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Certified Home Health Care Standards Of Practice

The Michigan Home Care recommends to its membership the following Standards of Practice as a basis of development for each agency’s individualized standards of care.


Guidelines For Implementation

The Michigan Home Care recommends to its membership the following Guidelines for Implementation of Standards of Practice as a basis of development for each agency’s individualized guidelines.


Standard I

Services are provided in accordance with professionally recognized standards and licensing requirements of each discipline and comply with regulatory requirements.



  1. Professional and paraprofessional credentials are verified for authenticity and validity per agency policy.
  2. Criminal background checks are conducted for job applicants, who shall be deemed eligible for employment in accordance with agency policy.
  3. Employee files are maintained and updated per agency and/or regulatory policies.
  4. The agency maintains a written job description for all professional staff.
  5. Supervision of staff is provided per agency policy, regulations and individualized per knowledge/skill level of staff.
  6. Policies and responsibilities of contracted staff are specified in appropriate contract language and includes Medicare exclusion verbage.
  7. Employees are assigned to provide care in accordance with agency policy. Factors influencing the choice of personnel may include:
    1. Skill level required
    2. Availability of personnel
    3. Client/family requests
    4. Third party payor coverage
    5. Physician’s orders
  8. The home care organization provides opportunities to all staff for participation in continuing education activities on an individual or group basis.
  9. The home care organization selects appropriate professionals to conduct or provide for continuing education programs/activities.
  10. The home care organization provides staff with access to educational resources.

Standard II

Initial assessment visit is completed by the appropriate professional per payer requirements.



  1. Patients are accepted on service on the expectation that the agency can meet their needs in their home setting.
  2. The professional nurse (RN) or qualifying therapist completes the initial assessment on all skilled care cases.
  3. The initial assessment visit determines immediate care and support needs of the patient and also determines eligibility for the Medicare home health benefit.
  4. The initial assessment visit of the client may include but is not limited to the following:
    1. Holistic assessment of the client’s physical, psychological, and social status
    2. Drug regimen review
    3. Assessment of the client’s residence/environment.
    4. Assessment of the client’s concerns and immediate needs.
    5. The client’s medical history, physician orders, medical treatment plan
    6. Assessment of the client’s support systems, community resources
    7. Assessment of family dynamics, social and cultural factors affecting health
    8. An explanation of parameters of services
    9. Completion of necessary administrative paperwork related to reimbursement and agency policies
    10. Development of an individualized plan of care
    11. Establishment of an emergency disaster plan
    12. Validating and obtaining further physician’s orders as necessary.
    13. Arranging therapy and support services as assessed.
  5. The assessment information is recorded in a timely and efficient manner according to regulatory requirements and agency policy.
  6. The frequency of reassessment visits are determined in accordance with regulatory requirements, patient condition changes, and agency policies.

Standard III

Data collection is ongoing and systematic. The data is accessible, communicated, and recorded.



  1. The professional records the data in a timely, standardized, systematic, and concise form. The home care agency maintains a record keeping system that provides for:
    1. Systematic and complete collection of data
    2. Frequent updating of records
    3. Accessibility to the records, as determined by agency policy
    4. Confidentiality of the records per HIPAA standards
  2. Staff are responsible for making observations on each visit that may include:
    1. Physical and mental status
    2. Environment and safety
    3. Support systems
    4. Family dynamics
    5. Social and cultural factors affecting health
  3. The changes in client condition are reported to the supervisor or physician as appropriate.

Standard IV

Problem statements are derived from client needs.



  1. All assessment data are interpreted and analyzed in collaboration with the client and family prior to formulating problem statements.
  2. The client’s potential and limitations are considered when developing a problem statement.
  3. Problem statements are updated and/or revised as necessary as client condition warrants.

Standard V

The individualized plan of care includes goals and expected outcomes derived from the assessment data.


