CarePath Solutions
The 10 Most Common HHSC Deficiencies, and How Texas Home Health Agencies Can Avoid Them
This article breaks down the ten most common deficiencies cited by HHSC during Texas home health surveys, and shows agencies exactly how to avoid them. If you operate a PAS or Licensed Home Health agency, this guide will help you strengthen compliance, prevent costly citations, and stay fully prepared for unannounced surveys.
Enoma Ojo, PhD
10/10/20261 min read
Texas home health agencies lose thousands of dollars and months of operational time because of preventable HHSC survey deficiencies. Whether you are a PAS agency or a Licensed Home Health provider, these are the issues surveyors cite most often, and how to stay fully compliant.
1. Incomplete or Non-Compliant Policies & Procedures
Most agencies use generic templates that do not match Texas TAC §558 requirements.
Fix: Build Texas-specific policies with Administrator/Alternate Administrator duties, emergency preparedness, infection control, and client rights clearly defined.
2. Missing Administrator & Alternate Administrator Qualifications
Surveyors frequently cite agencies for improper training hours or missing documentation.
Fix: Ensure 8-hour/16-hour training is completed, documented, and available in the survey binder.
3. Inadequate Personnel Files
Missing background checks, OIG/SAM verification, TB tests, competency evaluations, or job descriptions.
Fix: Create a standardized onboarding checklist and audit every file quarterly.
4. Failure to Conduct Required Supervisory Visits
PAS agencies must complete supervisory visits every 90 days.
Fix: Use a digital calendar or EMR reminders to track due dates.
5. Poor Documentation of Service Delivery
Incomplete visit notes, missing times, or vague descriptions.
Fix: Train caregivers on detailed, defensible documentation.
6. Incomplete Emergency Preparedness Program
Agencies often fail to maintain drills, hazard assessments, or communication plans. Fix: Update your EPP annually and document all training.
7. Missing or Incorrect Client Rights Notices
Surveyors check for proper posting and client acknowledgment.
Fix: Include rights in the admission packet and post them visibly in the office.
8. Failure to Maintain a Clean, Compliant Office
Surveyors cite clutter, unlocked files, or missing signage.
Fix: Maintain a clean, professional office with locked storage and required postings.
9. Incomplete QAPI Program
Many agencies have a QAPI plan but no evidence of ongoing performance improvement.
Fix: Conduct quarterly QAPI meetings and document measurable outcomes.
10. Incorrect or Missing Form 2020 Submission Requirements
Agencies often misunderstand what must be completed before HHSC will schedule the survey.
Fix: Ensure policies, office setup, personnel files, and training are fully complete before submitting Form 2020.
© 2026 Enoma Ojo. All rights reserved
www.texascaresolutions.com
