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Home Health Aide Supervision...Right & Wrong

Posted by Melissa Cott on Feb 4, 2022

The objective of the home health supervisory visit is to determine...

• if the aide is following the careplan,
• if the careplan is meeting the patient's needs,
• if the patient/caregiver is satisfied with the careplan and the performance of the aide.

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Ask open ended questions to get the patient/caregiver's true opinion. .

You want to avoid getting 'yes' or 'no' answers from the patient/caregiver and obtain an objective observation of what the aide is doing. It's common for the patient/caregiver to want to prevent the aide from 'getting in trouble' if s/he is not performing tasks.  The patient/caregiver may feel the s/he will lose services if s/he complains .  Its important to ask questions correctly to get the true nature of services being provided.

To get the true picture...

Ask 'open-ended' questions:

• What time does the aide arrive?  (instead of 'Does the aide arrive at 8am like s/he is supposed to?')
• What time does the aide leave?  (instead of 'Does the aide stay the full 2 hours?')

To get the true picture of what the aide really does:

• What are the tasks that the aide performs? (instead of 'Does the aide help you with your bathing?  Does the aide do the laundry?')
• What would you like to change about the careplan? (instead of 'Are you happy with the careplan?')
• Do you want to keep the same aide or try someone new? (instead of 'Are you happy with your aide?')

The CoP rules for HHA supervisory visits...

• The every-two-week requirement for supervisory visits for patients receiving skilled care translates into at least once every 14 days.

• A therapist can supervise the aide if the patient receives therapy as the only skilled service.
• There are no federal restrictions on the scope of supervision by a therapist.  If the aide is providing only personal care services, the therapist can still make the supervisory visits.
• The Conditions of Participation require a supervisory visit for patients receiving only personal care services at least once every 60 days.  Only a registered nurse can make these visits and the home health aide or personal care worker must be present and providing care.
• Neither a licensed practical nurse nor a therapy assistant can make supervisory visits.
• Only visits to the home, not telephone calls, fulfill the supervision requirements

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Aides play a vital role in the delivery of home health and hospice care as they are the ones most frequently in contact with patients. In the performance of their role, it is critical they carry out tasks strictly in accordance with the patient’s Plan of Care (POC) as assigned by the RN. To evaluate whether aides are adequately meeting the patient’s and the family’s needs as identified in the POC, RN supervisory visits were established by the Centers for Medicare and Medicaid Services (CMS) as a requirement under the Conditions of Participation (COP) for home health and hospice agencies. To know how you can better keep track and comply with this requirement, here are some quick information on the supervisory visits.

Home Health

The Registered Nurse (RN) responsible for the patient’s nursing care oversees the home health aide services. During a supervisory visit, the RN must assess if the aide is following the POC, if the POC itself is meeting the patient’s needs, and if the patient or caregiver is satisfied with the POC and the aide’s performance. CMS requires that for patients receiving skilled care, supervisory visits should take place at least once every two weeks or 14 days. Whether the home health aide should be present or not during the visit will depend on the aide’s experience level, abilities, and performance as well as the patient’s needs. For those not receiving skilled care, supervisory visits must take place at least once every 60 days while the aide is present and delivering care. In addition to these, an annual supervisory visit with direct observation measures must be performed for each aide that provides services on behalf of your agency.

In the hospice arena, RN supervisory visits for hospices must take place no less frequently than every 14 days. For example, if the visit was conducted on a Tuesday, the next one should be done no later than the Tuesday that falls exactly two weeks after. In addition to the evaluation of the aide’s adherence to the POC , as well as his or her performance, the supervision process should ensure the aide develops a compassionate interpersonal relationship with the patient and the family, complies with infection prevention and control policies, reports changes in the patient’s conditions, and honors the patient’s rights. Should concerns arise during a visit wherein the aide is not present, the RN will conduct a separate supervisory visit to observe and evaluate the aide while he or she is performing care. Should a performance concern arise during this separate visit, a competency evaluation must be completed on the hospice aide based on the RN’s feedback. An annual on-site RN supervisory visit is also required to perform direct care observation for each hospice aide.

