Under 42 CFR 484.80(c), a Medicare-certified home health agency may not let an aide furnish home health services until the aide has passed a competency evaluation covering all 14 subject areas in 42 CFR 484.80(b)(3), performed by a registered nurse in consultation with other skilled professionals as appropriate. The RN must observe 5 of those areas with a patient or pseudo-patient: communication; reading and recording temperature, pulse and respiration; personal hygiene and grooming; safe transfers and ambulation; and range of motion and positioning.
The other 9 may be tested in writing, orally, or by observation. An "unsatisfactory" rating in more than 1 area is a fail, and the agency must document all of it. That is the federal floor; your state may require more.
What does 42 CFR 484.80 say about competency evaluation?
42 CFR 484.80(c) requires every home health aide to pass a competency evaluation on all 14 subject areas in 42 CFR 484.80(b)(3) before furnishing home health services for a Medicare-certified home health agency. A registered nurse performs the evaluation, and the agency must keep documentation that shows it.
Not every aide on your roster needs all 14 areas from you: 2 groups meet 42 CFR 484.80 differently. A nurse aide who completed a state-approved nurse aide training and competency evaluation program, and is currently listed in good standing on the state nurse aide registry, qualifies under 42 CFR 484.80(a)(1)(iii). An aide who furnishes only Medicaid personal care services must meet the state's qualification standards and shows competency only in those services, under 42 CFR 484.80(i).
A home care agency that is not Medicare certified is outside 42 CFR 484.80, a condition of participation for Medicare home health agencies. For its aides, check your state's rules.
CMS's surveyor guidance says a stricter state requirement on aide competency evaluations "takes precedence over the federal requirement".
What must the RN observe, and on whom?
Which skills must the RN watch the aide perform?
The RN must observe 5 areas with a patient or pseudo-patient: 42 CFR 484.80(b)(3)(i), (iii), (ix), (x) and (xi).
| Paragraph | Area or task, in the rule's words | How it must be evaluated | Source |
|---|---|---|---|
| (b)(3)(i) | Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(i), (c)(1) |
| (b)(3)(ii) | Observation, reporting, and documentation of patient status and the care or service furnished | Written, oral, or observed | 42 CFR 484.80(b)(3)(ii), (c)(1) |
| (b)(3)(iii) | Reading and recording temperature, pulse, and respiration | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(iii), (c)(1) |
| (b)(3)(iv) | Basic infection prevention and control procedures | Written, oral, or observed | 42 CFR 484.80(b)(3)(iv), (c)(1) |
| (b)(3)(v) | Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor | Written, oral, or observed | 42 CFR 484.80(b)(3)(v), (c)(1) |
| (b)(3)(vi) | Maintenance of a clean, safe, and healthy environment | Written, oral, or observed | 42 CFR 484.80(b)(3)(vi), (c)(1) |
| (b)(3)(vii) | Recognizing emergencies and the knowledge of instituting emergency procedures and their application | Written, oral, or observed | 42 CFR 484.80(b)(3)(vii), (c)(1) |
| (b)(3)(viii) | The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property | Written, oral, or observed | 42 CFR 484.80(b)(3)(viii), (c)(1) |
| (b)(3)(ix) | Appropriate and safe techniques in performing personal hygiene and grooming tasks that include: | Observed with a patient or pseudo-patient, task by task | 42 CFR 484.80(b)(3)(ix), (c)(1) |
| (b)(3)(ix)(A) | Bed bath | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(ix)(A) |
| (b)(3)(ix)(B) | Sponge, tub, and shower bath | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(ix)(B) |
| (b)(3)(ix)(C) | Hair shampooing in sink, tub, and bed | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(ix)(C) |
| (b)(3)(ix)(D) | Nail and skin care | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(ix)(D) |
| (b)(3)(ix)(E) | Oral hygiene | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(ix)(E) |
| (b)(3)(ix)(F) | Toileting and elimination | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(ix)(F) |
| (b)(3)(x) | Safe transfer techniques and ambulation | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(x), (c)(1) |
| (b)(3)(xi) | Normal range of motion and positioning | Observed with a patient or pseudo-patient | 42 CFR 484.80(b)(3)(xi), (c)(1) |
| (b)(3)(xii) | Adequate nutrition and fluid intake | Written, oral, or observed | 42 CFR 484.80(b)(3)(xii), (c)(1) |
| (b)(3)(xiii) | Recognizing and reporting changes in skin condition | Written, oral, or observed | 42 CFR 484.80(b)(3)(xiii), (c)(1) |
| (b)(3)(xiv) | Any other task that the HHA may choose to have an aide perform as permitted under state law | Written, oral, or observed | 42 CFR 484.80(b)(3)(xiv), (c)(1) |
Notice what 42 CFR 484.80(b)(3)(iii) leaves out: blood pressure. If your aides take it, add it under (b)(3)(xiv) and document how it was taught and tested.
