Table of Contents. Page ADMINISTRATIVE JOINT COMMISSION. Washington

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1 Table of Contents Page ADMINISTRATIVE Definition of Organization LD (b) Mission Statement, Goals, and LD Philosophy Services Offered LD LD LD LD (1)(g) 055(1)(a)(iv) 060(2) Service Area Payment for Services Fee Schedule Target Population LD Service Limitations Hours of Operation Administrative Control IC LD LD LD LD LD LD LD LD (1)(a)(v) (1)(e) 055(1)(a)(i)(vi) 055(3)(a-n) Ethics Committee LD Corporate Compliance Plan Branch Offices Professional Advisory Committee LD LD LD LD LD (2)

2 Page ADMINISTRATIVE Cont Annual Evaluation APR (2) IC IM LD LD LD LD LD LD LD MM PI Admission Criteria LD PC PC (1)(a)(vi)(A)(I) 060(1) Discharge/Transfer from Service LD NPSG PC PC (1)(a)(vi)(A)(II)( b) 060(1) 110(1)(f) PC PC Contingency Plan 055(1)(c) Agency Closure Procedures 040(c)(ii)(iii) 055(1)(c) Backup Coverage of Services 055(A)(II) Business Associate Contract Anti Fraud Program LD Professional Standards & Principles LD PC Financial Records LD Financial Planning LD (1)(d) Capital Expenditures LD Services Provided under Contract LD (1)(a)(iii) 055(1)(a)(vi)(A)(III) 065(12) Research Activities/Investigational Studies MM RI

3 Page ADMINISTRATIVE Cont Public Disclosure APR APR LD LD Disclosure to Licensing Authority APR APR APR APR APR Change of Ownership/Administrative Control Plan of Correction Information Management IM IM (b) (1)(c) (j) (c)(i)(vi)(d)(e) APR (c)(iv)(v) 060(1) Page HUMAN RESOURCES Reasonable Accommodations Personnel Records HR (1)(5)(6)(7)(8)(9 ) Employment References HR (3) 070(2) Time Records OIG Excluded List Selection of Personnel HR HR HR (4)(5) LD Classification of Personnel HR HR HR LD (1)(a)(ii) 065(2) Volunteers 055(1)(a)(iii) Ethics LD LD LD RI Employee Dress Code Employee Health Assessments HR IC Payday Benefits & Wages

4 Page HUMAN RESOURCES Cont Confidentiality RI Orientation & Staff Development EC EC (6)(7) 070(3) HR HR LD PC PC Policy & Procedure Agreement Competency Evaluation HR (10) 070(4) Cell Phone and Texting Performance Evaluation HR LD Employee Discipline LD Termination/Separation of Employment Employee Grievances LD Smoking Professional Peer Review Professional Reporting PC (1)(a)(vi)(A)(IV) 065(10) 070(9) Drug Testing Conflict of Interest APR LD LD Knowledge/Resource Center IC IM PC (7)

5 Page RIGHTS RESPONSIBILITIES ETHICS Client Conduct Responsibility & Rights APR IM LD RI RI RI RI RI RI RI RI Non Discrimination LD (1) Program Accessibility Solicitation/Distribution for Referrals Ethical Complaints Patients Complaints & Grievances APR (1) RI Reporting Abuse Neglect or PC (10) Exploitation RI Criminal History Checks HR (1)(i) 065(12) 070(5) Nurse Aide Registry National Sex Offender Registry Out-of-Hospital Do Not Resuscitate Order RI Advanced Directives RI (13) Declaration for Mental Health Treatment Coordination of Client Care LD LD PC PC (4) Facilitating Communication RI (5) After Hours Care PC

6 Page PATIENT INFORMATION Security of Clinical Information EC IM IM RC RI Data Backups Retention of Clinical Records IM IM RC RC Timeliness of Entries in Clinical IM Record IM RC RC RC Client Records IM IM RC RC Patient Identification NPSG Physician Orders/Plan of Care PC RC (1)(c) 110(1)(b)(v) 110(1)(e) 055(1)(c) 110(2)(3) 055(1)(d) 080(1)(C)(ii) 110(1)(b)(ii)(iv) 055(1)(c) 110(1)(a)(b)(i)(v)(vi )(vii)(viii)(c)(i-x) 080(1)(C)(iii)(iv)(v)( vi) Physician Signatures RC Physician Delegation Physician Verification RN Delegation 060(15) Clinical Record Review/Quarterly IM Review RC Abbreviations IM Prohibition on Transporting Patient Medication Profile MM MM MM MM NPSG (3)

