Georgia Home Health Policy and Procedure Manual
For Georgia home health agencies licensed by the Department of Community Health's Healthcare Facility Regulation Division, whether or not they are Medicare-certified. The manual has 56 policies and 45 forms, with the patient forms in English and Spanish, written to Georgia's home health rules (Rules 111-8-31), Georgia statutes 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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Georgia · Home health
56 policies written to the Georgia rules, with 45 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
- 56
- Forms
- 45
- Categories
- 14
- 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.
GA-HH-CMP-01Free sample
Client rights
Complaints and Grievances
Makes it easy for patients and the people who care for them to complain, and makes sure every complaint is logged, acknowledged within 5 days, investigated, resolved within 30 days, and used to improve care, with no reprisal. Tells patients how to contact the Department of Community Health complaint line. Georgia’s home health rules set no complaint time frames, so the Agency sets its own; if the Agency is Medicare-certified, 42 CFR §484.50(e) applies.
Read the full policy GA-HH-SG-01Free sample SafeguardingAbuse, Neglect, and Exploitation of Elder Persons and Disabled Adults: Recognition and Reporting
Requires every staff member who has reasonable cause to believe that an elder person (65 or older) or a disabled adult has been abused, neglected, or exploited to make sure a report is made immediately to Adult Protective Services and to law enforcement, as O.C.G.A. §30-5-4 requires. Georgia’s statute sets no hour limit for the reporter, so "immediately" is the Agency’s own standard. Covers recognition, protection, the internal steps, immunity, the misdemeanor for failure to report, and residents of long-term care facilities.
Read the full policy GA-HH-IC-01Free sample Infection controlInfection Prevention and Control Program
Sets up the Agency’s infection prevention and control program for every patient: standard precautions and bag technique on every visit, transmission-based precautions, surveillance of infections with a log reviewed monthly and fed into quality improvement, reporting of notifiable diseases to public health, staff health, and education for staff, patients, and caregivers.
Read the full policy
Georgia rules
What Georgia's home health rules ask your policies to cover
- Plan of treatment. Written for every patient, signed by the physician, and reviewed by the physician and agency staff at least every 60 days. Ga. Comp. R. & Regs. 111-8-31-.09(a)
- Oral orders. Recorded and signed at once by the nurse or therapist, sent to the physician within five business days, and countersigned in the record within 30 days. Ga. Comp. R. & Regs. 111-8-31-.09(c)
- Aide supervision. A registered nurse, or another professional for other services, visits the residence at least every two weeks for every patient who receives aide services. Ga. Comp. R. & Regs. 111-8-31-.08(d)
- Group of professional personnel. At least one physician, one registered nurse and one member who is neither an owner nor an employee. It reviews key policies each year and meets at least once a quarter. Ga. Comp. R. & Regs. 111-8-31-.07(3)
- Clinical records. Notes written the day of service and filed at least weekly. Records kept six years after the last encounter, or six years after a minor comes of age. Ga. Comp. R. & Regs. 111-8-31-.09(d) and (e)
- Reports to the physician. A written summary of clinical and progress notes goes to the attending physician at least every 60 days and at discharge, and dated case conference minutes are kept in the record. Ga. Comp. R. & Regs. 111-8-31-.08(e)
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:
When was the plan last reviewed by the physician? Was it within 60 days of the last review?GA-HH-CP-01Plan of Treatment and Care Planning
Show me the supervisory visit notes for this aide patient for the last two months. Are they no more than two weeks apart?GA-HH-AID-02Home Health Aide Assignment, Written Instructions, and Supervisory Visits
Who is on your group of professional personnel? Which member is the physician, which is the registered nurse, and which member is neither an owner nor an employee?GA-HH-GOV-02Group of Professional Personnel
Where do you report suspected abuse of an elder person or disabled adult in Georgia, and how quickly?GA-HH-SG-01Abuse, Neglect, and Exploitation of Elder Persons and Disabled Adults: Recognition and Reporting
Show me your last annual program evaluation. Who took part, including consumers, and when was it reported to the governing body?GA-HH-QA-01Annual Program Evaluation and Quarterly Clinical Record Review
The full pack
Browse all 56 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 56 policies
Client rights5
GA-HH-CMP-01Free sample
Complaints and Grievances
Makes it easy for patients and the people who care for them to complain, and makes sure every complaint is logged, acknowledged within 5 days, investigated, resolved within 30 days, and used to improve care, with no reprisal. Tells patients how to contact the Department of Community Health complaint line. Georgia’s home health rules set no complaint time frames, so the Agency sets its own; if the Agency is Medicare-certified, 42 CFR §484.50(e) applies.
