Home Health Agency Compliance Checklist
Use This Compliance Checklist When You Need Home Health Agency
Agency Name
Email
example@example.com
Agency Attributes
What Health Services are Provided?
Companion Care
Personal Care
Respite Care
Specialized Home Care
Nursing Care
Non-medical Care
Chores
Other
Have a medicare certification?
Please Select
Yes
No
Have a medicaid certification?
Please Select
Yes
No
Does the agency conduct background checks on all employees?
Please Select
Yes
No
Does the agency offer a free initial in-home consultation?
Please Select
Yes
No
Does the agency provide a single caregiver per client, or does it offer a team approach?
Please Select
Single
Team
Is the caregiver licensed to practice in your state? Does he/she hold an accreditation from a organization?
Please Select
Yes
No
Staff Attributes
What Type of Staff is Available to Deliver Service?
Registered Nurse
Physical Therapist
Speech Therapist
Occupational Therapist
Home Health Aide
Nutritionist
Social Worker
Other
Staff available nights/weekends for emergencies?
Please Select
Yes
No
Staff can provide the type/hours of care of doctor ordered?
Please Select
Yes
No
Does the staff develop the personalized care plan?
Please Select
Yes
No
Is the staff bonded or insured by the agency?
Please Select
Yes
No
Who will cover the insurance?
How soon could the care start?
What is the hourly or daily charge?
How long has your staff been serving in the home care industry?
How many hours does the staff serve for home care?
Submit
Should be Empty: