Home Health and Hospice Personnel File Audit Checklist for ACHC, CHAP and Joint Commission Surveys (2026)

A home health agency or hospice that wants Medicare certification can be surveyed by the state survey agency or, instead, accredited by an organization CMS has approved. CMS calls the second route deemed status: the agency 'has voluntarily applied for, and received, accreditation from a CMS-approved national accrediting organization', the accreditor has recommended it, and CMS has accepted the recommendation (42 CFR 488.1). To be approved, an accreditor's program must 'meet or exceed the Medicare program requirements' (42 CFR 488.1), and the accreditor must re-survey every accredited provider, unannounced, 'no later than 36 months after the prior accreditation effective date' (42 CFR 488.5(a)(4)(i)).

ACHC, CHAP and The Joint Commission each hold that approval for both programs. The terms below are from CMS's final notices in the Federal Register:

The Joint Commission's hospice term is shorter than usual: CMS says it could not observe a Joint Commission hospice survey during the early-2025 travel suspensions at HHS, so it granted a shorter approval (90 FR 23338-23339).

When one of them surveys you for deemed status, the Conditions of Participation are the floor and the accreditor's own standards sit on top (see the section on what each accreditor adds, below). Today each accreditor writes its own standards and CMS reviews them for comparability. In its recent approvals CMS required ACHC to revise its home health standards to match the personnel qualifications at 42 CFR 484.115 (90 FR 10082), and required CHAP to add guidance for its hospice surveyors on reviewing personnel records for training requirements (89 FR 89017). From June 16, 2027 the floor becomes explicit: a CMS final rule requires accreditors to 'include the applicable Medicare regulatory language as their minimum accreditation standards' (42 CFR 488.4(a)(3) as revised, 91 FR 36464).

One difference from a state survey is worth knowing. CMS's protocol for state surveyors of home health agencies says personnel records 'are not routinely reviewed unless the surveyor identifies concerns' in staff and patient interviews, home visits or clinical record reviews (State Operations Manual, Appendix B, Rev. 245, Task 4). The hospice protocol differs: surveyors review a sample of personnel records for orientation, competency assessment and in-service training, check criminal background checks against 42 CFR 418.114(d), and 'Perform a random sample of 2 hospice aide personnel records' to confirm the annual supervisory observations (Appendix M, Rev. 222). How each accreditor samples personnel files is set by its own survey process. Ask yours, and audit as if every file will be opened.

The rules below say what each file must show. They do not say how to audit it, so this section is our recommendation, not a requirement.

1. Build the list from the roster, not the file cabinet. Include every employee, contractor and person furnishing services under arrangement, and for a hospice every volunteer, who worked in the period a surveyor will look at, plus anyone who left during it. The file nobody pulled is the one that becomes a finding.
2. Audit each person against the rows for their role. An aide file and an RN file fail for different reasons, and a hospice file carries rows a home health file does not. Work through the checklist below by category.
3. Mark every row present and current, present but expired, missing, or not applicable with the reason written down. A blank is a finding.
4. Check dates against each other, not only against today. Competency evaluation before the first visit; Form I-9 Section 2 within three business days of hire; the hepatitis B vaccine offered within 10 working days of initial assignment; the hospice background check within three months of employment where your state sets no timing; 12 in-service hours in every 12-month period.
5. Fix forward and date honestly. If a document is missing, obtain it now and date it today. A record created later and dated earlier is worse than the gap it covers, and a surveyor who finds one stops trusting the rest of the file.
6. Repeat on a schedule. Audit each new hire's file at 30 days, the whole roster at least once a year (ACHC's annual compliance checklists recommend a yearly personnel record audit too), and every file again before your accreditation window opens. Your accreditor must re-survey, unannounced, within 36 months of your last accreditation date (42 CFR 488.5(a)(4)(i)).

Some records belong in every personnel file, whatever the role.