7 Page PATIENT INFORMATION Cont Medication Administration Record MM MM (3) 060(8) MM MM MM MM Medication Storage MM MM (3) 060(8) Emergency Medication MM (3) Medication/Prescriptions Orders MM (3) MM PC Confused Medications MM (3) MM Administration of Blood PC (3) Adverse Drug Reactions MM (3) Vaccine Storage and 060(3) Transportation Medication Reminding MM Page NON-CLINICAL Billing Referrals 060(1) Verification of Primary Payer Staffing Issues Faxing IM Protected Health Information Password/Usernames IM IM Red Flag Rules Page CLINICAL In Service Education HR LD Patient Education PC Wound Care Management Pain Management PC (7) 070(6)

8 Page CLINICAL Cont Reporting Emergencies in the Home Cardiopulmonary Resuscitation (CPR) EC EC PC Sharp Debridement of non viable tissue Clinical Procedures Care Planning PC PC PC PC PC PC RN Pronouncement Assessment of Patients PC PC PC PC PC Nurse Supervision HR LD Registered Nurse PC PC Licensed Practical Nurse PC PC Certified Nursing Aide HR HR Therapy Services HR PC Therapy Evaluation Medical Social Worker HR PC Medical Social Worker Evaluation Dietician HR PC (11) 060(11) 065(8) 070(7) 055(1)(a)(vi)(A)(I) 080(1)(a)(b)(c)(ixiii)(d)(i) 055(1)(a)(vi)(A)(I) 055(1)(a)(vi) 065(10) 095(1)(2)(3)(4)(5) 095(6)

9 Page SAFETY/INFECTION CONTROL Infection/Exposure Control Plan IC IC IC IC IC CLIA Waiver IC LD LD WT , WT , WT , WT , WT Universal Body Substance IC Precautions Management of IC Infections/Exposures in Personnel IC IC Personal Protective Equipment IC IC Hand washing IC NPSG (6) 060(7) 065(9) 060(6) 060(6) 060(7) 060(6) 060(7) 060(6) Aseptic Technique PC (6) Sterile Technique 060(6) Respiratory & Tuberculosis 060(6) Precautions Tuberculosis Exposure Control 060(6) Plan LD Contaminated Reusable Materials IC (6) Disposition Contaminated Waste Disposal IC IC (6) Therapy Bag Techniques IC IC (6)

10 Page SAFETY/INFECTION CONTROL Cont Multidrug-Resistant Organisms Communication of Hazards to Personnel IC LD (6) Hepatitis B Vaccination 060(6) Influenza Vaccination IC Influenza Vaccination Compliance IC Information & Training IC Evaluating & Maintaining Records of infections Reporting of Communicable Diseases IC IC IC (6) 060(6) 060(6) 060(7) Record Keeping 060(6) Medical Equipment Malfunction EQ (6) Hazardous Waste Handling & EC (6) Labeling OSHA Bloodborne Pathogen 060(6) Training Incident/Accident Reporting EC EC EC EC LD Sentinel Events LD Agency Personnel Safety Personal Safety Agency Personnel Safety/ Unsafe Home Visits APR Accidental Exposure EC Accidental Prevention EC EC LD NPSG NPSG Fall Prevention EC NPSG

11 Page SAFETY/INFECTION CONTROL Cont Car Accident Reporting Disaster/Emergency Preparedness EM EM EM EM EM EM EM IM Material Safety Data Sheet EC Fire Safety Utilities/Equipment Management 060(14) Page QUALITY MANAGEMENT Quality Assessment/Performance EC Plan EC IC LD LD LD LD LD MM PI PI (1)(a)(vi)(A)(V) 115(2) PI Patient Satisfaction Survey PI (3) Non Patient Satisfaction Survey PI Page PROVISIONS OF INTRAVENOUS THERAPY Provisions of Intravenous Therapy Administration of IV Therapy Nurse Responsibility Patient Education Anaphylaxis Protocol Possession of Supplies Possession of Dangerous Drugs

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