TABLE OF CONTENTS ORGANIZATION AND ADMINISTRATION 1 PERSONNEL, VOLUNTEERS, AND CONTRACTORS 29

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2 TABLE OF CONTENTS ORGANIZATION AND ADMINISTRATION 1 Mission Statement... 2 Policy and Procedure Development and Implementation... 3 Governing Body... 6 Professional Advisory Committee Orientation for Governing Body and PAC Members Organizational Structure Organizational Chart Compliance/Whistleblower Policy Medicare/Medicaid Fraud and Abuse Conflict of Interest Public Disclosure Legal Requirements Closure/Transfer of Ownership PERSONNEL, VOLUNTEERS, AND CONTRACTORS 29 Equal Employment and Affirmative Action Criminal History, Disclosure, and Background Inquiries Personnel Selection Personnel Requirements Home Health Aide Training (Optional) Physician Licensure Verification Personnel File Content and Management Conditions of Employment Orientation to Agency Continuing Education Agency Resource Materials Performance Evaluation Supervision of Clinical Staff Supervision of Non-Clinical Staff Supervision of Home Health Aides... 62

3 Supervision of Homemakers Corrective Action Personnel Grievances and Complaints Smoke Free Workplace Drug and Alcohol Free Workplace Drug Testing Intimidation, Discrimination, and Harassment Ethical Issues Job Description: Administrator Job Description: Director of Clinical Services Job Description: Office Manager Job Description: Quality Coordinator/Compliance Officer Job Description: Clinical Supervisor Job Description: Registered Nurse Case Manager Job Description: Licensed Vocational Nurse Job Description: Physical Therapist Job Description: Physical Therapy Assistant Job Description: Occupational Therapist Job Description: Occupational Therapist Assistant Job Description: Speech Language Pathologist Job Description: Masters-Prepared Social Worker Job Description: Bachelors-Prepared Social Worker/Social Work Assistant Job Description: Dietitian Job Description: Home Health Aide Job Description: Scheduler/Patient Care Coordinator PATIENT CARE POLICIES AND PROCEDURES 134 Scope and Availability of Home Health Care Services Patient Rights and Responsibilities Advance Directives Eligibility and Covered/Non-Covered Services Certification/Re-Certification/Face-To-Face Process Informed Consent OASIS Comprehensive Assessment

4 Admission On-Call Services Skilled Nursing Services Physical Therapy Services Occupational Therapy Services Speech Therapy Services Medical Social Worker Services Home Health Aide Services Homemaker Services Dietary Counseling Services Laboratory Services Telemedicine Policy Durable Medical Equipment and Supply Services Contracted Services Coordination of Care Case Conferences Patient/Caregiver Education Communicating with Patients Pain Management Physician Plan of Care Orders Behavior Management Use of Restraints Medication Administration Medication Assistance Medication Disposal Advance Beneficiary Notices Patient Transfer Patient Discharge Patient Expiration at Home CLINICAL RECORDS/INFORMATION MANAGEMENT 233 Information Management Plan Record Retention and Disposal Notice of Privacy Practices

5 HIPAA Compliance for PHI* Release and Disclosure of Patient Health Information Patient Request for Restrictions on Use/Disclosure of PHI Patient Privacy and Security Patient Clinical Record Patient Charting PERFORMANCE IMPROVEMENT 263 Performance Improvement Program Performance Improvement Initiatives Performance Improvement Monitoring Clinical Record Review Annual Program Evaluation Research Patient Satisfaction Survey Patient/Family Complaints and Grievances Risk Management Mandatory Reporting of Abuse and Neglect Patient/Personnel Incident Reporting Adverse Drug Reactions Medication Errors Adverse Events INFECTION CONTROL 309 Tuberculosis Exposure Control Hepatitis B Prevention/Vaccination Infection Control/Exposure Plan Universal Precautions Employee Exposure to Bloodborne Pathogens Disposal of Needles, Syringes, and Sharps Hazardous Waste Disposal Reportable Diseases SAFETY 338

6 Safety Management Workplace Safety Safe Medical Devices Act/Medical Device Tracking Personnel Safety Pets in the Home Food Handling Fall Prevention Violence in the Workplace Emergency Care Emergency/Disaster Preparedness and Procedures... Error! Bookmark not defined. Staff and Patient Home Safety Home Environment/Safety Assessment OSHA 300/300A/301 Logs Employee Protective Equipment FINANCIAL POLICIES 370 Financial Management Fee Setting and Collections Liability Insurance Budget Preparation Strategic Plan Financial Monitoring Chart of Accounts Claims Submission and Denied Claims Processes Billing Audits and Annual Financial Review Accounts Receivable and Payable Transportation Reimbursement Payroll Compensation and Benefits Petty Cash Inventory/Fixed Assets RESOURCE TOOLKIT 397 Compliance Plan Education Elements Samples of Suspected Home Health Care Compliance Violations

7 Developing a Patient Bill of Rights Sample: Individual Statement Regarding Conflict of Interest Sample: Continuous Care Personnel Orientation Sample: Physician License Verification Request Form Sample: Complaint Form Sample: Employee Complaint Form Sample: Patient Medication Disposal Form Sample: Home Health Quality Grid OSHA Injury and Illness Recordkeeping and Reporting Research Informed Consent Form Research Documentation California Title 22 Definitions California License Requirements Title 22/Division 5/Chapter California Title 22 Division 5 Chapter 6 Plans of Correction Requirements