Michigan Home Health Policy and Procedure Manual
For Michigan home health agencies that are Medicare-certified. Michigan does not license home health agencies: LARA's Bureau of Survey and Certification surveys them for Medicare, or an accrediting organization does. The manual has 57 policies and 50 forms, with every patient form in English and Spanish, written to the home health Conditions of Participation (42 CFR Part 484), the Michigan Medicaid Provider Manual for Medicaid patients, and the Michigan laws that reach a home health agency, such as the Workforce Background Check (MCL 333.20173a). 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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Michigan · Home health
57 policies written to the Michigan rules, with 50 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
- 57
- Forms
- 50
- 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.
MI-HH-CMP-01Free sample
Client rights
Complaints and Grievances
Sets out how anyone, and in particular a patient, representative, caregiver or family member, can complain to the Agency about care or treatment that is (or is not) furnished, or about lack of respect for the patient’s property or person; how the Agency logs, acknowledges within 5, investigates and resolves within 30 each complaint, documents both its existence and its resolution, and prevents further violations and retaliation while it is investigated (42 CFR §484.50(e)); how complaints of abuse, neglect, privacy or discrimination are routed; and the outside bodies a patient may contact at any time, including Michigan Department of Licensing and Regulatory Affairs (LARA), Bureau of Survey and Certification, Complaint Intake Section, P.O. Box 30838, Lansing, Michigan 48909; toll-free Complaint Hotline 800-882-6006; online complaint form at https://apps.lara.state.mi.us/BscComplaintIntakeForm. Michigan sets no complaint time frames for home health agencies, so the time frames are the Agency’s own.
Read the full policy MI-HH-SG-01Free sample SafeguardingAdult Abuse, Neglect, and Exploitation: Recognition and Mandatory Reporting
Sets out how every staff member recognizes and reports suspected abuse, neglect (including self-neglect) and exploitation of an adult patient, or of another vulnerable adult met during a visit. Michigan law (MCL 400.11a) requires anyone employed to provide health care to make an immediate oral report to MDHHS, in practice through MDHHS Centralized Intake for Abuse and Neglect at 855-444-3911, and 42 CFR §484.50(e)(2) requires staff to report immediately to the Agency as well. The policy covers what the report must contain, when to call 911, the Medicaid supplemental visits MDHHS may request, reports to the Attorney General when the alleged abuser is a provider, confidentiality and immunity, the civil fine for failing to report, documentation on Form MI-HH-SG-01-A, and follow-up care.
Read the full policy MI-HH-IC-01Free sample Infection controlInfection Prevention and Control Program
Sets out the Agency’s infection prevention and control program under 42 CFR §484.70: standard precautions and transmission-based precautions in the home, hand hygiene, the nursing bag and equipment cleaning, a coordinated agency-wide surveillance program that is part of QAPI, investigation of clusters and outbreaks, action plans, education of staff, patients and caregivers, and how Michigan’s communicable disease reporting rules apply (physicians and laboratories must report; nurses and agency infection control staff may report to the local health department).
Read the full policy
Michigan rules
What the federal and Michigan rules ask your policies to cover
- Assessments. An initial assessment visit within 48 hours of referral or of the patient's return home, or on the ordered start of care date, and a comprehensive assessment no later than 5 calendar days after the start of care. 42 CFR §484.55
- Aide supervision. For patients receiving skilled care, a registered nurse or therapist assesses aide services at least every 14 days. For Michigan Medicaid patients, the supervising RN also co-signs all aide documentation. 42 CFR §484.80(h); MPM Home Health §10.2
- Medicaid aide authorization. Aide services for a Michigan Medicaid patient need prior authorization after the first 90 days, and each renewal must reach MDHHS no less than 15 business days before the current authorization ends. MPM Home Health §10.1
- Background checks. Anyone who will regularly have direct access to patients has a fingerprint-based state and FBI criminal history check through the Michigan Workforce Background Check, with conditional employment only as the statute allows. MCL 333.20173a
- Abuse reporting. Staff employed to provide health care report suspected abuse of an adult to MDHHS immediately. For a child, nurses, therapists, social workers and other listed professionals report immediately and file a written report within 72 hours after a telephone report. MCL 400.11a(1); MCL 722.623(1)(a)
- Records. Clinical records are kept 5 years after discharge, and Michigan Medicaid records not less than seven years from the date of service. 42 CFR §484.110(c)(1); MPM General Information for Providers §14.1
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:
Michigan does not license home health agencies: show me your Medicare certification and your CMS Certification Number.MI-HH-GOV-03Medicare Certification, Surveys, Ownership Disclosure, Branch Offices, and Reporting Changes
This Medicaid patient has had aide services for more than 90 days. Show me the prior authorization and the renewal request date.MI-HH-ADM-03Eligibility, Certification, Face-to-Face Encounter, Homebound Status, and Medicaid Prior Authorization
For this Michigan Medicaid patient, show me the RN co-signature on the aide notes.MI-HH-AID-02Home Health Aide Assignment, Care Instructions, and Supervision
Has anyone worked under conditional employment? Show me the signed statement and how they were supervised or met the conditions.MI-HH-HR-03Criminal History Checks Under the Michigan Workforce Background Check Program
If your aide saw bruises on a patient and the patient said a family member hit her, what would the aide do, and how fast?MI-HH-SG-01Adult Abuse, Neglect, and Exploitation: Recognition and Mandatory Reporting
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Browse all 57 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 57 policies
Client rights5
MI-HH-CMP-01Free sample
Complaints and Grievances
Sets out how anyone, and in particular a patient, representative, caregiver or family member, can complain to the Agency about care or treatment that is (or is not) furnished, or about lack of respect for the patient’s property or person; how the Agency logs, acknowledges within 5, investigates and resolves within 30 each complaint, documents both its existence and its resolution, and prevents further violations and retaliation while it is investigated (42 CFR §484.50(e)); how complaints of abuse, neglect, privacy or discrimination are routed; and the outside bodies a patient may contact at any time, including Michigan Department of Licensing and Regulatory Affairs (LARA), Bureau of Survey and Certification, Complaint Intake Section, P.O. Box 30838, Lansing, Michigan 48909; toll-free Complaint Hotline 800-882-6006; online complaint form at https://apps.lara.state.mi.us/BscComplaintIntakeForm. Michigan sets no complaint time frames for home health agencies, so the time frames are the Agency’s own.