Form I-9. Section 1 is completed 'at the time of hire' and Section 2 'within three business days of the hire', after the employer examines the identity and work authorization documents (8 CFR 274a.2(b)(1)(i)(A), (b)(1)(ii)). Keep it 'three years after the date of the hire or one year after the date the individual's employment is terminated, whichever is later' (8 CFR 274a.2(b)(2)(i)(A)). If work authorization expires, reverify 'not later than the date work authorization expires' (8 CFR 274a.2(b)(1)(vii)). Copies of the documents are optional, but copies you make are kept with the I-9 or with the employee's records (8 CFR 274a.2(b)(3)).

Exclusion screening. No Condition of Participation sets a frequency for checking the OIG exclusion list. What federal law fixes is the consequence: no federal health care program payment may be made for items or services furnished by an excluded person (42 CFR 1001.1901(b)(1)), and OIG recommends checking before hire and then monthly (OIG, Updated Special Advisory Bulletin, May 8, 2013, p. 15). A home health agency's arranged entities and individuals must not have been 'excluded or terminated from any federal health care program or Medicaid' (42 CFR 484.105(e)(2)(ii)). The OIG exclusion screening guide covers when monthly becomes binding and what the screening file holds.

Emergency preparedness training. A home health agency gives initial training to 'all new and existing staff, individuals providing services under arrangement, and volunteers', then training 'at least every 2 years', and keeps documentation of it (42 CFR 484.102(d)(1)(i)-(iii)). A hospice gives initial training to 'all new and existing hospice employees, and individuals providing services under arrangement', trains at least every 2 years, and keeps 'documentation of all emergency preparedness training' (42 CFR 418.113(d)(1)). Both retrain after a significant update to the policies. The two-year interval has been the federal text since amendments published September 30, 2019 (84 FR 51825; 84 FR 51815); the exercises that test the plan are still at least annual (42 CFR 484.102(d)(2); 418.113(d)(2)).

Infection control education. Both rules require it without setting a frequency. Home health agencies educate 'staff, patients, and caregiver(s)' (42 CFR 484.70(c)); hospices educate 'employees, contracted providers, patients, and family members and other caregivers' (42 CFR 418.60(c)). Record the date and topic in each file so you can show it happened.

Bloodborne pathogens, for every worker with occupational exposure. Train 'At the time of initial assignment to tasks where occupational exposure may take place' and 'At least annually thereafter', each annual session 'within one year of their previous training' (29 CFR 1910.1030(g)(2)(ii), (iv)). Training records carry the session dates, a summary of the contents, the trainers' names and qualifications, and the attendees' names and job titles, and are kept 'for 3 years from the date on which the training occurred' (29 CFR 1910.1030(h)(2)). Offer the hepatitis B vaccine after training and within 10 working days of initial assignment, and have anyone who declines sign the Appendix A statement (29 CFR 1910.1030(f)(2)(i), (iv)). Vaccination status goes in a confidential employee medical record kept for the duration of employment plus 30 years (29 CFR 1910.1030(h)(1)).

What the federal home health rules leave to the state. The current text of 42 CFR part 484 contains no requirement for a criminal background check, TB screening, an orientation or a personnel record as such. Those come from state licensure law, which the Conditions of Participation bring in by requiring compliance with state law and state licensure (42 CFR 484.100), and from accreditor standards. The Florida and North Carolina guides set out what those two states add.

Every professional must hold the license, certification or registration the state requires. A home health agency must ensure that 'all persons furnishing services to patients' are 'licensed, certified, or registered, as applicable' (42 CFR 484.100(b)). Hospice professionals, including those under contract or arrangement, 'must be legally authorized (licensed, certified or registered)', and 'All personnel qualifications must be kept current at all times' (42 CFR 418.114(a)). The file needs the current credential and its expiration date, not only the one collected at hire.

The federal discipline standards add education and experience a license alone may not show:

Skilled services must be 'authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under § 484.115' (42 CFR 484.75(a)); the hospice rule says the same of licensed professional services under 418.114 (42 CFR 418.62(a)). Licensed staff also take part in agency in-service training (42 CFR 484.75(b)(9); 418.62(c)), so their files should show it.

The federal text does not say how to verify a license. The accreditors do; see the section on what each one adds.

A Medicare-certified home health agency may use an aide only if the person completed one of four routes: a training program plus a competency evaluation; a competency evaluation program alone; a state-approved nurse aide training and competency evaluation program, with the person 'currently listed in good standing on the state nurse aide registry'; or a qualifying state licensure program (42 CFR 484.80(a)(1)). The file shows which route, with the proof.

