Araya Consulting LLC · Los Angeles Market

California HHA Operational Bible

From Zero to Operational — the complete startup command center for ACHC-accredited home health agencies in California. Every section is survey-ready, regulation-cited, and built for the LA market.

42 CFR Part 484 CDPH Licensed ACHC Accredited Medi-Cal Enrolled 2025 Edition Confidential · Internal Use Only

⚠

California-Specific Warning

California employment law, AB5 contractor rules, CDPH licensing requirements, and Medi-Cal managed care enrollment timelines are significantly different from federal minimums. Never rely on federal guidance alone in this state.

Regulatory Frameworks

4

CMS · CDPH · ACHC · DHCS

Pre-Launch Checklist Items

60+

Tier 1 · Tier 2 · Tier 3

Patient Journey Steps

11

Referral through Final Claim

Insurance Types Required

9

All CRITICAL before operations

CCN Timeline

90d

60–120 days after state validation

LA Medi-Cal Market Share

25%

15–25% of potential HH volume

How to Use This Bible

📖 Reading Order

Read Sections 1–3 before anything else — regulatory foundation
Use Section 5 as your daily pre-launch checklist — do not skip items
Section 6 covers office setup — physical space requirements are non-negotiable
Sections 7–9 cover clinical operations, documentation, and billing
Return to this document monthly during your first year

🗂 Section Map

Regulatory: CMS, CDPH, ACHC, DHCS, OIG
Legal: Entity structure, insurance, HIPAA
HR: AB5, CA employment law, handbook
Checklist: Tier 1/2/3 pre-launch gates
Clinical: Patient journey, OASIS, PDGM
Finance: Revenue cycle, projections

Critical Path — Do These First

💡

Billing Before CCN = False Claims Act Exposure

You CANNOT bill Medicare without your CMS Certification Number (CCN). Submit CMS-855A to Noridian immediately. Timeline: 60–120 days after state validation. Begin Medi-Cal enrollment simultaneously — it takes 90–180 days separately.

🎯 Top Priority Actions (Day 1)

Confirm CDPH license is active and covers all service counties
Submit CMS-855A to Noridian — track every 2 weeks
Submit Medi-Cal enrollment to DHCS simultaneously
Select and activate PEO for payroll/HR before first hire
Execute BAA with all technology vendors before loading any PHI
Activate OASIS-capable EMR — test end-to-end before first patient
Designate Compliance Officer and Privacy/Security Officer

Section 2 · Know Your Masters

Regulatory Foundation

A California home health agency operates under four simultaneous regulatory frameworks. Ignorance of any one of them is an existential threat to your license and your investment.

CMS · 42 CFR Part 484 CDPH Licensure ACHC Deemed Status DHCS Medi-Cal

Regulator	Jurisdiction	Consequence of Non-Compliance
CMS — Centers for Medicare & Medicaid Services	Federal — Medicare/Medicaid CoPs (42 CFR Part 484)	Loss of Medicare certification, recoupment, exclusion
CDPH — CA Dept of Public Health	State licensure, state survey authority	License revocation, civil penalties, forced closure
ACHC — Accreditation Commission for Health Care	Deemed status for Medicare — replaces CMS survey	Loss of accreditation = loss of deemed status = CMS survey
DHCS — CA Dept of Health Care Services	Medi-Cal enrollment and Managed Care oversight	Termination from Medi-Cal = loss of Medicaid revenue

Federal

CMS — Conditions of Participation (42 CFR Part 484)

Your federal bible — every policy, workflow, and staffing decision must be defensible under these CoPs

▼

The CoPs are the legal minimum standards for operating a Medicare-certified home health agency. Major categories:

CFR Section	Subject
484.40	Patient Rights
484.55	Comprehensive Assessment (OASIS)
484.60	Care Planning, Coordination, and Quality of Care
484.65	Quality Assessment and Performance Improvement (QAPI)
484.70	Infection Prevention and Control
484.75	Skilled Professional Services
484.80	Home Health Aide Services
484.100	Compliance with Federal, State, and Local Laws
484.105	Organization and Administration of Services
484.110	Clinical Records

cms.gov — HHA Regulations & Guidance →

State

CDPH — California Dept of Public Health Licensure

Your permission to operate in California — covers specific counties, requires annual renewal

▼

License must be posted in a visible location in your office
Covers specific counties — every county of operation must be listed
Annual renewal — submit 120 days before expiration
Change in administrator, ownership, or location requires written CDPH notification within 10–30 days
Branch offices may require separate licensure or notification depending on distance and services

cdph.ca.gov — HHA Licensing Portal →

Accreditation

ACHC — Accreditation Commission for Health Care

Deemed status for Medicare — grants CMS survey exemption when maintained

▼

Your ACHC accreditation grants you deemed status — CMS accepts it in lieu of a federal survey. Maintaining it requires:

Annual self-assessments and attestations
Unannounced survey readiness at all times
Notification to ACHC of any significant organizational change
QAPI program active and documented from Day 1

⚠

Survey-Ready = Always Ready

ACHC surveys are unannounced. Your Survey-Ready Binder must be at the front desk, accessible within 2 minutes, at all times. See Office Setup section for binder contents.

achc.org — Accreditation Portal & Standards Library →

Critical

Medicare Provider Number (CCN) — Do Not Bill Without This

ACHC accreditation alone does not authorize Medicare billing — you need the CCN from Noridian

▼

🚨

False Claims Act Exposure

Billing before CCN issuance = False Claims Act exposure. Submit CMS-855A to Noridian immediately and follow up every 2 weeks. Timeline: 60–120 days after state validation. Apply NOW — this is your longest lead-time item.

MAC for California: Noridian Healthcare Solutions — noridianmedicare.com
Submit CMS-855A — Medicare Enrollment Application for Institutional Providers
Track submission confirmation number and follow up every 2 weeks
Request expedited processing if available and clinically justified

DHCS

Medi-Cal Enrollment — DHCS

15–25% of LA home health volume — begin enrollment simultaneously with Medicare

▼

Apply through DHCS at dhcs.ca.gov — requires active CDPH license and Medicare certification (or pending)
Timeline: 90–180 days — begin simultaneously with Medicare enrollment
Also enroll separately with Medi-Cal Managed Care plans: LA Care, Molina, Health Net, Anthem, CalOptima
Each managed care plan requires independent credentialing — allow 90–180 days per plan

💡

Don't Skip Managed Care Credentialing

Each LA Care, Molina, Health Net, Anthem, and CalOptima plan is a separate credentialing application. Start all of them on Day 1. Missing one plan = missing revenue for 6+ months while you wait.

Compliance

OIG Compliance Program

Required for federal health programs — failing to have one is evidence of willful non-compliance

▼

Designate a Compliance Officer (can be Administrator initially)
Publish a Code of Conduct and distribute to all staff
Provide annual compliance training — document it
Establish an anonymous reporting mechanism (hotline, suggestion box, or online form)
Conduct internal audits on a scheduled basis

oig.hhs.gov — Compliance Guidance for HHAs →

Section 3 · Build the Wall First

Legal & Business Setup

Your entity structure, registrations, and insurance protect everything you build. Get these right before any clinical operation begins.

