Home Health Certification Face-to-Face Narrative

Patient Name: [Patient legal name]

DOB: [Date of birth]

MRN: [Medical record number]

Certifying Practitioner: [Name, credentials]

Home Health Agency: [Agency name]

Certification Type: [Initial Certification / Recertification]

Start of Care Date: [Start of Care date / pending from HHA]

Certification Period: [Start date – End date]

Face-to-Face Encounter

(Include for Initial Certification only. Omit entire section for Recertification.)

Encounter Date: [Face-to-face encounter date]

Setting and Modality: [In-person / Telehealth] at [Location]

Encountering Clinician: [Name, credentials] (If different from certifying practitioner, state relationship.)

Relation to Home Health Need: [Statement that encounter addressed the primary reason home health services are needed]

Source Document: [Reference to encounter documentation, e.g., office visit note dated..., hospital discharge summary dated...]

(If encounter note is not yet available, document that it has been requested and do not finalize certification attestation until verified.)

Clinical Findings Supporting Home Health Need

[Brief narrative of the primary condition or precipitating event driving home health referral, recent clinical trajectory, and why home health is needed now] (Include only findings that support homebound status and skilled need.)

• Objective findings: [Pertinent vitals, exam findings, wound characteristics, mobility assessment] (Include only if available and relevant.)
• Functional limitations: [Transfers, gait, endurance, ADL deficits, need for cues or supervision]
• Risk factors: [Medication complexity, rehospitalization risk, fall history, cognitive concerns, home safety issues]

(If objective data are limited, state source of information: patient report, caregiver, discharge summary, or pending HHA assessment.)

Qualifying Diagnoses

(List in order of relevance to home health need. Include only diagnoses that contribute to homebound status, skilled need, or care complexity. Codes optional.)

1. [Primary diagnosis driving home health referral]
2. [Secondary diagnosis relevant to homebound status or skilled need]
3. [Additional relevant diagnosis] (Include only if applicable.)

Homebound Status

(Document both Medicare criteria with patient-specific functional details. Do not use templated phrases without individualized supporting information.)

Criterion 1: [Patient needs assistive device and/or assistance from another person to leave home / Leaving home is medically contraindicated]. [Patient-specific details: device(s) used, type and amount of assistance required, or nature of medical contraindication]

Criterion 2: [Patient has normal inability to leave home and leaving requires considerable and taxing effort]. [Patient-specific details: distance and exertion limits, dyspnea, fatigue, pain, instability, fall history, cognitive or safety concerns]

Permitted absences: [Medical appointments, dialysis, religious services, or short infrequent non-medical events as tolerated]

Need for Skilled Services

(Include only disciplines actually ordered. Omit non-applicable discipline sections. Link skilled tasks to patient-specific clinical problems.)

Skilled Nursing

• Skilled tasks: [e.g., wound assessment and dressing changes, complex medication management, disease monitoring requiring nursing judgment, injections/infusions, caregiver training]
• Clinical problem requiring skill: [Patient-specific rationale for why nursing skill level is required]

Physical Therapy

• Baseline impairments and safety risks: [Strength, balance, gait deviations, transfer deficits, fall risk]
• Skilled interventions: [Gait training, transfer training, therapeutic exercise, balance training, home safety]
• Functional goals: [Mobility restoration, fall risk reduction, safe ambulation]

(If evaluation pending, document clinical rationale for expected skilled PT need.)

Occupational Therapy

• Baseline impairments and safety risks: [ADL deficits, upper extremity function, cognition, energy conservation needs]
• Skilled interventions: [ADL retraining, adaptive equipment training, cognitive strategies, safety training]
• Functional goals: [Independence and safety in ADLs, energy conservation]

(If evaluation pending, document clinical rationale for expected skilled OT need.)

Speech-Language Pathology

• Baseline impairments and risks: [Dysphagia, aphasia, dysarthria, cognitive-communication deficits, aspiration risk]
• Skilled interventions: [Swallow assessment and therapy, communication strategies, diet modification, caregiver training]
• Goals: [Safe oral intake, communication effectiveness]

(If evaluation pending, document clinical rationale for expected skilled SLP need.)

Medical Social Work

• Identified needs: [Caregiver strain, resource coordination, advance care planning, psychosocial barriers]
• Skilled interventions: [Assessment, counseling, linkage to community resources, safety planning]

Coordination and Plan

Plan of care status: [Established / To be established with HHA]

Disciplines authorized: [SN / PT / OT / SLP / MSW]

High-level goals: [e.g., wound healing, fall risk reduction, medication safety, mobility restoration, rehospitalization prevention]

Communication plan: [HHA contact expectations and escalation pathway]

Follow-up: [Clinic visits, telehealth, specialty referrals, labs as relevant]

Certification Attestation

(Complete attestation only when all eligibility elements are verified.)

Initial Certification

(Include for Initial Certification only.)

• The patient is homebound.
• The patient requires qualifying skilled services: [Specify skilled disciplines].
• Services are furnished under a plan of care established and periodically reviewed by the certifying practitioner.
• The patient is under the care of the certifying practitioner.
• A face-to-face encounter occurred within the required timeframe and was related to the primary reason for home health services.

Recertification

(Include for Recertification only.)

• The patient continues to be homebound.
• The patient continues to require skilled services: [Specify ongoing skilled disciplines and needs].
• The plan of care has been reviewed and will continue to be periodically reviewed by the certifying practitioner.
• The patient remains under the care of the certifying practitioner.

(If any eligibility element cannot be verified, do not complete attestation. Document pending information and source below.)

Pending information: [Element pending, source requested, date requested, follow-up plan] (Include only if applicable.)

Skilled management and evaluation justification: [Clinical justification for why skilled nursing oversight is required to manage and evaluate an otherwise unskilled care plan] (Include only if SN is ordered solely for management and evaluation. Place immediately before signature.)

Practitioner Signature: ________________________________

Printed Name and Credentials: [Name, credentials]

Date/Time: [Date and time of signature]