It is important to note that CMS has temporarily waived the requirement for both the two-week and annual supervisory visits for the duration of the Public Health Emergency (PHE). As more people get vaccinated however, we are drawing near to the expiration of the PHE which means the resumption of these supervisory visits. Proactive visit planning and documentation is critical to complying with this Medicare requirement. In this regard, Data Soft Logic with its intelligent solutions can provide you with an ultra-efficient planning tool, the Interactive Patient Calendar . It is a dynamic and data-driven calendar which gives you a quick but comprehensive snapshot of each patient’s care schedule, level of care, number of visits, assigned disciplines, and relevant documentation. This feature, which is available in both Home Health Centre and Hospice Centre , is a launching pad for your documentation and SmartNotes, including the visit notes, wound notes, and collaboration notes. With the Interactive Patient Calendar , you can readily plot supervisory visits, create visit documentation, and provide quality healthcare. To know how you can take full advantage of this feature for your agency’s efficiency, schedule a demo with us now .

References: Centers for Medicare and Medicaid Services. State Operations Manual Appendix B -Guidance to Surveyors: Home Health Agencies Part I -Investigative Procedures. , 2015. Medicare Learning Network. FACT SHEET ENHANCING RN SUPERVISION of HOSPICE AIDE SERVICES PRINT-FRIENDLY VERSION HOSPICE SERVICES. , July 2020.

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Home health services

Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover eligible home health services as long as you need part-time or intermittent skilled services and as long as you’re “homebound,” which means:

• You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury.
• Leaving your home isn’t recommended because of your condition.
• You’re normally unable to leave your home because it’s a major effort.

Covered home health services include: 

• Medically necessary part-time or intermittent skilled nursing care
• Physical therapy
• Occupational therapy
• Speech-language pathology services
• Medical social services
• Part-time or intermittent home health aide care ( only if you’re also getting skilled nursing care at the same time)
• Injectable osteoporosis drugs for women
• Durable medical equipment
• Medical supplies for use at home

A doctor or other health care provider (like a nurse practitioner) must have a face-to-face visit with you before certifying that you need home health services. A doctor or other health care provider must order your care, and a Medicare-certified home health agency must provide it.

In most cases, "part-time or intermittent" means you may be able to get skilled nursing care and home health aide services up to 8 hours a day, with a maximum of 28 hours per week. You may be able to get more frequent care for a short time if your doctor or other health care provider determines it's necessary.

Medicare doesn't pay for:

• 24-hour-a-day care at your home
• Meals delivered to your home
• Homemaker services (like shopping and cleaning)  that aren’t related to your care plan
• Custodial or personal care  that helps you with daily living activities (like bathing, dressing, or using the bathroom), when this is the only care you need

You're not eligible for the home health benefit if you need more than part-time or "intermittent" skilled nursing care . You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.

Your costs in Original Medicare

• $0 for covered home health care services.
• After you meet the Part B deductible, 20% of the Medicare-approved amount for Medicare-covered medical equipment.

Before you start getting your home health care, the home health agency should tell you how much Medicare will pay. The agency should also tell you if any items or services they give you aren't covered by Medicare, and how much you'll have to pay for them. This should be explained by both talking with you and in writing. The home health agency should give you a notice called the Advance Beneficiary Notice" (ABN) before giving you services and supplies that Medicare doesn't cover.

If you get services from a home health agency in Florida, Illinois, Massachusetts, Michigan, or Texas, you may be affected by a Medicare demonstration program. Under this demonstration, your home health agency, or you, may submit a request for pre-claim review of coverage for home health services to Medicare. This helps you and the home health agency know earlier in the process if Medicare is likely to cover the services. Medicare will review the information and cover the services if the services are medically necessary and meet Medicare requirements.

Your Medicare home health services benefits aren't changing and your access to home health services shouldn’t be delayed by the pre-claim review process. For more information, call us at 1-800-MEDICARE.

Things to know

During the COVID-19 pandemic, nurse practitioners, clinical nurse specialists, and physician assistants can provide home health services, without the certification of a physician.

Related resources

• Medicare & Home Health Care
• Find home health services
• More about home health care 
• Your rights as a home health patient
• Complaints about your home health agency
• How will I know if the agency is reducing or stopping my services?
• Medicare & You: home health care (video)

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The Business of Senior Care

Are you doing supervisor visits 🙋.

