The Compliance Doctor, LLC SM

Home Health Agency Administrative/Clinical Policy Manual-New Start Up Business

Everything you need in a manual for newly formed Home Health AGencies.

All HHAs must have the core policy manual to obtain state licensing. This manual beats the expected and producing world recognition for it's integrity and ease of reading to understanding it's intentions. This manual gets you up and running as it meets state licensing requirements as well as federal medicare certification requirements. The table of contents listed below is the current manual for the years 2011-2012 as they have already been updated to the federally changed regulations for medicare certification: (the table of contents) {This is CAHC requirements for Policies and Procedures.} 1A.-Administrative policies -Personnel policies -Clinical policies -Job descriptions 1B. Each policy shall contain the following components: -The general policy statement of intent -Documentation requirements -The procedure to follow for implementation of policy, such as : =Who is responsible =What steps or actions are to be taken =Where the required action is to take place =Time frame for required action For example, the Initial Assessment policy will include the following: A registered nurse is responsible for performing a nursing assessment in the patient's home by the second day of service. 1C.At least annually, the provider shall review the policies and job descriptions to ensure compliance with all federal, state and local laws;contractual requirements and CAHC standards. The provider shall document the date of this annual review. 1D. All newly implemented and revised policies shall be presented for review at the annual Advisory Committee meeting. The provider shall document the implementation and revision dates for each policy. 1E.The provider shall maintain a list of all CAHC-required policies and job descriptions in the policy manual. The list shall contain: -The implementation date -Any revision dates,if applicable -The annual review date Note:It is acceptable for the dates to be on each separate policy,as long as there is a list of all policies. The provider shall have written job descriptions defining each employee position. 2A. The provider shall have written job description for each position on the organizational chart .Examples include: Director of Nursing,Nursing Supervisor,Certified Homemaker-Home Health Aide and Field Nurse. 2B.Each job description shall contain the following components,at minimum: -Qualifications, including:-Relevant education requirements -Required certification/license, if applicable -Duties and responsibilities -Reporting structure. 3A.The following CAHC-required policies shall be reviewed annually: Administrative Policies -Advisory Committee policy -Corporate Compliance policy -On-Call policy -Infection control policy -Performance Improvement policy -Risk Management policy Personnel Policies -Personnel Records policy -Employment Application policy -Interview policy -References policy -Validation of Credentials policy -Health Requirements policy(Tuberculin Skin Testing TST policy, if applicable. -Agency Orientation policy -PCS: Clinical Competency policy -IHSN: Clinical Competency policy -Performance Evaluation policy -PCS: In service policy -Education Requirements for Nurses policy -PCS: Training Program policy -Rehire policy -Staffing Cases policy -Nurse Preceptor policy, if applicable Clinical Policies -Clinical Records policy -Admissions policy -Interruption of service policy -Discharge policy -Intake policy -PCS: Physician's Certification of Need for Services policy -IHSN:Physician's Orders policy -Advance Directives policy -Service Agreement policy -Patient's Bill of Rights policy ( Grievance policy ) -Initial Assessment policy ( -Pain Management, -Emergency Preparedness policy ) -IHSN: Medication policy -PCS:Plan of Care policy -IHSN: Nursing Plan of Care policy -Orientation to the Case policy -PCS: Weekly Activity Sheet policy -IHSN:Nursing Progress Notes policy -Case Monitoring policy -Clinical Supervision policy -Reassessment policy -Patient Discharge Planning policy -Identification and Reporting Requirements for Child Abuse,Elder Abuse and Domestic Violence. 4A.The provider shall have written job descriptions for each position on the organizational chart.It shall include -Director of Nursing -Nursing Supervisor -Certified Homemaker-Home health Aide -Field Nurse WIth the remaining policies in our manual to cover you on the requirements for: Patient Information Packet Patient Bill of Rights and Responsibilities Home Care Patient Rights and Responsibilities Advance Directives Advance Directive Information Form Patient Information on Advance Directives Durable Power of Attorney for Healthcare Declaration to Withdraw/Withhold Treatment Patient Informed Decision Making Consents Privacy and Confidentiality of Information Confidentiality Statement Form Uses and Disclosures for Which an Authorization is Required Consent for Uses or Disclosures to Carry Out Treatment, Payment of Healthcare Operations Consent to Blood/Blood Product Transfusion(s) Form Patient Consents and Authorizations Form Authorization/Agreement for Services Form Photographing/Videotaping Patients Authorization and Consent Form - Photograph and Publication Emergency Intervention Do Not Resuscitate (DNR)/Do Not Intubate (DNI) Do Not Resuscitate and/or Do Not Intubate Request Form Withholding and Withdrawing Life Support Patient Concerns/Grievances Patient Concerns/Grievance Process Flowchart About the Right to Express Grievances Patient Complaint Form Patients with Special Communication Needs Code of Ethics Ethics Committee Conflict Resolution Conflict of Interest Conflict of Interest Disclosure Form Financial Incentives/Clinical Decision Making Patient Abuse, Neglect or Exploitation - Adult Patient Abuse, Neglect or Exploitation - Child Suspected Adult or Child Abuse Report Form - Sample SECTION II - PROVISION OF CARE, TREATMENT AND SERVICES Acceptance/Admission of Patients Intake Service Admission Record Form Intake/Referral Form Orders for Service Form Patient Identification Accuracy Patient Assessment Functions and Qualifications Assessment Nursing Assessment/Medical History Form Pain Management Pain Management Education Patient Risk of Falls Assessment Nursing Progress Report Form Nursing Diagnosis Form Care Planning On-Call Coverage Patient Visits - Scheduling Supervision of Care and Services Care Planning and Coordination Care Plan Implementation Interdisciplinary Care Planning Home Health Certification and Plan of Treatment Form Skilled Nursing Plan of Care Form Personal Care Instructions Personal Care Instructions Form Verbal/Telephone Orders Read-Back Confirmation of Physician Telephone/Verbal Orders Confirmation of Physician Telephone/Verbal Orders Form Guidelines for Medical Management and Physician's Responsibilities Coordination of Services Multidisciplinary Patient Education Patient Education Patient/Family Education Record Form Patient and Family Education Handouts: Patient Education - Medical Equipment Patient Instruction Sheets Nutritional Assessment Nutritional Assessment Form Care of the Terminally Ill Patient Administration of Blood Components Discharge/Transfer/Referral of Patients Criteria for Discharge - Transfer/Discharge Summary Medication Transfer Communication Patient Discharge Instructions Form Discharge Summary - Final Visit Note Skilled Nursing Discharge Summary Form Discontinuance of Service Against Medical Advice Form Physician Discharge Summary Form Discharge Summary Plan/Transfer Form Monthly Medical Update Form Waived Testing Glucose Monitor Operator Proficiency Record Form Glucose Monitor Quality Control Glucose Monitor Quality Control Log Critical Test Result Reporting Infusion Pump Safety SECTION III - MEDICATION MANAGEMENT Medication Management - Patient Information Medication Profile Form "A" Medication Profile Form "B" Emergency Medications Medication Orders and Administration First Dose Home IV Antimicrobial Administration and Management of Anaphylaxis Medication Monitoring Medication Safety Adverse Drug Reaction Reporting Adverse Drug Reaction Reporting Form Medication Errors Reducing Medication Errors Use of Investigational Treatments/Trials Medication Management Program Controlled Drug Disposal Medications - Patient Self Administration SECTION IV - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION Infection Control Program Infection Control Committee Infection Report Form Standard Precautions Tuberculosis Screening Program Health Questionnaire for Positive Tuberculosis Skin Test Reactions Tuberculosis Risk Assessment Flowchart Guidelines for Prevention of Tuberculosis Transmission in the Home Tuberculosis Problem Evaluation Flowchart Tuberculosis Training Program Outlines Employee Health Employee Health Program Exposure Control Plan Sharps Injury Protection Plan - Addendum to Exposure Control Plan Sharps Injury Log Employee Exposure to Blood and Body Fluids Form Hand Hygiene Employee Health - Employee Illnesses Employee Absence Report Form Employee Health - Immunizations Employee Health - Injury On the Job Reporting AIDS/HIV Positive Guidelines Post Exposure Prophylaxis Hepatitis Informed Consent for Hepatitis B Vaccine Form Hepatitis B Vaccine Declination Form Exposure to HIV Reporting Patient Infections Nursing Bag Techniques SECTION V - IMPROVING ORGANIZATION PERFORMANCE Organizational Performance Improvement Plan Performance Measurement Sentinel Events Root Cause Analysis A Framework for a Root Cause Analysis and Action Plan in Response to a Sentinel Event Root Cause Analysis Flowchart Fiscal Planning Home Health PI Monitoring and Evaluation Plan Home Health PI Trending Sheet Home Health PI Outcome Evaluation Home Health PI Volume Measures/Statistics Home Health Documentation Form Problem Conclusion Action Plan Monitoring Medication Inadvertent Incident Report Form Performance Improvement Analysis - Medication Inadvertent Incident Form Home Health Service Questionnaire Form Home Health Medical Records Audit Form Performance Improvement Monitoring and Evaluation Plan (Blank) Performance Improvement Trending Sheet (Blank) Performance Improvement Outcome Evaluation (Blank) Performance Improvement Volume Measures/Statistics (Blank) SECTION VI - LEADERSHIP Organization and Structure Governance - Board of Directors/Management Company Governance - Sole Proprietorship Organization Chart Board of Directors Chain of Command Agency Supervision Role of Agency Leadership in Performance Improvement Policy and Procedure Approval Annual Agency Evaluation Compliance with Federal, State and Local Laws Annual Operating Budget Communication of Information Mission Statement Philosophy Contracted Services Non-Discrimination Policy Professional Advisory Committee Physician Licensure Verification Patient Safety Plan Components of a Patient Safety Program - Patient Safety Program Checklist Patient Safety Program Plan - Appendix A - 2004 Home Care National Patient Safety Goals Patient Safety Program Plan - Appendix B - 2005 Home Care National Patient Safety Goals SECTION VII - ENVIRONMENT SAFETY AND EQUIPMENT MANAGEMENT Statement of Policy Letter of Appointment - Safety Director Duties of Safety Director Duties of Department Manager in Safety Program Safety - Hazard Surveillance Program Home Hazard Analysis Checklist Initial Home Safety Evaluation and Instruction Form Safety Precautions When Using Oxygen Safety When Moving Objects Safety Education Safety and Security Training for Home Health Personnel Employee Safety Information Form Security Plan Security Education Hazardous Materials and Waste Plan Infectious Waste Management Plan Antineoplastic Waste Management Chemotherapy Liquid Spills Emergency Management Plan Hazard Vulnerability Analysis Emergency Management - Hazard Vulnerability Analysis Worksheet Bomb Incident Plan Detecting Suspicious Packages/Letters Bomb Threat Report Form Natural Disaster Management Plan Terrorism Response Plan Emergency Management Plan - Drills Durable Medical Equipment Equipment Delivery and Set-Up Medical Equipment Used by Staff Medical Device Problem and Recall Incident Reports Incident Report Form Fire Safety Plan Fire Drill Report Form Safe Medical Devices Utility Systems Management Plan SECTION VIII - MANAGEMENT OF HUMAN RESOURCES Staff Selection Criminal Background Checks Criminal Background Check Release of Information Authorization Form Staff Recruitment, Retention and Education Applications for Employment Equal Opportunity Employment Current Licensure/Certification and Registration Attendance and Tardiness Change in Personal Information Classification of Employees Performance Evaluations Position Description/Performance Evaluation - Home Health Administrator Annual Competency Clinical Skills Assessment - Home Health Administrator Position Description/Performance Evaluation - Home Health Director of Patient Care Services Performance Evaluation - Age-Related Competency - Home Health Director of Patient Care Services Annual Competency Clinical Skills Assessment - Home Health Director of Patient Care Services Position Description/Performance Evaluation - Home Health Intake Nurse Performance Evaluation - Age-Related Competency - Home Health Intake Nurse Annual Competency Clinical Skills Assessment - Home Health Intake Nurse Position Description/Performance Evaluation - Home Health Clinical Supervisor Performance Evaluation - Age-Related Competency - Home Health Clinical Supervisor Annual Competency Clinical Skills Assessment - Home Health Clinical Supervisor Position Description/Performance Evaluation - Home Health Case Manager Performance Evaluation - Age-Related Competency - Home Health Case Manager Annual Competency Clinical Skills Assessment - Home Health Case Manager Position Description/Performance Evaluation - Home Health LPN/LVN Performance Evaluation - Age-Related Competency - Home Health LPN/LVN Annual Competency Clinical Skills Assessment - Home Health LPN/LVN Licensed Practical/Vocational Nurse Supervision LPN/LVN Supervisory Visit Note Position Description/Performance Evaluation - Home Health Physical Therapist Performance Evaluation - Age-Related Competency - Home Health Physical Therapist Annual Competency Clinical Skills Assessment - Home Health Physical Therapist Position Description/Performance Evaluation - Home Health Occupational Therapist Performance Evaluation - Age-Related Competency - Home Health Occupational Therapist Annual Competency Clinical Skills Assessment - Home Health Occupational Therapist Position Description/Performance Evaluation - Home Health Speech Therapist Performance Evaluation - Age-Related Competency - Home Health Speech Therapist Annual Competency Clinical Skills Assessment - Home Health Speech Therapist Position Description/Performance Evaluation - Home Health Medical Social Worker Performance Evaluation - Age-Related Competency - Home Health Medical Social Worker Annual Competency Clinical Skills Assessment - Home Health Medical Social Worker Position Description/Performance Evaluation - Home Health Aide Performance Evaluation - Age-Related Competency - Home Health Aide Annual Competency Clinical Skills Assessment - Home Health Aide Employment of Certified Home Health Aides/Nursing Assistants Certified Home Health Aide Supervision Supervision Checklist Form Certified Home Health Aide Competency Evaluation Program Certified Home Health Aide Skills Checklist Certified Home Health Aide Skills Checklist Form Orientation Program Orientation - Certified Home Health Aide Services Employee Education Programs Monitoring of CHHA and CNA Inservice Hours Continuing Education/Inservice Attendance Record Form Ethical Dilemmas in Patient Care - Staff Rights Disciplinary Action Dress Regulations Employee Assistance Program Employee Communications Employee Photo Identification Employee Requests for Time Off Employment of Foreign Applicants Employment of the Disabled Employment of Relatives Exit Interviews Exit Interview Form Garnishment of Wages Holiday Policy Payroll Distribution/Time Verification Personnel Files - Position Control Personnel Requisition Form Re-Employment Reference Checking Sick Leave Policy Termination of Employment Vacation Policy Workers' Compensation SECTION IX - MANAGEMENT OF INFORMATION Information Management Plan Patient Access to Medical Records Confidentiality of the Medical Record Approved Symbols and Abbreviations Approved Symbols and Abbreviations List Unacceptable Abbreviations and Symbols Unacceptable Abbreviation and Symbol List Payment for this manual can be made with Check or Credit Card, Please Contact the office @ 323-603-8333 and we can take your credit card information over the phone or you can mail to us the payment with the mailing address: The Compliance Doctor @ 2643 South Halm Ave. Los Angeles, CA 90034

Price: 495.00