42 CFR §484.50(e)
GA-HH-PR-01
Patient Rights and Responsibilities
Sets out the rights and responsibilities of every patient, the written notices the Agency gives during the initial evaluation visit before care is furnished, how staff explain rights and confirm the patient understands them, how representatives exercise rights, and how the Agency protects rights in daily practice. Georgia’s home health rule has no patient rights section, so the Agency applies the federal home health patient rights to every patient as its own standard; they are a federal condition if the Agency is Medicare-certified.
42 CFR §484.50
GA-HH-PR-02
Advance Directives, POLST, and Do-Not-Resuscitate Orders
Explains how the Agency gives every adult patient written information about the right to make health care decisions and to make an advance directive under Georgia law, records whether the patient has one, follows the patient’s advance directive, do-not-resuscitate order, or POLST form, responds to a cardiac or respiratory arrest, and never conditions care on whether the patient has an advance directive.
42 CFR §489.102
GA-HH-PR-03
Admission Agreement, Informed Consent, and Disclosure of Charges
Explains how the Agency verifies payment before the first visit, completes the written home health services agreement, obtains informed consent to care and written consent to release information, tells the patient orally and in writing what Medicare, Medicaid, or other payers are expected to pay and what the patient may owe, and gives the required written notices before non-covered care or before care is reduced or ended.
42 CFR §484.50(c)(7)
GA-HH-PR-04
Language Access, Accessibility, and Nondiscrimination
Sets out how the Agency identifies each patient’s language and communication needs, provides qualified interpreters, translated documents, and auxiliary aids at no cost, tells patients this help is available, and makes sure no patient is denied services or discriminated against.
42 CFR §484.50(f)
Service delivery9
GA-HH-ADM-01
Patient Acceptance, Referral Intake, and Public Information About Services
Sets out how the Agency receives referrals, decides whether it can accept a patient, applies the same acceptance criteria to every referral, records every referral it does not accept with the reason, serves only the counties it is authorized to serve, and keeps its public description of services accurate.
Ga. Comp. R. & Regs. 111-8-31-.09
GA-HH-ADM-02
Initiation of Care and the Initial Evaluation Visit
Sets the Agency’s time frame for starting care after a referral is accepted, requires a registered nurse to make the initial evaluation visit for every patient, explains what happens at that visit, and sets out what staff do when the visit cannot be made on time, when the physician’s plan must be changed after the evaluation, and when care is put on hold.
Ga. Comp. R. & Regs. 111-8-31-.08(a)
GA-HH-ADM-03
Medicare Eligibility, Certification, Face-to-Face Encounter, and Homebound Status
Explains how the Agency confirms, for each Medicare patient, that the patient is eligible for the Medicare home health benefit, including homebound status and the need for skilled services; obtains a signed certification and recertification from a qualified physician or allowed practitioner; documents the face-to-face encounter; and makes sure the record supports eligibility before any claim is made.
42 CFR §424.22
GA-HH-CC-01
Coordination of Services, Case Conferences, and Summary Reports to the Physician
Requires everyone who cares for a patient to keep in contact with the Agency so that their work complements each other and supports the plan of treatment; requires dated minutes of case conferences in the clinical record; and requires a written summary report of clinical and progress notes to be sent to the attending physician at least every 60 days and at discharge.
Ga. Comp. R. & Regs. 111-8-31-.08(e)
GA-HH-CC-02
Supervisor Availability, After-Hours Care, and On-Call
Makes sure the supervising nurse or a similarly qualified alternate is available at all times during operating hours, that a person authorized in writing acts when the Administrator is absent, and that patients can reach a registered nurse by telephone 24 hours a day through the Agency’s on-call system.
