1.0.0

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name: home_health_visit_operations description: "Running home health and home care visits so none are missed and every one is provable: aide and nurse assignments matched to care plan tasks and travel time, electronic visit verification handled as part of the visit instead of an afterthought, missed and late visit recovery the same day, family and agency communication when a visit changes, and visit notes checked against the care plan before billing. Use when assigning an aide or nurse to a patient, building a visit schedule from a plan of care, checking EVV records, recovering a missed or late visit, or auditing visit notes before a claim goes out."

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Home Health Visit Operations

Purpose

Run visits as one chain: plan of care, written assignment, schedule with real travel time, visit with verification captured in the visit, note checked against the plan, then billing. Visits fail in predictable places. An aide gets a task that is not in the plan. A schedule gives ten minutes for a twenty five minute drive. A visit happens but the verification record is fixed from memory that night. A missed visit is found at billing, a week later, when recovery is no longer possible. This skill closes each break on the day it happens, with a record a covering clinician or a surveyor can follow cold.

Two layers shape everything below. Federal Conditions of Participation in 42 CFR Part 484 set the plan, assignment, supervision, and record duties for Medicare certified home health agencies. Section 12006 of the 21st Century Cures Act sets electronic visit verification for Medicaid personal care and home health services. State Medicaid programs, state practice acts, and payer contracts add their own rules on top, and those rules differ by state. Never borrow a state rule from another state.

Workflow

1. Build the state and payer profile before the first visit

Do this once per state and payer, and redo it when the guidance changes.

• EVV: which services need EVV in that state, the state aggregator or chosen vendor, how manual edits are made and reason coded, how long a visit record may sit before it must be transmitted, and what the claim edit does when EVV and claim data do not match.
• Aide scope: which tasks aides may perform under state law, any state training or registry check beyond the federal rule, and any task the state reserves to licensed staff.
• Supervision additions: any state interval shorter than the federal intervals in section 8, and any state form for the supervisory visit.
• Private duty and home care cases that are not Medicare certified home health: which parts of this skill the agency adopts as its own policy, stated in writing, so staff do not mix a policy choice with a federal duty.
• Documentation timing: agency deadline for a completed, authenticated note, stated in hours from the end of the visit.

A profile item with no primary source behind it stays marked UNVERIFIED. Do not schedule or bill on an unverified item.

2. Turn the plan of care into visit orders

Start from the signed individualized plan of care required by 42 CFR 484.60. The plan names the diagnoses, the services, supplies, and equipment, the frequency and duration of visits, the measurable goals, and the patient and caregiver education. It is reviewed and revised as often as the condition requires, and at least once every 60 days from start of care.

For each discipline in the plan, write a visit order a scheduler can act on without interpreting it:

1. Patient, discipline, and service type exactly as the plan words it.
2. Visits per week and weeks, or the exact dates when the plan gives dates.
3. Visit length the plan or the assessment supports, in minutes.
4. Tasks for the visit, taken from the plan and the orders. A vague order such as therapy as needed is not schedulable. Send it back for a frequency and duration.
5. Goals the visit works toward, copied from the plan, so the note in section 7 has something real to check against.

Verbal orders enter the same way. The nurse or qualified practitioner who may receive them under state law documents, signs, dates, and times the order in the clinical record, the plan is updated to include it, and authentication by the ordering practitioner follows agency policy and state law. A visit worked from a verbal order that never reached the plan is a visit worked from no order.

3. Assign the person, with written instructions

Follow 42 CFR 484.80(g) for aide assignments under a certified agency, and use the same shape for any non-skilled home care assignment.

• A registered nurse or other appropriate skilled professional assigns the aide to a specific patient. That professional, a physical therapist, speech language pathologist, occupational therapist, or the registered nurse, prepares written patient care instructions for that patient.
• Check every assigned task against four tests before the assignment leaves the office: ordered by the physician or allowed practitioner, included in the plan of care, permitted under state law, and consistent with that aide training and competency record. A task that fails any test comes off the assignment and goes back to the assigning professional.
• Aide duties stay inside the federal shape: hands on personal care, simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications ordinarily self administered.
• Match the person, not just the slot: language the patient uses, transfer and mobility skill the case needs, known allergies or precautions in the instructions, pets, access notes, and any prior continuity the patient relies on. Continuity is a clinical fact for many patients, not a courtesy. Record why a regular aide was replaced.
• The aide is part of the interdisciplinary team. The assignment sheet says who to report a change in condition to, by name and phone, and that the report happens during the visit, not at the end of the week.

For skilled visits, assign a clinician whose license, competency, and current caseload fit the ordered service. A licensed practical nurse works under registered nurse direction as state law provides, and an aide supervisory assessment is never assigned to a licensed practical nurse. Federal rule puts that assessment with a registered nurse or other appropriate skilled professional.

4. Schedule with travel time counted

Build the day from drive time, not from hope.