• Training: classroom and supervised practical training totaling at least 75 hours, with 'A minimum of 16 hours of classroom training' before 'a minimum of 16 hours of supervised practical training' (42 CFR 484.80(b)(1)-(2)), covering the subjects listed in 484.80(b)(3). The agency 'must maintain documentation that demonstrates that the requirements of this standard have been met' (42 CFR 484.80(b)(4)).
• Competency evaluation before the first visit: an individual may furnish services 'only after that individual has successfully completed a competency evaluation program' (42 CFR 484.80(c)). A registered nurse performs it, and five subject areas are observed with a patient or pseudo-patient (42 CFR 484.80(c)(1), (3)). An aide rated unsatisfactory in a task may not perform it without direct RN supervision until retrained and re-evaluated, and unsatisfactory ratings in more than one required area mean the evaluation was not passed (42 CFR 484.80(c)(4)).
• The 24-month lapse: after 'a continuous period of 24 consecutive months' with no services furnished for compensation, the aide must complete another program before providing services (42 CFR 484.80(a)(2)). Check prior employment dates at hire.
• In-service: 'at least 12 hours of in-service training during each 12-month period', supervised by a registered nurse and documented (42 CFR 484.80(d)). CMS's surveyor guidance treats the 12 hours as met for the 12 months after an aide completes training and competency evaluation, unless the agency introduces a new procedure that calls for more (Appendix B, G774).
• The observation that belongs in the aide's file: for aides serving patients who receive skilled services, a registered nurse or other skilled professional must 'make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care' (42 CFR 484.80(h)(1)(iv)). For aides serving only patients without skilled services, the registered nurse observes each aide on site semi-annually (42 CFR 484.80(h)(2)(ii)). The 14-day and 60-day supervisory visits assess the services a patient receives, and the aide need not be present at them (42 CFR 484.80(h)(1)(i)(B), (h)(2)(i)(B)). A deficiency verified on site requires 'retraining and a competency evaluation for the deficient and all related skills' (42 CFR 484.80(h)(3)).
• If you train aides yourself: the instructor is a registered nurse with at least 2 years of nursing experience, at least 1 of them in home health care, or someone under that nurse's general supervision (42 CFR 484.80(e)), and an agency with certain compliance problems or sanctions in the previous 2 years may not offer the programs (42 CFR 484.80(f)).
• Medicaid personal care aides: an individual furnishing only personal care services as defined in 42 CFR 440.167 must meet the state's qualification standards and 'only needs to demonstrate competency in the services the individual is required to furnish' (42 CFR 484.80(i)).

Florida adds its own aide rules on top of these; the Florida home health aide requirements guide sets them side by side.

The hospice aide rules follow the home health ones, with two differences in supervision.

• Qualification: the same four routes, the last being 'A State licensure program' (42 CFR 418.76(a)(1)), and the same 24-month lapse rule (42 CFR 418.76(a)(2)).
• Training, competency and in-service: at least 75 hours, with 16 classroom hours before 16 supervised practical hours (42 CFR 418.76(b)(1)-(2)); a competency evaluation by a registered nurse before the aide furnishes services (42 CFR 418.76(c)); and 'at least 12 hours of in-service training during each 12-month period', supervised by a registered nurse and documented (42 CFR 418.76(d)). CMS's hospice surveyor guidance accepts the 12 hours on 'a calendar year basis, an employment anniversary basis, or a rolling 12 month basis as long as each aide meets this in-service training requirement' (Appendix M, L620).
• Supervision: a registered nurse makes an on-site visit to the patient's home at least every 14 days (42 CFR 418.76(h)(1)(i)); unlike the home health rule, the hospice text offers no virtual alternative. Separately, a registered nurse must 'make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care' (42 CFR 418.76(h)(2)), and observing the aide with one patient is enough (Appendix M, L632). A concern verified on site requires a competency evaluation of the deficient skill and all related skills (42 CFR 418.76(h)(1)(iii)).
• Homemakers: a qualified homemaker meets the standards in 42 CFR 418.202(g) and 'has successfully completed hospice orientation addressing the needs and concerns of patients and families coping with a terminal illness', or is a qualified hospice aide (42 CFR 418.76(j)).