  1. To achieve the goals and expected outcomes the professional will:
    1. Evaluate the referral for appropriateness and accept or reject the referral accordingly
    2. Provide appropriate professional intervention
    3. Provide available community resources
    4. Provide instructions for a safe environment
    5. Minimize further dependency and deterioration as possible
    6. Initiate or develop a support system as needed
    7. Encourage client/family participation in determination of goals.
    8. Educate the client and family toward goals and expected outcomes
  2. Expected outcomes for services provided by the professional may include:
    1. An improved level of functioning
    2. Maximum rehabilitation potential
    3. Projected independent living potential without caregiver assistance
    4. Physical and mental comfort

Standard VI

Plans for care are established by the physician’s written orders and include interventions to achieve the identified goals and expected outcomes.


  1. The professional will:
    1. Develop a written individualized plan of care
    2. Review and revise plan as condition warrants
    3. Encourage client and family to participate in the development/revision in the plan of care
    4. Include information regarding community resources in the plan of care when needed
    5. Identify emergency plans for clients
  2. The paraprofessional follows a discipline specific plan of care prepared by the professional.

Standard VII

Interventions assist the client to achieve or maintain maximum potential.


  1. Interventions are developed based on expected client outcomes.
  2. Professional interventions are:
    1. Specific/individualized
    2. Consistent with the plan of care
    3. Consistent with the defined standards of practice
    4. Conform with payer requirements/criteria
    5. In accordance with the client’s physiological, psychological, and social behavior
    6. Inclusive of teaching and education.
  3. Interventions and the client’s response to the interventions are recorded systematically and timely.
  4. The agency maintains a policy/procedure manual for professional interventions.
  5. The agency maintains an internal review to ensure that interventions follow the established policies/procedures.
  6. Agency services are coordinated with and communicated to other members of the health care team and community.
  7. Paraprofessional interventions are:
    1. General in nature but individualized to the client
    2. Incorporated in the paraprofessional plan of care
    3. Consistent with the client’s physiological condition including functional status and psychological social behavior
    4. Appropriate to the level of experience and/or training of the paraprofessional
    5. Recorded systematically and timely
  8. Supervision of the paraprofessional is done on an on-going basis and per regulatory requirements and agency policy
  9. Agency services are coordinated with and communicated to other members of the health care team and community.
  10. Care is provided in accordance with accepted standards of practice in the community.

Standard VIII

The client’s progress toward goal achievement is evaluated regularly by the client and home care provider.


  1. Plans toward goal achievement are dependent on continuous and ongoing evaluation of mutually agreed upon outcomes.
  2. Baseline and current data are reviewed and interpreted to measure progress toward goals.
  3. Active participation of client, family, or significant other is encouraged to revise priorities, goals, and interventions.
  4. The professional documents revisions and evaluations.
  5. A quality assurance mechanism is in place to evaluate the client’s progress toward goal achievement.

Standard IV

Continuity of care is assured through a process of planning and referral to appropriate community resources.


  1. The plan of care includes the utilization of available and appropriate resources. They may include any or all of the following:
    1. Support Service
    2. Client education materials
    3. Community resources
    4. Medical equipment resources
  2. The client/family/significant other are provided with information needed to make decisions and choices about:
    1. Promoting, maintaining and restoring health
    2. Seeking and utilizing appropriate health care personnel
    3. Maintaining and using health care resources
  3. The professional identifies and plans for services to meet health care needs.
  4. During transition from one agency to another, the professional provides adequate information to assure coordination of services.
  5. There is documentation in the client record of coordination among referral sources.

Standard X

An emergency disaster plan is established for the client.


  1. During initial assessment the emergency disaster plan will be established.
  2. The emergency plan may include, but is not limited to the following:
    1. Phone numbers of police, fire, ambulance, physician, pharmacy, home care organization, primary contact person, medical equipment company
    2. Basic home safety precaution
    3. Changes in medical condition to report to physician and/or home care organization
  3. The emergency plan is reviewed with the client, family, and caregivers.
Michigan HomeCare & Hospice Association
2140 University Park Drive, Suite 220
Okemos, MI 48864
Phone: (517) 349-8089 Fax: (517) 349-8090

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