Entity Structure Business Registrations Insurance HIPAA + CMIA

3.1 — Business Entity & Tax Structure

Work with a California healthcare attorney and CPA before making entity decisions. Your choice affects liability, taxation, and investor capacity.

Entity Type	Liability Protection	Tax Treatment	Best For
LLC	Strong	Pass-through (default)	Solo owner, simplicity
S-Corp	Strong	Pass-through, payroll savings	Owner taking salary + distributions
C-Corp	Strong	Double taxation	Outside investors, large scale
Professional Corp (PC)	Moderate	Pass-through	Clinical-owned entities in CA

3.2 — Required Business Registrations

Federal & State

California Secretary of State — entity registration
IRS — FEIN (Federal Employer ID Number) — irs.gov/ein
California FTB — Franchise Tax Board registration
California EDD — Employment Development Department
California SUI — State Unemployment Insurance
California SDI — State Disability Insurance

Local & Safety

Cal/OSHA — Employer registration and IIPP (required by law)
City of Los Angeles — Business Tax Registration Certificate
NPI Type 2 — Organization NPI — nppes.cms.hhs.gov
NPI Type 1 — Individual NPIs for all licensed practitioners
DEA registration if controlled substances are relevant

3.3 — Insurance Requirements — Non-Negotiable

🚨

No Insurance = No Operations

Workers' compensation is required before your first hire. General and professional liability are required before your first patient. These are not suggestions — they are survival requirements.

Insurance Type	Minimum Coverage	Priority
General Liability	$1M per occurrence / $3M aggregate	CRITICAL
Professional Liability (Malpractice)	$1M per occurrence / $3M aggregate	CRITICAL
Workers' Compensation	California state-mandated — required before first hire	CRITICAL
Cyber Liability	$1M minimum — you hold PHI	CRITICAL
Employment Practices Liability (EPLI)	$1M minimum — CA employment law is aggressive	CRITICAL
Directors & Officers (D&O)	$1M minimum	HIGH
Commercial Auto	$1M — staff drive to patients	HIGH
Hired & Non-Owned Auto	Required if staff use personal vehicles	HIGH
Umbrella Policy	$2M+ recommended	MEDIUM

3.4 — HIPAA & CMIA Compliance Infrastructure

HIPAA is federal law. California's CMIA (Confidentiality of Medical Information Act) is stricter. Both apply — build your infrastructure to the higher CMIA standard.

🔒 Required Privacy Infrastructure

Designate a Privacy Officer and Security Officer (can be same person at startup)
Complete a HIPAA Security Risk Assessment — required by law, document it
Draft and distribute Notice of Privacy Practices (NPP) to all patients at admission
Build Breach Notification Protocol — 72 hours to HHS for breaches affecting 500+ individuals
Execute Business Associate Agreements (BAAs) with ALL vendors touching PHI before access is granted — EMR, billing company, answering service, cloud storage, shredding company
Implement minimum necessary standard in all staff workflows

⚠

California CMIA — Stricter Than Federal HIPAA

California's CMIA adds stricter patient authorization for certain disclosures and stronger civil penalty exposure. Build to CMIA standards — it meets and exceeds HIPAA automatically.

Section 4 · Nobody Works Until This Exists

HR & Employment

California is the most employee-protective state in the nation. Every requirement here applies from your very first hire. Ignorance is not a defense.

AB5 Warning Daily OT · Double Time CFRA · PDL PEO Recommended

4.1 — HR Delivery Model

✓

Recommended Approach

PEO for payroll and benefits administration + California healthcare HR consultant for policy writing and compliance during your first 90 days. This combination protects you from both payroll errors and employment law violations simultaneously.

Model	What It Provides	Cost	Recommended?
PEO (Professional Employer Organization)	Payroll, benefits, workers' comp, HR compliance, onboarding. Examples: TriNet, ADP TotalSource, Paychex PEO, Rippling, Justworks	2–12% of gross payroll	YES — Best for startup
In-House HR Manager	Full control, long-term scalability, custom culture	$70K–$90K/year + benefits	When census exceeds 20 patients
Fractional HR Consultant	Policy setup, compliance advising, handbook writing, issue resolution	$2K–$5K/month retainer	Good bridge strategy

4.2 — California Employment Law Non-Negotiables

Law / Requirement	What It Means	Reference
Daily Overtime	OT after 8 hrs/day AND 40 hrs/week — not just weekly like federal	CA Labor Code 510
Double Time	Required after 12 hrs/day or after 8 hrs on the 7th consecutive day	CA Labor Code 510
Meal Breaks	30-min unpaid break for shifts over 5 hours — not waivable without written mutual agreement	CA Labor Code 512
Rest Breaks	10-min paid break per 4 hours worked — cannot be waived	CA IWC Wage Orders
Paid Sick Leave	Minimum 5 days (40 hours) per year effective 2024	CA SB 616 (2024)
CFRA	Family Rights Act — applies to 5+ employees (federal FMLA requires 50+)	CA Gov Code 12945.2
PDL	Pregnancy Disability Leave — up to 4 months, separate from CFRA	CA Gov Code 12945
SB 1343	Mandatory harassment prevention training — all employees (1hr), supervisors (2hrs)	CA Gov Code 12950.1
Itemized Wage Statements	Required on every paycheck — non-compliance = $50–$100/employee/pay period	CA Labor Code 226
At-Will Employment	Either party can terminate — but California courts scrutinize implied contracts in handbooks	CA Labor Code 2922

4.3 — AB5 Warning — Independent Contractor Classification

🚨

California AB5 — ABC Test — All Three Must Be True

A — Free from control and direction of the hiring entity
B — Work is outside the usual course of the hiring entity's business
C — Customarily engaged in an independently established trade or occupation

Most RNs, LVNs, therapists, and HHAs providing ongoing home health services FAIL Prong B because skilled clinical services ARE the usual course of your business.

Consequence: Back payroll taxes, workers' comp premiums, overtime, missed meal break premiums, civil penalties, class action exposure.

CONSULT A CALIFORNIA EMPLOYMENT ATTORNEY before classifying any clinical worker as 1099.

4.4 — Employee Handbook Required Sections (California)

Employment & Leave Policies

At-will employment (California-specific language)
Equal opportunity and anti-discrimination (FEHA)
Harassment and abusive conduct prevention (FEHA + SB 1343)
ADA and FEHA reasonable accommodation procedures
Pregnancy Disability Leave (PDL)
CFRA / FMLA leave policies and coordination
California Paid Sick Leave (SB 616)
PTO accrual, usage, payout at separation
Split shift premium policy

Clinical & Compliance Policies

HIPAA and CMIA confidentiality acknowledgment
Social media policy — zero tolerance for patient information
Drug-free workplace — testing circumstances
Personal vehicle use, MVR requirements, auto insurance verification
EVV requirements for all clinical visits
Mandatory reporter obligations (elder/dependent adult abuse)
Professional boundaries in patient homes
Mileage reimbursement procedures
Progressive discipline and immediate termination offenses

4.5 — Pre-Employment File Requirements

⚠

No File = No First Patient Contact

Every clinical hire must have a complete employment file before their first patient contact. OIG/SAM exclusion checks must be documented at hire and rechecked MONTHLY for all staff and contractors.