42 CFR §484.50(e)
MI-HH-PR-01
Patient Rights and Responsibilities
Sets out how the Agency tells every patient and representative about the patient's rights and responsibilities and the Agency's transfer and discharge policies during the initial evaluation visit, before any care is given; how it obtains the signed receipt; how it reaches a patient-selected representative within 4 business days; who may exercise a patient's rights; and how staff protect each right listed in 42 CFR §484.50(c) in daily practice, including the state home health hotline and the local advocacy and quality contacts each patient must be given.
42 CFR §484.50
MI-HH-PR-02
Advance Directives, Patient Advocate Designations, Do-Not-Resuscitate Orders, and MI-POST
Sets out how the Agency gives every adult patient written information about the right under Michigan law to accept or refuse treatment and to make advance directives before the patient comes under the Agency's care, records whether the patient has a patient advocate designation, living will, out-of-hospital do-not-resuscitate order or POST form, puts that information in the plan of care, follows valid documents, never conditions care on them, and educates staff and the community, as 42 CFR §489.102 requires.
42 CFR §489.102
MI-HH-PR-03
Admission Agreement, Informed Consent, and Disclosure of Charges
Sets out how the Agency obtains the patient's informed consent to care and keeps it current, honors a refusal, and tells each patient orally and in writing, before care starts, what Medicare, Michigan Medicaid or other programs are expected to pay, what is not covered, and what the patient may have to pay, using the Home Health Services Agreement and Consent. It applies the Michigan Medicaid rules on billing beneficiaries, payment in full, prior authorization, missed visits and consent to share behavioral health information.
42 CFR §484.50(c)(4) and (7)
MI-HH-PR-04
Language Access, Accessibility, and Effective Communication
Sets out how the Agency finds out each patient's language and communication needs, provides qualified interpreters, translated documents and auxiliary aids and services at no cost, avoids relying on family members or children to interpret, records each use, and keeps the written language access and effective communication procedures that 42 CFR §484.50(f) and the Section 1557 rule (45 CFR Part 92) require.
42 CFR §484.50(f)
Service delivery9
MI-HH-ADM-01
Referral Intake, Acceptance-to-Service, and Public Information About Services
Sets out how the Agency receives and screens every referral, applies one written acceptance-to-service policy to every prospective patient (anticipated needs, caseload and case mix, staffing levels, and staff skills and competencies), records the decision, tells the referral source and the patient the outcome, refers onward when it cannot accept, and keeps accurate public information about its services and their limits. It applies the Michigan Medicaid rules on service setting, health plan authorization, evaluation visits and selective acceptance.
42 CFR §484.105(i)
MI-HH-ADM-02
Initial Assessment Visit and Start of Care
Sets out who makes the initial assessment visit, when it must happen (within 48 hours of referral, within 48 hours of the patient's return home, or on the ordered start-of-care date), what the clinician does at that visit before any care is given, how Medicare eligibility and homebound status are first checked, how the start of care is set and documented, and what to do when the visit cannot be made on time. It adds the Michigan Medicaid rules on the date of first visit, pre-existing orders and eligibility checks.
42 CFR §484.55(a)
MI-HH-ADM-03
Eligibility, Certification, Face-to-Face Encounter, Homebound Status, and Medicaid Prior Authorization
Sets out how the Agency confirms, documents and keeps current each patient's eligibility for home health care: for Medicare patients, the beneficiary qualifications in 42 CFR §409.42, homebound status, the physician or allowed practitioner certification and recertification, and the face-to-face encounter under 42 CFR §424.22; for Michigan Medicaid patients, the written order and plan of care, the face-to-face encounter, medical necessity and setting, and prior authorization of home health aide services by the MDHHS Program Review Division after the first 90 days, with renewals received at least 15 business days before the end of each authorization.
