What do Medicare's home health conditions of participation ask of the administrator in 2026?
The short answer
The conditions of participation are the 15 federal requirements in 42 CFR Part 484 your agency must meet to bill Medicare, and the rule makes the administrator responsible for all day-to-day operations. Your state survey agency checks them unannounced, at least every 36 months. In our read, start with the plan of care, the requirement CMS's 2019 counts show cited most.
Your agency can bill Medicare because it meets a set of federal rules called the conditions of participation. The rule says the administrator must "be responsible for all day-to-day operations of the HHA," and CMS's surveyor guidance adds that each agency "should be able to demonstrate such involvement upon survey."
How the rules are built
The conditions sit in 42 CFR Part 484, and most are split into lettered standards. Missing one is a standard-level deficiency. A condition-level deficiency means the whole condition is out of compliance, and in our read that difference decides how hard a survey lands: CMS bases sanctions, and most terminations, on noncompliance with a condition.
CMS tells surveyors that a single miss can cross that line: "One instance of noncompliance with a standard that poses a serious threat to patient health and safety is enough to find condition-level noncompliance." Several standard-level deficiencies in one condition can add up to the same finding.
How a survey runs
Your state survey agency has to survey you no later than 36 months after your last standard survey, and "All HHA surveys must be unannounced." A survey may also come within 2 months of a change in ownership, administration or management, and must come within 2 months of a significant number of complaints.
Surveyors start with a short list CMS calls Level 1 standards, checked through clinical record reviews, home visits with each patient's consent, and interviews with patients and staff; a Level 1 deficiency widens the survey to every standard in that condition, and substandard care widens it to all 15 conditions.
What surveyors cited most
CMS publishes citation counts in QCOR, its Quality, Certification and Oversight Reports, and its home health data is dated: QCOR says "all data after May 19, 2021 is missing or inaccurate." The counts below are for 2019, the last year before the pandemic, so they can't tell you today's ranking. That year QCOR counted 4,562 home health surveys.
| Requirement (CMS tag) | Condition | 2019 citations |
|---|---|---|
| What the plan of care must include (G574) | 484.60 Care planning | 706 |
| Review of all current medications (G536) | 484.55 Comprehensive assessment | 533 |
| Plan of care (G572) | 484.60 Care planning | 459 |
| Providing the services in the plan of care (G710) | 484.75 Skilled professional services | 383 |
| Infection prevention (G682) | 484.70 Infection control | 321 |
| Conformance with physician orders (G578, a 2019 tag no longer in CMS's guidance) | 484.60 Care planning | 295 |
| Only as ordered by a physician (G580) | 484.60 Care planning | 272 |
| Emergency preparedness testing (E0039) | 484.102 Emergency preparedness | 250 |
| Promptly alerting the physician to changes (G590) | 484.60 Care planning | 246 |
| Discharge and transfer summaries (G1022) | 484.110 Clinical records | 223 |
G948, the tag for your own day-to-day responsibility, was cited 147 times. Only 307 of those surveys found a condition out of compliance, and on them care planning was the condition cited most (117), then QAPI (102) and emergency preparedness (98). Your own condition, organization and administration, came fourth, at 91.
Your own condition: organization and administration
You report to a governing body, which holds legal authority for the agency, reviews its budget and oversees QAPI. A clinical manager has to be available during all operating hours, and so do you or "a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body." The overall plan and budget, with an annual operating budget and a capital expenditure plan covering at least 3 years, is reviewed and updated at least annually.
The newest standard, 484.105(i), came in CMS's 2025 home health payment rule and took effect January 1, 2025. You keep an acceptance-to-service policy, reviewed every year and applied to every referral, that addresses the patient's anticipated needs, your case load and case mix, your staffing levels, and your staff's skills and competencies. You also make accurate information about your services and their limits public, and review it at least once a year. CMS added surveyor guidance for both, tags G990 and G992, on August 5, 2026.
Where the patient-care citations come from
Every plan of care carries the items on the rule's list, and every drug, service and treatment in it has an order behind it, which is what G580 checks. When a nurse takes an order by phone, the nurse writes it down, signs it, dates it and times it. You review each plan at least every 60 days, and the practitioner hears from you promptly when a patient's condition changes in a way that suggests the plan isn't working (G590).
A registered nurse (or a therapist, if therapy is the only service ordered) makes the initial visit within 48 hours of referral, within 48 hours of the patient's return home, or on the start of care date the practitioner ordered. The full comprehensive assessment is finished no later than 5 calendar days after start of care. In it, your nurse goes through every medication the patient is using and looks for possible side effects and drug reactions, the review behind G536.
For a patient who also gets skilled care, a registered nurse or therapist checks the aide's work at least every 14 days, and that visit (G808) was cited 220 times in 2019. For a patient who gets only aide services, a registered nurse visits at least every 60 days and observes the aide in person at least twice a year.
When a patient leaves your care, the discharge summary (G1022) goes to the next practitioner, if there is one, within 5 business days. A transfer summary goes within 2.
After a condition-level finding
The survey agency mails Form CMS-2567 within 10 working days after the survey, and you have 10 calendar days to return a plan of correction. The same 10 days is your window to ask for informal dispute resolution of condition-level findings.
Without immediate jeopardy, CMS either terminates your agreement or imposes alternative sanctions for up to 6 months: a civil money penalty, suspension of payment for new admissions, temporary management, a directed plan of correction or directed in-service training. If you're still out of compliance and haven't met the plan's terms, CMS terminates within 6 months of the survey's last day. With immediate jeopardy, the rule says "CMS immediately terminates the HHA provider agreement," and it terminates no later than 23 days from the survey's last day if the jeopardy hasn't been removed.
A civil money penalty can reach "$10,000 as adjusted annually" for each day of noncompliance. That's $26,262 under the 2025 figures in 45 CFR 102.3, and HHS made no adjustment for 2026, so the 2025 figure still applies.
A monthly self-check
The counts and timing in this checklist are our suggestions.
- Pull five active charts. Check each plan of care against the list in 484.60(a)(2) and confirm every service delivered last month had an order behind it.
- Check this month's start-of-care assessments. Look for the full medication review and a completion date within 5 calendar days.
- Read the [verbal order](https://www.enzo.health/glossary/verbal-orders) log. Each one should be signed, dated and timed by the clinician who took it.
- Print aide supervision dates. Flag any patient with skilled care whose aide went more than 14 days without a supervisory assessment, and any aide-only patient without an RN visit in the last 60 days.
- Check last month's discharges and transfers against the summary deadlines.
- Find the written authorization. Confirm your pre-designated person's authorization is in writing from you and the governing body, and that the clinical manager schedule has no uncovered operating hour.
Enzo is a home health EHR.
Questions agencies are asking
We're accredited. Do these rules still apply?
Yes. If you're accredited with deemed status, you can be exempt from routine state surveys, but you meet the same conditions, and CMS can order a validation survey.
Does a standard-level citation matter if it never becomes condition-level?
You still answer it with a plan of correction. And if a condition-level citation on your next survey is substantially the same as a standard-level one from your last, CMS counts it as a repeat deficiency, and sanctions can rest on repeat deficiencies.