Universal Requirements — All Staff

Signed offer letter with at-will language
I-9 — complete within 3 business days of hire start
W-4 and California DE-4 withholding forms
Background check — LiveScan / DOJ fingerprinting
OIG SAM.gov exclusion check — document date, recheck MONTHLY
LEIE check (OIG List of Excluded Individuals)
Signed employee handbook acknowledgment
Signed HIPAA acknowledgment and confidentiality agreement
Signed mandatory reporter acknowledgment
Emergency contact and personal information form
Direct deposit authorization

Clinical Staff Additional Requirements

Current CA license — verify via BREEZE portal (primary source only)
License expiration date in tracking system
TB test results — 2-step if no documented prior history
Flu vaccine documentation or signed declination
CPR/BLS certification — current within 2 years
MVR (Motor Vehicle Record) — at hire and annually
Personal auto insurance verification — minimum CA liability limits
Signed mileage reimbursement agreement
CHHA-specific: CDPH CHHA certification + Nurse Aide Registry check + competency evaluation by supervising RN before first patient

Section 5 · Do Before First Patient

Pre-Launch Master Checklist

Do not admit a single patient until every item in Tiers 1 and 2 is complete. Work this checklist sequentially within each tier — some items have dependencies.

Tier 1 — Critical Path Tier 2 — Pre-Operational Tier 3 — First 30–90 Days

⚠

Sequential Dependencies

Work this checklist sequentially within each tier. You cannot post jobs until your PEO is set up, and you cannot submit your first claim until your CCN is issued. Dependencies matter.

🔴 Tier 1 — Critical Path: Must Complete Before Any Hire or Patient

Legal & Regulatory

Confirm CDPH HHA license is active, current, covers all service counties
Confirm ACHC accreditation is active and tied to current address
Submit CMS-855A to Noridian — track and follow up every 2 weeks
Submit Medi-Cal enrollment application to DHCS
Verify NPI Type 2 for organization is active — nppes.cms.hhs.gov
Register with California EDD for payroll taxes
Register CA SUI and SDI
Register with Cal/OSHA — document IIPP
Obtain LA Business Tax Registration Certificate
Obtain all insurance policies — get certificates of insurance
Execute BAA with all technology vendors before any PHI is loaded

HR Foundation

Select and contract with PEO — complete employer setup
Complete CA Employee Handbook — reviewed by CA employment attorney
Build pre-employment file checklist and onboarding workflow
Set up payroll system — confirm pay schedule, mileage reimbursement
Set up EVV system — configure for CA requirements (AuthentiCare for Medi-Cal)
Set up OIG/SAM monthly exclusion check — calendar for 1st of every month

Technology

Select and implement EMR — confirm OASIS-E capability
Execute BAA with EMR vendor before loading patient data
Set up office phone system with auto-attendant and after-hours routing
Set up dedicated fax line — eFax or RingCentral
Set up HIPAA-compliant email — Google Workspace or Microsoft 365
Set up secure messaging for clinical team — TigerConnect or similar
Set up mileage tracking for field staff — MileIQ or Everlance

🟡 Tier 2 — Pre-Operational: Complete Before First Patient

Staffing

Hire Administrator — update CDPH license if new person
Hire DPCS — must be RN — California license
Designate Alternate Administrator in writing
Hire or contract minimum 1 RN Case Manager
Hire Intake Coordinator / Admissions RN
Hire Administrative Assistant / Office Coordinator
Contract PT, OT, SLP — PRN or staffing agency
Contract Medical Social Worker — PRN initially acceptable
Complete pre-employment files for ALL hires
Complete general orientation for all staff
Complete clinical orientation for all clinical staff
Complete OASIS training for all RN and therapy staff
Complete EVV training — test with mock visit

Clinical Systems

Activate all P&P documents — assign owners, effective dates, review dates
Build and load care plan templates in EMR
Build visit note templates — include homebound and skilled need fields
Build OASIS workflow in EMR — test SOC to submission
Build 485 template and physician signature tracking workflow
Set up physician order tracking — verbal orders, countersignature deadlines
Set up supervisory visit tracking for HHA cases
Set up QAPI committee — schedule monthly meeting

Revenue Cycle

Select and contract billing company OR hire billing specialist
Execute BAA with billing company before sharing patient data
Set up PDGM training for billing staff and DPCS
Build payer matrix — list every payer you will accept
Submit credentialing applications to all target Medicare Advantage plans
Set up ERA with Noridian
Set up EFT with Noridian — required for Medicare payments

🟢 Tier 3 — In Parallel with Early Operations (First 30–90 Days)

Growth & Marketing

Launch referral marketing — begin hospital, physician, and SNF outreach
Hire Community Liaison / Marketer
Submit credentialing to Medi-Cal Managed Care plans in LA County
Build website with SEO-optimized content
Claim Google Business Profile — complete and verify
Create LinkedIn agency page and personal administrator profile
Hire additional RN Case Managers as census grows
Hire LVN(s) as census grows and RN supervisory structure supports
Complete first QAPI data review — document findings and corrective actions
Complete first internal chart audit — document results

Section 6 · Your Operational Command Center

Office Setup

Your office is your clinical records hub, intake nerve center, survey-ready showcase, and the physical embodiment of your professionalism to every referral source who visits.

6.1 — Physical Space Requirements (CDPH)

Requirement	Standard	California Notes
Private office space	Separate from other businesses	Cannot share with unrelated business
Medical records storage	Secure, locked, fireproof	HIPAA requires PHI protection from unauthorized access
Staff workspace	Adequate for clinical documentation	Surveyors evaluate whether staff can work effectively
Meeting space	IDT and staff meetings	Can be a conference table in a common area
Reception/intake area	Professional, private for patient conversations	Cannot conduct patient intake in open hallway
ADA compliant	Accessible to patients/families	Required for public-facing spaces
Signage	Agency name and license visible	CDPH license must be posted

6.2 — Office Technology Checklist

Hardware — Minimum Startup

Desktop/laptop computers — 1 per full-time admin staff
Laptops or tablets for DPCS and clinical manager
2 shared computers / hot-desks for PRN clinical staff
Multi-function printer with scanning and faxing (healthcare runs on fax)
High-speed internet — minimum 100 Mbps dedicated business line
Backup internet connection — critical if EMR is cloud-based
Battery backup / UPS for all computers and networking
Dedicated shredder — cross-cut minimum (HIPAA requirement)
Secure filing cabinets — locking, fire-resistant for paper records
Office phone system with multi-line and auto-attendant
Dedicated after-hours on-call phone line with routing protocol

Software — Required Before Go-Live

EMR system — OASIS-capable, PDGM grouper, EVV integration, billing module
HIPAA-compliant email — Google Workspace or Microsoft 365 (require signed BAA)
Secure messaging — TigerConnect, Klara, or Imprivata Cortext
Telehealth platform — Doxy.me or Zoom for Healthcare (with BAA)
Mileage tracking — MileIQ or Everlance — deploy to all field staff phones
MDM (Mobile Device Management) — required if staff use personal devices (BYOD)
Cloud backup — all clinical records backed up encrypted, off-site
Password manager — LastPass for Business or 1Password — enforce org-wide
VPN — required for any staff accessing clinical systems remotely

