Documentation Gaps Dominate Home Health Survey Deficiencies

By: Susan Mills, RN

Senior Program Director

Posted: October 28, 2025

Top survey deficiencies across home health and other home-based care programs share a common theme: standard findings related to documentation, according to the latest Quality Review edition of Surveyor 

For home health agencies, the most frequent accreditation survey deficiencies tend to be consistent year over year and come largely from Section 5: Provision of Care and Record Management. Data from this year’s analysis supports that trend. All five of the top deficiencies for ACHC Home Health Accreditation come from Section 5 and will likely be familiar to many.  

Why does Section 5 continue to be so challenging? Many of the standards in this section require a large number of elements that must be documented by multiple team members. Various factors can complicate coordination and consistency. Documentation often suffers, resulting in missing, inadequate, or incomplete evidence of compliance.

Good news

Agencies surveyed during our recent reporting period are making measurable advances in care quality. A comparison of this year’s results with those from three years ago shows consistent improvement. The aggregated average frequency of the top eight deficiencies in 2022 was 41%. This year, that average dropped to 32%.

New this year

Continuous improvement is woven into all we do at ACHC, including the annual Quality Review edition of Surveyor. In our recent issue, “tips for compliance under each standard profile are enhanced to address varying levels of accreditation knowledge and experience across your agency. Explore our new Accreditation Nerd categories to see which is best for you. 


Discover more articles about Home Health Accreditation.