HHA Survey Investigation Worksheet 1: Patient Sample
PROJECT_NUM
Agency Name/CCN: FACILITY NAME / PROVIDER NUM _________________________________Survey Date: _______________________________
Surveyor Name(s) and ID #: ___________________________________ RR Date HV date if applicable: _________________
Patient Name/Confidential ID #: ________________________________ Referral Date: ______________ SOC: _______________________________
Primary/Secondary Diagnoses: _______________________________________________________________________________________________
Discipline(s) ordered (circle): SN PT OT SLP MW Aide Discipline observed during HV (circle): RN LPN PT PTA OT COTA SLP MSW SW Asst. Aide
Attach copies of current plan of care, medication profile and subsequent orders, ADL & IADL OASIS items, Aide plan (if applicable) and any other
documentation related findings.
REFER TO APPENDIX B FOR FULL REGULATION TEXT AND INTERPRETIVE GUIDELINES
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
484.40 Release of PT identifiable OASIS information
(G350)
484.45 Reporting OASIS Information
Other: G372, G374, G376, G378, G380, G382, G384,
G386
HHA SURVEY INVESTIGATION WORKSHEET 1: PATIENT SAMPLE
2
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
484.50 Patient Rights (G406)
Participate in care(G434)
Investigation of complaints(G476)
Investigate complaints made by patient(G478)
Treatment or care(G480)
Mistreatment, neglect or abuse(G482)
Document complaint and resolution(G484)
Protect patient during investigation(G486)
Immediate reporting of abuse by all staff(G488)
Level 2 Standards
Have a confidential clinical record(G438)
Other:
G408, G410, G412, G414, G416, G418, G420, G422,
G424, G426, G428, G430, G432, G436, G440, G442,
G444, G446, G448, G450, G452, G454, G456, G458,
G460, G462, G464, G466, G468, G470, G472, G474,
G490
HHA SURVEY INVESTIGATION WORKSHEET 1: PATIENT SAMPLE
3
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
484.55 Comprehensive assessment of patient (G510)
Initial assessment visit(G512)
RN performs assessment(G514)
Completion of the comprehensive
assessment(G518)
5 calendar days after start of care(G520)
Eligibility for Medicare home health benefits(G522)
Therapy services determine eligibility(G524)
A review of all current medications(G536)
Update of the comprehensive assessment(G544)
Within 48 hours of the patient return(G548)
Level 2 Standards
Last 5 days of every 60 days unless(G546)
At discharge(G550)
Other:
G516, G526, G528, G530, G532, G534, G538, G540,
G542
HHA SURVEY INVESTIGATION WORKSHEET 1: PATIENT SAMPLE
4
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
484. 60 Care Planning, Coordination and Quality of
care (G570)
Plan of care(G572)
Plan of care must include(G574)
Conformance with Physician orders (G578)
Only as ordered by a physician(G580)
Influenza and Pneumococcal Vaccinations (G582)
Level 2 Standards
Review and Revision of the Plan of Care (G586)
Revised by a Physician every 60 days (G588)
Promptly alert relevant physician of changes (G590)
Other:
G576, G584, G592, G594, G596, G598, G600, G602,
G604, G606, G608, G610, G612, G614, G616, G618,
G620, G622
Patient Name/ID: _________________________________________________________Surveyor Name/ID: _______________________________
HHA SURVEY INVESTIGATION WORKSHEET 1: PATIENT SAMPLE
5
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
484.65 Quality Assessment/Performance
Improvement (G640)
Other:
G642, G644, G646, G648, G650, G652, G654, G656,
G658, G660
484.70 Infection Prevention and Control (G680)
Other:
G682, G684, G686
484.75 Skilled Professional Services (G700)
Responsibilities of Skilled Professional (G704)
Interdisciplinary Assessment of the Patient (G706)
Development and Evaluation of the Care Plan