Four hospice rules reach every file, not only the aides'.

• Orientation: orientation 'about the hospice philosophy to all employees and contracted staff who have patient and family contact' (42 CFR 418.100(g)(1)), and 'an initial orientation for each employee that addresses the employee's specific job duties' (42 CFR 418.100(g)(2)).
• Competency and in-service: the hospice 'must assess the skills and competence of all individuals furnishing care, including volunteers furnishing services', must have written policies describing how it assesses competency, and must 'maintain a written description of the in-service training provided during the previous 12 months' (42 CFR 418.100(g)(3)).
• Criminal background checks: required 'on all hospice employees who have direct patient contact or access to patient records', and hospice contracts must require contracted entities to check their employees with the same contact or access (42 CFR 418.114(d)(1)). Follow state requirements; where the state has none, the check must be obtained 'within three months of the date of employment for all states that the individual has lived or worked in the past 3 years' (42 CFR 418.114(d)(2)). The file needs the date the check was obtained, so the timing can be shown.
• Volunteers: volunteers work 'in defined roles and under the supervision of a designated hospice employee' (42 CFR 418.78), and the hospice 'must maintain, document, and provide volunteer orientation and training that is consistent with hospice industry standards' (42 CFR 418.78(a)). A volunteer who provides professional services must hold any license or registration the state requires (Appendix M, L644).

One definition widens all four. For part 418, an employee includes 'a volunteer under the jurisdiction of the hospice' (42 CFR 418.3). Read literally, the background check rule and the job-specific orientation rule reach volunteers too. CMS's surveyor guidance does not address the point either way, so this is our reading of the definition, not a CMS statement; the safer course is to screen and orient volunteers as you do staff.

Hospices that provide inpatient care directly have the one rule that names the personnel record outright: training and demonstrated competency in restraint and seclusion must be documented 'in the staff personnel records' (42 CFR 418.110(o)(4)).

A home health agency 'must ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of this part', must keep a written agreement with each such entity or individual, and may not use one that has been denied Medicare or Medicaid enrollment, excluded or terminated from a federal health care program, had its billing privileges revoked, or been debarred (42 CFR 484.105(e)(1)-(2)). For aides under arrangement, the agency must ensure they 'have met the training or competency evaluation requirements, or both' and must supervise them as it does its own (42 CFR 484.80(h)(5)). Administrative and supervisory functions may not be delegated to another agency (42 CFR 484.105).

A hospice's arranged services must be 'Furnished in a safe and effective manner by qualified personnel' under written agreements (42 CFR 418.100(e)(2)). Professionals under contract or arrangement must be legally authorized like employees (42 CFR 418.114(a)); contracts must require criminal background checks of contracted employees with patient contact or record access (42 CFR 418.114(d)(1)); and orientation on the hospice philosophy covers contracted staff with patient and family contact (42 CFR 418.100(g)(1)).

In practice, keep a file, or a section of the vendor file, for each contracted person that shows the same rows as an employee in the same role: license, qualification, training, competency and, for a hospice, the background check.

Each accreditor sets standards on top of the federal floor. What follows is only what each one publishes openly. Their full manuals are gated or sold, so this guide summarizes rather than quotes them, and gives a standard number only where a public document prints it.

ACHC

ACHC offers its personnel file survey checklists free. The home health checklist, [802] (revised July 30, 2024), lists what a surveyor expects to find in each file, by standard. Beyond the federal rows above, it includes initial and annual TB screening (HH4-2C.01); hepatitis B vaccination or a signed declination (HH4-2D.01); a signed job description or contract (HH4-2E.01); a current driver's license and MVR check, if applicable (HH4-2F.01); a criminal background check, an OIG exclusion list check and a national sex offender registry check, if applicable (HH4-2H.01); evidence of access to personnel policies (HH4-2I.01); the most recent annual performance evaluation (HH4-2J.01); verification of qualifications for non-licensed personnel (HH4-4A.01); evidence of orientation (HH4-5A.01); initial and annual competency assessment (HH4-6A.01); an initial and annual on-site observation visit (HH4-7C.01); evidence of annual education (HH4-8A, HH4-8A.01); a signed confidentiality statement (HH2-5A); and evidence of CPR, if applicable (HH2-6B.01). The hospice checklist, [803] (revised June 27, 2023), carries the same items under HSP numbers and adds restraint competency for inpatient units (HSP4-9A).

