California Home Health Policy and Procedure Manual
For California home health agencies licensed by the California Department of Public Health (CDPH), whether or not they are Medicare-certified. The manual has 58 policies and 51 forms, written to Health and Safety Code section 1725 and following, the home health regulations in Title 22 (sections 74600 to 74749) and, for certified agencies, the home health Conditions of Participation (42 CFR Part 484). Each policy opens with a plain-English summary and names the rule it follows, and every one is filled in with your agency's details. You get Word and PDF files to keep, and your staff sign off on their phones.
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California · Home health
58 policies written to the California rules, with 51 forms. Every one is filled in with your agency's details.
- A plain-English summary first
- The rule each policy follows
- Word and PDF downloads, yours to keep
- Policies
- 58
- Forms
- 51
- Categories
- 13
- Policy Pack · required
- $950one-timeIncludes 90 days in the portal with Premium. To keep it open after that, Premium is $99 a month or $990 a year.
Read before you buy
3 free sample policies, shown in full for a sample agency.
CA-HH-CMP-01Free sample
Client rights
Complaints and Grievances
Sets out how the Agency receives, records, investigates, and resolves complaints by patients, families, guardians, and representatives about care that is (or fails to be) furnished or about lack of respect for property, as 22 CCR §74743(b)(6) requires, with the patient’s right to complain without discrimination or reprisal (§74743(b)(4)), the written notice of the Department’s district office hotline at acceptance (§74743(g)), the Agency’s own time frames for acknowledging and resolving complaints (5 and 30), how complaints of abuse, discrimination, and privacy are routed, how patients can complain to the Department and other outside bodies, and how complaints feed the quality program. Federal duties under 42 CFR §484.50(e) apply if the Agency is Medicare-certified.
Read the full policy CA-HH-SG-01Free sample SafeguardingElder and Dependent Adult Abuse: Mandated Reporting
Every employee of a California home health agency is a care custodian and a mandated reporter of elder and dependent adult abuse (Cal. Welf. & Inst. Code §§15610.17(c), 15630(a)). This policy sets out what must be reported (physical abuse such as hitting, slapping or pushing, abandonment, abduction, isolation, financial abuse, and neglect), the time limits (by telephone or through a confidential internet reporting tool immediately or as soon as practicably possible, with a written or internet report within two working days if reported by telephone), where to report (county Adult Protective Services or local law enforcement, and the shorter two-hour and 24-hour route when the patient lives in a long-term care facility), the signed statement every employee gives before starting work (§15659), the confidentiality of reports and reporters, and how the Agency protects patients and handles allegations against its own staff.
Read the full policy CA-HH-IC-01Free sample Infection controlInfection Prevention and Control, Communicable Disease Reporting, and Outbreak Reporting
Sets out the Agency’s infection prevention and control program: the policies 22 CCR §74721(c)(4) requires to prevent, identify, and control infections; standard and transmission-based precautions, hand hygiene, bag technique, and cleaning of equipment; surveillance of infections among patients and staff on Form CA-HH-IC-01-A; reporting of reportable diseases and of outbreaks to the local health officer under 22 CCR §§74725 and 74727 and 17 CCR §2500 (immediately by telephone, within one working day, or within seven calendar days, as the disease list sets); patient and caregiver education; and the annual evaluation of the infection control program (22 CCR §74742(c)(3)). If the Agency is Medicare-certified, the program also meets 42 CFR §484.70 and is part of the QAPI program.
Read the full policy
California rules
What California's home health rules ask your policies to cover
- Plan of treatment and orders. The plan of treatment and telephone orders are signed by the practitioner within 30 working days, and reviewed at least every 62 days. 22 CCR §§74697 and 74701
- Aide supervision. On site at least every two weeks for patients receiving skilled care, and at least every 62 days, while the aide is giving care, for patients receiving personal care only. 22 CCR §74709
- Yearly policy review. A group that includes a physician and a registered nurse reviews the patient care policies every year. Cal. Health & Safety Code §1727.5(d)
- Quality management. Every six months, a review of a sample of clinical records (5 percent of the census, at least 20 and at most 100), and a yearly evaluation of the agency by a group that includes a physician. 22 CCR §74742
- Breach of medical information. Reported to CDPH and to the patient no later than 15 business days after it is detected. Cal. Health & Safety Code §1280.15(b)
- Records. Kept at least seven years after discharge. For minors, at least one year after age 18 and never less than seven years. 22 CCR §74731(d)
Questions a surveyor may ask
Every policy lists questions a surveyor may ask about it, so your staff can practice the answers. A few from this manual:
Show me this patient’s plan of treatment. When was it signed, and when was it last reviewed by the physician?CA-HH-CP-01Plan of Treatment, Plan of Care, and Plan for Personal Care Services
Show me the supervisory visit records for this patient for the last three months. Were they on site, and how often?CA-HH-AID-02Aide and Personal Care Assignments, Written Instructions, and Supervisory Visits
Who reviewed your patient care policies this year? Show me that the group included a physician and a registered nurse.CA-HH-GOV-04Professional Advisory Group, Annual Policy Review, and Written Administrative Policies
How do you count the 15 business days, and from when?CA-HH-PRV-03Breach of Medical Information: Reports to the Department and to Patients
An aide sees bruises on a patient’s arms and the patient says her son grabbed her. What does the aide do, and by when?CA-HH-SG-01Elder and Dependent Adult Abuse: Mandated Reporting
The full pack
Browse all 58 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 58 policies
Client rights6
CA-HH-CMP-01Free sample
Complaints and Grievances
Sets out how the Agency receives, records, investigates, and resolves complaints by patients, families, guardians, and representatives about care that is (or fails to be) furnished or about lack of respect for property, as 22 CCR §74743(b)(6) requires, with the patient’s right to complain without discrimination or reprisal (§74743(b)(4)), the written notice of the Department’s district office hotline at acceptance (§74743(g)), the Agency’s own time frames for acknowledging and resolving complaints (5 and 30), how complaints of abuse, discrimination, and privacy are routed, how patients can complain to the Department and other outside bodies, and how complaints feed the quality program. Federal duties under 42 CFR §484.50(e) apply if the Agency is Medicare-certified.
