Regulatory & Compliance
Reviewed by Zach Newman · Last reviewed July 2026
In home health, one missed signature or a late Face-to-Face encounter can turn a compliant episode into a denied one. Agencies operate under the Conditions of Participation, CMS certification rules, and survey standards that leave little room for interpretation. This glossary of home health regulations defines the CMS compliance terms that govern how agencies stay certified and survey-ready, from homebound status and the Plan of Care to Immediate Jeopardy and the plan of correction.
34 terms36-Month Rule
The 36-month rule is a Medicare enrollment regulation (42 CFR 424.550(b)) that applies when majority ownership of a home health agency changes within 36 months of its initial enrollment or its most recent change in majority ownership. When triggered, the Medicare provider agreement and billing privileges do not transfer to the buyer, who must instead enroll as a brand-new provider and complete a new state survey or accreditation.
60-Day Certification Period
The 60-day certification period is the length of time a physician or allowed practitioner certifies a patient's need for home health care in a single certification. Under PDGM (the Patient-Driven Groupings Model), each 60-day certification period contains two 30-day payment periods. Care continuing beyond day 60 requires a recertification, supported by a recertification OASIS assessment and an updated plan of care.
ABN (Advance Beneficiary Notice)
An Advance Beneficiary Notice of Non-coverage (ABN, Form CMS-R-131) is a standardized notice a home health agency gives an original Medicare patient before furnishing care the agency believes Medicare will not pay for. A properly executed ABN explains why coverage is expected to be denied and what the care will cost, and it lets the patient choose whether to receive and pay for the care. Without a valid ABN, the agency usually cannot bill the patient after a Medicare denial.
Accreditation (ACHC, CHAP, TJC)
Accreditation is a voluntary evaluation in which a CMS-approved accrediting organization certifies that a home health agency meets standards that meet or exceed the Medicare Conditions of Participation. For home health, the three accreditors with CMS deeming authority are the Accreditation Commission for Health Care (ACHC), Community Health Accreditation Partner (CHAP), and The Joint Commission (TJC). Accredited agencies with deemed status are surveyed by their accreditor instead of the state for routine certification purposes.
Allowed Practitioners (NP, PA, CNS)
Allowed practitioners are nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) who are permitted to certify eligibility, order services, and establish and review the plan of care for Medicare home health patients. The authority was granted permanently by the CARES Act in 2020 and operates within each state's scope of practice laws.
Anti-Kickback Statute
The Anti-Kickback Statute (AKS) is a federal criminal law that prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce or reward referrals of business payable by federal health care programs such as Medicare and Medicaid. Because home health agencies live on referrals, the AKS shapes how they can compensate liaisons and medical directors and how they interact with referral sources. This page is educational and general; it is not legal advice.
CMS (Centers for Medicare & Medicaid Services)
The Centers for Medicare & Medicaid Services (CMS) is the federal agency within the Department of Health and Human Services that administers Medicare, Medicaid, and the Children's Health Insurance Program. For home health agencies, CMS sets the Conditions of Participation, payment policy under the Home Health Prospective Payment System, OASIS and quality reporting requirements, and program integrity rules. Nearly every operational requirement in a Medicare-certified agency traces back to CMS.
Change of Ownership (CHOW)
A change of ownership (CHOW) occurs when a Medicare-certified home health agency's ownership transfers to a new entity in a way that meets the regulatory definition at 42 CFR 489.18, such as an asset sale, merger, or consolidation. In a standard CHOW the Medicare provider agreement automatically transfers to the buyer, and with it successor liability for the seller's Medicare obligations, including overpayments.
Condition-Level Deficiency
A condition-level deficiency is a survey finding that a home health agency is out of compliance with an entire Condition of Participation, not just an individual standard within it. It is the most serious routine survey outcome short of immediate jeopardy, and it starts a termination track: the agency loses Medicare participation within 90 days (23 days under immediate jeopardy) unless compliance is restored and verified. CMS can also impose alternative sanctions alongside the termination timeline.
Conditions of Participation (CoPs)
The Conditions of Participation (CoPs) are the federal health and safety requirements that home health agencies must meet to participate in Medicare and Medicaid. They are codified at 42 CFR Part 484 and cover patient rights, comprehensive assessment, care planning, skilled services, quality improvement, and agency administration. State surveyors and accrediting organizations measure agencies against the CoPs, and serious noncompliance can end an agency's ability to bill Medicare.