42 CFR §424.22
MI-HH-CC-01
Coordination of Care, Case Conferences, Summary Reports, and Coordination With Home Help and MI Choice
Sets out how the Agency coordinates each patient's care: communication with every physician or allowed practitioner involved in the plan of care, integration of all orders and of all services (direct and under arrangement), involvement of the patient, representative and caregivers, ongoing education and training, case conferences among disciplines, summary reports to practitioners, and, for Michigan Medicaid patients, coordination with Home Help and MI Choice so that services are not duplicated and do not happen at the same time.
42 CFR §484.60(d)
MI-HH-CC-02
Clinical Manager Availability, After-Hours Care, and On-Call
Sets out how the Agency makes sure a clinical manager, and the Administrator or a pre-designated person, is available during all operating hours; how patients can reach a clinician at any hour through the after-hours line; who takes on-call duty and what on-call staff must do; the Agency's own response-time standards for after-hours calls; and how after-hours calls, visits and orders are documented and handed over.
42 CFR §484.105(b)(3) and (c)
MI-HH-CS-01
Scope of Home Health Services
Defines the home health services the Agency furnishes as a Medicare-certified home health agency: skilled nursing and at least one other therapeutic service, at least one of them furnished directly by Agency employees, all furnished on a visiting basis in the place the patient uses as home and in line with current clinical practice guidelines. Sets out how the Agency decides which services it offers, how services under arrangement are controlled, and what the Michigan Medicaid home health benefit covers and does not cover, so that staff do not promise, furnish or bill a service the Agency cannot provide or a payer will not cover.
42 CFR §484.105(f)
MI-HH-CS-04
Laboratory Services and CLIA
Sets out when the Agency’s laboratory testing falls under the Clinical Laboratory Improvement Amendments (CLIA) rules in 42 CFR Part 493: testing with Agency equipment needs a CLIA certificate (a certificate of waiver for waived tests only), helping a patient use their own FDA-cleared home-use device does not, the Agency never substitutes its equipment for the patient’s, and specimens are sent only to laboratories certified for the tests ordered. Covers specimen collection, handling and result follow-up, and reporting CLIA changes.
42 CFR §484.100(c)
MI-HH-DC-01
Discharge Planning, Transfer and Discharge Summaries
Sets out the Agency's discharge planning process from admission onward, how it helps patients who transfer to another home health agency or are discharged to a skilled nursing facility, inpatient rehabilitation facility or long-term care hospital choose a provider using quality and resource use data, what information it sends to the receiving facility or practitioner, and the deadlines for the discharge summary (within 5 business days of discharge) and the transfer summary (within 2 business days of a planned transfer, or of learning of an unplanned transfer). It adds the Michigan Medicaid duty to develop a transfer or discharge plan at admission and to ensure continuity with Home Help and MI Choice.
42 CFR §484.58
MI-HH-DC-02
Transfer and Discharge Notice, Discharge for Cause, and Notices of Non-Coverage
Sets out the only grounds on which the Agency may transfer or discharge a patient, the steps the Agency must take before discharging a patient for cause, the written notice the Agency gives every patient before a transfer or discharge, and the Medicare notices: the Notice of Medicare Non-Coverage at least 2 days before covered services end (with the patient's right to a fast appeal to the Quality Improvement Organization and the Agency's same-day duties when an appeal is filed), the Home Health Change of Care Notice when the Agency reduces or stops services, and the Advance Beneficiary Notice when Medicare may not pay. Michigan sets no separate discharge notice period for home health agencies; the Agency's notice periods are Agency standards.
42 CFR §484.50(d)
Patient care3
MI-HH-ASM-01
Comprehensive Assessment and Updates
Sets out who completes each patient's comprehensive assessment, the deadline (no later than 5 calendar days after the start of care), the minimum content (including the drug regimen review, caregivers' willingness, ability and availability, the representative, OASIS items and the individual emergency plan), and when the assessment must be updated: the last 5 days of every 60 days, within 48 hours of return home from a hospital admission of 24 hours or more, at discharge, and whenever the patient's condition changes. It adds the Michigan Medicaid assessment of family ability and other personal care services.
42 CFR §484.55
MI-HH-ASM-02
OASIS Data Collection, Accuracy, Transmission, and Privacy Notice
Sets out which patients have OASIS data collected (all patients of any payer except those under 18, those receiving maternity services, and those receiving only personal care, housekeeping or chore services), how clinicians collect OASIS accurately as part of the comprehensive assessment, how the Agency gives the OASIS privacy notice, and how completed assessments are encoded, checked and transmitted to the CMS system within 30 days of completing the assessment, using compliant software and the CMS-assigned branch identification number.