6.3 — Clinical Supply Inventory

🏥 Office Clinical Closet — Stock Before First Patient

Nitrile gloves — all sizes (S, M, L, XL) — 2 boxes per size
Surgical masks — minimum 100
N95 respirators — minimum 50, assorted sizes
Isolation gowns — minimum 50
Face shields or goggles — minimum 10
Hand sanitizer (70%+ alcohol)
Blood pressure cuffs — manual and digital — 2 of each for loan
Pulse oximeters — 5 minimum
Digital thermometers — no-touch preferred — 5 minimum
Stethoscopes — 3 for loan/spare
Glucometers and test strips — 5 kits
Basic wound care: gauze (2x2, 4x4), ABD pads, Kerlix, Coban, tape
Foley catheter kits — sizes 14Fr, 16Fr, 18Fr
Sharps containers and biohazard bags

🎒 Field Staff Go-Bag Standard

Stethoscope
Blood pressure cuff
Pulse oximeter
Thermometer
Glucometer with supplies
PPE kit: 10 gloves/size, 5 masks, 2 gowns, hand sanitizer
Basic wound care supplies
Sharps container — 1-quart portable
Biohazard bags — 5 minimum
Agency ID badge
Blank visit forms / agency paperwork (backup to EMR)
Emergency contact card for patient
Agency after-hours phone number card

6.4 — Survey-Ready Binder — Always at Front Desk

📋

Surveyors Can Arrive Unannounced

Your front desk must be able to hand this binder to any surveyor within 2 minutes of arrival. Keep it current — outdated documents are a finding.

Survey-Ready Binder Contents

Current CDPH Home Health Agency License — original or certified copy
Current ACHC Accreditation Certificate
Medicare Provider information (CCN, NPI, effective date)
Administrator and DPCS contact information — current
Current P&P index with effective and review dates
Most recent QAPI report with committee meeting minutes
Emergency Preparedness Plan — current version
Organizational chart — current
Current staff roster with roles, license numbers, and expiration dates
Infection Control Plan — current version
Patient Rights document — current version

Section 7 · Build Your Clinical Team

Org Chart & Staffing

California HHA staffing requirements are specific. Every licensed role must be verified through primary source, and supervision requirements are non-negotiable at survey.

7.1 — Chain of Command

Owner / Board

Ownership Entity

Administrator

$90K–$130K · CDPH Required

DPCS

RN Required · $110K–$145K

Alt. Administrator

Designated from existing staff

Community Liaison

$75K–$90K + incentive

Billing Specialist

$65K–$85K or outsource

Clinical Manager

RN · $100K–$128K

Intake Coordinator

RN preferred · $80K–$100K

Admin Assistant

$52K–$66K

RN Case Manager

$85K–$115K

LVN

$62K–$78K

PT / OT / SLP

$85–$120/hr contracted

Medical Social Worker

$65–$90/hr contracted

CHHA

CDPH Certified · $22–$32/hr

7.2 — Full Salary & Hiring Priority Table

Role	License Required	Hire Priority	LA Salary Range 2025
Administrator	Per CDPH requirements	Before operations	$90,000–$130,000
Director of Patient Care Services (DPCS)	RN — California license	Before first patient	$110,000–$145,000
Clinical Manager / Supervisor	RN — California license	Before first patient	$100,000–$128,000
Intake Coordinator / Admissions RN	RN preferred (LVN acceptable)	Before first patient	$80,000–$100,000
RN Case Manager	RN — California license	Before first patient	$85,000–$115,000
LVN	LVN — California license	As census grows	$62,000–$78,000
Physical Therapist (PT)	CA PT license	Contract PRN	$90–$120/hr
Occupational Therapist (OT)	CA OT license	Contract PRN	$85–$115/hr
Speech-Language Pathologist (SLP)	CA SLP license	Contract PRN	$85–$110/hr
Medical Social Worker (MSW)	MSW or BSW + licensure	Contract PRN	$65–$90/hr
CHHA (Certified Home Health Aide)	CDPH CHHA certification	As orders come in	$22–$32/hr
Community Liaison / Marketer	RN preferred	Month 2	$75,000–$90,000 + incentive
Admin Assistant / Scheduler	None clinical required	Before operations	$52,000–$66,000
Billing Specialist	Coding cert preferred	Before first claim	$65,000–$85,000 or outsource

7.3 — Supervision Requirements

🚨

CHHA Supervision — California Critical Requirement

Every HHA must have an RN supervisory visit within 2 weeks of beginning a new patient assignment. Supervisory visits must continue every 2 weeks for as long as aide services are provided. These are NOT optional and WILL be cited at survey if missing. The supervisory visit must be documented as a separate visit note — not merged with a skilled nursing visit note.

Supervisor	Supervises	Frequency	Documentation Required
DPCS / Clinical Manager	All RN Case Managers	Monthly minimum	Documented in HR file
RN Case Manager	LVN	Per visit or as clinically indicated	Supervisory note in EMR
RN Case Manager	CHHA on assigned case	Every 2 weeks — MANDATORY	Separate supervisory visit note in EMR
PT	PTA	Per Medicare rules — on-site or real-time electronic	Supervisory note
OT	COTA	Same as PT/PTA	Supervisory note
Clinical Manager	All clinical staff — competency validation	Annual + upon change in clinical assignment	Competency checklist in HR file

Section 8 · Referral to Final Claim

The Patient Journey

Every revenue breakdown, every compliance deficiency, every audit finding traces back to a failure somewhere in this 11-step journey. Master this flow and everything else clicks.

11 Steps Start of Care to Final Claim OASIS · 485 · PDGM

1

Referral Received

Log in intake tracker immediately. Record: date/time, referral source, patient name, diagnosis, insurance, urgency. Acknowledge to referral source within 1 hour. Top LA sources: hospital case management, orthopedic/neurology/cardiology practices, SNFs, primary care, wound care, oncology.

1-hour acknowledgment SLAEMR intake log

2

Eligibility Screening — 4 Medicare Criteria

Before committing to admission, verify ALL FOUR: (1) Under physician care with plan of care. (2) Needs skilled nursing, PT, or SLP — OR continuing OT after one of those was established. (3) Homebound — leaving home requires considerable effort. (4) Medicare Part A or B enrolled. Failure of ANY criterion = no Medicare coverage.

Homebound assessmentInsurance verificationSkilled need confirmation

3

Physician Order — Verbal Order or Face-to-Face

Obtain verbal order to start home health from ordering physician. Confirm face-to-face encounter was within 90 days prior OR 30 days after SOC. Face-to-face must be documented by certifying physician. Missing or incomplete face-to-face = denial and potential recoupment.

90-day prior / 30-day after windowF2F documentation

4

Start of Care (SOC) — OASIS Assessment

SOC OASIS must be completed within 5 days of the first billable visit. This is your payment grouper. Every OASIS answer drives your PDGM case-mix adjustment. The OASIS determines your clinical grouping, functional impairment level, and comorbidity adjustment. Accuracy here is everything — undercoding costs revenue, overcoding triggers audits.

5-day window from first visitOASIS-EPDGM grouper

5

Plan of Care (485) — Within 7 Days of SOC

CMS-485 must be signed by physician within 7 days of SOC completion. Track countersignature religiously — delayed 485 = claim hold. Your physician order tracking system must alert at Day 5, Day 7, and escalate at Day 10. Never submit a claim without a signed 485.

