1. Percentage of clients with documentation of a referral for services from a licensed medical provider prior to initiation of services. 

Initiation of Services and Assessment: Agencies must contact the client within one business day of the agency's receipt of a referral from a licensed medical provider.

Agencies must initiate services within two business days of receipt of the referral or when specified by the referring provider.

Service initiation must include a comprehensive assessment of the client’s physical, psychosocial, and home safety status. Assessments may include, as relevant to the client’s needs and planned services:

• Past medical history
• Acute or chronic health conditions
• Current system of support to meet basic needs and activities of daily living
• Fall risk and home and environmental safety
• Cognition and level of consciousness
• Access to food and emergency assistance
• Access to primary and specialty medical care
• Ability to self-manage prescribed therapies
• Nursing assessment (for skilled nursing services), including a head-to-toe assessment
• Current regimen and response to prescribed symptom management and prevention
• Current medication list
• Emergency contact(s)

2. Percentage of clients with documentation that a comprehensive assessment was completed within two business days of receipt of the referral or at the time specified by the ordering provider.

Care Plan: Agency staff must complete a care plan based on the client’s needs that includes:

• Need for Home and Community-Based Health Services, including, as applicable: 
  • Assistance with activities of daily living (e.g., personal hygiene, dressing, eating) or basic cooking and cleaning assistance 
  • Day treatment or adult daycare services 
  • Durable medical equipment
• Types and quantity of services, and length of time the agency will provide services.

Staff must update the care plan at least every 60 days.

3. Percentage of clients with documentation of a client-centered care plan.
    
4. Percentage of clients with documentation of review and update to their care plan every 60 days at a minimum.

Provision of Services: Staff must provide services in accordance with the client’s care plan and document all services in the client’s record. Documentation must include:

• The type of service provided
• The date of service
• The location of services (e.g., the client’s home or an outside facility)
• The signature of the professional who provided services.

If staff identify a client need outside the agency's scope, the agency must refer the client to an outside provider. Agencies shall assist clients and caregivers in making informed decisions on referral services. Staff must document all referrals in the client record.

5. Percentage of client charts with documentation of services provided, in accordance with the care plan, including: (Pilot Measure 2025-2026)
   1. Type of service provided
   2. Date of service
   3. Location of service
   4. Signature of the professional providing services

Transfer and Discharge: Agencies will develop a transfer or discharge plan in coordination with the client or client’s caregiver for any of the following circumstances:

• The agency is not able to meet the level of care required by the client.
• The client transfers services to another service program.
• The client discontinues services.
• The client relocates out of the service delivery area.
• The agency determines that the client’s home or current residence is not physically safe or appropriate for the provision of Home and Community-Based Health Services.

When agencies transfer services, they must document a referral to an appropriate service provider.

6. Percentage of clients transferred or discharged from services with documentation of a transfer or discharge plan developed in coordination with the client or client’s caregiver to facilitate a safe transfer, handoff, or discharge from services.