22 CCR §74743(b)(6)
CA-HH-PR-01
Patient Rights and Responsibilities
Sets out the rights of every patient of the Agency under 22 CCR §74743 and, if the Agency is Medicare-certified, 42 CFR §484.50; when and how the written notice of rights is given and documented; who may exercise rights for a patient who cannot; the information every patient receives at acceptance, including the home health hotline of the CDPH district office; how complaints are taken without reprisal; and the responsibilities the Agency asks patients to share.
22 CCR §74743
CA-HH-PR-02
Advance Directives, POLST, and Do-Not-Resuscitate Orders
Sets the Agency’s written policies and procedures on advance directives (22 CCR §74743(c)(2)(B); 42 CFR §489.102): written information on California law (the Health Care Decisions Law, Probate Code Division 4.7) before care starts; asking about and recording advance health care directives, powers of attorney for health care, surrogates, POLST forms, and prehospital do-not-resuscitate forms; honoring them in the home; conscience objections; and never conditioning care on whether a patient has a directive.
22 CCR §74743(c)(2)(B)
CA-HH-PR-03
Consent for Care, Service Agreement, and Disclosure of Payment Liability
Sets out how the Agency obtains and records the patient’s consent to care and the service agreement (22 CCR §74735(a)(7)); how the patient is told, before care starts, the disciplines and visit frequency proposed and, orally and in writing, what Medicare, Medi-Cal, or other payers may pay and what the patient may have to pay (22 CCR §74743(c), (e)); how changes in that information are given (no later than 30 calendar days under §74743(f), and before the next visit if Medicare-certified); refusal of care; and the advance written notices CMS requires before non-covered care or a reduction or end of care.
22 CCR §74743(e)
CA-HH-PR-04
Language Access, Auxiliary Aids, and Effective Communication
Sets the Agency’s written language access, effective communication, and reasonable modification procedures (45 CFR §92.8(d)-(f)): how staff identify a patient or companion with limited English proficiency or a communication disability; how they get a qualified interpreter, qualified translator, or auxiliary aid at no cost; who may not interpret; machine translation; translated materials; and how information is given in plain language and accessible formats (42 CFR §484.50(f)).
45 CFR §92.201
CA-HH-PR-05
California End of Life Option Act: Agency Policy, Notice, and Staff Conduct
Records the governing body’s choice, under the California End of Life Option Act (Cal. Health & Safety Code §443 et seq.), either to allow staff to participate in medical aid in dying within the law or to prohibit participation while staff act within the course and scope of their employment or contract (§443.15(a)); requires the written notice to staff upon employment or affiliation and every year, and posting of the current policy on the Agency’s website (§443.15(b), (i)); and sets the conduct rules every staff member follows in either case: never coerce, never mislead, give information and referrals on request, document requests, and respect the patient’s choice.
Cal. Health & Safety Code §443.15
Service delivery10
CA-HH-ADM-01
Patient Acceptance, Referral Intake, and Service Area
Sets out how the Agency receives referrals and decides, consistently and without discrimination, whether to accept a patient: only on a reasonable expectation that the patient’s needs can be met (22 CCR §74721(c)(2)) and only if the Agency can provide adequate care (§74695(b)); that patients needing medical orders are under the care of a physician or other licensed practitioner (§74695(a)); the service area limits (§74607(a); the SB 164 moratorium on service area changes); and, if the Agency is Medicare-certified, the acceptance-to-service policy reviewed every year and the public information on services and limits (42 CFR §484.105(i)).
22 CCR §74695
CA-HH-ADM-02
Initial Nursing Assessment, Start of Care, and Comprehensive Assessment
Sets out how care starts: the Agency’s own start-of-care time frame; the registered nurse’s initial nursing assessment before any care (22 CCR §74707(a)(2)), including the initial assessment of the patient and the care environment for aide cases (§74709(a)(1)); consulting the practitioner when the initial plan does not meet the patient’s needs (§74697(c)); and, if the Agency is Medicare-certified, the initial assessment visit within 48 hours, the comprehensive assessment within 5 calendar days after the start of care with its required content, and its updates (42 CFR §484.55).