Are you completing your supervisory visits? Supervising your staff can be a time consuming process for sure. You are required to conduct a supervisory visit at least every 3 months for all direct care staff. It's busy enough just making sure staff are scheduled for shifts right!! But, did you know the regulations changed? Now, you can conduct supervisory visits via TELEHEALTH! With the exception of the annual supervision requirement in Part 7.8(A)(3) and responding to consumer complaints in Part 7.8(C), the HCA may conduct supervisory visits using telehealth, so long as the HCA continues to ensure consumer care and treatment are delivered in accordance with the service plan that addresses the consumer’s status and needs. (1) The designated supervisor may evaluate the delivery of care and services required every three (3) months at Part 7.8(A)(2) through an interactive audiovisual connection with the homemaker or personal care worker and consumer. The results of the supervisory visit must be documented by the qualified employee (Chapter 26, Section 7.9(A)) Today, let's take a look at  what needs to be completed on a Supervisory Visit!  

Make sure your Supervisory Visits have all these items...

• Done by a designated supervisor:  make sure that whomever does the visits has a job description that includes 'supervision of Personal Care Workers and Homemakers', and you have a policy designating all your supervisors in writing
• Occurs at least every 3 months: fine tune a system to be able to ensure supervision of every direct care staff member within 3 months (i.e. complete all the visits during each quarter, split your caregivers names by last name into 3 groups and then assign each group to a month of the quarter)
• Includes consumer satisfaction assessment:  remember it's not all about observing the caregiver, be sure to ask the client about their satisfaction and the direct care staff following the care plan
• Staff competency and adherence to service plan: a surveyor is going to want to see documentation that you evaluated the staff members ability to perform the tasks for the client
• In-person or telehealth: this is new, so be sure to update your form or find some way to indicate on EVERY supervisory visit that it was conducted in-person of via telehealth
• In-person annual evaluation w/ observation and relationship with customer: while using telehealth is tempting to complete the required visits, this annual evaluation is one that you for sure have to do in-person!

Your supervisory visits are to make sure you have happy clients AND staff...

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Important Clarification on In-Home Supervisory Visits for Home Care Families

June 30th, 2021

UPDATED: In-home nurse agency supervisory visits are still optional for most Home Care Program families

We have an important clarification to share about the status of home nursing agency supervisory visits.

A previous version of this post stated that home nurse agency supervisory visits must now resume in-person without exceptions for all Home Care Program participants. That information is no longer accurate.

We have received clarification from the Illinois Department of Public Health (IDPH). The department’s June 24 notice about required in-person supervisory visits only applies to home health aides (CNAs) providing care in the home. It does not apply to all nurses working in the home.

At this time, in-person supervisory visits are only required when:

• A CNA is providing care in the home.
• The parent/guardian is a licensed nurse and providing care as a paid caregiver in the home.

If your home nursing care does not fall in these categories, in-person supervisory visits are not required and remain optional. (Please note that DSCC still encourages nursing agencies to perform in-home supervisory visits when possible to ensure the health and safety of our participants.)

We apologize for the confusion!

The emergency amendments that suspended in-person supervisory visits during the pandemic are still in place.

If you have questions or additional concerns about the status of in-home supervisory visits, please contact your DSCC Care Coordinator.

Our DSCC Team will continue to prioritize the health of your child and family and work with our state partners to provide guidance and support.

Once again, we regret any confusion and are happy to help answer any questions and address your concerns.

Thank you for your understanding.

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Home Visitor Safety

You can work with other program administrators and community resources to implement policies, procedures, and strategies that can contribute to home visitors’ and families’ safety in unsafe situations. As you put safety plans and measures in place, keep the following concepts in mind [ 5 ]:

Sometimes situations, such as crises, arise that pose some degree of risk to the safety of family members and home visitors.  The potential for physical harm exists in any emotionally charged crisis. Staff should never overlook or discount that potential.

Home visitors’ skills in handling a potentially dangerous situation shape intervention decisions. Sometimes home visitors find themselves faced with, or caught up in, a family situation that is too complex or too dangerous for them to address directly. At such times, it is critical to recognize that the situation is beyond their intervention abilities and to discuss alternatives with their supervisor.

The best predictor of impending danger is behavior. Safety measures are called for if a family member's current or past behavior includes violent/abusive acts, threats of harm, criminal activities, the use of addictive substances, signs of a serious emotional disorder, or threats of suicide. These measures are needed at several points in the intervention process: before face-to-face visits with the family, during face-to-face visits, and as part of referral and follow-up services.