Deemed Status
Deemed status means CMS accepts a home health agency's accreditation by a CMS-approved accrediting organization as evidence that the agency meets the Medicare Conditions of Participation. Agencies with deemed status are surveyed by their accreditor (ACHC, CHAP, or The Joint Commission) instead of the state survey agency for routine certification purposes. Complaint investigations, validation surveys, and CMS enforcement authority remain fully in place.
Emergency Preparedness Rule
The Emergency Preparedness Rule is a Medicare Condition of Participation (42 CFR 484.102) requiring home health agencies to maintain an all-hazards emergency preparedness program. The program has four required elements: an emergency plan built on a documented risk assessment, supporting policies and procedures, a communication plan, and a training and testing program.
Face-to-Face Encounter
The face-to-face encounter is a Medicare requirement that the patient see the certifying practitioner, or another permitted clinician, within 90 days before or 30 days after the home health start of care, for a reason related to the primary reason the patient needs home health. Without a compliant, documented encounter, the certification is incomplete and the claim is not payable.
False Claims Act
The False Claims Act (FCA) is the federal government's primary tool for combating fraud against programs like Medicare and Medicaid. It imposes civil liability on anyone who knowingly submits, or causes the submission of, false or fraudulent claims for payment, with remedies that include treble damages and substantial per-claim penalties. Home health has been a sustained FCA enforcement focus for decades. This page is educational and general, not legal advice.
HHCCN (Home Health Change of Care Notice)
The Home Health Change of Care Notice (HHCCN, Form CMS-10280) is a standardized notice home health agencies give original Medicare patients when the agency reduces or stops specific services listed on the plan of care while the patient continues receiving other home health care. It covers changes driven by physician orders as well as changes the agency makes for its own business reasons, such as staffing shortages.
HIPAA in Home Health
HIPAA (the Health Insurance Portability and Accountability Act) sets national standards for protecting patient health information, enforced through the Privacy, Security, and Breach Notification Rules. Home health agencies face distinctive HIPAA risks because protected health information (PHI) travels with clinicians into patients' homes, personal vehicles, and mobile devices rather than staying inside a facility.
Home Health Moratoria
Home health moratoria were temporary bans CMS imposed on the enrollment of new home health agencies in geographic areas with documented fraud risk, using authority created by the Affordable Care Act. CMS lifted the last home health moratoria in January 2019, but the underlying authority remains on the books, and the episode still shapes how new agencies are screened and how agency licenses are valued in former moratorium states.
Homebound Status
Homebound status is a threshold eligibility requirement for the Medicare home health benefit: the patient must be confined to the home as defined in the Medicare Benefit Policy Manual, Chapter 7. The test has two parts, requiring both a qualifying reason the patient cannot readily leave home and a normal inability to leave home, with leaving requiring considerable and taxing effort. Homebound does not mean bedbound, and certain absences from home are permitted.
Immediate Jeopardy
Immediate jeopardy (IJ) is the most severe survey determination: a finding that a provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient. For a home health agency, an IJ finding compresses the Medicare termination timeline to 23 days unless the jeopardy is removed, and it demands immediate action rather than routine correction.
NOMNC (Notice of Medicare Non-Coverage)
The Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123) is a standardized notice that tells a Medicare patient when all covered home health services will end and explains the right to a fast appeal through a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Agencies must deliver it at least two calendar days before covered services end, and the requirement applies to both original Medicare and Medicare Advantage patients.
NPI (National Provider Identifier)
An NPI (National Provider Identifier) is a unique 10-digit number that identifies a health care provider in standard transactions, required under HIPAA and issued through the National Plan and Provider Enumeration System (NPPES). In home health, NPIs identify the billing agency and the certifying and attending practitioners on claims, orders, and the plan of care.
OIG Exclusion List
The OIG exclusion list, formally the List of Excluded Individuals/Entities (LEIE), is the HHS Office of Inspector General's database of people and entities barred from participating in federal health care programs. Medicare and Medicaid will not pay for items or services furnished, ordered, or prescribed by an excluded party, so home health agencies must screen employees, contractors, and vendors against the list and act immediately on matches.
