19. Sources and clinical references

MASTER-level citations, current as of the version date. Companies and agencies may append payer-specific requirements (MAC LCDs, ADR criteria, local notification parameters) as overlays without altering the MASTER version.

• CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 7 — Home Health Services. Skilled nursing care (§ 40.1), observation and assessment (§ 40.1.2.1), teaching and training (§ 40.1.2.3), management and evaluation of the plan of care (§ 40.1.2.2), homebound (§ 30.1), and reasonable and necessary services (§ 20.1.2). Management and evaluation of the plan of care is frequently the operative category for psychosocial coordination.
• 42 CFR Part 484 — Conditions of Participation for Home Health Agencies. The comprehensive assessment, which includes psychosocial status (§ 484.55), and care planning and coordination of services (§ 484.60).
• CMS OASIS-E2 Guidance Manual, effective April 1, 2026. The social-determinants-of-health items (for example transportation, social isolation, and health literacy) used in the comprehensive assessment and quality reporting.
• Community Health Accreditation Partner (CHAP) Standards of Excellence for Home Health. [Insert the exact standard title, version, section, and effective date per the edition held by the agency.]
• Psychosocial and social-determinant references. Caregiver-strain and burden assessment and social-determinants-of-health screening aligned with the OASIS-E2 items. The mandated reporting of suspected abuse, neglect, or exploitation is handled in the Safety reference, and mood and risk screening in the Psychiatric / Mental Health reference.

Usage note: Every narrative and smart phrase in this module is a structured example to be edited to reflect what was actually assessed and the patient's specific orders. Documentation must reflect the real visit; do not copy unchanged.