7-day countersignature deadlineCMS-485Track in EMR

6

OASIS Submission to iQIES

SOC OASIS must be transmitted to CMS iQIES within 30 days of the assessment date. Late submissions are a CoP violation. Confirm your EMR submits directly to iQIES and track submission receipts. CMS uses this data for quality reporting and payment validation.

30-day iQIES submission windowTrack receipt confirmation

7

Skilled Visit Delivery & EVV Documentation

All clinical staff must clock in/out via EVV at the patient's home for every visit. California Medi-Cal requires AuthentiCare. Medicare Advantage plans increasingly require EVV as well. Every visit note must document: skilled need, homebound status, patient response, progress toward goals, and any changes. Document as if the auditor is reading it the next day — because they might be.

EVV mandatoryAuthentiCare for Medi-CalHomebound in every note

8

HHCAHPS Patient Experience Survey

Required for Medicare-certified HHAs. Your HHCAHPS vendor contacts discharged patients to survey care quality. Scores are publicly reported on Home Health Compare. Poor scores hurt your referral relationships and your value-based purchasing payment. Enroll with a CMS-approved HHCAHPS vendor before your first discharge — enrollment takes several weeks.

CMS-approved vendor requiredPublic reporting

9

Recertification (Every 60 Days) or Discharge

If the patient continues to meet eligibility criteria at Day 55–60, complete Recertification OASIS (ROC), new 485, and new physician certification. If patient has met goals, plateaued, or no longer qualifies, begin discharge planning. Discharge OASIS due within 2 days of last visit. Premature or delayed discharge triggers audit risk.

60-day episodeROC OASISNew 485 required

10

Claim Submission (RAP → Final Claim)

PDGM eliminated RAPs as of CY2022 — replaced with Notice of Admission (NOA). NOA must be submitted within 5 days of SOC — late NOA = penalty of 1/30th of payment per day late. Final claim submitted after all visits for the 30-day payment period are complete. Submit within timely filing limits (generally 12 months from date of service for Medicare).

NOA within 5 days30-day payment periodTimely filing

11

Payment, Denial Management & Appeals

Medicare pays via EFT — confirm EFT setup with Noridian. Review ERAs for adjustments, denials, and underpayments. Denial rate target: under 5%. Common denial reasons: homebound not documented, skilled need not justified, missing F2F, late NOA. Appeal all denials within 120 days. A 20%+ denial rate indicates a clinical documentation problem, not a billing problem.

EFT payment<5% denial target120-day appeal window

Top LA Referral Sources — Cultivation Strategy

Source Type	Key Contacts	Relationship Strategy
Hospital Case Management	Director of CM, case managers, social workers, discharge planners	In-person visits, same-day admission capability, preferred vendor list
Orthopedic Surgery Practices	Office manager, physician directly	Lunch-and-learn on post-surgical home health criteria, eligibility guide
Neurology / Stroke Programs	Outpatient therapy staff, physiatrists, neurologists	OASIS education on stroke outcomes, functional improvement data
Cardiology / CHF Clinics	NPs, PAs, cardiologists	CHF readmission reduction data — home health keeps patients out of ER
Skilled Nursing Facilities	DON, Social Worker, Discharge Planner	Discharge coordination, clean transitions, reliability
Primary Care Physicians	Office manager, MA, physician	Homebound criteria education, easy referral process (one fax)
Wound Care Centers	Wound care nurse, physician	Complex wound management capability — show your clinical competency
Oncology Practices	Oncology nurse navigator, social worker	Post-chemo weakness, IV therapy, complex nursing

Section 9 · Your Revenue Engine

OASIS & PDGM

PDGM is how Medicare pays you. OASIS is how Medicare decides what to pay. These two systems are inseparable — your clinical documentation directly drives your revenue. Understand this engine or it will destroy your margins.

Patient-Driven Groupings Model 30-Day Payment Periods OASIS-E Case Mix Adjustment

PDGM Payment Structure

Payment Period

30

Days per payment period (was 60 under PPS)

Case Mix Groups

432

Unique payment groups in PDGM

PDGM Variables

5

Timing · Admission source · Clinical · Functional · Comorbidity

LUPA Threshold

2

2 visits or fewer = Low Utilization Payment Adjustment (flat rate, not case mix)

The 5 PDGM Payment Variables

Variable 1: Timing

Early (first 30 days of a new episode) vs. Late (all subsequent 30-day periods). Early periods pay more because patient needs are typically higher at the start of care. A new episode resets the timing clock — new referring physician or 60-day gap in services.

Variable 2: Admission Source

Community (admitted from home, physician office, etc.) vs. Institutional (admitted from hospital, SNF, IRF, LTCH within 14 days of discharge). Institutional source pays more — it reflects higher acuity patients. Verify this at every admission — it's a yes/no with payment implications.

Variable 3: Clinical Grouping

12 clinical groups based on the primary diagnosis on the 485. Your OASIS M1021 (Primary Diagnosis) and M1023 (Other Diagnoses) must be accurate. The clinical group determines which functional impairment tier applies. Wrong primary diagnosis = wrong payment group = audit risk.

Variable 4: Functional Impairment Level

Based on OASIS functional items: M1800, M1810, M1820, M1830, M1840, M1850, M1860. Three levels: Low, Medium, High. Higher functional impairment = higher payment. OASIS documentation must support your scoring — surveyors and auditors compare OASIS scores to clinical notes.

Variable 5: Comorbidity Adjustment

Based on secondary diagnoses on the 485. CMS has defined comorbidity subgroups that receive additional payment. Document all relevant secondary diagnoses — do not leave money on the table. Accurate comorbidity capture requires clinical review of the referring physician's records and H&P.

LUPA — Low Utilization Payment Adjustment

⚠

LUPA Destroys Margins

If a 30-day period has 2 or fewer visits, it is paid at a flat per-visit rate — not the full case-mix-adjusted rate. This is often less than 30% of the expected PDGM payment. Monitor utilization weekly. Early discharge and low-visit-frequency patterns trigger LUPAs.

OASIS Assessment Types & Windows

OASIS Type	When to Complete	Submission Window	Consequence if Late
SOC (Start of Care)	Within 5 days of first billable visit	Within 30 days of assessment date	CoP violation, payment delay
ROC (Resumption of Care)	After 60-day gap or inpatient stay	Within 30 days of assessment date	CoP violation
Recertification	Day 55–60 of each 60-day cert period	Within 30 days of assessment date	Cannot bill next period
Follow-up (FU)	When significant change in condition	Within 30 days of assessment date	Clinical documentation gap
Transfer	When patient transfers to inpatient facility	Within 30 days of assessment date	Quality reporting gap
Discharge	Within 2 days of last visit	Within 30 days of assessment date	Quality data gap, CoP violation

Section 10 · Data-Driven Compliance

QAPI & Compliance

Your QAPI program is not optional — it's a CoP requirement active from Day 1. A functioning QAPI program is also your best defense in any survey, audit, or legal proceeding.