42 CFR §484.45
MI-HH-CP-01
Individualized Plan of Care
Sets out how the Agency builds, with the patient, an individualized written plan of care containing every element of 42 CFR §484.60(a)(2) (and, for Michigan Medicaid patients, the extra elements in the Medicaid Provider Manual), records all orders in it, gets it signed by the physician or allowed practitioner, reviews and revises it at least every 60 days and whenever the patient's condition requires, communicates every revision, and gives the patient and caregiver written instructions with the visit schedule, medications, treatments and the clinical manager's contact information.
42 CFR §484.60(a)
Clinical tasks8
MI-HH-AID-01
Home Health Aide Qualifications, Training, and Competency Evaluation
Sets out who may work as a home health aide for the Agency and how the Agency proves it: the four routes to qualification in 42 CFR §484.80(a), the 24-month lapse rule, the 75-hour training program content and its classroom and practical hours, the competency evaluation an RN performs before an aide furnishes any service (with the tasks that must be observed), the 12 hours of in-service training each 12 months, instructor qualifications, the sanctions that bar an agency from running a program, and the records the Agency keeps. Michigan has no separate state training rule for home health aides; Michigan Medicaid adopts the federal standard.
42 CFR §484.80(a) to (f)
MI-HH-AID-02
Home Health Aide Assignment, Care Instructions, and Supervision
Sets out how home health aides are assigned to patients with written care instructions, what aides may and may not do, how they report changes, and how they are supervised: for patients receiving skilled services, a supervisory assessment at least every 14 days (no more than one virtual in a 60-day episode) and an annual on-site observation of each aide; for patients receiving only aide services, an RN on-site visit every 60 days and a semi-annual on-site observation. For Michigan Medicaid patients the Michigan Medicaid Provider Manual adds a 14-day supervisory visit by the RN or therapist, a 60-day RN visit where no skilled service is provided, and RN co-signature of all aide documentation.
42 CFR §484.80(g) and (h)
MI-HH-CS-02
Skilled Nursing Services and Michigan Nursing Practice
Sets out how the Agency furnishes skilled nursing: who may furnish and supervise it, what registered nurses and licensed practical nurses each do under the Michigan Public Health Code, how nursing tasks are delegated, the responsibilities every nurse carries under 42 CFR §484.75, and the Michigan Medicaid rules on covered and noncovered nursing visits and RN co-signature of LPN notes for Michigan Medicaid patients.
42 CFR §484.75
MI-HH-CS-03
Therapy and Medical Social Services
Sets out how the Agency furnishes physical therapy, occupational therapy, speech-language pathology and medical social services: the qualifications in 42 CFR §484.115 and the Michigan licenses each discipline holds, supervision of assistants, therapy assessment and the Medicare reassessment rule, medical social services, and the Michigan Medicaid limits (therapy only when medically necessary, speech therapy only for certain Children’s Special Health Care Services children, and no Medicaid coverage of medical social services).
42 CFR §484.75
MI-HH-CS-05
Death in the Home and Pronouncement of Death
Sets out what staff do when a patient dies or is found dead at home: when to start CPR and call 911, when a valid do-not-resuscitate order or MI-POST form applies, when a registered nurse may pronounce death under MCL 333.1033, when the county medical examiner must be notified under MCL 52.203, how the family, physician and funeral home are contacted, and how the death is documented and the patient discharged.
MCL 333.1033
MI-HH-MED-01
Medication Management, Drug Regimen Review, and Vaccines
Sets out how the Agency manages patients’ medications: the drug regimen review in every comprehensive assessment, medication reconciliation, follow-up of problems with the practitioner, the written medication schedule given to the patient, administration only on order, the aide’s limited role in medications ordinarily self-administered, teaching, adverse reactions and errors, controlled substances and disposal, and influenza and pneumococcal vaccines under a policy developed with a physician or other listed practitioner. Includes the Michigan Medicaid limits on nurse visits for oral medications and insulin syringes.
42 CFR §484.55(c)(5)
MI-HH-MED-02
Intravenous Therapy and Infusion Services
Sets out how the Agency furnishes intravenous and other infusion therapy at home: patient selection, complete orders, coordination with the infusion pharmacy, which nurses may perform which infusion tasks (with the Agency’s own limits on LPN infusion tasks), vascular access device care, infection prevention, first doses and anaphylaxis, patient and caregiver teaching, monitoring and complications, and the Michigan Medicaid rule on when an HHA may furnish infusion nursing.
42 CFR §484.60(b)(1)
MI-HH-ORD-01
Physician and Allowed Practitioner Orders and Verbal Orders
Sets out how the Agency receives, records and follows physician and allowed practitioner orders: drugs, services and treatments only as ordered; who may accept a verbal order; how a verbal order is written down, read back, signed, dated and timed; the Agency’s time frame for the practitioner’s signature; and the Medicare and Michigan Medicaid rules that orders and verbal orders be signed before billing, that services be ordered before they start or change, and that ordering practitioners be enrolled in Michigan Medicaid.