Ga. Comp. R. & Regs. 111-8-31-.07(5)
GA-HH-CS-01
Scope of Home Health Services
Defines the home health services the Agency provides under Georgia’s home health agency rules: part-time or intermittent skilled nursing plus at least one other therapeutic service, on a visiting or hourly basis in the patient’s place of residence, under a plan of treatment signed by the physician. Sets how services are added or changed, how services under arrangement stay under Agency control, and how the public is told accurately what the Agency does and does not offer.
Ga. Comp. R. & Regs. 111-8-31-.08
GA-HH-CS-04
Laboratory Services and Waived Testing
Makes sure no Agency staff member performs a laboratory test on a patient’s specimen without a current CLIA certificate covering it, limits Agency testing to waived tests done exactly as the manufacturer directs, keeps help with a patient’s own self-testing separate from Agency testing, and sends specimens only to certified laboratories.
42 CFR §484.100(c)
GA-HH-DC-01
Discharge Planning, Transfer, and Discharge Summaries
Requires the Agency to plan for discharge from the start of care, help patients who are moving to another home health agency or to a skilled nursing, inpatient rehabilitation, or long-term care hospital choose a provider using quality and resource use data, send a copy of the record or an abstract with a patient who transfers, send the attending physician a summary report at discharge, and, if the Agency is Medicare-certified, send discharge and transfer summaries within the federal time frames.
42 CFR §484.58
GA-HH-DC-02
Transfer and Discharge Notice, Including Discharge for Cause
Sets out the only grounds on which the Agency transfers or discharges a patient, the written notice the Agency gives and when, the Medicare notice before covered services end, the steps that must be taken before any discharge for cause, and what happens after transfer or discharge. Georgia’s home health rule sets no discharge notice period; the Agency applies the federal grounds to every patient and sets its own advance notice period.
42 CFR §484.50(d)
Patient care3
GA-HH-ASM-01
Comprehensive Assessment and Reassessment
Sets out who assesses each patient, what the comprehensive assessment covers, when it is completed and updated, how medicines are checked, and how assessment deadlines are tracked. Georgia requires a registered nurse to make the initial evaluation visit and to reevaluate the patient’s nursing needs regularly; if the Agency is Medicare-certified, the federal comprehensive assessment and its time frames also apply, and the Agency uses the same time frames for every patient as its own standard.
42 CFR §484.55
GA-HH-ASM-02
OASIS Data Collection, Accuracy, and Transmission
Sets out how a Medicare-certified Agency collects OASIS data as part of the comprehensive assessment, checks it for accuracy, encodes and transmits it to CMS within 30 days of completing the assessment, corrects errors, and protects the data. Georgia has no OASIS rule; this policy applies only if the Agency is Medicare-certified.
42 CFR §484.45
GA-HH-CP-01
Plan of Treatment and Care Planning
Requires an individual written plan of treatment for every patient, established in consultation with Agency staff and signed by the physician, covering the content Georgia requires; requires review by the physician and Agency staff as often as the patient’s condition requires and at least every 60 days; requires staff to alert the physician promptly to changes; and requires each patient to receive written visit, medication, and treatment instructions.
Ga. Comp. R. & Regs. 111-8-31-.09(a)
Clinical tasks8
GA-HH-AID-01
Home Health Aide Selection, Training, and Competency Evaluation
Sets out how the Agency selects home health aides on the qualities Georgia requires, trains them in every area the Georgia rule lists, and, applying the federal home health aide standards to every aide, verifies a qualifying training or competency program, evaluates competency through a registered nurse before any assignment, retrains after unsatisfactory ratings, and gives at least 12 hours of in-service training each year.
Ga. Comp. R. & Regs. 111-8-31-.08(d)
GA-HH-AID-02
Home Health Aide Assignment, Written Instructions, and Supervisory Visits
Sets out how a registered nurse assigns each aide to a particular patient, how the RN or therapist writes the aide’s instructions, what aides may and may not do, and how supervisory visits are made: Georgia requires an RN (or other appropriate professional) visit to the patient’s residence at least every two weeks for every patient who receives aide services, which the Agency applies together with the federal observation rules.
Ga. Comp. R. & Regs. 111-8-31-.08(d)
GA-HH-CS-02
Skilled Nursing Services: Registered Nurse and Licensed Practical Nurse Duties
Sets out how skilled nursing is provided by or under the supervision of a registered nurse and in line with the plan of treatment: what Georgia requires of RNs and LPNs in home health, how LPNs are supervised, the Board of Nursing standards every nurse follows, clinical notes written the day of the visit, and prompt reporting of changes to the physician.