1. Put each visit on the map in sequence. Use actual drive time between addresses at that time of day, plus parking and building access time where it applies.
2. Add visit length from the order. The gap between the end of one visit and the start of the next must be at least the travel time plus a buffer the agency sets in the profile. A gap shorter than that is a late visit planned in advance. Fix the sequence, move a visit, or reassign before the day starts.
3. Check the day total: visits, travel, documentation time, and any supervision visits in section 8. A day that only works if notes are done at home unpaid and unverified is not a workable day.
4. Give the patient a window, not a false exact time, unless the service needs an exact time. State the window when the visit is confirmed and again the day before for early visits.
5. Lock the schedule the afternoon before, with one named person on point for changes that night and morning. Changes after the lock go through that person, so two schedulers never promise the same aide to two patients.

Check a proposed week before it is published with the tool:

python3 scripts/visit_check.py schedule --file week.json

verdict: FEASIBLE, or a list of tight gaps and overlaps by visit id

The file shape and a full example sit in references/worked-week.md.

5. Run the visit, with EVV inside the visit

Electronic visit verification is part of the visit, not paperwork after it. For Medicaid personal care and home health services, Section 12006 of the 21st Century Cures Act, adding Section 1903(l) of the Social Security Act, requires a system that verifies six things for each visit:

1. The type of service performed.
2. The individual receiving the service.
3. The date of the service.
4. The location of service delivery.
5. The individual providing the service.
6. The time the service begins and ends.

Federal deadlines were January 1, 2020 for personal care services and January 1, 2023 for home health care services, with state programs now enforcing their own claim edits on top.

At clock in, in the home, in this order:

• Confirm the patient, the service type, and your own identity in the EVV method the state profile names. Mobile app, telephony from the home phone, or another approved method are all valid when the state allows them. Federal guidance does not require GPS by itself. It requires that the six elements be verified.
• If EVV fails in the home, use the backup method in the profile at once, note the failure time and reason, and tell the office the same day. A record created from memory days later, with no failure note, reads as a manual edit problem in every state program that tracks edit rates.
• Work only the assigned tasks, plus a safety response to a condition you find. If the patient asks for a task outside the instructions, explain the limit plainly, offer to call the office together, and report the request. Do not quietly expand the assignment.
• Report any change in condition to the registered nurse or appropriate skilled professional during the visit, as the assignment sheet directs.
• At clock out, verify start and end time against the actual visit before you leave. Correct a wrong clock entry through the state manual edit process, with a reason code, while the facts are still checkable.

For services that do not require EVV, keep the same six facts in the visit record anyway. One habit for every visit is stronger than two habits sorted by payer.

6. Recover a missed or late visit the same day

A visit counts as missed when the scheduled window closes with no visit, and as late when arrival falls outside the window the patient was given. Both trigger recovery the same day. Next week is not recovery.

1. Name the cause in plain categories, and record only the one that fits: patient not home, patient or family refused, patient in hospital or facility, caregiver ill or in an emergency, caregiver no show with no notice, weather or road closure, agency scheduling error, access failure such as a locked building or wrong address on file.
2. Attempt contact at once through every channel on file: patient phone, caregiver or family contact, and the building or facility when relevant. Log each attempt with time and result.
3. Tell the assigning clinician the same day for any missed skilled visit, any missed aide visit where the task is time sensitive such as medication assistance, bathing for a patient who cannot wait, or a meal, and any second miss for the same patient in the same episode.
4. Offer a concrete recovery: a same day visit by a qualified replacement, a same day visit later by the same person when the cause allows, or the next day at a stated time when the clinician agrees the delay is safe. Write who agreed to the delay. A delay nobody clinical approved is an agency decision with no cover.
5. Tell the patient and family contact what happened, what the recovery is, and when to expect the person, in one call, before the original window is forgotten. Apologize once, plainly, for an agency cause. Do not blame a named aide to a family.
6. File the missed or late record that day: scheduled time, cause, contact attempts, clinician notified, recovery offered and accepted or refused, and the new visit id. Never bill a visit that did not occur. A refused visit is documented as refused, with the patient words noted, and the clinician decides whether the plan needs a change.
7. A second miss for the same patient, or a pattern for the same aide or the same route, goes to the weekly review in section 9 that week, not into a private note.

Check recovery records with the tool:

python3 scripts/visit_check.py audit --file week.json

verdict: READY, or gaps by visit id

7. Check the note against the care plan before billing

No claim goes out on a note nobody compared to the plan. The clinical record duties in 42 CFR 484.110 require the record to hold the assessment, clinical notes, plans of care, and orders, all interventions including medication administration, treatments, and services with responses to them, and the goals with progress toward them. Every entry must be legible, clear, complete, authenticated, dated, and timed. Records are retained for 5 years after discharge unless state law requires longer.