42 CFR §484.60(b)
Safeguarding3
MI-HH-SG-01Free sample
Adult Abuse, Neglect, and Exploitation: Recognition and Mandatory Reporting
Sets out how every staff member recognizes and reports suspected abuse, neglect (including self-neglect) and exploitation of an adult patient, or of another vulnerable adult met during a visit. Michigan law (MCL 400.11a) requires anyone employed to provide health care to make an immediate oral report to MDHHS, in practice through MDHHS Centralized Intake for Abuse and Neglect at 855-444-3911, and 42 CFR §484.50(e)(2) requires staff to report immediately to the Agency as well. The policy covers what the report must contain, when to call 911, the Medicaid supplemental visits MDHHS may request, reports to the Attorney General when the alleged abuser is a provider, confidentiality and immunity, the civil fine for failing to report, documentation on Form MI-HH-SG-01-A, and follow-up care.
MCL 400.11a
MI-HH-SG-02
Child Abuse and Neglect: Mandated Reporting
Sets out how staff recognize and report suspected child abuse or neglect, whether the child is a patient or another child in a patient’s home. Under Michigan’s Child Protection Law, nurses, physicians, physician assistants, physical therapists and assistants, occupational therapists, social workers and other listed professionals must make an immediate report to MDHHS Centralized Intake by telephone or through the online reporting system, and file a written report (form DHS-3200) within 72 hours after a telephone report (MCL 722.623). Staff not listed in the statute, including home health aides, must report to the Agency at once and may report directly. The policy covers report content, notifying the person in charge, confidentiality and immunity, penalties, and documentation.
MCL 722.623
MI-HH-SG-03
Allegations Against Staff: Protection, Investigation, and Corrective Action
Sets out what the Agency does when anyone alleges that a person furnishing services on its behalf mistreated, neglected, or verbally, mentally, sexually or physically abused a patient, caused an injury of unknown source, or took a patient’s property: make the outside reports first, protect the patient at once (including removing the staff member from patient contact while the allegation is investigated), prevent retaliation, investigate and document the allegation and its outcome on Form MI-HH-SG-03-A as 42 CFR §484.50(e)(1) requires, take corrective action, and make the reports that follow a substantiated finding (LARA for licensees, the Workforce Background Check rules, the Attorney General where a Medicaid provider is involved).
42 CFR §484.50(e)(1)
Infection control3
MI-HH-IC-01Free sample
Infection Prevention and Control Program
Sets out the Agency’s infection prevention and control program under 42 CFR §484.70: standard precautions and transmission-based precautions in the home, hand hygiene, the nursing bag and equipment cleaning, a coordinated agency-wide surveillance program that is part of QAPI, investigation of clusters and outbreaks, action plans, education of staff, patients and caregivers, and how Michigan’s communicable disease reporting rules apply (physicians and laboratories must report; nurses and agency infection control staff may report to the local health department).
42 CFR §484.70
MI-HH-IC-02
Bloodborne Pathogens Exposure Control Plan, Sharps, and Medical Waste
Sets out the Agency’s bloodborne pathogens exposure control plan under MIOSHA Occupational Health Standard Part 554, which binds Michigan employers whose employees have occupational exposure: exposure determination (Category A and B), the written plan and its annual review with safer devices and input from frontline staff, universal precautions, engineering and work practice controls, personal protective equipment at no cost, sharps containers and regulated waste, laundry and specimens, hepatitis B vaccination offered within 10 working days of initial assignment, post-exposure evaluation, training at assignment and every year, the sharps injury log, and record retention. Explains that the Michigan Medical Waste Regulatory Act does not treat waste generated by a home health care agency as "medical waste" and sets the Agency’s own handling standard.
Mich. Admin. Code R 325.70001 to R 325.70018 (MIOSHA Part 554)
MI-HH-IC-03
Employee Health Screening, Tuberculosis Screening, and Immunizations
Sets out the Agency’s employee health program: health screening after a job offer, tuberculosis screening and testing following the 2019 CDC and National Tuberculosis Controllers Association recommendations for health care personnel (baseline individual risk assessment, symptom evaluation and test; no routine annual testing; post-exposure testing; annual TB education), hepatitis B vaccination under MIOSHA Part 554, influenza and other vaccinations offered by the Agency, work restrictions for ill or exposed staff, and confidential employee health records. No Michigan rule sets tuberculosis or health screening for home health agency staff; the Agency adopts these as its own standards under the accepted standards of practice required by 42 CFR §484.70(a).
42 CFR §484.70(a)
Emergency preparedness1
Records2
MI-HH-REC-01
Clinical Records: Content, Authentication, Timeliness, and Retention
Sets out what the Agency keeps in the clinical record of every patient (42 CFR §484.110), how entries are written, timed, authenticated and corrected, the discharge and transfer summaries and when they are sent, the extra content Michigan Medicaid requires for its patients, how long records are kept (at least seven years after discharge as the Agency’s own standard, which meets the federal five years after discharge, the Michigan Medicaid seven years from the date of service and the seven years Michigan requires of licensed health professionals), and how records are protected, made available and finally destroyed.