42 CFR 484.80(b)(3) also has a paragraph (xv), but it is a duty rather than a 15th subject area: the agency is responsible for training aides, as needed, in skills not covered in the basic checklist.
The checklist below has these rows, plus 3 blank ones for tasks your agency adds, an S or U column, a 42 CFR 484.80(c)(4) result box and a remediation log.
Download the competency evaluation checklist (Excel, free, no email required)
What counts as a pseudo-patient?
If you have read that a pseudo-patient is not allowed, you read old guidance.
42 CFR 484.2 defines a pseudo-patient as "a person trained to participate in a role-play situation, or a computer-based mannequin device" that can respond to and interact with the aide. The pseudo-patient must show the general characteristics of your agency's primary patient population in key areas such as age, frailty, functional status and cognitive status. A mannequin that cannot respond or interact does not meet the 42 CFR 484.2 definition.
CMS's surveyor guidance adds that the simulated environment "must mimic the reality of the homecare environment, including environmental distractions and constraints," and that the RN observes each task "in its entirety". Aides who passed a competency evaluation before 13 January 2018 need not repeat the patient-observed portions.
Before the rule published 30 September 2019, the observed areas needed a patient, and a CMS FAQ of 23 January 2019 said a pseudo-patient was not permitted. That FAQ expired on 15 March 2024.
Who may run the evaluation, and can your agency do it?
Under 42 CFR 484.80(c)(3), a registered nurse performs the evaluation, in consultation with other skilled professionals as appropriate. Under 42 CFR 484.80(c)(2) and (f), any organization may offer a competency evaluation program, except a home health agency that in the previous 2 years did any of the following:
- was out of compliance with 42 CFR 484.80(b), (c), (d) or (e);
- let someone who is not a qualified home health aide furnish aide services, licensed health professionals and volunteers aside;
- had an extended or partially extended survey after being found to have furnished substandard care, or for other reasons as determined by CMS or the state;
- was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction;
- met any other condition in 42 CFR 484.80(f), such as suspended Medicare payments or temporary management.
If a partially extended or extended survey finds a condition-level deficiency, your agency may finish a program in progress but may not accept new candidates or begin a new program for 2 years from CMS's written notice. Correcting the deficiency does not lift the bar.
The agency may still use a contractor. CMS says the contractor may be permitted to run the program on the agency's premises, as long as the agency has no influence or role in how it is run.
An evaluation the aide passed elsewhere counts once the agency has documentation of it from the aide or the training facility.
What happens when an aide passes or fails?
What is a pass, and what is a fail?
Under 42 CFR 484.80(c)(4), an aide with 1 area rated unsatisfactory still passes; an unsatisfactory rating in more than 1 of the required areas is a fail.
A home health aide is not considered competent in any task for which he or she is evaluated as unsatisfactory. An aide must not perform that task without direct supervision by a registered nurse until after he or she has received training in the task for which he or she was evaluated as "unsatisfactory," and has successfully completed a subsequent evaluation. A home health aide is not considered to have successfully passed a competency evaluation if the aide has an "unsatisfactory" rating in more than one of the required areas.
42 CFR 484.80(c)(4)
| Result | What it means for the aide | Source |
|---|---|---|
| No area rated U | Passed | 42 CFR 484.80(c)(4) |
| U in 1 area | Passed, but the aide must not perform the task rated U without direct supervision by a registered nurse until trained in it and re-evaluated successfully | 42 CFR 484.80(c)(4) |
| U in 2 or more areas | Not passed; the aide may not furnish home health services for the agency | 42 CFR 484.80(c), (c)(4) |
Does a U on 1 of the 6 hygiene tasks under (b)(3)(ix) make the whole (ix) area unsatisfactory? 42 CFR 484.80(c)(4) does not say. Settle it in your written policy before the first evaluation.