22 CCR §74707(a)(2)
CA-HH-ADM-03
Medicare and Medi-Cal Eligibility, Certification, Face-to-Face Encounter, and Homebound Status
For a Medicare-certified agency, sets out how Medicare eligibility is checked and documented: the qualifying conditions (confined to the home, under the care of a physician or allowed practitioner, need for a qualifying skilled service, under a plan of care, served by a participating agency) (42 CFR §409.42); certification and the face-to-face encounter no more than 90 days before or within 30 days after the start of care (§424.22(a)); recertification at least every 60 days (§424.22(b)); supporting documentation; the financial relationship bar; the Notice of Admission within 5 calendar days (§484.205(j)); and signatures before billing. For Medi-Cal and other payers, eligibility and authorization are checked under the payer’s current rules.
42 CFR §424.22
CA-HH-ASM-01
OASIS Data Collection, Accuracy, Privacy, and Transmission
For a Medicare-certified agency, sets out how OASIS data are collected as part of the comprehensive assessment and its updates (42 CFR §484.55(b)-(d)), checked for accuracy (§484.45(b)), encoded and transmitted to the CMS system within 30 days of completing each assessment using FIPS 140-2 compliant software and the CMS-assigned branch identification number (§484.45(a), (c), (d)), kept confidential and never released to the public in patient-identifiable form (§484.40), and explained to patients in the OASIS privacy notice (§484.50(a)(1)(iii)).
42 CFR §484.45
CA-HH-CC-01
Coordination of Services, Significant Change Notification, and Case Conferences
Sets the Agency’s policies stating when notification is required for a significant change in a patient’s condition (22 CCR §74697(d)), who notifies the attending practitioner and the team and how fast, and how notifications are recorded (§74697(e)); how the Director of Patient Care Services and the registered nurse coordinate all services (§§74703(a), 74707(a)(4)); how therapists, social workers, and dietitians report (§§74711(b)(4), 74713(c)(3), 74715(b)(3)); case conferences, including contracted staff (§74719(b)(3)(D)); and, if the Agency is Medicare-certified, prompt alerts to the practitioner and coordination of care (42 CFR §484.60(c)-(d)).
22 CCR §74697(d)
CA-HH-CC-02
Supervisor Availability, Operating Hours, After-Hours Care, and Medical Emergencies
Sets the Agency’s operating hours and makes sure the Director of Patient Care Services (or a registered nurse designee) and a nurse supervisor (or a registered nurse designee), at the parent office and every branch, are on the premises or immediately accessible by telecommunications during operating hours when patients are receiving services (22 CCR §§74703(a), 74705(a), 74609); sets the Agency’s after-hours on-call service; and sets the written plan to handle medical emergencies (§74721(c)(1)). If the Agency is Medicare-certified, the administrator or a pre-designated person, and a clinical manager, are available during all operating hours (42 CFR §484.105(b)).
22 CCR §74721(c)(1)
CA-HH-CP-01
Plan of Treatment, Plan of Care, and Plan for Personal Care Services
Sets out how the Agency writes, signs, follows, reviews, and changes each patient’s plan: the plan of treatment (plan of care for Medicare and Medi-Cal agencies) for every patient whose care requires medical orders, approved and signed by the attending practitioner within 30 working days and reviewed at least every 62 days, with the 14 required elements (22 CCR §74697(a)-(b)); the written plan for personal care services for patients without a physician’s plan (§74697(f)); telling patients in advance of changes (§74743(c)); and, if the Agency is Medicare-certified, the federal plan of care content, review at least every 60 days, communication of revisions, and written information to the patient (42 CFR §484.60).
22 CCR §74697
CA-HH-CS-01
Scope of Services and Services Approved on the License
Sets out which home health services the Agency provides: only the types of service the Department has approved and shown on the license (22 CCR §§74627, 74693(d)), each under the direction of a qualified licensed person with written policies and reference material, provided directly or under written arrangement, with equipment checked at every visit and enough qualified staff to deliver what is ordered. Adding or deleting a service is reported to the Department in writing within 10 days (22 CCR §74667(b)(8)). A Medicare-certified agency also makes skilled nursing and at least one other therapeutic service available and provides at least one of them directly (42 CFR §484.105(f)).
22 CCR §74693
CA-HH-DC-01
Discharge Planning, Transfer and Discharge Summaries, and Completion of Discharged Records
Sets out how the Agency plans each patient’s discharge from the start of care (the discharge and referral plan in the plan of treatment, 22 CCR §74697(b)(12)); involves social workers (§74713(c)(6)); records the discharge statement with the date, reason, and condition on discharge (§74735(a)(9)); completes the records of discharged patients within 30 days (§74731(c)); and, if the Agency is Medicare-certified, runs an effective discharge planning process using quality and resource use data (42 CFR §484.58), sends the discharge summary within 5 business days and transfer summaries within 2 business days (§484.110(a)(6)), and updates the comprehensive assessment at discharge (§484.55(d)(3)).
