The Comprehensive Assessment in Home Health
By: Becky Tolson, RN, BS
Manager, Survey Operations
Posted: August 5, 2025
A comprehensive assessment is a critical first step in developing an individualized plan of care for home health patients. The Medicare Conditions of Participation (CoPs) and ACHC Standards outline clear expectations that assessments are thorough, timely, and center around each patient’s specific needs and goals. These standards guide home health agencies in evaluating the patient’s current health, psychosocial, functional, and cognitive status as well as the patient’s strengths, goals, and care preferences.
According to the CoPs, an initial assessment is to be completed within 48 hours of the referral or return home, or on the date noted by the physician or allowed practitioner for the start of care. The initial assessment is conducted to identify the immediate care needs and to confirm that the agency can meet these within the patient’s place of residence.
A comprehensive assessment must be completed within five calendar days of the patient’s start of care.A registered nurse must be involved in completing the initial and comprehensive assessment if nursing services are ordered. In cases where therapies are the only services ordered, a relevant therapist may complete the assessment.
The comprehensive assessment is interdisciplinary. It addresses physical health, mental, social, environmental, and economic components as well as any functional limitations, Assessment of the patient’s current health status includes relevant past medical history and all active health and medical problems.
Cognitive, mental, and psychosocial components screen for the patient’s ability to understand, remember, and take part in developing and implementing the plan of care. The assessment evaluates how relationships, living environment, safety, and security may affect the delivery of services. The patient’s functional status includes assessment of their independent functioning in the home, such as the ability to perform activities of daily living.
The patient and their family must be included in the assessment process to ensure incorporation of the patient’s strengths, goals, and care preferences. This collaborative approach ensures that care remains patient-centered, with measurable outcomes throughout their home health care experience.
The admitting clinician must also assess the patient’s continuing need for home health, their medical, nursing, rehabilitative, social, and discharge planning needs, review all current medications, identify available primary caregivers and patient representatives, if any. For Medicare beneficiaries, eligibility for the Medicare home health benefit must be determined, including homebound status incorporating the current version of the Outcome and Assessment Information Set (OASIS) items.
Once complete, the assessment findings are used to develop an individualized plan of care that addresses all identified services and needs. The plan must be reviewed and updated regularly—at least every 60 calendar days or more often as the patient’s condition changes.
In summary, both the CoPs and ACHC Standards require that a comprehensive home health assessment be prompt, interdisciplinary, and patient centered. Through team and family collaboration, clear documentation, and consistent reassessment, home health agencies can ensure high-quality care that supports the needs of patients and their families.
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