Ga. Comp. R. & Regs. 111-8-31-.08(a)
GA-HH-CS-03
Therapy and Medical Social Services
Sets out how physical, occupational, and speech therapy, audiology, and medical social services are given by qualified, Georgia-licensed professionals under the plan of treatment, what therapy orders must say, how therapy assistants and social work assistants are supervised, and how therapists and social workers document and coordinate with the rest of the team.
Ga. Comp. R. & Regs. 111-8-31-.08(b)
GA-HH-CS-05
Death in the Home and Pronouncement of Death
States that Agency nurses and other staff do not pronounce death, because Georgia law allows registered nurses to pronounce only in the settings named in O.C.G.A. §31-10-16, and tells every staff member exactly what to do when a patient appears to have died: call 911 or follow the patient’s valid do-not-resuscitate plan, stay, call the office, and leave the scene undisturbed.
O.C.G.A. §31-10-16
GA-HH-DEL-01
Nursing Assignment to Unlicensed Personnel and Proxy Caregivers
Sets out when an Agency RN may assign a task to a home health aide or other unlicensed person under the Georgia Board of Nursing standard (no complex observations or critical decisions, exact unchanging directions, predictable outcome), how the RN checks the aide’s skills and keeps watch, what can never be assigned, and why the Agency does not use the Georgia proxy caregiver route.
Ga. Comp. R. & Regs. 410-10-.01
GA-HH-MED-01
Medication Management, Drug Regimen Review, and Vaccines
Sets out how Agency nurses and therapists check every medicine a patient may be taking and promptly report problems to the physician, as Georgia requires; how medications are given only as ordered; what aides may do to assist with medications ordinarily self-administered; how adverse reactions and errors are handled; the written medication schedule for the patient; and the conditions for giving influenza and pneumococcal vaccines.
Ga. Comp. R. & Regs. 111-8-31-.09(c)
GA-HH-ORD-01
Physician Orders and Oral Orders
Sets out who may give and receive orders for Agency patients and how oral orders are handled under Georgia’s rule: the nurse or therapist immediately records and signs the oral order, forwards the written order to the physician within five business days, and the physician’s countersignature is documented in the record within 30 days. Adds the federal rules for Medicare-certified agencies, including countersignature before billing.
Ga. Comp. R. & Regs. 111-8-31-.09(c)
Safeguarding2
GA-HH-SG-01Free sample
Abuse, Neglect, and Exploitation of Elder Persons and Disabled Adults: Recognition and Reporting
Requires every staff member who has reasonable cause to believe that an elder person (65 or older) or a disabled adult has been abused, neglected, or exploited to make sure a report is made immediately to Adult Protective Services and to law enforcement, as O.C.G.A. §30-5-4 requires. Georgia’s statute sets no hour limit for the reporter, so "immediately" is the Agency’s own standard. Covers recognition, protection, the internal steps, immunity, the misdemeanor for failure to report, and residents of long-term care facilities.
O.C.G.A. §30-5-4
GA-HH-SG-02
Child Abuse and Neglect Reporting
Requires every staff member who has reasonable cause to believe that a child (under 18) has been abused to make sure an oral report is made to the Division of Family and Children Services immediately, and in no case later than 24 hours, as O.C.G.A. §19-7-5 requires. Covers children who are patients and children staff meet in a patient’s home, the internal notification route, immunity, privilege, and the misdemeanor for failure to report.
O.C.G.A. §19-7-5
Infection control3
GA-HH-IC-01Free sample
Infection Prevention and Control Program
Sets up the Agency’s infection prevention and control program for every patient: standard precautions and bag technique on every visit, transmission-based precautions, surveillance of infections with a log reviewed monthly and fed into quality improvement, reporting of notifiable diseases to public health, staff health, and education for staff, patients, and caregivers.
42 CFR §484.70
GA-HH-IC-02
Bloodborne Pathogens Exposure Control Plan
The Agency’s written Exposure Control Plan under the OSHA bloodborne pathogens standard, which applies directly in Georgia: which jobs have exposure, the engineering and work practice controls and protective equipment staff use, hepatitis B vaccination within 10 working days of initial assignment, what happens after an exposure, labels, training at assignment and every year, the annual plan review with frontline input, and recordkeeping.