42 CFR §484.58
CA-HH-DC-02
Termination of Services, Transfer and Discharge Notice, and Discharge for Cause
States the reasons for which the Agency terminates services (22 CCR §74721(c)(3)), which also form its transfer and discharge policy for patients (42 CFR §484.50(a)(1)(i), (d)); how and when the patient is told in writing in advance (Agency standard, since California sets no home health discharge notice period); the Notice of Medicare Non-Coverage at least 2 days before Medicare-covered services end and the patient’s right to a fast QIO appeal (42 CFR §§405.1200-405.1202); the steps the Agency must take before discharging a patient for cause (§484.50(d)(5)); and the discharge statement (22 CCR §74735(a)(9)).
22 CCR §74721(c)(3)
Clinical tasks9
CA-HH-AID-01
Home Health Aide Certification, Training, In-Service, and Competency
Sets out who may give home health aide services for the Agency and how the Agency proves each aide is qualified: only a person certified by the California Department of Public Health as a home health aide gives personal care under a physician’s plan of treatment (Cal. Health & Safety Code §1727(d)); the CDPH registry is checked before hire or patient contact (§1736.4(c)); each aide shows competency in every service before giving it (22 CCR §74710(b)); each aide completes at least 12 hours of in-service training in each 12-month period of certification and renews the certificate every two years on the birthday (§1736.2); and any training program the Agency runs meets 22 CCR §74747 and the instructor and online rules. If the Agency is Medicare-certified, every aide also meets 42 CFR §484.80(a)-(f).
22 CCR §74745
CA-HH-AID-02
Aide and Personal Care Assignments, Written Instructions, and Supervisory Visits
Sets out how aides are assigned and supervised. A registered nurse (or, when the patient receives therapy but no skilled nursing, the therapist) assesses the patient and the care environment, assigns the aide, and writes the care instructions; aides do only the duties in 22 CCR §74710 and never administer medications; supervisory visits are made on site at least every two weeks for patients receiving skilled care and at least every 62 days, while the aide is giving care, for patients receiving only aide or personal care services, with registered nurse visits when a licensed vocational nurse is delegated. If the Agency is Medicare-certified, the 14-day, 60-day, annual, and semi-annual supervision rules in 42 CFR §484.80(h) also apply, and the stricter rule governs.
22 CCR §74709
CA-HH-CS-02
Skilled Nursing Services: Registered Nurse and Licensed Vocational Nurse Duties
Sets out what registered nurses and licensed vocational nurses do for the Agency’s patients under 22 CCR §74707: the RN gives the initial nursing assessment before care begins and the ongoing assessment, notifies the practitioner of significant changes, coordinates services, documents, and teaches; the LVN may do everything except the assessment and coordination duties, and teaches only within the Vocational Nursing Practice Act. Both have one year of prior professional nursing experience; clinical notes are signed and incorporated into the record at least every seven working days; and nursing services are reviewed under the quality management program.
22 CCR §74707
CA-HH-CS-03
Therapy, Medical Social Services, and Diet Counseling
Sets out how the Agency provides physical therapy, occupational therapy, speech therapy, medical social services, and diet counseling: each by or under the supervision of a qualified professional of that discipline and according to the plan of treatment, with the duties 22 CCR §§74711, 74713, and 74715 list; therapy orders that state the specific procedures, frequency, and duration (22 CCR §74701(d)); and no use of physical therapy aides in place of certified home health aides (22 CCR §74709(d)).
22 CCR §74711
CA-HH-CS-04
Laboratory Services, Specimen Collection, and Waived Testing
Sets out when Agency staff may perform laboratory tests in the home and what they need first: a CLIA certificate (42 CFR Part 493) and a California clinical laboratory registration for waived tests, or a license for moderate or high complexity tests (Cal. Bus. & Prof. Code §1265); a practitioner order; competent staff; and results reported to the practitioner and filed in the record (22 CCR §74735(a)(6)). Assisting a patient with the patient’s own FDA-cleared self-test device is not Agency testing. Specimens go only to laboratories certified under CLIA and licensed or registered in California.
42 CFR §484.100(c)
CA-HH-CS-05
Death of a Patient at Home
Sets out what staff do when a patient dies or is found dead at home: honor a valid POLST or do-not-resuscitate request and otherwise call 911; never make a legal pronouncement of death unless the Agency has confirmed that California law allows it in that situation; notify the attending physician, the family, and the coroner whenever Gov. Code §27491 calls for the coroner’s inquiry (including deaths where no physician attended the patient in the 20 days before death); leave the body and devices undisturbed in a coroner’s case; and close the record with a discharge statement of the date, reason, and condition (22 CCR §74735(a)(9)).