42 CFR 484.65 Monthly Committee Internal Audits Survey Readiness

Key Performance Indicators — Target Benchmarks

30-Day Rehospitalization

<15%

Target: below national avg

ED Use Without Hospitalization

<12%

Track per OASIS M2410

Claim Denial Rate

<5%

Above 10% = documentation problem

OASIS Submission Timeliness

100%

Zero late transmissions

485 Signature Rate ≤7d

>95%

Track in EMR by physician

HHA Supervisory Visit Compliance

100%

Every 14 days — zero exceptions

OIG Exclusion Check

Monthly

All staff + contractors — document date

Staff License Expiration

0

Zero expired licenses on active staff

Patient Falls Rate

<3%

Track per 100 patients

Internal Audit Schedule

Audit Type	Frequency	Sample Size	Owner
OASIS accuracy review	Monthly	10% of all SOC/ROC/Recerts	DPCS or Clinical Manager
485 signature timeliness	Monthly	All certifications	Billing Specialist
HHA supervisory visit compliance	Monthly	All active HHA cases	RN Case Managers
Visit note documentation quality	Monthly	2 notes per clinician	Clinical Manager
OIG/SAM exclusion checks	Monthly	All staff and contractors	Compliance Officer
License expiration tracking	Monthly	All active clinical staff	Admin / HR
Billing and claims review	Monthly	All denied claims + 5% random	Billing Specialist
Personnel file completeness	Quarterly	All active staff	HR / Admin
Emergency preparedness plan review	Annually	Full plan review	Administrator
HIPAA Security Risk Assessment	Annually	All systems and workflows	Security Officer
P&P review and update	Annually (minimum)	All active policies	DPCS + Administrator

Survey Readiness — Common Deficiency Categories

🔴 Highest-Frequency Citations

OASIS accuracy — functional scoring not supported by visit notes
HHA supervision — supervisory visit not completed every 14 days
Care plan not individualized — template goals not updated to patient
Missing or late 485 signatures — physician countersignature
Homebound not documented in visit notes
QAPI not functional — no minutes, no data, no corrective actions
Personnel file deficiencies — missing TB, CPR, or license primary source

✓ Survey-Ready Behaviors

Every visit note includes homebound status statement
Every visit note includes skilled need justification
QAPI committee meets monthly — minutes and corrective actions documented
Survey-Ready Binder at front desk — updated monthly
Staff knows who to call first if surveyor arrives — rehearsed, not improvised
All personnel files complete — audit-ready at any time
P&P accessible, dated, and followed — not just filed

Section 11 · Protect Your Investment

Financial Management

Home health is a cash-flow-intensive business with a 60–90 day delay between service delivery and payment. Most agencies that fail in Year 1 die from cash flow, not clinical problems.

Revenue Cycle PDGM Rate 12-Month Projection Failure Points

Why HHAs Fail — The Critical Failure Points

🚨

Most HHA Failures Are Cash Flow, Not Clinical

A typical California HHA needs 90–120 days of operating capital before Medicare pays its first claim. This means payroll, rent, supplies, insurance, and overhead for 3–4 months with zero Medicare revenue. Plan for this — it is not optional.

Failure Point	Description	Prevention
Undercapitalization	Running out of cash before Medicare CCN is issued and first claims are paid	Minimum $250K–$500K operating capital before first patient
LUPA traps	Cases consistently hitting 2-visit threshold — paying full clinical costs but receiving LUPA rates	Weekly utilization review; clinical justification for every case plan
Denial spiral	Denial rate exceeds 15% — collections staff overwhelmed, cash flow collapses	OASIS accuracy audits; homebound documentation in every note
Physician 485 delays	Claims held 30–60 days waiting for physician countersignature	Aggressive follow-up system; physician education; pre-signed orders workflow
Wrong payer mix	Accepting too many Medi-Cal fee-for-service or low-rate managed care plans	Build payer matrix with rates before contracting; negotiate rates aggressively
Uncontrolled overtime	California daily overtime and double time rules destroy per-visit margins if scheduling is loose	Scheduling system with OT alerts; PRN pool for overflow visits
Missing recoupments	ADRs (Additional Documentation Requests) not responded to timely — automatic recoupment	Track all ADRs; respond within 30 days; escalate to attorney if needed

Medicare PDGM Base Payment Benchmarks (2025)

National Base Rate / 30-day period

~$2,000

Before case-mix adjustment (varies by year)

High Acuity Case Mix Rate

~$3,500+

Institutional early + high functional + comorbidity

LUPA Rate (Low Utilization)

~$150

Per visit — for 2 or fewer visits in period

Non-Routine Supplies Add-On

Separate

Billed separately from PDGM episodic rate

12-Month Financial Projection Framework

Month	Patient Census (est.)	Gross Revenue (est.)	Key Milestone
1–2	0 — Pre-operational	$0	CCN application pending; PEO, EMR, staff hired
3	1–3 patients	$0 collected (claims pending)	First patients admitted; CCN received; first claims submitted
4	3–8 patients	First Medicare payments received	First 30-day claims paid; Medi-Cal enrollment processing
5–6	8–15 patients	$30K–$60K/month	Managed care credentialing completing; referral volume building
7–9	15–25 patients	$60K–$120K/month	First QAPI review; hire second RN CM; LVN if clinically appropriate
10–12	25–40 patients	$120K–$200K/month	Full payer mix activated; consider in-house billing at this volume

Startup Capital Requirements

Operating reserves: 3–4 months of projected operating expenses before first Medicare payment
Office setup: $15K–$40K (lease deposit, furniture, equipment)
Technology: $10K–$25K (EMR setup, IT, phones)
Insurance premiums (first year): $25K–$60K
Legal and consulting fees: $15K–$30K
Licensing and accreditation fees: $5K–$15K
Initial supply inventory: $5K–$10K
Total estimated startup: $250K–$500K minimum

Revenue Cycle KPIs to Track Weekly

Days in AR: Target under 45 days
Clean claim rate: Target above 95%
Denial rate: Target under 5%
Collection rate: Target above 97% of net revenue
NOA submission timeliness: 100% within 5 days of SOC
LUPA rate: Target under 10% of 30-day periods
Average revenue per visit: Track by payer and discipline

Section 12 · Building Your Clinical Culture

Orientation & Training

Orientation is your first and most powerful cultural statement. Staff who are disoriented on Day 1 become disengaged by Day 30 and resigned by Day 90. Do this right.

General Orientation Clinical Orientation OASIS Training HHA Competency

Week-by-Week Orientation Schedule

Week 1 — Foundation

General Orientation — All Staff

Agency mission, values, and culture. Organizational chart and reporting structure. Employee handbook review and acknowledgment. HIPAA and CMIA training — mandatory, documented. Mandatory reporter training (elder/dependent adult abuse — AB 1440). EVV system training — all clinical staff. Workplace safety and IIPP (Cal/OSHA). Emergency preparedness and evacuation plan. Payroll, timekeeping, mileage reimbursement procedures. IT systems login, email, secure messaging, passwords.

Week 2 — Clinical Foundation

Clinical Orientation — All Clinical Staff

Medicare and Medi-Cal home health eligibility criteria — homebound, skilled need. OASIS overview and your agency's OASIS workflow. Care planning — individualized goals, physician orders, 485 process. Infection prevention and control — standard precautions, PPE, sharps. Documentation standards — what constitutes a compliant visit note. Homebound documentation — how to write it so it protects the claim. Patient rights and grievance procedure. Mandatory incident and adverse event reporting. Emergency protocols — patient falls, medical emergencies in the home.

