A Medicare home health survey is unannounced, comes at least every 36 months, and starts small. Surveyors read a short list of standards tied most closely to patient care, visit patients at home with consent, and review charts they pick. A problem on that list widens the survey. A serious one widens it to every condition of participation.
The survey rules are in 42 CFR part 488, subpart I (488.700 to 488.745). What follows a condition-level finding is in subpart J (488.800 to 488.865). How surveyors run the day is in the State Operations Manual, Appendix B, "Guidance to Surveyors: Home Health Agencies" (Rev. 245, issued August 5, 2026; its survey protocol is Rev. 219).
Appendix B is guidance, and it says so: its interpretive guidelines "are not binding and do not replace or supersede the law or regulations." Every quotation below is from one of those sources unless another is named.
How Often the Survey Comes
Section 488.730(a): "Each HHA must be surveyed not later than 36 months after the last day of the previous standard survey." That is the outer limit, not a schedule. A survey "may be conducted as frequently as necessary." Two events can pull it forward:
- A change in ownership, administration or management. A survey "may be conducted within 2 months" of it (488.730(b)).
- Complaints. A survey "must be conducted of an HHA within 2 months of when a significant number of complaints against the HHA are reported" (488.730(c)(1)).
Nobody will warn you. "All HHA surveys must be unannounced" (488.725(a)), and anyone who tells an agency the date of a standard survey "is subject to a Federal civil money penalty" (488.725(c)).
| Survey | When | Source |
|---|---|---|
| Initial certification | Entering Medicare; "reviews all CoPs" | Appendix B, Part I.B.1 |
| Recertification | At most every 36 months; begins as a standard survey | 488.730(a); Appendix B, Part I.B.2 |
| Abbreviated standard | Complaints, change of ownership or management, reapplication after deactivation | 488.705 |
| Post-survey revisit | After citations; condition-level ones require "an onsite post-survey revisit" | Appendix B, Part I.B.3 |
| Validation | Deemed agencies, by sample or on substantial allegations | 488.9(a) |
Before an initial survey, a new agency needs MAC approval of its CMS-855A and care to "a minimum of 10 skilled patients." The state or "AOs with CMS deeming authority" may conduct it; the startup path is in how to start a home health agency.
Standard, Partial Extended, Extended
Appendix B: "CMS has identified a select number of standards, called Level 1 standards, most closely related to the agency's ability to deliver quality patient care." The standard survey reads those.
| Step | Trigger | Covers |
|---|---|---|
| Standard | Routine | Level 1 standards |
| Partial extended | "Noncompliance is identified in any Level 1 standard" | "All remaining standards within the CoP that contains a Level 1 standard deficiency" |
| Extended | Substandard care, or obvious condition-level noncompliance | "All 15 CoPs" |
Substandard care means "noncompliance with one or more conditions of participation identified on a standard survey, including deficiencies which could result in actual or potential harm to patients" (488.705). The extended survey then "must be conducted not later than 14 calendar days after completion of a standard survey" (488.720(b)). One exception: an OASIS transmission deficiency (484.45(a)) "does not trigger a partial extended or extended survey."
The Entrance Conference
Every team includes "at least one Registered Nurse." For a standard survey, Appendix B Task 2 has surveyors request:
- "The number of unduplicated skilled care admissions from the 12 months prior to the survey, including all payer sources and all HHA locations." This sets the sample size.
- Active skilled patients with start of care or resumption dates, admitting diagnosis, disciplines, and clinically complex treatments.
- "The schedule of home visits that will be performed during the survey."
- "A complete list of all discharged patients in the past six months."
- Staff with job title and hire date, the organizational chart, admission packet, complaint log, and abuse tracking log if available.
An extended survey adds aide training records, QAPI activity, the CLIA certificate and the emergency preparedness plan.
Tip
Practice, not rule: since the survey is unannounced, keep the Task 2 list ready to produce on any working day, starting with the 12-month unduplicated skilled admissions count that sets the sample.