29 CFR §1910.1030
GA-HH-IC-03
Sharps, Medical Waste, and Patient Instruction
Sets out how Agency staff handle sharps and other waste they generate in patients’ homes, how sealed containers are collected and treated through an authorized biomedical waste contractor, what staff do about loose sharps found in a home, and how patients and families are taught, by word and in writing, to dispose of their own household sharps safely.
29 CFR §1910.1030
Emergency preparedness1
Records2
GA-HH-REC-01
Clinical Records: Content, Timeliness, Protection, and Retention
Requires a clinical record for every patient that holds everything Georgia lists in Ga. Comp. R. & Regs. 111-8-31-.09(d), with clinical notes written the day service is given and filed at least weekly; sets the rules for signing, correcting, storing, moving, and releasing records; and keeps records for six years after the last encounter (adults) or six years after a minor reaches the age of majority, with diagnostic items kept ten years under O.C.G.A. §31-33-2.
Ga. Comp. R. & Regs. 111-8-31-.09(d)
GA-HH-REC-02
Patient Access to Records, Copies, and Release of Information
Sets out how patients, their representatives, and others ask for and receive copies of the clinical record and other health information: the HIPAA right of access, the Georgia 30-day rule and fee limits in O.C.G.A. §§31-33-2 and 31-33-3, the free copy within 4 business days for a Medicare-certified agency, deceased patients, refusals on health grounds, and written authorization for every release the law does not otherwise allow.
O.C.G.A. §31-33-2
Privacy3
GA-HH-PRV-01
HIPAA Privacy and OASIS Confidentiality
Protects the privacy of patients’ health information under the HIPAA Privacy Rule and Georgia’s rule that clinical record information is safeguarded and released only with written consent unless the law authorizes it. Names the Administrator as Privacy Official, sets out when information may be shared, lists patients’ privacy rights and the time frames for each, keeps OASIS data confidential, and requires training, sanctions, and business associate agreements.
45 CFR Part 164 Subpart E
GA-HH-PRV-02
HIPAA Security
Puts in place the HIPAA Security Rule’s administrative, physical, and technical safeguards for electronic patient information, with particular attention to the laptops, tablets, and phones clinicians carry into patients’ homes: risk analysis and risk management, access control, device rules, encryption, OASIS transmission, security incidents, backup and contingency planning, business associates, and disposal.
45 CFR §§164.302-164.318
GA-HH-PRV-03
HIPAA Breach Notification
Sets out what the Agency does when patient information may have been lost, stolen, sent to the wrong person, or otherwise compromised: same-day internal reporting, containment, a documented four-factor risk assessment, and every notice HIPAA requires (individuals within 60 calendar days of discovery, the HHS Secretary, and the media for large breaches), with the limited Georgia breach notice law explained.
45 CFR §§164.400-164.414
Human resources5
GA-HH-HR-01
Personnel Policies, Qualifications, Orientation, In-Service Training, and Evaluation
Sets the written personnel policies Georgia requires: a job description and qualifications for every position, Georgia licensure for every health professional, orientation before the first visit, job-specific competency, in-service training for every discipline, and performance evaluations kept current.
Ga. Comp. R. & Regs. 111-8-31-.07(6)
GA-HH-HR-02
Personnel Records and Employee Health Examinations
Sets out what goes in every personnel file (job description, qualifications, licenses, evaluations, health examinations, and evidence of the background, registry, and license checks), how the files are kept confidential and shown to the Department, how criminal history information is protected, and how long files are kept.
Ga. Comp. R. & Regs. 111-8-31-.07(6)
GA-HH-HR-03
Criminal Background Checks and Registry Checks (Georgia Long-term Care Background Check Program)
Applies the Georgia Long-term Care Background Check Program to the Agency: registry checks and a professional license check before the fingerprint-based criminal background check, a satisfactory determination before direct access (with a limited 30-day supervised grace period), the required notice on every application form, owner checks, appeals, and immediate removal of anyone the law bars.