PECOS
PECOS (Provider Enrollment, Chain, and Ownership System) is the online system CMS uses to manage Medicare provider and supplier enrollment. Home health agencies use PECOS to enroll, revalidate, and report changes such as ownership or new locations, and Medicare uses it to verify that the practitioner certifying home health services is eligible to do so. Claims can deny when the certifying practitioner is not properly enrolled.
Patient Rights in Home Health
Patient rights in home health are the protections guaranteed to every patient under the Medicare Conditions of Participation at 42 CFR 484.50. Agencies must inform patients of these rights verbally and in writing before care begins, honor them throughout the episode, and investigate complaints. Surveyors test compliance through record review and direct patient interviews.
Physician Certification
Physician certification is the attestation by a physician or allowed practitioner that a patient meets Medicare's home health eligibility requirements at the start of care. It is a condition of payment: the certification must cover five specific elements and be signed and dated before the agency bills the final claim for the first 30-day payment period. Since the CARES Act of 2020, nurse practitioners, physician assistants, and clinical nurse specialists can certify in addition to physicians.
Physician Recertification
Physician recertification is the attestation by the certifying physician or allowed practitioner, required at least every 60 days, that the patient continues to meet Medicare home health eligibility: homebound status, skilled need, and care under a reviewed plan of care. Unlike the initial certification, recertification does not require a new face-to-face encounter, but it must include the practitioner's estimate of how much longer skilled services will be required.
Plan of Care (CMS-485)
The plan of care is the individualized, practitioner-signed document that authorizes and directs every service a home health agency delivers to a patient. Required by both the Conditions of Participation (42 CFR 484.60) and Medicare coverage rules, it specifies diagnoses, services, visit frequencies, medications, goals, and safety measures. The industry still calls it the 485 after the retired CMS-485 form, and it must be reviewed and signed by the physician or allowed practitioner at least every 60 days.
Plan of Correction
A plan of correction (PoC) is the written response a home health agency must submit after a survey identifies deficiencies on the Statement of Deficiencies, Form CMS-2567. It describes how each deficiency will be corrected, how the agency will prevent recurrence, who is responsible, and by what date. The PoC is generally due within 10 calendar days of receiving the 2567, and an accepted PoC is required to stay on track with Medicare participation.
QAPI (Quality Assurance and Performance Improvement)
Quality Assurance and Performance Improvement (QAPI) is the agency-wide, data-driven quality program required of every Medicare-certified home health agency by the Condition of Participation at 42 CFR 484.65. A compliant QAPI program continuously collects and analyzes quality data, acts on the findings through performance improvement projects, and shows measurable results, with the governing body accountable for the whole cycle.
Skilled Need
Skilled need is the Medicare home health eligibility requirement that the patient needs reasonable and necessary skilled services: intermittent skilled nursing care, physical therapy, speech-language pathology services, or a continuing need for occupational therapy. A service is skilled when its inherent complexity requires the judgment of a nurse or therapist to be performed safely and effectively, and the need must be documented, not assumed from a diagnosis.
Standard-Level Deficiency
A standard-level deficiency is a survey finding that a home health agency failed to meet a specific standard within one of the Medicare Conditions of Participation, while the condition as a whole remains met. It is the most common survey citation and requires a plan of correction, but it does not by itself trigger the termination track that follows a condition-level finding.
Stark Law
The Stark Law, formally the physician self-referral law, is a federal civil statute that prohibits a physician from referring Medicare patients for designated health services, a category that includes home health, to an entity with which the physician or an immediate family member has a financial relationship, unless a specific exception applies. It is a strict liability law: intent does not matter, and a technically noncompliant arrangement is a violation. This page is educational and general, not legal advice.
State Survey
A state survey is an unannounced on-site inspection of a home health agency conducted by the state survey agency acting on behalf of CMS. Surveyors evaluate the agency against the Medicare Conditions of Participation through home visits, clinical record review, and staff interviews. Standard surveys occur at least every 36 months, and complaint surveys can happen at any time.
Verbal Orders
A verbal order is a patient care order that a physician or allowed practitioner communicates orally, usually by phone, to a qualified clinician at the home health agency. The clinician documents the order immediately, and the ordering practitioner must later authenticate it with a dated signature. Unsigned verbal orders are one of the most common causes of delayed final claims and survey citations.
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