Week 3 — EMR Proficiency

EMR and Documentation Deep-Dive

EMR navigation — chart creation, visit notes, care plans, physician orders. OASIS data entry — field by field review of key scoring items. EVV workflow — mock visit clock-in/out from simulated patient home. Verbal order entry and countersignature tracking. Supervisory visit documentation for CHHA cases. PDGM basics — how your documentation drives payment. Case conference documentation. Discharge planning and discharge OASIS workflow.

Week 4 — Skills Validation

Competency Assessment

Skills demonstration — clinical competencies per role (RN, LVN, CHHA, PT, OT, SLP). Wound care competency — wound assessment documentation, dressing techniques. Medication management in the home setting. IV therapy competency for applicable staff. Fall prevention assessment and documentation. Cognitive and behavioral assessment basics. Return demonstration on at least 3 clinical skills. Supervisory observation visit with Clinical Manager. Written competency test — minimum passing score per agency policy.

Days 31–90 — Supervised Practice

Supervised Field Experience

Clinical Manager accompanies new staff on first 2–3 patient visits. New RN Case Managers carry reduced caseload (8–12 patients) for first 30 days. Weekly one-on-one with Clinical Manager or DPCS. Monthly QAPI data review — new staff participate. 90-day performance review — written and signed. Documentation audits — new staff charts reviewed monthly for first 90 days.

CHHA-Specific Training Requirements (CDPH)

⚠

CHHA May Not Begin Patient Care Until All Three Are Complete

A CHHA may not provide patient care until: (1) General and clinical orientation is complete, (2) Competency evaluation is completed and signed by a supervising RN, (3) First RN supervisory visit assignment is scheduled. Document all three with dates and signatures in the personnel file.

Annual Training Requirements — All Staff

HIPAA annual refresher training — documented
Infection prevention and control annual update
Emergency preparedness annual training
OASIS accuracy refresher (clinical staff)
Sexual harassment prevention (SB 1343)

Mandatory reporter refresher
OIG compliance training
EVV system updates (as applicable)
CPR/BLS renewal (every 2 years)
License renewal — verify primary source

Quick Reference Links

Regulatory References

Primary-source regulatory links and required forms. Bookmark these — regulations change. Always verify against the current source, not a summary.

Federal Regulatory Sources

🏛 CMS — Home Health

CoPs, OASIS, PDGM guidance, Home Health Compare

CMS HHA Regulations →

HHQAPI Resources →

📋 Noridian — California MAC

CMS-855A enrollment, claims submission, LCD policies, ERA/EFT setup

Noridian Healthcare Solutions →

🔍 OIG Exclusion Database

SAM.gov and LEIE monthly checks — all staff and contractors

OIG LEIE →

SAM.gov →

📊 iQIES — OASIS Submission

OASIS data submission portal, quality reporting, Home Health QRP

iQIES Portal →

California State Sources

🏥 CDPH — Home Health Licensing

License application, renewal, county expansion, administrator changes

CDPH HHA Licensing →

💊 DHCS — Medi-Cal Enrollment

Provider enrollment, managed care plans, DHCS billing guides

DHCS Provider Portal →

🔎 BREEZE — License Verification

California license primary source verification — all clinical staff

CA License Search →

⚖ CA Labor Commissioner

Wage orders, overtime rules, meal/rest break requirements

CA Labor Standards →

Accreditation

✅ ACHC Accreditation

Standards library, accreditation portal, annual attestations, survey preparation resources

ACHC Accreditation Portal →

📚 OIG Compliance Guidance

Compliance program guidance specifically for home health agencies

OIG HHA Compliance Guidance →

Required Forms — CMS

Form	Name	Purpose
CMS-485	Home Health Certification and Plan of Care	Physician order / Plan of Care — required for every certification period
CMS-855A	Medicare Enrollment Application — Institutional Providers	Initial Medicare enrollment and CCN application
OASIS-E	Outcome and Assessment Information Set	Patient assessment at SOC, ROC, Recert, FU, Transfer, Discharge
Notice of Admission (NOA)	Home Health Notice of Admission	Replaces RAP — must be submitted within 5 days of SOC
CMS-1500	Health Insurance Claim Form	For Part B therapy claims when applicable
UB-04	Uniform Bill 04	Institutional claim form — Medicare Part A home health claims
ABN	Advance Beneficiary Notice of Noncoverage	Required when providing non-covered services to Medicare beneficiaries

📌 Document Information

Compiled by: Araya Consulting LLC
Market: State of California — Los Angeles
Edition: 2025

Classification: Confidential — Internal Use Only
Note: Return to this document monthly — regulations change
Contact: arayaconsultingllc@gmail.com

Medicare Reimbursement Tool · CY 2025 Estimates

PDGM Reimbursement Calculator

Estimate your 30-day Medicare Home Health payment based on PDGM case-mix variables. Results are estimates — actual payment depends on your MAC, geographic wage index, and outlier adjustments.

⚙ Enter Patient Variables

1. Episode Timing

EARLY

1st 30-day period

LATE

2nd+ 30-day period

2. Admission Source

COMMUNITY

No inpatient stay within 14 days

INSTITUTIONAL

Hospital/SNF within 14 days

3. Clinical Grouping

4. Functional Impairment Level

LOW

Mild

MEDIUM

Moderate

HIGH

Severe

5. Comorbidity Adjustment

NONE

No qualifying

LOW

1 comorbidity

HIGH

2+ comorbidities

6. Planned Visits (30 days)

7. Rural Patient?

NO (+0%)

Toggle for +3% rural add-on

8. Geographic Wage Index

Estimated 30-Day Medicare Payment

$2,174

EC — Musculo — Low FI — No Comorbidity

📊 Payment Breakdown

CY2025 Base 30-Day Rate$2,007.00

Case-Mix Weight (group × FI)1.0824

Wage-Adjusted Base$2,093.00

Comorbidity Adjustment+$0.00

Rural Add-On+$0.00

ESTIMATED PAYMENT$2,174

⚠ LUPA Analysis

LUPA Threshold

5

visits minimum

Your Visit Count

10

planned visits

✓ Above LUPA threshold — full period payment applies

📈 Census Revenue Projection

Active patients on census:

Monthly revenue (est.)$32,610

3-Month projection$97,830

6-Month projection$195,660

📋 PDGM Weight Reference Table (CY2025 Approximations)

Verify actual published weights at cms.gov/medicare/home-health before use in formal financial planning.