42 CFR §484.110
MI-HH-REC-02
Patient Access to Records, Copies, and Release of Information
Sets out how a patient or the patient’s personal representative gets to see or receive a copy of the clinical record (free of charge, at the next home visit or within 4 business days, whichever comes first, under 42 CFR §484.110(e)), how other protected health information is provided under HIPAA and the Michigan Medical Records Access Act, how requests to amend and requests for an accounting of disclosures are handled, and when the Agency may release records to others with or without the patient’s written authorization, including Michigan Medicaid’s own rules on releases, subpoenas and behavioral health consent.
42 CFR §484.110(e)
Privacy3
MI-HH-PRV-01
HIPAA Privacy and Michigan Confidentiality Laws
Sets out how the Agency, as a HIPAA covered entity, protects the privacy of every patient’s health information: the Privacy Official and complaint contact (45 CFR §164.530(a)), minimum necessary and role-based access, the uses and disclosures the Agency makes with and without a patient’s authorization, the stricter Michigan and federal rules for HIV, mental health and substance use disorder information, the Notice of Privacy Practices and its acknowledgment (Form MI-HH-PRV-01-A), patients’ privacy rights, safeguards in the home and in the field, privacy complaints, sanctions, mitigation and non-retaliation.
45 CFR Part 164, Subpart E
MI-HH-PRV-02
HIPAA Security
Sets out the administrative, physical and technical safeguards the Agency uses to protect electronic protected health information under the HIPAA Security Rule (45 CFR Part 164, Subpart C): the Security Official, the yearly risk analysis and risk management plan, user accounts (including CHAMPS MILogin access and the EVV mobile application), passwords and multi-factor authentication, encryption of laptops, phones and email, mobile devices in the field, audit log review, security incident response, backups and the contingency plan, device and media disposal, business associates, and the yearly evaluation.
45 CFR Part 164, Subpart C
MI-HH-PRV-03
Breach Notification Under HIPAA and the Michigan Identity Theft Protection Act
Sets out what the Agency does when protected health information or other personal information may have been lost, stolen, seen or sent where it should not go: immediate reporting to the Privacy Official, containment, the four-factor risk assessment under 45 CFR §164.402, notice to patients without unreasonable delay and in no case later than 60 calendar days after discovery, notice to HHS and, for more than 500 residents of a state, to the media, the law enforcement delay, breaches by business associates, the yearly HHS report for smaller breaches, and the separate Michigan Identity Theft Protection Act duties for personal information (such as employees’ Social Security numbers) that HIPAA does not cover. Form MI-HH-PRV-03-A records each assessment and notice.
45 CFR §164.400 to §164.414
Human resources5
MI-HH-HR-01
Personnel Qualifications, Job Descriptions, Orientation, In-Service Training, and Evaluation
Sets out how the Agency defines each job, checks that every person meets the qualifications in 42 CFR §484.115 before they work, orients new staff, gives ongoing in-service training (including at least 12 hours a year for home health aides and emergency preparedness training at least every 2 years), observes competency, and evaluates performance. Michigan sets no state training-hour rule for home health agencies; the Agency’s orientation adds Michigan abuse reporting, MIOSHA bloodborne pathogens training and EVV.
42 CFR §484.115
MI-HH-HR-02
Personnel Records, Employee Health Information, and Record Access
Sets out what the Agency keeps in each personnel file to show that staff meet the qualifications and training requirements of 42 CFR Part 484, how employee health and background check information is kept separate and confidential (MCL 333.20173a(9); MIOSHA Part 554), how employees may review their own records under Michigan’s Bullard-Plawecki Employee Right to Know Act, and how long records are kept.
42 CFR §484.115
MI-HH-HR-03
Criminal History Checks Under the Michigan Workforce Background Check Program
Sets out how the Agency, as a Medicare-certified home health agency and therefore a "covered facility" under Michigan’s Workforce Background Check law (MCL 333.20173a), completes a fingerprint-based state and FBI criminal history check and a registry check before employing, independently contracting with, or granting clinical privileges to anyone who will regularly have direct access to patients; when conditional employment is allowed; which convictions and findings bar a person; and the duty of staff to report arraignments and convictions.
MCL 333.20173a
MI-HH-HR-04
Professional Licenses, Registries, and Reporting Licensee Misconduct
Sets out how the Agency verifies that every person furnishing services holds a current Michigan license, certification or registration where one applies (42 CFR §484.100(b)), checks nurse aide registry status for aides who qualify through it, confirms that ordering practitioners are not sanctioned, and how licensed staff meet their duty under MCL 333.16222 to report another licensee’s violations to the Department of Licensing and Regulatory Affairs.