22 CCR §74735(a)(9)
CA-HH-MED-01
Medication Management, Drug Regimen Review, and Medication Limits for Aides
Sets out how the Agency manages each patient’s medications: a complete medication profile with allergies given prominence in the record; a drug regimen review for every patient; medications given by nurses only on a signed or properly recorded order, as prescribed, and recorded as administered; aides who assist only with medications ordinarily self-administered and never administer medications of any kind; vaccines given only under a policy developed with a physician or allowed practitioner after screening for contraindications; patient teaching and a written medication schedule; and how medication errors, adverse reactions, controlled substances, and disposal are handled.
22 CCR §74701(f)
CA-HH-MED-02
Legend Devices, Medical Supplies, and Equipment
Sets out the Agency’s policies for the purchase, storage, furnishing, and transportation of legend devices, which Cal. Health & Safety Code §1727.5(f) requires and which a group including a physician and surgeon, a pharmacist, and a registered nurse reviews each year. The Agency purchases, stores, furnishes, and transports only the dangerous drugs and devices the Pharmacy Law exempts for licensed home health agencies (Cal. Bus. & Prof. Code §4057(c)), furnishes legend devices only on the prescription or order of a physician, dentist, or podiatrist, keeps a receipt and delivery log, and checks that equipment it supplies is in good working order at each visit (22 CCR §74693(c)).
Cal. Health & Safety Code §1727.5(f)
CA-HH-ORD-01
Practitioner Orders, Telephone Orders, and Order Review
Sets out how the Agency receives, records, carries out, signs, and reviews practitioner orders under 22 CCR §74701: no medication or treatment is given without the signed order of a person lawfully authorized to give it; telephone orders are received only by a licensed nurse or another person lawfully authorized to receive them, recorded immediately, and signed by the practitioner within 30 working days (and within the Agency’s own time frame of 14 days, whichever is sooner); therapy orders state the procedures, frequency, and duration; and every order is reviewed by the practitioner at least every 62 days. If the Agency is Medicare-certified, verbal orders are also signed, dated, and timed by the person who receives them, the plan of care is reviewed at least every 60 days, and orders are signed before billing.
22 CCR §74701
Safeguarding2
CA-HH-SG-01Free sample
Elder and Dependent Adult Abuse: Mandated Reporting
Every employee of a California home health agency is a care custodian and a mandated reporter of elder and dependent adult abuse (Cal. Welf. & Inst. Code §§15610.17(c), 15630(a)). This policy sets out what must be reported (physical abuse such as hitting, slapping or pushing, abandonment, abduction, isolation, financial abuse, and neglect), the time limits (by telephone or through a confidential internet reporting tool immediately or as soon as practicably possible, with a written or internet report within two working days if reported by telephone), where to report (county Adult Protective Services or local law enforcement, and the shorter two-hour and 24-hour route when the patient lives in a long-term care facility), the signed statement every employee gives before starting work (§15659), the confidentiality of reports and reporters, and how the Agency protects patients and handles allegations against its own staff.
Cal. Welf. & Inst. Code §15630
CA-HH-SG-02
Child Abuse and Neglect: Mandated Reporting
Licensed nurses, therapists, and social workers are mandated reporters of child abuse and neglect under the Child Abuse and Neglect Reporting Act (Cal. Penal Code §11165.7(a)(21)), and the Agency requires every other employee to report in the same way. This policy covers children who are patients and children staff meet in a patient’s home: what to report, the telephone report to county child protective services or a police or sheriff’s department immediately or as soon as is practicably possible, the written follow-up report within 36 hours (§11166(a)), the rule that telling a supervisor is never a substitute, the signed statement before employment (§11166.5), and the confidentiality of reporters (§11167(d)).
Cal. Penal Code §11166
Infection control3
CA-HH-IC-01Free sample
Infection Prevention and Control, Communicable Disease Reporting, and Outbreak Reporting
Sets out the Agency’s infection prevention and control program: the policies 22 CCR §74721(c)(4) requires to prevent, identify, and control infections; standard and transmission-based precautions, hand hygiene, bag technique, and cleaning of equipment; surveillance of infections among patients and staff on Form CA-HH-IC-01-A; reporting of reportable diseases and of outbreaks to the local health officer under 22 CCR §§74725 and 74727 and 17 CCR §2500 (immediately by telephone, within one working day, or within seven calendar days, as the disease list sets); patient and caregiver education; and the annual evaluation of the infection control program (22 CCR §74742(c)(3)). If the Agency is Medicare-certified, the program also meets 42 CFR §484.70 and is part of the QAPI program.
22 CCR §74721(c)(4)
CA-HH-IC-02
Bloodborne Pathogens and Aerosol Transmissible Disease Exposure Control
Sets out the Agency’s exposure control plans under Cal/OSHA: the bloodborne pathogens standard (8 CCR §5193), with an exposure control plan reviewed at least annually, safety-engineered sharps, hepatitis B vaccination made available within 10 working days of initial assignment with the California declination statement for staff who decline, immediate confidential post-exposure evaluation, the written opinion within 15 days, the Sharps Injury Log within 14 working days, and training at assignment and at least annually; and the aerosol transmissible diseases standard (8 CCR §5199), which applies to home health care, with the Agency’s decision whether it operates as a referring employer and the plan, screening, referral, vaccination, tuberculosis surveillance, and training that follow.
