Guides
Home care agency quality assurance reviewed: what holds up and what does not
Home care quality assurance holds up when it measures hours worked, visit records and review solicitation against the rules that govern each.
What to take away
This review of home care agency quality assurance names the elements that hold up and the ones that fail.
- Timekeeping is the quality assurance practice most likely to fail an audit, because travel between clients and waiting time count as hours worked.
- A caregiver who is not paid for a gap between visits will not report the gap, so your schedule data and your payroll data disagree.
- Review requests that target only happy families are the second common failure; the FTC treats selective solicitation as a deceptive practice.
- Client satisfaction surveys, including HHCAHPS for Medicare-certified home health agencies, measure the household's mood or patient experience, not the visit record. Keep both, and reconcile them monthly.
- Every corrective action needs an owner, a due date, and a later sample of the same work to prove the fix held.
- Named tools that hold up in audits include AxisCare, WellSky Personal Care, HHAeXchange, Sandata and HomeTrak when their visit timestamps reconcile to payroll.
What holds up
- Timekeeping
- DOL Fact Sheet 79D rules and EVV timestamps in AxisCare, WellSky Personal Care, HHAeXchange, Sandata or HomeTrak reconciled to payroll
- Visit record
- Arrival and departure time, tasks, caregiver name and credential, and any change in condition reported onward
- Review solicitation
- Asking every client who received service and disclosing incentives, as the FTC guide requires
- Complaint log
- Expectation, evidence, who responded, resolution and process change recorded
- Corrective action
- Owner, due date and a later sample of the same work
- Accreditation readiness
- Joint Commission, CHAP and ACHC survey standards applied to clinical records and performance improvement
What fails
- Timekeeping
- Unpaid gaps over fifteen minutes and schedule data that disagrees with payroll
- Visit record
- A clinical judgment about whether the client is safe at home
- Review solicitation
- Request cards only to happy families and review suppression
- Complaint log
- Satisfaction score used as the only quality measure
- Corrective action
- Fix marked complete without re-sampling
- Accreditation readiness
- Chart rebuilt after a survey notice
This article covers home care agency operations, not clinical, licensing, wage-hour, tax or legal advice. Requirements vary by state, payer and worker relationship, so confirm current duties with your state labor office, your CPA and a lawyer before changing payroll or scheduling.
What fails first: timekeeping under DOL Fact Sheet 79D
The U.S. Department of Labor fact sheet on hours worked for domestic service employment is the single most useful document for reviewing a home care schedule. It sets out when on-duty time, waiting time, travel between job sites and sleep time count as compensable hours.
The failure is structural, not clerical. If a caregiver finishes a 9 a.m. visit and the next client is at 11 a.m., the agency has to decide whether that gap is paid. Agencies that treat it as unpaid personal time create a record that contradicts the caregiver's own account of the day.
Medicaid-funded personal care services must use electronic visit verification, or EVV, under the 21st Century Cures Act. The requirement began Jan. 1, 2020, with a good faith exemption that ended Jan. 1, 2023. Named EVV and scheduling tools include AxisCare, WellSky Personal Care, HHAeXchange, Sandata and HomeTrak.
AxisCare and WellSky Personal Care record visit check-in and check-out and export hours to payroll. HHAeXchange and Sandata connect agency records to state Medicaid EVV aggregators. HomeTrak supports scheduling and payroll export for private duty agencies. Those tools hold up when their timestamps match the payroll export.
Three checks that catch unpaid gaps
- Compare visit timestamps against payroll export
- Document every gap over fifteen minutes
- Ask caregivers in a group setting
- Sample five travel-heavy routes
- Recompute paid hours by hand
If those three disagree, the payroll number is the one an investigator will question.
What a defensible visit record contains in Joint Commission, CHAP and ACHC surveys
A visit note that survives review carries the arrival and departure time, the tasks performed, the caregiver's name and credential, and any change in the client's condition that was reported onward. It does not carry a clinical judgment about whether the client is safe at home.
What a visit note should contain
Include
- Arrival and departure
- Yes
- Tasks performed
- Yes
- Caregiver name and credential
- Yes
- Condition changes reported
- Yes
- Client safety judgment
- No
Exclude
- Arrival and departure
- No
- Tasks performed
- No
- Caregiver name and credential
- No
- Condition changes reported
- No
- Client safety judgment
- Yes
That question belongs to the client's physician, nurse practitioner or the state health line. An agency that answers it in a visit note has taken on a liability it cannot carry.
The IRS recordkeeping guidance is the reference for how long and in what form to keep the supporting documents behind those notes: payroll records, purchase and sales records, and the documents that back assets and transactions.
Joint Commission Home Care Accreditation, Community Health Accreditation Partner and Accreditation Commission for Health Care publish survey standards for clinical records, care planning and performance improvement. Those standards hold up when the note matches the visit log. They fail when the chart is rebuilt after a survey notice.
Reviews and complaints as operating data: FTC guide holds up, selective solicitation fails
The FTC guide on soliciting and paying for online reviews states the rule plainly: ask genuine clients, do not filter for people likely to respond well, and disclose any incentive or connection. An agency that hands the request card only to families who praised the last visit is running a misleading review program.
The FTC's rule on consumer reviews and testimonials took effect in October 2024. It bans fake reviews, review suppression and buying positive reviews. Google Business Profile and Yelp are public review sites where selective requests show up. Neither platform changes the FTC rule.
Complaints deserve the same treatment as a missed shift. Log the expectation, the evidence, who responded, what the resolution was, and which process changed as a result.
A worked example: the unfilled Friday shift
A caregiver calls out Thursday night for a Friday 8 a.m. visit. The coordinator fills it with an aide who is already scheduled nearby.
The quality question is not whether the shift got covered. It is whether the replacement aide's travel time between the two clients was paid, whether the family was told who was coming, and whether the visit note was filed by Friday evening.
Run that three-part check on every fill for one month. The pattern that emerges tells you more about your operation than any satisfaction score.
Where the growth plan fits
Fill rate, caregiver turnover and gross margin per visit are the numbers that show whether quality is holding as you add clients. An agency that grows past its supervisory capacity starts missing the checks above.
The home care agency marketing and growth guide covers how to add referral sources without outrunning the coordinators who make these checks happen.
Common questions
Does paying caregivers for travel time between clients raise our costs?
It raises the visible cost of the hours you were already obligated to pay. The alternative is an unpaid-time claim, back wages and penalties, which cost more and arrive without warning. Confirm your obligations with your state labor office.
Can we ask only our happiest clients for reviews?
The FTC guidance says no. Ask every client who received service in the period, disclose any incentive, and let the reviews land where they land. Selective solicitation is the specific practice the guidance warns against.
Who decides whether a client can stay at home safely?
The client's physician or nurse practitioner, or the state health line in an urgent situation. Your agency documents what was observed and reports it onward. It does not make the determination.
How often should we sample visit records?
Monthly, on a rolling sample large enough to show a pattern. If the same gap appears twice, it is a process problem, not a caregiver problem, and the fix belongs in the schedule template.