For each completed visit, the checker, who is not the person who wrote the note when staffing allows, confirms:

1. Patient, date, service, and provider in the note match the EVV record on all six elements. A mismatch stops the claim until the record, not the claim, is corrected through the proper edit process.
2. Every task in the note is in the plan and in the written assignment for an aide visit, or in the orders for a skilled visit. A task outside the plan is either an undocumented order, which goes back for one, or out of scope work, which goes to the clinician.
3. Interventions are stated with enough detail to show what was done, and the patient response is recorded for each one, including a refusal or a task the patient could not complete.
4. The note states progress, or lack of it, toward at least one plan goal the visit works toward, in patient specific terms. Copied goal language with no observation does not pass.
5. Any change in condition found on the visit shows a report to the right clinician, with time, and any new order or plan change that followed.
6. Start and end time in the note support the units or visit charge being billed, and the note is authenticated by its author within the agency timing in the profile.
7. Skilled notes show why the service needed a skilled professional on that day, in that patient facts, not in a stock sentence. That showing is what separates a billable skilled visit from a visit that happened.

A note that fails any item returns to its author with the failed items named. The checker never rewrites another clinician note into passing form. Authorship stays with the author.

8. Keep the supervision clocks

Supervision is scheduled work with dates, not a hope that a nurse will be nearby.

• Aide services for a patient who is also receiving skilled nursing, physical or occupational therapy, or speech language pathology: a registered nurse or other appropriate skilled professional who knows the patient, the plan, and the written instructions completes a supervisory assessment at least every 14 days, under 42 CFR 484.80(h)(1). The aide does not need to be present for that assessment.
• Aide only patients, with no skilled service: a registered nurse makes an onsite visit at least every 60 days to assess quality of care and whether services meet the patient needs, and at least every six months makes an onsite visit to observe the aide performing non-skilled care, under 42 CFR 484.80(h)(3).
• A concern from any visit, complaint, or note review triggers an onsite observation visit regardless of the clock. If that visit verifies a deficiency, the agency runs retraining and a competency evaluation for the deficient skill and all related skills, and the aide completes it, before the aide resumes those tasks.
• Therapy assistants work on their own federal clock in the plan: plan reassessment visits by the qualified therapist so assistant visits never run past the interval the payer and 42 CFR Part 409 require. Put that date on the schedule when the assistant is assigned, not when it expires.

Track each clock from its last completed date, per patient and per aide, and review the list weekly. A missed supervision window is a compliance gap to disclose inside the agency and fix with a visit, never a date to edit.

9. Run the week, and review it

Daily, the person on point works one list: visits at risk today from call outs or weather, late arrivals so far, EVV failures, and missed visits in recovery from section 6. Nothing on that list waits for the weekly meeting.

Weekly, review in this order, with counts from the records, not from memory:

1. Missed and late visits by cause. Agency causes get a schedule or staffing fix, not an apology tour repeated weekly.
2. EV footprint: visits with manual edits, missing elements, or EVV to claim mismatches, and the fix for each before billing.
3. Notes held from billing by the check in section 7, and how long each has waited.
4. Supervision clocks due in the next 14 days.
5. Patients with two or more changes, misses, or refusals in the episode, for a clinician call about whether the plan still fits.

A worked week, including one recovered miss, is in references/worked-week.md. The federal sources for every rule above are in references/rules-and-sources.md.

Output Contract

For any caseload this skill runs, produce:

• A state and payer profile with each item sourced or marked UNVERIFIED.
• Visit orders drawn from the plan of care, with discipline, frequency, duration, tasks, and goals stated per patient.
• Written aide assignments that pass the four tests in section 3, with the reporting contact named.
• A published schedule that passes the travel check in section 4, with a named person on point for changes.
• An EVV record for each Medicaid covered visit holding all six federal elements, with failures and manual edits reason coded the same day.
• A same day recovery record for every missed or late visit, with cause, contact attempts, clinician notice, and the recovery visit id.
• A note check result per visit before billing, either PASS or the named failed items returned to the author.
• A supervision list with next due dates per patient, reviewed weekly.
• A weekly review with the five counts in section 9 and the fix assigned for each agency cause.

Operating Rules

• Never bill a visit that did not occur, a task that was not done, or time that the EVV record and the note do not both support.
• Never let a scheduler assign a task the plan does not contain. The plan changes through the clinician and the ordering practitioner, never through the schedule.
• Never create or backdate an EVV record, a note, or a supervision date to make a file look complete. A late record is filed late, with its reason, and the gap is owned.
• Never send an aide to perform a task outside state scope or outside that aide training and competency record, even when the family asks and the visit is short staffed.
• Keep patient information inside the agency record systems. Schedules, addresses, and access notes never travel in personal text threads or personal email.
• This skill is an operating workflow, not legal or clinical advice. Questions about state scope, a disputed refusal, or whether a service is covered go to the supervising clinician, the agency administrator, and counsel or the state agency as the question requires.