(G708)
Provide Services in the Plan of Care (G710)
Patient, Caregiver, and Family Counseling (G712)
Patient and Caregiver Education (G714)
Preparing Clinical Notes (G716)
Communicating with Physicians (G718)
HHA SURVEY INVESTIGATION WORKSHEET 1: PATIENT SAMPLE
6
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
Level 2 Standards
Supervise Skilled Professional Assistants (G724)
Nursing Services Supervised by RN (G726)
Rehab Services Supervised by PT, OT (G728)
Medical Social Services Supervised by MSW (G730)
Other:
G702, G720, G722
Patient Name/ID: _________________________________________________________Surveyor Name/ID: _______________________________
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
484.80 Home Health Services (G750)
Home Health Aide Assignments and Duties (G798)
Onsite Supervisory Visit Every 14 Days (G808)
Level 2 Standards
Competency Evaluation (G768)
12 Hours In-service Every 12 Months (G774)
HHA SURVEY INVESTIGATION WORKSHEET 1: PATIENT SAMPLE
7
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
Services provided by Home Health Aide (G800)
Duties of Home Health Aide (G802)
Non-Skilled Direct Observation Every 60 days (G814)
Home Health Aide Services Under Arrangement
(G820)
Other:
G752, G754, G756, G758, G760, G762, G764, G766,
G770, G772, G776, G778, G780, G782, G784, G786,
G788, G790, G792, G794, G796, G804, G806, G810,
G812, G816, G818, G822, G824, G826, G828
484.100 Compliance with Federal , State and Local
Laws (G848)
Level 2 Standards
Licensing (G860)
Other:
G850, G852, G854, G856, G858, G862, G864
Patient Name/ID: _________________________________________________________Surveyor Name/ID: _______________________________
HHA SURVEY INVESTIGATION WORKSHEET 1: PATIENT SAMPLE
8
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
484.102 Emergency Preparedness E-0001-SEE EP TOOL
TO DETERMINE COMPLIANCE
484.105 Organization and Administration of Services
(G940)
Administrator Must (G944)
Administrator Appointed By Governing Body (G946)
Responsible for All Day to Day Operations (G948)
Ensure Clinical Manager is Available (G950)
In Accordance with Current Clinical Practice (G984)
Level 2 Standards
Ensures Qualified Predesignated Person (G954)
Availability During all Operating Hours (G956)
Clinical Manager (G958)
Make Patient and Personnel Assignments (G960)
Coordinate Patient Care (G962)
Coordinate Referrals (G964)
Assure Patient Needs are Continually Assessed (G966)
Assure Implementation of Care Plan (G968)
HHA SURVEY INVESTIGATION WORKSHEET 1: PATIENT SAMPLE
9
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
Other:
G942, G952, G970, G972, G974, G976, G978, G980,
G982, G986, G988, G1018, G1020, G1022, G1024,
G1026, G1030.
484.110 Clinical Records (G1008)
Contents of Clinical Records (G1010)
Required Items in Clinical Record (G1012)
Interventions and Patient Response (G1014)
Goals in the Patients Care Plan (G1016)
Level 2 Standard
Protection of Records (G1028)
Other:
G1018, G1020, G1022, G1024, G1026, G1030.
Patient Name/ID: _________________________________________________________Surveyor Name/ID: _______________________________
HHA SURVEY INVESTIGATION WORKSHEET 1: PATIENT SAMPLE
10
CoPs AND Related G Tags (Level 1 G tags in bold
print)
Comments (indicate if determined by RR or HV) Not
Applicable /NA
484.115 Personnel Qualifications (G1050)
Other:
G1052, G1054, G1056, G1058, G1060, G1062, G1064,
G1066, G1068, G1070, G1072, G1074, G1076, G1078
Summary Comments/Corroborating Interviews (Document date, time, name/title of interviewee); Note: Surveyor Notes Worksheet (form CMS
807) is an alternative.
Minnesota Department of Health
Health Regulation Division
PO Box 64882
St. Paul, MN 55164-0882
www.health.state.mn.us
Effective May 2011
Rev. 3/18
CMSWKS1