8 CCR §5193
CA-HH-IC-03
Sharps, Home-Generated Medical Waste, and Patient Instruction
Sets out how the Agency handles sharps and medical waste that its staff generate while caring for patients, under the California Medical Waste Management Act (Cal. Health & Safety Code §117600 et seq.) and the Cal/OSHA bloodborne pathogens standard; how staff carry limited quantities of medical waste to the office under the materials of trade exception (up to 35.2 pounds, with a log the receiving facility keeps for two years); how the Agency confirms its generator status with the local enforcement agency; and how staff teach patients and caregivers to dispose of the patient’s own home-generated sharps, which may never go in the trash or recycling (§118286).
Cal. Health & Safety Code §117600
Emergency preparedness1
Records1
Privacy4
CA-HH-PRV-01
Privacy of Medical Information: HIPAA and the Confidentiality of Medical Information Act
Sets out how the Agency protects patients’ medical information under the California Confidentiality of Medical Information Act (Cal. Civ. Code §56 et seq.), the duty of every licensed home health agency to prevent unlawful or unauthorized access, use, or disclosure (Cal. Health & Safety Code §1280.15(a)), and the HIPAA Privacy Rule: the privacy official, minimum necessary use, when information may be shared without an authorization, what a valid authorization must contain (including the California 14-point type rule), the notice of privacy practices, patients’ privacy rights, business associates, conduct in the home, sanctions, and training.
Cal. Civ. Code §56.10
CA-HH-PRV-02
Security of Electronic Health Information
Sets the Agency’s security program for electronic patient information: the security official, the risk analysis and risk management plan, access control with unique logins, role-based access, automatic logoff, encryption, audit logs that record every change or deletion (Cal. Civ. Code §56.101(b)), mobile device rules for staff in the field, backups and a contingency plan, security incident handling, and the documentation the HIPAA Security Rule requires (45 CFR §§164.308-164.316), so that computerized records are protected as 22 CCR §74731(i) requires.
22 CCR §74731(i)
CA-HH-PRV-03
Breach of Medical Information: Reports to the Department and to Patients
Sets out what staff do the moment they suspect patient information has been seen, used, or sent without authorization, how the privacy official assesses it, and the reports that follow: to the Department and to the patient no later than 15 business days after detection (Cal. Health & Safety Code §1280.15(b); 22 CCR §79902), with the content the regulations require; HIPAA notice to patients, HHS, and the media where required (45 CFR §§164.404-164.408); California data breach notice where computerized personal information is involved (Cal. Civ. Code §1798.82); law enforcement delays; and the records the Agency keeps, including non-breach risk assessments for six years.
Cal. Health & Safety Code §1280.15(b)
CA-HH-REC-02
Patient Access to Health Records and Release of Information
Sets out how a patient or the patient’s personal representative inspects and gets copies of the health record (inspection within five working days and copies within 15 days under Cal. Health & Safety Code §123110; if Medicare-certified, a free copy at the next home visit or within 4 business days under 42 CFR §484.110(e); the HIPAA right of access in 45 CFR §164.524), who may and may not have access, fees, the patient’s right to add a 250-word addendum or ask for an amendment, the accounting of disclosures, and how release requests from anyone else are handled.
Cal. Health & Safety Code §123110
Human resources6
CA-HH-HR-01
Personnel Policies, Job Descriptions, Qualifications, Orientation, In-Service Training, and Evaluation
Sets the written personnel policies California requires (22 CCR §74721(c)(7)): qualifications, responsibilities, and conditions of employment for each type of personnel; hiring; orientation before the first visit, including the signed mandated reporter statements; competency; in-service training for each discipline (including the 12 hours a year certified home health aides need to renew); performance evaluation; and discipline.
22 CCR §74721(c)(7)
CA-HH-HR-02
Personnel Records
Sets out what is kept in each personnel record, how personnel records and employee health records are kept apart and protected, the right of current and former employees to inspect and copy their personnel records within 30 calendar days of a written request, and how long the records are kept (at least three years after employment ends under California law, seven years as the Agency’s standard).
Cal. Lab. Code §1198.5
CA-HH-HR-03
Employee Health Assessments, Tuberculosis Screening, and Employee Health Records
Requires a written health assessment for every employee with direct patient contact, done within six months before employment or within 15 days of starting, tuberculosis screening at hire and every year with a CDC-recommended, FDA-licensed test (unless the person has a documented prior positive test or treatment, or the local health officer certifies in writing that less frequent testing may be used), removal from patient contact for symptoms of infectious disease, and employee health records kept at least three years after employment ends.
22 CCR §74723
CA-HH-HR-04
Criminal Record Clearances, Aide Registry Checks, and Fair Chance Hiring
Sets out the criminal record clearances and checks California requires for a home health agency: CDPH certification (which includes a Department of Justice criminal record clearance) and a check of the CDPH registry before hiring any certified home health aide or placing one in contact with patients; fingerprinting of owners, five percent interest holders, and the Administrator; and fair chance hiring rules for any background check the Agency runs for other staff.