O.C.G.A. §31-7-354
GA-HH-HR-04
Professional License Verification and Reporting Nurses to the Georgia Board of Nursing
Makes sure every licensed or certified staff member holds a current Georgia license or recognized multistate license in good standing, verified at the source before hire and kept current, and sets out when the Agency must report a nurse to the Georgia Board of Nursing.
Ga. Comp. R. & Regs. 111-8-12-.04
GA-HH-HR-05
Staff Safety in the Home and Workplace Violence Prevention
Sets out how the Agency protects staff who work alone in patients’ homes and on the road: safety screening at referral, a home safety check at the first visit, a check-in and check-out system, rules for leaving an unsafe home without abandoning the patient, handling aggression, weapons, animals, and drugs, driving and weather, safe patient handling, and reporting and support after any incident.
29 U.S.C. §654(a)(1)
Governance6
GA-HH-GOV-01
Governing Body, Bylaws, Organization, and Lines of Authority
Names the governing body as the body with full legal authority for the Agency, requires written bylaws that the governing body adopts and periodically reviews, requires disclosure of officers, directors, and owners to the Department, and requires a written organizational chart showing administrative control and lines of authority down to the patient care level.
Ga. Comp. R. & Regs. 111-8-31-.07(1)
GA-HH-GOV-02
Group of Professional Personnel
Sets up the group of professional personnel that Georgia requires every home health agency to have: at least one physician and one registered nurse, other disciplines as appropriate, and at least one member who is neither an owner nor an employee. The group establishes and reviews key clinical and administrative policies every year and meets at least once a quarter.
Ga. Comp. R. & Regs. 111-8-31-.07(3)
GA-HH-GOV-03
Administrator, Alternate Administrator, and Supervising Physician or Registered Nurse
Sets the qualifications and duties of the full-time Administrator, requires a qualified person to be authorized in writing to act in the Administrator’s absence, and requires skilled nursing and therapy services to be supervised by a physician or registered nurse who, or whose similarly qualified alternate, is available at all times during operating hours.
Ga. Comp. R. & Regs. 111-8-31-.07(4)
GA-HH-GOV-04
Licensure, Certificate of Need, Service Area, Branch Offices, and Inspections
Explains how the Agency keeps its Georgia home health license and Certificate of Need current, serves only the counties it is authorized to serve, handles branch offices and subunits, prepares for and takes part in inspections, and reports changes that need Department approval before they happen.
Ga. Comp. R. & Regs. 111-8-31-.02
GA-HH-GOV-05
Services Under Arrangement and Contracted Personnel
Requires a written contract for every service provided under arrangement and for every person working under an hourly or per-visit contract, with the seven terms Georgia requires, and makes sure the Agency stays the primary agency that accepts patients, controls and evaluates the services, and checks the contractor’s staff.
Ga. Comp. R. & Regs. 111-8-31-.07(6)
GA-HH-GOV-06
Agency Closure, Change of Ownership, and Disposition of Records
Sets out what the Agency does if it closes, is sold, or changes ownership: a plan that keeps every patient safe and transferred, a records retention plan put into effect with the Department told where the records are, return of the license, and notice to patients.
Ga. Comp. R. & Regs. 111-8-31-.09(e)
Quality3
GA-HH-QA-01
Annual Program Evaluation and Quarterly Clinical Record Review
Carries out Georgia’s two evaluation duties: an overall evaluation of the Agency’s total program at least once a year, by the group of professional personnel (or a committee of it), Agency staff, and consumers, reported to the governing body and kept as an administrative record; and a review, at least quarterly, of a sample of active and closed clinical records by health professionals representing the scope of the program, documented by dated minutes.
Ga. Comp. R. & Regs. 111-8-31-.07(8)
GA-HH-QA-02
Quality Assessment and Performance Improvement (QAPI)
Sets up an ongoing, Agency-wide, data-driven quality assessment and performance improvement (QAPI) program that meets 42 CFR §484.65 for a Medicare-certified agency and is applied to the whole Agency as its own standard: a QAPI committee, quality indicators including OASIS outcomes and adverse events, immediate correction of threats to patient safety, performance improvement projects, and governing body oversight. It builds on the Georgia quarterly record review and annual evaluation in Policy GA-HH-QA-01.