What happens when an aide fails?
Under 42 CFR 484.80(c) and (c)(4), an aide rated unsatisfactory in more than 1 area has not passed and may not furnish home health services for the agency.
Before the aide performs a task rated U without direct RN supervision, 42 CFR 484.80(c)(4) requires training in that task and a subsequent evaluation the aide passes. 42 CFR 484.80(c)(5) requires the agency to document both. This page's reading of 42 CFR 484.80(c)(1) is that re-evaluating an observed area means an RN watching the aide again, with a patient or pseudo-patient.
42 CFR 484.80(c)(4) does not say:
- how many attempts an aide gets;
- how long an aide waits between attempts;
- how many hours of retraining, or in what format;
- who delivers the retraining;
- whether an aide who failed 2 or more areas repeats the whole evaluation or only the failed areas.
Your written policy answers those 5, and your state may have its own rule.
What if a later visit finds a problem?
Under 42 CFR 484.80(h)(3), if the registered nurse or other appropriate skilled professional verifies a deficiency in aide services during an on-site visit, the agency must conduct, and the aide must complete, retraining and a competency evaluation "for the deficient and all related skills".
42 CFR 484.80(h)(3) does not define which skills are "related". Your written policy should say how the RN decides.
Supervision is a separate standard. For a patient receiving skilled services, an RN or other appropriate skilled professional completes a supervisory assessment at least every 14 days, no more than 1 of them virtual per patient in a 60-day episode. The RN or other appropriate skilled professional also visits on-site when a concern is noted and observes each aide on-site once a year.
For a patient receiving only non-skilled care, the RN visits in person every 60 days and observes each aide on-site semi-annually.
The in-service hours that run alongside supervision are in the home health aide in-service guide.
Does an aide need a new competency evaluation every year?
Not under 42 CFR 484.80, which contains no annual competency re-evaluation. The yearly items in 42 CFR 484.80 are at least 12 hours of in-service training in each 12-month period and an annual on-site observation of each aide, semi-annual for non-skilled care.
A gap in work does trigger a new program: an aide with 24 consecutive months without paid aide work must complete a new program before working again, whatever the reason for the gap.
ACHC's home care standard HC4-6A, the annual rule you may have heard of, calls for competency assessment initially, before a new task, and at least annually. That is a home care standard, not a home health one.
Your accreditor's home health standard or your state may require an annual evaluation. This page has not read those, so check yours.
What must the competency file show a surveyor?
Surveyors review competency documentation for aides whose care they observe on a home visit or who are in the patient sample. On an extended survey, they can request aide training records and competency evaluations.
Your file has to show the evaluation met 42 CFR 484.80(c), and CMS's surveyor guidance, G772, says competency documentation must do 4 things:
- Describe the competency evaluation program, including the qualifications of the instructors.
- Verify that competency was determined by direct observation, with the results of those observations.
- Distinguish between skills evaluated during patient care and those taught in a laboratory, such as a skill lab demonstration.
- Describe how any skills beyond the basic list in 42 CFR 484.80(b)(3) were taught and tested.
An aide who cannot produce this documentation must successfully complete a competency evaluation before providing care to patients.
How do you run the evaluation with your own RN?
You can run a compliant competency evaluation with your agency's own RN, the free checklist above and a room set up like a patient's home. The 5 observed areas are direct observation by a registered nurse, watching the aide perform each task with a patient or pseudo-patient. No online course, video or written test replaces that.
The free tools are the checklist above, the text of 42 CFR 484.80 and 42 CFR 484.2 on eCFR, and Appendix B of CMS's State Operations Manual, including G772 on documentation.
- Check that your agency may run the program. Read the 2-year bar in 42 CFR 484.80(f) against your last 2 years of surveys and sanctions. If it applies, a contractor may be permitted to run the program on your premises, as long as your agency has no influence or role in how it is run.
- Check who needs the evaluation. For an aide on the state nurse aide registry, check the listing and keep the evidence; for an evaluation passed elsewhere, get the documentation.