Cal. Health & Safety Code §1736.4(c)
CA-HH-HR-05
Professional License and Certificate Verification
Requires every nurse, therapist, social worker, dietitian, and home health aide to hold a current California license, registration, or certificate before working and while working, checked with the issuing board or the Department at hire, at each renewal, and on a schedule, with immediate removal from duties when a credential lapses or is restricted.
22 CCR §74693(d)(1)
CA-HH-HR-06
Workplace Violence Prevention and Staff Safety in the Home
Sets out the Agency’s workplace violence prevention plan under the Cal/OSHA standard for health care, 8 CCR §3342, which applies to "Home health care and home-based hospice": a written plan in the Injury and Illness Prevention Program; risk assessment at intake, at the first visit, and whenever conditions change; correction of imminent hazards immediately and of serious hazards within seven days; post-incident response and investigation; a violent incident log with no personal identifying information; an annual review with employees; initial training and annual refresher training; records kept one year (training) and five years (incidents); and the reporting of any serious injury or death to Cal/OSHA within 8 hours (8 CCR §342). It also sets the Agency’s own visit safety practices.
8 CCR §3342
Governance7
CA-HH-GOV-01
Governing Body, Organization, and Lines of Authority
Names the governing body as the body with full legal authority and responsibility for the Agency, sets out its duties under 22 CCR §74717 (appoint a qualified administrator, manage fiscal affairs, prevent discrimination), requires an organizational chart showing lines of authority from the governing body down to the patient’s home and the control of any branch office, and keeps the ownership and control disclosures the Department requires.
22 CCR §74717
CA-HH-GOV-02
Administrator, Director of Patient Care Services, Designees, and Nurse Supervisors
Sets out the four management positions California requires (Administrator, administrator designee, Director of Patient Care Services, and DPCS designee), their written appointment, qualifications, duties and availability, the nurse supervisor for patients and branch offices, and the reports to the Department when any of them changes, including the one-time management personnel report due by March 31, 2027.
22 CCR §74718
CA-HH-GOV-03
Licensure, Moratorium, Report of Changes, Branch Offices, Inspections, and Plans of Correction
Keeps the Agency’s California home health agency license in force: annual renewal at least 30 days before expiry, posting the license, the SB 164 licensing moratorium and five-year change of ownership bar, written reports of change to the Department within 10 days, branch office approval, program flexibility requests, cooperation with inspections, and a plan of correction within 10 calendar days of receiving a statement of deficiencies.
Cal. Health & Safety Code §1726
CA-HH-GOV-04
Professional Advisory Group, Annual Policy Review, and Written Administrative Policies
Creates the professional advisory group that reviews the Agency’s patient care policies every year (a physician and surgeon and a registered nurse at minimum) and its legend device policies every year (a physician and surgeon, a pharmacist, and a registered nurse), lists the administrative policies 22 CCR §74721 requires and where each is found, and controls how policies are adopted, made available, reviewed, and revised.
Cal. Health & Safety Code §1727.5(d)
CA-HH-GOV-05
Services Arranged by Agreement and Contracted Personnel
Requires a written agreement meeting 22 CCR §74719 for every service not provided by Agency employees, keeps the Agency responsible for the quality and supervision of arranged care (including aides who are not Agency employees), and screens every contractor before and during the agreement.
22 CCR §74719
CA-HH-GOV-06
Change of Ownership, Voluntary Suspension or Closure, and Preservation of Health Records
Sets out what the Agency does before a change of ownership, a voluntary suspension or cancellation of its license, or a closure: notices to the Department, safe transfer of every patient, written arrangements for the custody of health records, and keeping records for the full retention period after the Agency stops operating.
22 CCR §74731(f)
CA-HH-GOV-07
Nondiscrimination and Civil Rights
States that the Agency does not refuse service or employment to, or discriminate against, any person on any ground protected by 22 CCR §74717(a)(3), the Unruh Civil Rights Act, or federal civil rights law; sets out the Section 1557 duties (coordinator, written policies, grievance procedure, training, notices) that apply when the Agency receives federal financial assistance; and explains how discrimination complaints are handled.
22 CCR §74717(a)(3)
Quality3
CA-HH-QA-01
Quality Management: Semi-Annual Clinical Record Review and Annual Evaluation of Agency Functioning
Sets out the quality management system California requires of every home health agency (22 CCR §74742): a semi-annual review of a stratified sample of clinical records (five percent of the total patient census, at least 20 and at most 100 records every six months, both concurrent and retrospective, against preset criteria of practice for each discipline, by a reviewer of equivalent or higher training), and an organized, documented evaluation of overall agency functioning at least once a year by a group that includes the Administrator, the Director of Patient Care Services, another licensed health care professional employed by the Agency, and at least one physician, with a documented plan to correct deficiencies within specified time frames.