Home visitors must always be aware of behaviors and situations that signal danger. Some violent incidents may be predicted, but many helping professionals fail to recognize signs of potential violence. Signs of loss of control and impending danger include expressions of anger and hostility. Staff may also sense that a situation is dangerous; know the family has access to guns or other weapons; be aware of violent acts or threats by family friends or relatives; and recognize mounting tension, irritability, agitation, brooding, and/or limit testing in family members.

Home visitors must be and feel safe if they are to support families. Home visitor safety can and must be addressed at many levels. The threat of violence does not occur only in the homes of families or in high-crime neighborhoods, but also in seemingly secure workplaces. Work conditions favorable to violence prevention require action at management, supervisory, and personal levels.

Some general strategies that you may consider include the following:

• Have home visitors work in pairs, particularly when they go to more dangerous neighborhoods. Accompany home visitors, if needed.
• Forge a relationship with the local police department. When police are aware of home visitors’ presence in the community, they may be able to provide protection such as self-defense training and alerts as to potentially hazardous events in the community.
• Provide cell phones, beepers, or other communication devices. Work with finance and other program staff to ensure the budget covers this equipment.
• Involve families in home visitor safety. They often know of potential safety hazards in the neighborhood (e.g., high-crime areas, gang activity) and can inform home visitors of the safest way to travel through the area.
• Work with program administrators and community resources to develop crisis protocols and make sure home visitors are aware of them. Provide opportunities for home visitors to review and practice implementing protocols. Topics may include child abuse/child neglect, substance misuse, violence in the neighborhood, and the presence of a contagious disease.
• Make sure that you or another administrator is “on call” whenever a home visitor is in the field, including after hours and weekends, so that home visitors can get an immediate response when needed.
• Make sure you know home visitors’ schedules. This should include family names and contact information, date and time of visit, and when to expect the home visitor to return. 

In addition, you might encourage home visitors to do the following [ 4 ]:

• Trust their instincts. If they feel something is not right or see something in the home that makes them uncomfortable (e.g., physical or verbal violence, alcohol/drug use, evidence of firearms, or the presence of an acutely intoxicated individual), follow established protocols and leave, if necessary. Encourage home visitors to say to the parent, “Maybe this isn’t a good time for a visit. Let’s reschedule.” Before going on future visits, encourage home visitors to talk with you about how to ensure their safety in the home. Work with home visitors to talk with the parent about the issues that made them feel uncomfortable and to make referrals if needed.
• Wear comfortable shoes.
• Get clear directions to the neighborhood and the home or apartment building, especially for new visits. Take a practice drive to make sure the directions work. Confirm how to enter the home if it is a duplex or apartment.
• Ask families where it is best to park, and park as close to the home as possible. Always park in well-lit areas. If it is not possible for the home visitor to park in a safe place, discuss other options, such as meeting the family in another setting or being driven and picked up by a co-worker.
• Put any important or valuable items in the trunk of the car before arriving for the visit. Avoid carrying and wearing expensive items.
• Contact parents before a visit so they can be on the lookout for the home visitor.
• If no one answers the door, sit in the car or drive around the block rather than wait at the door. Make sure to specify the amount of time home visitors should wait if a family is not home as part of your home visit protocol.
• Make sure home visitors’ cars are in good working order and that there is plenty of gas in the tank.
• Organize belongings so they do not have to take time to search for them. For example, when they leave a home visit, they should have their keys in hand.

4 Rebecca Parlakian and Nancy Seibel, Help Me Grow Home Visitor Curriculum (Cuyahoga County, OH: Help Me Grow of Cuyahoga County, 2005).

5 Head Start Bureau, “Assessing Family Crisis.” Excerpts from Training Guides for the Head Start Learning Community: Supporting Families in Crisis (Washington, DC: Department of Health and Human Services, Administration for Children and Families, Administration for Children, Youth and Families, 2000), https://eclkc.ohs.acf.hhs.gov/mental-health/article/assessing-family-crisis.

Resource Type: Article

National Centers: Early Childhood Development, Teaching and Learning

Program Option: Home-Based Option

Last Updated: May 22, 2023

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