Home Health Articles and Information


May 26, 2020 6:00:00 AM / by Kristi Bajer, BSN, RN, COS-C

Four Things to Document for Audit Proof Maintenance Care

Last week in the blog we discussed how to qualify a patient for maintenance care.  Simply being on service for a long time does not mean a patient is automatically a “maintenance care” case.  If you missed last week’s blog, you may view the MAINTENANCE CARE DECISION TREE HERE.

Now, if you have determined your patient meets the criteria for maintenance care, the type of documentation in your chart must be carefully reviewed.  We suggest clinical documentation should be done as if every chart will be audited.  When providing maintenance care there are four things that need to be charted in every episode provided to ensure your documentation is audit proof.


  • Document why the program requires the skill of a clinician to provide the service.
  • Document the patient’s condition, the state of stability achieved, and exactly what you intend to          preserve or maintain.
  • Document what decline in patient status would indicate the re-engagement of restorative                      services.
  • Document home bound status specifically charting what stops the patient from getting                             equivalent services outside of the home?

OperaCare has a suite of evidence-based care pathways available to our subscribers including maintenance care.  We also offer education to providers on gathering evidence-based practice for care planning to improve overall patient outcomes and streamline the quality assurance process. 

Click below to learn more.

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Tags: PDGM, Outcomes, Compliance, Home Health, Quality assurance, Home Health Care, Maintenance Care

Kristi Bajer, BSN, RN, COS-C

Written by Kristi Bajer, BSN, RN, COS-C

Kristi Bajer BSN, RN, COS-C, brings over 10 years of real world experience as a clinician, director, and administrator in home health. She is a firm believer in diagnosis driven evidence-based care in home health. Currently, she assists agencies with external chart audits and Medicare appeals, as well as providing training and coaching on OperaCare implementation and building QAPI programs using data to drive success and protect agencies from government audits.