The Records They Pull
The sample is "case-mix stratified" (488.710(a)(1)), across closed and active patients, all payers, parent and branches. Appendix B, Table 2:
| Unduplicated skilled admissions, past 12 months | Closed | Home visit with record review | Record review only | Minimum total |
|---|---|---|---|---|
| Less than 300 | 2 | 3 | 2 | 7 |
| 301 to 500 | 3 | 4 | 3 | 10 |
| 501 to 700 | 4 | 5 | 4 | 13 |
| 701 or more | 5 | 7 | 5 | 17 |
Closed records come first from the Potentially Avoidable Event Report, under measures where the agency exceeds the national observation. Those charts also get checked for discharge and transfer summaries (484.110(a)(6)) and "the HHA's compliance with the 60-day recertification of care," which ties back to the OASIS assessment schedule. Active patients include multi-discipline cases, every branch, and complex care such as infusion, wound care and anticoagulation. "The surveyor selects the patients according to the sample criteria, rather than the HHA selecting the home visit sample."
The Home Visit
Appendix B calls the home visit "the most important means of information gathering during the HHA survey." The regulation allows it "only with their consent" (488.710(a)(2)). The agency calls to request permission. The surveyor confirms that "refusal would not affect their home health benefits" and has the patient or caregiver sign Form CMS-36. If a patient refuses, "the surveyor should select an alternate patient." In the home the surveyor is to "observe, but do not interfere with, the delivery of care."
What They Read
"The HHA standard survey evaluates compliance with eight of the 15 HHA CoPs." Table 1 lists Level 1 tags under patient rights (484.50), comprehensive assessment (484.55), care planning and coordination (484.60), infection prevention (484.70), skilled professional services (484.75), home health aide services (484.80), organization and administration (484.105) and clinical records (484.110). It also lists emergency preparedness (484.102) with three E-tags from Appendix Z.
Inside them: the RN initial visit that determines eligibility "including homebound status" (G514, see homebound status), comprehensive assessment "no later than 5 calendar days after the start of care" (G520), aide supervision (G808 to G812, see supervisory visits), and record authentication and protection (G1024, G1028). Appendix B's sample staff question is how they "transport and secure protected health information" (see HIPAA for home health agencies).
Each of the 15 conditions has its own tag (G406 for 484.50, G510 for 484.55, G1008 for 484.110), and the tags under it are its standards. Personnel files, policies and contracts "are not routinely reviewed unless the surveyor identifies concerns."
Standard-Level and Condition-Level
A standard-level deficiency is "noncompliance with one or more of the standards that make up each condition of participation" (488.705). A condition-level deficiency means deficiencies "of such character as to substantially limit the provider's or supplier's capacity to furnish adequate care or which adversely affect the health and safety of patients" (488.24(b)). Appendix B's test: "One instance of noncompliance with a standard that poses a serious threat to patient health and safety is enough to find condition-level noncompliance." Multiple standard-level deficiencies in one condition can be enough too.
Warning
No ranking of most-cited tags appears here, because none was checked against a dated CMS dataset. The Level 1 list above is what the standard survey reads.
The Exit Conference and After
Surveyors describe the preliminary findings, without tag numbers, and "the surveyor is not a consultant." Form CMS-2567 comes "generally no later than 10 working days after the exit conference," and "is available to the public upon request."
| Situation | What part 488 says | Section |
|---|---|---|
| Any sanction | "A non-compliant HHA must submit a plan of correction for approval by CMS" | 488.810(e) |
| Disputing condition-level findings | Informal dispute resolution, in writing, "within the same 10 calendar day period that the HHA has for submitting an acceptable plan of correction" | 488.745(d) |
| Condition-level, no immediate jeopardy | Terminate, or alternative sanctions "for a period not to exceed 6 months" | 488.830(a) |
| Still out of compliance, plan of correction not met | Termination "within 6 months of the last day of the survey" | 488.830(d) |
| Immediate jeopardy not removed | Termination "no later than 23 days from the last day of the survey" | 488.825(a)(2) |
The alternative sanctions are civil money penalties, suspension of payment for new admissions, temporary management, a directed plan of correction and directed in-service training (488.820). They reach "the parent HHA and its respective branch offices" (488.810(d)), and "a pending hearing does not delay the effective date of a sanction" (488.810(g)(2)).