ACHC's annual compliance checklists for home health ([514]) and hospice ([518]), both revised in 2026, add two items worth a date on the calendar. Direct care personnel need 12 hours of in-service education in the past 12 months and non-direct care personnel 8 hours (HH4-8A.01; HSP4-6A.01), on required topics that include grievances and complaints, infection control, ethics, workplace and patient safety, patient rights and the compliance program. And ACHC recommends auditing personnel records every year for all required elements, then writing and carrying out a plan of correction for the gaps. On credentials, ACHC's own article says licensed home health staff are credentialed at hire and before their credentials expire, with the information obtained from the issuing state authority (HH4-2B.01; ACHC, The Importance of Verifying Personnel Credentials, April 18, 2023). No public ACHC text sets that timing for hospice.

Two cautions. The TB wording differs between ACHC documents: the personnel checklists say initial and annual TB screening, while the annual compliance checklists say an annual TB risk assessment sets the type and frequency of screening. And some checklist numbers (HH4-1A.02, HH4-2F.01, HH4-4A.01, HSP4-2F.01, HSP4-9A) do not reappear in ACHC's 2025 and 2026 documents. Check both against your current manual.

CHAP

CHAP offers its standards free through a download form, so this guide does not quote them. Its Standards Monitor lists the current editions as Home Health Standards of Excellence v.5.2.0 and Hospice Standards of Excellence v.3.2.0, both effective March 23, 2026. What CHAP publishes without a form are its policy lists and document request lists, dated July 2025. The home health policy list ties personnel policies and hiring criteria to HRM.1, aide training and competency to HRM.10 and HRM.11, supervision of personnel to HRM.18, evaluation of personnel performance to HRM.22, the aide annual observation visit to HRM.23, and TB testing and screening to IPC.14. The hospice list ties written job descriptions to HSRM.2.D, competency assessment policies to HSRM.14.I and performance evaluations to HSRM.29.D. The document request lists ask for a list of active personnel with hire dates, contracted staff included, and for competency documentation by discipline, contractors included and, for hospice, volunteers too. Those numbers predate the March 2026 editions, so confirm them in your manual. CHAP's own list of its most frequent 2025 hospice deficiencies puts the 14-day registered nurse supervisory visit for hospice aides (HSRM.25.I) at number five.

The Joint Commission

The Joint Commission's home care standards are in its manual, which accredited organizations reach through its extranet and others buy, so this guide does not quote them. Its public Standards FAQs for home care sit in the Human Resources (HR) chapter, and three of them, updated in 2026, bear directly on the file. Primary source verification is required to confirm a license, certification or registration when law or regulation requires one; the organization does it, and the record shows the date, who verified, what was verified and the result, because a copy of the license alone does not meet the intent (FAQ 000001472, updated April 22, 2026). Human resources standards apply to contract and volunteer staff who provide care, who should be managed like employees (FAQ 000001200, updated April 23, 2026). And criminal background checks are expected where law, regulation or the organization's own policy requires them, with every check documented (FAQ 000001098, updated April 22, 2026).

On competence, the Joint Commission's 2021 sample staff competency policy for home health and hospice cites HR.01.06.01, EP 6: competence is reassessed and documented at least 'once every three years', or more often if policy, law or regulation requires, after a first assessment during orientation. We could not confirm that number from a dated 2026 page, so check your manual before citing it. The federal hospice rule asks for competency assessment of everyone furnishing care (42 CFR 418.100(g)(3)), and ACHC's checklists ask for it every year, so treat three years as the Joint Commission's outer limit, not a target.

No federal rule sets one retention period for a whole personnel file. The federal periods that exist are specific:

State law and your accreditor may set longer periods. Write one retention period into policy that covers the longest that applies to you; the Florida and North Carolina guides list those two states' periods.