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).
• 42 CFR Part 484 — Conditions of Participation for Home Health Agencies. Comprehensive assessment (§ 484.55) and care planning and coordination of services (§ 484.60).
• CMS OASIS-E2 Guidance Manual, effective April 1, 2026. Includes nutrition- and weight-related items 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.]
• Therapeutic-diet and malnutrition references. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update (renal nutrition); American Diabetes Association Standards of Care in Diabetes — 2026 (medical nutrition therapy); 2022 AHA/ACC/HFSA Heart Failure Guideline (sodium and fluid); the International Dysphagia Diet Standardisation Initiative (IDDSI) framework (texture-modified diets); and the Academy of Nutrition and Dietetics / ASPEN malnutrition characteristics and GLIM criteria. Disease-specific diet parameters are applied in the corresponding Disease overlays.

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.