22 CCR §74742
CA-HH-QA-02
Quality Assessment and Performance Improvement (QAPI)
Sets the Agency’s quality assessment and performance improvement (QAPI) program: an effective, ongoing, agency-wide, data-driven program that the governing body oversees, that measures and tracks quality indicators (including OASIS-based measures and adverse patient events), focuses on high risk, high volume, and problem-prone areas, corrects threats to patient safety at once, runs documented performance improvement projects each year, and sustains improvement. Required by 42 CFR §484.65 if the Agency is Medicare-certified and applied to all patients as the Agency’s own standard, integrated with the California quality management system (22 CCR §74742).
42 CFR §484.65
CA-HH-QA-03
Incident Reporting, Investigation, and Adverse Events
Sets out how staff report incidents and adverse events (falls, medication errors, injuries, lost records, exposures, threats, missed visits that cause harm), what they do first to protect the patient, who is told, the reports to outside agencies that the law requires (abuse, breach of medical information, records defaced or destroyed early, reportable diseases and outbreaks, workplace violence), how incidents are investigated, and how they feed the QAPI program’s tracking of adverse events (42 CFR §484.65(c)(2)). It notes that California’s adverse event reporting statute for hospitals does not apply to home health agencies.
42 CFR §484.65(c)(2)
Business4
CA-HH-BUS-01
Budgeting, Accounting, Institutional Planning, and the Annual Utilization Report
Puts the governing body in charge of the Agency’s management and fiscal affairs, requires the Administrator to run an effective budgeting and accounting system, sets out the annual plan and budget (with the federal capital expenditure plan if the Agency is Medicare-certified), and makes sure the verified annual report for the preceding calendar year is filed on or before March 15 each year.
22 CCR §74718(a)(6)
CA-HH-BUS-02
Charges, Billing, Claims, Medi-Cal Records, and Overpayments
Bills only for services that were ordered, provided by qualified staff, documented on time, and covered; tells patients what they may have to pay before care starts and of any change within the time California and federal rules allow; keeps Medi-Cal service records for 10 years; and returns overpayments, including Medicare overpayments within the federal 60-day rule.
Cal. Welf. & Inst. Code §14124.1
CA-HH-BUS-03
Electronic Visit Verification for Medi-Cal Home Health Care Services
Captures every Medi-Cal home health care services visit through California Electronic Visit Verification (CalEVV), or an approved alternate system that sends data to CalEVV, recording the six data elements the 21st Century Cures Act requires; sets out check-in and check-out, corrections, and the match between the EVV record, the clinical note, and the claim.
42 U.S.C. §1396b(l)
CA-HH-BUS-04
Public Information, Advertising, and Use of the Home Health Agency Name
Makes the Administrator responsible for the accuracy of every advertisement, brochure, website, and public statement, limits public material to services the Department has approved on the license and to the approved service area, protects the protected terms "home health agency" and "home health", and, if the Agency is Medicare-certified, reviews public information on services and limits at least annually.
22 CCR §74718(a)(5)
Ethics2
CA-HH-ETH-01
Compliance Program, Exclusion and Suspended Provider Screening, and False Claims Prevention
Sets up the Agency’s compliance program: a code of conduct, a compliance officer, training, ways to report concerns without retaliation, monthly screening of every employee, contractor, owner, and governing body member against the federal exclusion list and the Medi-Cal Suspended and Ineligible Provider List, investigation and correction, and education about the federal and California false claims laws.
Cal. Welf. & Inst. Code §14043.61
CA-HH-ETH-02
Referral Payments, Kickbacks, Patient Inducements, and Referral Services
Forbids offering, paying, soliciting, or receiving anything of value for patient referrals under California law (the Medi-Cal anti-kickback statute, Business and Professions Code section 650 for licensed staff, and the ban on for-profit referral services) and federal law (the Anti-Kickback Statute, the beneficiary inducement rule, and the physician self-referral law), and sets rules for relationships with referral sources, gifts, and marketing staff pay.
Cal. Welf. & Inst. Code §14107.2
Questions
Questions about this manual
Is this the right manual for my license?
It is for home health agencies licensed by CDPH. Home care organizations licensed by the Department of Social Services need the California home care manual, and hospices need the California hospice manual.
Can we open a new branch office?
Usually not, for now. Since June 29, 2026, CDPH may not issue a new home health agency license or add a branch office until no later than 90 days after revised regulations take effect, except on a written finding of unmet need (Health and Safety Code §§1728.9 and 1728.95). CDPH treats a change of service area the same way. License renewals and other reports of change continue.
What must we report about our managers?
Since June 29, 2026, an agency reports its four management personnel (Administrator, administrator designee, Director of Patient Care Services and DPCS designee) to CDPH, and any change within 10 business days. Agencies already licensed send the first report by March 31, 2027 (Health and Safety Code §1728.1(e)). Policy CA-HH-GOV-02 covers this.
What do the 58 policies cover?
Client rights (6), service delivery (10), clinical tasks (9), safeguarding (2), infection control (3), emergency preparedness (1), records (1), privacy (4), human resources (6), governance (7), quality (3), business (4) and ethics (2).
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