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HCTP Resource Center

Free interactive agency tool

Home Care Agency Documentation Self-Audit

Twelve practical checks to reveal whether your daily agency records connect policies, staff responsibility, service delivery, and leadership review. No registration required.

Your assessment

Mark “Documented” only when you can locate the actual record. Otherwise select “Needs attention.”

0 / 12 reviewed

Client journey

Inquiry and referral

Can you locate a dated intake or inquiry record and identify who handled the next step?

Evidence to look for: Inquiry log, referral record, assigned follow-up, intake completion

Admission and agreements

Do you have the records needed to establish the service relationship before care begins?

Evidence to look for: Signed service agreement, rights acknowledgments, admission checklist

Service plan alignment

Can a reviewer trace what the client needs to what a caregiver was instructed to deliver?

Evidence to look for: Evaluation, current service plan, task instructions, revision history

Service delivery

Visit and task records

Can you retrieve records showing what services occurred and any changes or exceptions?

Evidence to look for: Visit notes, service logs, missed-visit and refusal documentation

Client communication

Are important communications and changes followed through to a documented resolution?

Evidence to look for: Contact logs, change reports, notifications, follow-up records

Incidents and complaints

Can you connect an incident or complaint to the action, escalation, and review that followed?

Evidence to look for: Incident/complaint form, notifications, investigation, corrective action

Personnel

Hiring and screening

Can you retrieve evidence that staff were reviewed against the qualifications required for their assigned roles?

Evidence to look for: Application, role description, screening/qualification records where applicable

Orientation and competency

Do staff records show applicable orientation, training, competency, and updates?

Evidence to look for: Orientation checklist, training log, competency records where required

Supervision and performance

Does the agency record required supervision and follow-up when performance concerns arise?

Evidence to look for: Supervisory visit records, evaluations, coaching, remediation

Agency controls

Policy version and ownership

Can staff identify the current policy and the role responsible for carrying it out?

Evidence to look for: Current manual, revision history, role assignments, policy acknowledgment

Quality review and correction

Can you demonstrate that missing or incorrect documentation is identified and corrected?

Evidence to look for: Audit checklist, issue log, owner, correction, verification

Record security and closeout

Are records stored and closed in a controlled way, with access and retention rules applied?

Evidence to look for: Access controls, retention procedure, discharge and file closeout checklist

Action summary

Your next documentation priorities

You've assessed 0 of 12 areas. Finish the remaining questions for a complete self-review.

This tool is an educational documentation review, not a determination of regulatory compliance, licensing readiness, accreditation, or approval. Requirements depend on the actual provider pathway, service scope, and payer/program.

Explore the 43-document system

Move from a missing form to a connected operating process.

Explore HCTP's operational forms, learn how Policies & Procedures connect to records, or start with your state's provider pathway.

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