As HCA members strive to remain compliant with regulations and procedures that impact CHHAs, LHCSAs and hospices, we are happy to announce that the state Department of Health has made available the tools its surveyors use for conducting surveys of home care and hospice agencies. Please click the links below under each program type.
HCA members are advised to review the forms to gain a better understanding of their responsibilities in a multitude of areas, including quality assurance; clinical records; personnel records; influenza vaccinations; emergency preparedness; home care registry; Medicare conditions of participation; infection control; health commerce system; and more.
CHHA Files
CHRC Protocol REVISED May 2018
CMS CHHA CoPs Interpretive Guidelines 8-31-18
CMS CHHA Priority Tags Survey Protocol Jan 2018
CMS CHHA TAGS-Level 1 and 2 Listing Jan 2018
CMS QSO 18-13 MEMO CHHA Survey Protocol Jan 2018
Casper Report Guidance-Issued March 2018
CHHA Pre-Survey Preparation Worksheet-Feb 2018
CHHA Entrance Conference Surveyor Tool-July 2018
CHHA Clinical Record Revised CoPs July 2018
CHHA Contract Worksheet-Feb 2018
CHHA Emergency Preparedness Surveyor Worksheet Distributed 11-16-17
CHHA QAPI & Infection Survey Tool March 2018
Health Commerce System Tool-June 2017
Home Care Registry Survey Tool-April 2017
Influenza Vaccination Flu Mask Worksheet-June 2017
Personnel Record Review Form-June 2017
Organization and Administration Worksheet-JULY 2018
LHCSA FILES
Electronic Plan of Correction Info-June 2017
CHRC Protocol REVISED May 2018
Consent For Home Visit_DOH_June 2017
Employee List for Personnel Record_DOH_June 2017
LHCSA Pre-Survey Worksheet -June 2017
Health Commerce System Tool-June 2017
Home Care Registry Survey Tool-April 2017
LHCSA Entrance Conference Surveyor TOOL-REVISED JULY 2017
LHCSA Contracts Worksheet-REVISED JULY 2017
LHCSA QA Surveillance Tool-June 2017
Influenza Vaccination Flu Mask Worksheet-June 2017
Emergency Preparedness Tool-Revised 1-30-18
LHCSA Governing Authority Tool-June 2017
Clinical Record Review Form-June 2017
Home Visit Worksheet-June 2017
Personnel Record Review Form-June 2017
Hospice Files
Home Care Registry Survey Tool
Entrance Conference Surveyor Tool Sept 2018
Hospice Clinical Rec Rev Tool FINAL
CMS Hospice-Questions-for-Home-Visits
Consent For Home Visit-June 2017
Hospice Contract Worksheet-Sept 2018
Hospice Survey Tools Index 9-28-18
Hospice Pre-Survey Prep WORKSHEET Sept 2018
Health Commerce System Tool-June 2017
HOSPICE BEREAVEMENT Worksheet May 2016
Hospice Survey Investigation Worksheet Calendar 6-6-13
HOSPICE VOLUNTEER Worksheet May 2016
Hospice Infection Control Worksheet May 2017
Personnel and Volunteer Review Sept 2018
Influenza Vaccination Flu Mask Worksheet June 2017
Hospice Emergency Preparedness Surveyor Worksheet Distributed 11-16-17