Deemed Status
Deemed status means CMS certified the agency after accreditation "from a CMS-approved national accrediting organization," that organization's recommendation, and CMS's acceptance of it (488.1). Appendix B says such agencies are "exempt from routine surveys by SAs." An accrediting organization applying for CMS approval must agree to re-survey "through unannounced surveys, no later than 36 months after the prior accreditation effective date" (488.5(a)(4)(i)). A deemed agency can still get a state validation survey, and if found out of compliance "will no longer be deemed to meet the Medicare conditions or requirements" (488.9(c)(1)). A final rule (91 FR 36370, June 16, 2026) amends these provisions effective June 16, 2027.
Key Takeaways
- The survey is unannounced and comes at least every 36 months (488.730(a)), sooner after ownership changes or complaints.
- The standard survey reads Level 1 standards. A Level 1 finding widens it to the whole condition; substandard care, to all 15 conditions.
- The 12-month unduplicated skilled admissions count sets the sample. Surveyors pick the charts and home visits.
- Home visits need the patient's consent, and refusing does not affect benefits.
- A condition-level deficiency means a plan of correction, possible sanctions for up to 6 months, and termination if compliance is not restored.
Frequently asked questions
How often is a home health agency surveyed?
At least every 36 months. Under 42 CFR 488.730(a) each agency must be surveyed not later than 36 months after the last day of the previous standard survey, and a survey may come as often as necessary. A significant number of complaints must bring one within 2 months.
Do surveyors tell the agency before they come?
No. 42 CFR 488.725(a) says all home health agency surveys must be unannounced. Anyone who tells an agency the date of a standard survey is subject to a federal civil money penalty.
What is the difference between a standard and an extended survey?
A standard survey reviews the Level 1 standards. A Level 1 finding expands it to a partial extended survey of that whole condition. Substandard care requires an extended survey of all 15 conditions, within 14 calendar days of the standard survey.
Can a patient refuse a surveyor's home visit?
Yes. Home visits happen only with the patient's consent under 42 CFR 488.710(a)(2), and Appendix B says refusal does not affect the patient's home health benefits. The surveyor picks another patient.
What happens after a condition-level deficiency?
Without immediate jeopardy, 42 CFR 488.830 has CMS terminate the provider agreement or impose alternative sanctions for up to 6 months. Immediate jeopardy that is not removed ends in termination no later than 23 days from the last day of the survey (488.825).
Sources
- 42 CFR part 488, subpart I, Survey and Certification of Home Health Agencies: 488.705 definitions, 488.710 standard surveys, 488.715 partial extended, 488.720 extended, 488.725 unannounced, 488.730 frequency, 488.745 informal dispute resolution. Survey rules are in subpart I; subpart J is sanctions.
- 42 CFR part 488, subpart J, Alternative Sanctions for Home Health Agencies With Deficiencies: 488.805, 488.810, 488.820, 488.825, 488.830.
- 42 CFR 488.1 (deemed status), 488.5, 488.9, 488.24, 488.26.
- CMS, State Operations Manual, Appendix B, Guidance to Surveyors: Home Health Agencies (Rev. 245, issued 08-05-26; survey protocol Rev. 219): Part I, Part II Tasks 1 to 7, Table 1 (Level 1 standards) and Table 2 (sample size).
- Federal Register, Medicare Program; Strengthening Oversight of Accrediting Organizations (AOs) and Preventing AO Conflicts of Interest, and Related Provisions, 91 FR 36370, June 16, 2026, effective June 16, 2027.
- Related on this site: how to start a home health agency, homebound status walkthrough, OASIS assessment schedule, supervisory visit requirements, HIPAA compliance for home health agencies.