42 CFR §484.100(b)
MI-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: the MIOSHA general duty to keep the workplace free from recognized hazards, home safety risk assessment and flags, visit scheduling, check-in and check-out, escorts and joint visits, safe driving (including Michigan’s hands-free law), managing aggression and leaving unsafe situations, pets, weapons, pests and environmental hazards, safe patient handling, reporting and reviewing incidents, MIOSHA reporting of work-related deaths within 8 hours and in-patient hospitalizations, amputations and losses of an eye within 24 hours, injury records, support for staff, and discharge for cause when the home cannot be made safe.
MCL 408.1011
Governance7
MI-HH-GOV-01
Governing Body, Organization, and Lines of Authority
Sets out how the governing body of the Agency holds full legal authority and responsibility for its management and operation, adopts governing documents, appoints the Administrator, oversees fiscal affairs and the quality program, and keeps a written description of the organization, services and lines of authority down to the patient care level. Michigan does not license home health agencies, so the structure follows 42 CFR §484.105 and §484.65(e), which bind the Agency as a condition of its Medicare certification, and the Michigan Medicaid Provider Manual.
42 CFR §484.105(a)
MI-HH-GOV-02
Administrator, Alternate Administrator, and Clinical Manager
Sets out how the governing body appoints a qualified Administrator, how a qualified pre-designated person is authorized in writing to act when the Administrator is not available, how one or more qualified clinical managers oversee all patient care services and personnel, and how the Agency makes sure the Administrator or alternate and a clinical manager are available during all operating hours, as 42 CFR §484.105(b) and (c) and §484.115(a) and (c) require.
42 CFR §484.105(b) and (c)
MI-HH-GOV-03
Medicare Certification, Surveys, Ownership Disclosure, Branch Offices, and Reporting Changes
Explains that Michigan does not license home health agencies and that the Agency operates under its Medicare certification, surveyed by LARA’s Bureau of Survey and Certification for CMS (or by an accrediting organization). Sets out how the Agency keeps its certification current: ownership and management disclosure to the survey agency, reporting branches, reporting enrollment changes to Medicare within 30 or 90 days, the 36-month rule and the 2026 nationwide enrollment moratorium for home health agencies, and survey readiness.
42 CFR §484.100
MI-HH-GOV-04
Policy Management, Annual Agency Review, and Document Control
Sets out how the Agency writes, approves, issues, reviews and withdraws its policies and forms, how it tracks the review intervals the Conditions of Participation fix (yearly for the acceptance-to-service policy, public information and the overall plan and budget; at least every 2 years for the emergency preparedness program), and how the governing body completes an annual review of the Agency’s services, quality and compliance. Michigan sets no state review interval for home health policies.
42 CFR §484.105(b)(1)(iv)
MI-HH-GOV-05
Services Under Arrangement and Contracted Personnel
Sets out how the Agency furnishes services through other agencies, organizations or individuals under a written agreement while keeping overall responsibility for the services and the way they are furnished, as 42 CFR §484.105(e) requires; screens arranged providers for enrollment denial, exclusion, revocation and debarment; makes sure contracted staff with direct access to patients pass the Michigan Workforce Background Check; and puts HIPAA business associate terms in place.
42 CFR §484.105(e)
MI-HH-GOV-06
Agency Closure, Change of Ownership, and Continuity of Records
Sets out how the Agency plans for and carries out a closure or a change of ownership so that patients are moved safely to other providers, staff and payers are told, and clinical records are kept for the required periods even after the Agency stops operating, as 42 CFR §484.110(c)(2) requires. Michigan Medicaid records are kept at least seven years from the date of service regardless of change in ownership or termination of participation.
42 CFR §484.110(c)(2)
MI-HH-GOV-07
Nondiscrimination and Civil Rights Compliance
Commits the Agency to accept and serve patients, and to employ staff, without discrimination on the grounds federal and Michigan law protect; sets out the notice of nondiscrimination and language assistance, the grievance procedure for civil rights complaints, and how the Agency meets the Michigan Medicaid nondiscrimination condition, under Section 1557 (45 CFR Part 92), Title VI, Section 504, the Age Discrimination Act, the ADA, and Michigan’s Elliott-Larsen and Persons with Disabilities Civil Rights Acts.
45 CFR Part 92
Quality2
MI-HH-QA-01
Quality Assessment and Performance Improvement (QAPI)
Sets out the Agency’s quality assessment and performance improvement (QAPI) program under 42 CFR §484.65: an ongoing, Agency-wide, data-driven program that covers every service (including services under arrangement), focuses on outcomes including emergent care use, hospital admissions and readmissions, tracks adverse patient events, and is overseen by the governing body. It names the QAPI committee and its quarterly cycle, the indicators the Agency measures (OASIS outcomes, Home Health Quality Reporting Program and value-based purchasing results, infections, incidents, complaints, aide supervision, documentation, EVV for Michigan Medicaid visits), how problems are prioritized and corrected, the performance improvement projects recorded on Form MI-HH-QA-01-A, and the evidence the Agency keeps to show CMS that the program works.