Clinical Grouping	Early/Comm	Early/Inst	Late/Comm	Late/Inst	LUPA Min
Musculoskeletal Rehabilitation	1.0824	1.1390	0.8562	0.9210	5
Neuro / Stroke Rehabilitation	1.2150	1.3210	0.9340	1.0120	5
Wound Care (Non-Surgical)	1.1680	1.2240	0.9100	0.9740	3
Surgical Aftercare / Orthopedic	1.0540	1.1180	0.8320	0.8980	5
Complex Nursing Interventions	1.3400	1.4850	1.0650	1.1340	3
MMTA — Cardiac & Circulatory	0.9620	1.0450	0.7850	0.8590	3
MMTA — Endocrine	0.9020	0.9880	0.7240	0.8010	2
MMTA — GI / GU	0.9290	1.0110	0.7540	0.8290	2
MMTA — Infectious / Neoplasms	1.2980	1.4020	1.0280	1.1050	3
MMTA — Respiratory	1.0110	1.0950	0.8140	0.8890	3
MMTA — Other	0.8750	0.9420	0.7010	0.7730	2
Behavioral Health Care	0.9470	1.0180	0.7680	0.8430	3

FI adjustment: Medium +7%, High +13%. Comorbidity: Low +5%, High +10%. Wage split: 77.137% labor × wage index + 22.863% non-labor. Source: Approximated from CMS CY2025 HH PPS Final Rule.

Operational Intelligence · Side-by-Side Reference

Home Health Agency vs. Hospice

A comprehensive comparison across licensing, eligibility, intake, patient journey, charting, operations, billing, staffing, and compliance.

🔑 The Core Distinction

🏠 Home Health Agency

Skilled, curative / restorative care. Goal: treat, rehabilitate, improve. Patient is homebound but expected to improve — not dying.

Medicare Part A or B
42 CFR Part 484 (CoPs)
Requires CMS-485 physician order
OASIS-E at SOC/ROC/discharge
PDGM — 30-day payment periods
No prognosis requirement

🕊 Hospice

Comfort-focused, palliative care. Goal: manage symptoms, provide dignity. Patient has elected to forgo curative treatment.

Medicare Part A only
42 CFR Part 418
Requires physician certification ≤6 months prognosis
IDG assessments — no OASIS
Per diem — 4 levels of care
Patient signs election statement — waives curative Medicare

✅ Patient Eligibility

Criteria	🏠 Home Health	🕊 Hospice
Prognosis	No terminal prognosis required. Patient expected to improve or stabilize.	Physician must certify life expectancy ≤6 months. Re-certified every 60 days.
Homebound Status	Required. Considerable effort to leave home — document every visit.	Not required. Patient can leave home freely.
Skilled Need	Must require RN, PT, OT, or SLP. CHHA alone is insufficient.	Any terminal patient — skilled need is not the threshold.
Election	Physician order + patient consent. No special election form.	Hospice Election Statement required. Patient formally waives curative Medicare Part A.
Medicare Part	Part A (post-acute) or Part B (standalone)	Part A only. Curative Part A coverage suspended during election.

📋 Intake Journey — Step by Step

🏠 HHA Intake

1. Referral + Insurance Verification

Verify Medicare/managed care eligibility. Check for active hospice election — cannot serve simultaneously.

2. Verbal Physician Order

Obtain verbal start-of-care order. Written CMS-485 must follow within 30 days.

3. SOC Visit + OASIS-E

RN completes full assessment, OASIS-E, medication reconciliation, homebound documentation.

4. Consent Packet Signed

Patient Rights, HIPAA NPP, Consent for Treatment, AOB, Advance Directive acknowledgment, EVV notice.

5. NOA Submitted (5-day rule)

Notice of Admission to Medicare within 5 days. Late = $27.50/day penalty.

6. OASIS Submitted to iQIES

SOC OASIS-E locked and submitted within 30 days. Feeds STAR ratings and HHCAHPS.

🕊 Hospice Intake

1. Referral + Benefits Counseling

SW or RN explains Hospice Benefit to patient and family — what it covers, what curative coverage is waived.

2. Hospice Election Statement Signed

Critical legal document. Patient formally waives curative Medicare Part A for terminal diagnosis.

3. Dual Physician Certification

Both Hospice Medical Director AND attending physician certify terminal prognosis ≤6 months with clinical narrative.

4. IDG Initial Meeting

Full IDG convenes: RN, SW, Chaplain, Aide, Volunteer Coordinator, Medical Director. Develop IPOC together.

5. Comprehensive Assessment (48 hrs)

RN assesses pain, spiritual/psychosocial needs, caregiver burden. Hospice-provided medications ordered by MD.

6. Bereavement Plan Initiated

Family bereavement assessment begins at admission. Must provide 13 months support post-death. No HHA equivalent.

📝 Charting & Documentation

Document	🏠 HHA	🕊 Hospice
Assessment Tool	OASIS-E — 100+ elements. At SOC, ROC, Follow-Up, Transfer, Discharge. Submitted to iQIES.	Comprehensive Assessment — agency-defined per 42 CFR §418.54. No OASIS equivalent.
Plan of Care	CMS-485 — physician-signed, 60-day validity, covers diagnosis/function/meds/visit frequency.	IDG IPOC — interdisciplinary, covers medical + psychosocial + spiritual + bereavement. Updated every 15–30 days.
Homebound Doc	Required every visit. Must state specific homebound reason. Top audit target.	Not required. Irrelevant to hospice eligibility.
IDG Meeting Notes	Not required by CoP.	Mandatory. Full IDG attendance documented. Minimum every 15 days for GIP. Survey deficiency target.
Death Documentation	Document and discharge. No specialized death process.	Core competency — TOD note, RN pronouncement, family notification, body disposition, bereavement initiation, Medicare discharge claim.

$ Billing & Reimbursement

Area	🏠 HHA	🕊 Hospice
Payment Model	PDGM — 30-day periods. Rate varies by timing, source, clinical group, FI level, comorbidity.	Per diem daily rate. RHC ≈$215/day. CHC ≈$1,400/day. GIP ≈$1,100/day. Paid every calendar day regardless of visit count.
LUPA Risk	Real risk. Falls below threshold = per-visit rate only. Manage visit delivery carefully.	No LUPA equivalent. Per diem paid every day regardless of visits delivered.
What Medicare Covers	Skilled nursing, PT, OT, SLP, MSW, CHHA (with skilled service), related medical supplies.	Everything related to terminal diagnosis: nursing, aide, SW, chaplain, volunteer, DME, medications, inpatient respite, bereavement.
Cap / Limits	No annual cap if medical necessity continues. Recertify indefinitely.	Aggregate hospice cap applies. CMS limits total payments per patient per cap year (~$33k). Overage must be repaid.

⚡ Quick-Reference Matrix

Topic	🏠 HHA	🕊 Hospice
Federal CoP	42 CFR Part 484	42 CFR Part 418
Goal	Curative / Restorative	Comfort / Palliative
Prognosis required	No	Yes — ≤6 months
Homebound required	Yes — every visit	No
Assessment tool	OASIS-E	Comprehensive Assessment
Plan of care	CMS-485	IDG IPOC
Medical Director required	No	Yes — CoP required
Chaplain required	No	Yes — core IDG
Volunteer program	Not required	Yes — 5% care hours
Bereavement program	Not required	13 months post-death
LUPA risk	Yes — visit minimum	No — daily rate
CA State License	H&S Code §1726	H&S Code §1745

⚠ CAN A PATIENT HAVE BOTH?

A patient cannot receive HHA and hospice simultaneously for the same terminal diagnosis. If your HHA patient elects hospice, discharge them from HHA. They can return to HHA only upon revocation of hospice. Exception: HHA-type Part B services for an unrelated condition during hospice — rare, requires careful documentation.