- Write the policy for what the rule leaves open: the 5 retraining questions above, whether a U on 1 hygiene task fails all of (b)(3)(ix), and how the RN decides which skills are "related" under (h)(3). Check your state's rules first.
- Record the program description and the qualifications of the instructors, and of the RN evaluator. Add any task beyond the basic list, such as blood pressure, under (b)(3)(xiv), with how it is taught and tested.
- Prepare the written or oral test for the 9 areas that allow one: (b)(3)(ii), (iv), (v), (vi), (vii), (viii), (xii), (xiii) and (xiv). Write questions from the rule's wording for each area and take the answers from your agency's procedures, such as which changes an aide reports and to whom.
- Set up the 5 observed areas with a patient, or a pseudo-patient that meets 42 CFR 484.2 and matches your patients, in a room that mimics a home, distractions and constraints included. A role-player who moves and answers like a healthy adult does not match a caseload of frail patients.
- Have the RN observe each task in full and mark S or U, each of the 6 hygiene tasks separately. Mark which tasks were seen during patient care and which in a lab or simulation.
- Give a result per area using the 42 CFR 484.80(c)(4) table above. Take an aide with 13 areas S and a U in transfers: passed, but no transfers without direct RN supervision until retrained and re-evaluated successfully.
- Remediate and document. Train the aide in each task rated U and re-evaluate; for an observed area, that means an RN watching again, on this page's reading of (c)(1). 42 CFR 484.80(c)(5) requires documentation of both. When a supervisory visit later verifies a deficiency, (h)(3) requires retraining and a competency evaluation "for the deficient and all related skills".
- File it so it answers the 4 G772 points above, with the signed scoring sheet and the remediation log.
| Task | Who does it | Rough time |
|---|---|---|
| Written policy (step 3) | Director of nursing | 2 to 3 hours, once |
| Program description and added tasks (step 4) | Director of nursing | 1 to 2 hours, once |
| Written or oral test for the 9 areas (step 5) | RN or director of nursing | 3 to 5 hours, once |
| Pseudo-patient briefing and room setup (step 6) | RN | 1 to 2 hours, once |
| Written or oral test, per aide | RN | 30 to 60 minutes |
| Observation of the 5 areas, per aide (step 7) | RN | 1.5 to 2.5 hours |
| Result, remediation log and filing, per aide | RN and office staff | 20 to 30 minutes |
These are working estimates, not CMS figures; your patient population, added tasks and remediation change them. The other rules a home health agency trains against are in the home care training requirements map.
What goes wrong most often in competency checks?
- Letting an online course or a written test stand in for the observed areas. 42 CFR 484.80(c)(1) requires observation with a patient or pseudo-patient, and 42 CFR 484.80(c)(3) makes a registered nurse the evaluator. A course certificate does not show that observation.
- A file that does not say how competency was determined. An aide who cannot produce the G772 documentation must successfully complete a competency evaluation before providing care.
- Letting an aide with a U do that task alone. Under 42 CFR 484.80(c)(4), the aide must not perform it without direct RN supervision until retrained and re-evaluated. Tell the scheduler, not only the aide.
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Other questions about aide competency evaluations
Can the competency evaluation be done online?
Not the 5 observed areas. 42 CFR 484.80(c)(1) requires those areas to be evaluated by observing the aide perform each task with a patient or pseudo-patient, and 42 CFR 484.80(c)(3) requires a registered nurse to do it. The other 9 may be a written or oral examination; 42 CFR 484.80 does not address online delivery.
Can an LPN perform the competency evaluation?
No. 42 CFR 484.80(c)(3) says a registered nurse performs it, in consultation with other skilled professionals as appropriate.
Does a CNA on the state registry need your agency's evaluation?
Not under the federal rule, if the aide completed a state-approved nurse aide training and competency evaluation program and is currently listed in good standing on the state nurse aide registry. The agency is responsible for making sure every aide meets 42 CFR 484.80, so check the listing and keep the evidence in the file. Your state may require more.
Does blood pressure have to be tested?
Not under 42 CFR 484.80(b)(3)(iii), which lists temperature, pulse and respiration only. Your state may require more. An agency whose aides take blood pressure adds it under (b)(3)(xiv) and documents how it was taught and tested.