42 CFR §484.65
MI-HH-QA-02
Incident Reporting, Adverse Events, and Investigations
Sets out how staff report incidents and adverse patient events on Form MI-HH-QA-02-A, what the clinical manager does first, which events also go to an outside authority (suspected abuse, neglect or exploitation; crimes; licensee misconduct; work injuries; privacy breaches; Michigan Medicaid provider preventable conditions), how events are investigated and when a root cause analysis is done, how patients and practitioners are told, and how incidents are tracked and analyzed in the QAPI program as 42 CFR §484.65 requires. Michigan has no separate incident reporting rule for home health agencies, so internal time frames are the Agency’s own standards.
42 CFR §484.65(c)(2)
Business4
MI-HH-BUS-01
Overall Plan, Annual Operating Budget, and Capital Expenditure Plan
Sets out how the Agency, under the direction of the governing body, prepares an overall plan and budget that includes an annual operating budget and a capital expenditure plan for at least a 3-year period, through a committee of the governing body, administrative staff and medical staff (if any), and reviews and updates them at least annually, as 42 CFR §484.105(h) requires; and how fiscal records are kept for Michigan Medicaid review.
42 CFR §484.105(h)
MI-HH-BUS-02
Charges, Billing, Claims, and Overpayments
Sets out how the Agency tells patients about charges, what must be in place before a Medicare or Michigan Medicaid claim is submitted (signed plan of care, countersigned verbal orders, prior authorization number for Medicaid aide services, EVV), the Michigan Medicaid rules on billing beneficiaries, payment in full, timely filing and factoring, and how overpayments are reported and returned.
Michigan Medicaid Provider Manual, General Information for Providers, Sections 10, 11 and 13
MI-HH-BUS-03
Electronic Visit Verification for Michigan Medicaid Home Health Care Services
Sets out how the Agency uses electronic visit verification for Michigan Medicaid home health care services, as section 1903(l) of the Social Security Act and the Michigan Medicaid Provider Manual require: which services and patients are covered, the HHAeXchange state system or an approved alternative, how staff clock in and out, how manual edits are kept to a minimum to meet the 85 percent quarterly compliance threshold MDHHS enforces from April 1, 2026, and how visit data is protected.
42 U.S.C. §1396b(l)
MI-HH-BUS-04
Michigan Medicaid Enrollment in CHAMPS, Revalidation, and Disclosures
Sets out how the Agency enrolls in Michigan Medicaid through CHAMPS (available only to Medicare-certified home health agencies), discloses owners, managing employees, agents and board members, consents to screening, site visits and fingerprinting, reports every change within 35 days, revalidates at least every five years, controls CHAMPS user access, and responds to suspension, termination and appeal processes.
Michigan Medicaid Provider Manual, General Information for Providers, Section 2
Ethics2
MI-HH-ETH-01
Compliance Program, Exclusion Screening, and False Claims Prevention
Sets out the Agency’s compliance program: a code of conduct, a person responsible for compliance, confidential reporting without retaliation, screening of staff, contractors and governing body members against the federal exclusion list, SAM.gov and the MDHHS Sanctioned Provider List, auditing and monitoring, investigation and correction, and education about the federal False Claims Act and Michigan’s Medicaid False Claim Act, so that findings of fraud or waste are appropriately addressed (42 CFR §484.65(e)(4)).
42 CFR §1001.1901
MI-HH-ETH-02
Referrals, Kickbacks, Patient Inducements, and Marketing
Prohibits the Agency and its staff from offering, paying, soliciting or receiving anything of value for patient referrals, and from offering patients inducements to choose the Agency, under the federal Anti-Kickback Statute, the physician self-referral law, the beneficiary inducement civil monetary penalty, and Michigan’s Medicaid False Claim Act (MCL 400.604); protects patient choice; and requires accurate public information and marketing.
42 U.S.C. §1320a-7b(b)
Questions
Questions about this manual
Is this the right manual for my agency?
It is for Medicare-certified home health agencies in Michigan. Agencies that give only non-medical care, such as Home Help or MI Choice providers, need the Michigan home care manual, and hospices need the Michigan hospice manual. An agency that is not Medicare-certified is outside this manual.
Does Michigan license home health agencies?
No. LARA states that state licensing is not required for home health agencies. An agency's standing rests on its Medicare certification, and Michigan Medicaid enrolls only a home health agency that is Medicare-certified (Michigan Medicaid Provider Manual, Home Health, Section 1).
Do the policies cover Michigan Medicaid patients?
Yes. Where the Michigan Medicaid Provider Manual is stricter, the policies add its rules for Medicaid patients only, such as RN co-signature of aide and LPN notes, aide prior authorization after the first 90 days, and records kept not less than seven years from the date of service.
What do the 57 policies cover?
Client rights (5), service delivery (9), patient care (3), clinical tasks (8), safeguarding (3), infection control (3), emergency preparedness (1), records (2), privacy (3), human resources (5), governance (7), quality (2), business (4) and ethics (2).
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