42 CFR §484.65
GA-HH-QA-03
Incident Reporting, Investigation, and Adverse Events
Requires every incident, adverse event, and injury of unknown source to be reported the same day, recorded on an Incident Report, investigated in proportion to its seriousness within Agency time frames (Georgia’s home health rules set none), and used by QAPI to prevent a repeat. Covers notifying the physician and family, protecting the patient during an investigation, Board of Nursing employer reports, and the link to abuse reporting.
42 CFR §484.65(c)(2)
Business4
GA-HH-BUS-01
Overall Plan, Annual Operating Budget, and Capital Expenditure Plan
Requires the Agency, under the direction of the governing body, to prepare an overall plan and an annual operating budget, a three-year capital expenditure plan whenever capital expenditures are anticipated, and to review and update the plan, budget, and capital plan at least annually, supported by an effective budgeting and accounting system.
Ga. Comp. R. & Regs. 111-8-31-.07(7)
GA-HH-BUS-02
Charges, Billing, Claims, and Overpayments
Makes sure the Agency bills only for services that were ordered, provided, documented, and signed as the rules require; tells patients about charges before care begins; and finds, reports, and returns overpayments on time.
42 CFR §409.43
GA-HH-BUS-03
Electronic Visit Verification for Georgia Medicaid Home Health Care Services
Requires every Georgia Medicaid Home Health Care Services visit on or after September 14, 2026 to be captured through electronic visit verification, using the state system (Netsmart Mobile Caregiver+) or an approved alternate system, so that the type of service, the patient, the worker, the date, the location, and the start and end times are recorded at the point of care.
42 U.S.C. §1396b(l)
GA-HH-BUS-04
Certificate of Need Conditions: Access Regardless of Ability to Pay, Indigent and Charity Care, and Annual Reporting
Turns the Agency’s Certificate of Need commitments into practice: no patient is excluded on the basis of age, disability, gender, race, or ability to pay; indigent and charity care is provided and recorded at the level stated on the Certificate of Need; the Agency takes part in Medicare, Medicaid, and PeachCare for Kids; and the annual and special surveys the Department requires are filed accurately and on time.
Ga. Comp. R. & Regs. 111-2-2-.32
Ethics2
GA-HH-ETH-01
Compliance Program, Exclusion Screening, and False Claims Prevention
Sets up the Agency’s compliance program, with a code of conduct, a compliance officer, training, a confidential reporting line with no retaliation, auditing, and corrective action, and requires every employee and contractor to be screened against the Georgia Medicaid Exclusion List, the federal LEIE, and SAM before hire and every month.
42 CFR §1001.1901
GA-HH-ETH-02
Referrals, Kickbacks, Patient Inducements, and Marketing Accuracy
Prohibits paying or receiving anything of value for referrals, offering patients inducements to choose the Agency, and certification by practitioners with a disqualifying financial relationship, and requires every public statement, advertisement, and marketing activity to describe the Agency’s services accurately.
42 U.S.C. §1320a-7b(b)
Questions
Questions about this manual
Is this the right manual for my license?
It is for agencies licensed as home health agencies under Rules 111-8-31, whether or not they are Medicare-certified. Private home care providers, including those licensed for nursing services, need the Georgia private home care manual, and hospices need the Georgia hospice manual.
Georgia's home health rules have no patient rights section. What does the manual do?
Rules 111-8-31 have no rule on patient rights, complaints, infection control or emergency preparedness. For those topics the manual follows the federal Conditions of Participation, which bind a Medicare-certified agency, and applies them to every patient as your agency's own standard.
Does a new home health agency need a certificate of need?
Yes, and so does an expansion of an existing agency's service area, except after certain acquisitions (Rule 111-2-2-.32(1)). Policy GA-HH-BUS-04 covers the commitments that come with it, such as serving patients regardless of ability to pay.
When does EVV start for Georgia Medicaid home health visits?
Georgia Medicaid Home Health Care Services claims with dates of service on or after September 14, 2026 must go through electronic visit verification. Policy GA-HH-BUS-03 covers how visits are captured and what happens when a worker cannot clock in or out.
What do the 56 policies cover?
Client rights (5), service delivery (9), patient care (3), clinical tasks (8), safeguarding (2), infection control (3), emergency preparedness (1), records (2), privacy (3), human resources (5), governance (6), quality (3), business (4) and ethics (2).
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