ADMINISTRATIVE CHAP CORE TAC
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1 Table of Contents Page ADMINISTRATIVE Definition of Organization CI.2a Mission Statement, Goals, and CI.1a,b Philosophy Services Offered CII.2a Service Area Payment for Services Fee Schedule Target Population Hours of Operation Administrative Control CI.2a,b,c,d,e,f,g,h,i CI.3a,b,c CI4.c,d,h CIII.3c Ethics Committee CI.7a,b,c Corporate Compliance Plan Branch Offices CII.5g Professional Advisory Committee CII.5f Annual Evaluation CI.5a CII.5f CIII.2a Admission Criteria CI.5c Discharge/Transfer from Service CI.5c Contingency Plan Agency Closure Procedures Backup Coverage of Services Business Associate Contract
2 Page ADMINISTRATIVE Cont Anti Fraud Program Professional Standards & Principles CIII.5a Financial Records 252 CIII.3a-g CIII.4a,b,d,e Financial Planning 252 CII.4a CIII.3a,b,c,d,e,f,g CIII.4c Capital Expenditures CIII.3a,d Services Provided under Contract CI.5c 289 CIII.2a,b Research Activities/Investigational Studies CI.8a-e Public Disclosure CI.4d CII.1a Disclosure to Licensing Authority Change of Ownership/Administrative Control Information Management CIII.6A Page HUMAN RESOURCES Reasonable Accommodations Personnel Records CI.5d,h 246 CIII.1g,h Employment References CIII.1g Time Records OIG Excluded List Selection of Personnel CIII.1b CIII.1g Classification of Personnel CI.4a,b CIII.1a 244 CIII.1c,g Volunteers Ethics CI.7b Employee Dress Code CIII.1m
3 Page HUMAN RESOURCES Cont Employee Health Assessments CI.5d,e Payday Benefits & Wages Confidentiality CI.5c,d CIII.1g Orientation & Staff Development CI.3c CI.5d,e CII.2c CII.3c CII.7g CII.8c CIII.1f,g,k Policy & Procedure Agreement Competency Evaluation CIII.1g Cell Phone and Texting Performance Evaluation CI.5d CIII.1g,i,j Employee Discipline Termination/Separation of Employment CI.5d CIII.1e Employee Grievances,d Smoking Professional Reporting CI.5c Drug Testing Conflict of Interest Knowledge/Resource Center CI.5c,i CIII.1f Page RIGHTS RESPONSIBILITIES ETHICS Client Conduct Responsibility & Rights CII.1b,c,d Non Discrimination CI.5c CIII.1a Program Accessibility Solicitation/Distribution for 255 Referrals Ethical Complaints
4 Page RIGHTS RESPONSIBILITIES ETHICS Cont Patients Complaints & Grievances CII.8a,b,c Reporting Abuse Neglect or 249 Exploitation Rights of the Elderly Criminal History Checks (Staff) CIII.1g Criminal History Checks (Admin) CIII.1g Employee Misconduct Registry (EMR) Nurse Aide Registry National Sex Offender Registry Out-of-Hospital Do Not Resuscitate Order Advanced Directives Declaration for Mental Health Treatment Coordination of Client Care CII.2b Facilitating Communication CI.6a,b After Hours Care CI.5c 290 Page PATIENT INFORMATION Security of Clinical Information CI.5h CII.5a,b Data Backups Retention of Clinical Records CI.5h CII.5a Timeliness of Entries in Clinical CI.5h Record CII.5a,c,d,e Client Records CI.5h CII.5a Patient Identification Physician Orders/Plan of Care CI.5c Physician Signatures Physician Delegation Physician Verification
5 Page PATIENT INFORMATION Cont RN Delegation Clinical Record Review/Quarterly 287 Review Abbreviations CI.5c Prohibition on Transporting Patient Medication Profile Medication Administration Record Medication Storage Emergency Medication Medication/Prescriptions Orders Confused Medications Administration of Blood Adverse Drug Reactions Vaccine Storage and 303 Transportation Medication Reminding Page NON-CLINICAL Billing Referrals CI.5c Verification of Primary Payer Staffing Issues CII.2a Faxing Protected Health Information CI.5c Password/Usernames Red Flag Rules Page CLINICAL In Service Education CIII.1g,l Patient Education CI.5g Wound Care Management Pain Management Reporting Emergencies in the CI.5c 281 Home Cardiopulmonary Resuscitation 281 (CPR) Clinical Procedures Care Planning 281
6 Page CLINICAL Cont RN Pronouncement Assessment of Patients CI.5c Nurse Supervision Registered Nurse Licensed Vocational Nurse Certified Nursing Aide Therapy Services Therapy Evaluation Medical Social Worker Medical Social Worker Evaluation Dietician Page SAFETY/INFECTION CONTROL Infection/Exposure Control Plan,c,e,g 285 CII.7a-n CLIA Waiver Universal Body Substance 285 Precautions Management of Infections/Exposures in Personnel CI.5e CII.7b,i Personal Protective Equipment CI.5e Hand washing CI.5g Aseptic Technique Sterile Technique Respiratory & Tuberculosis CI.5e 285 Precautions CII.7i Tuberculosis Exposure Control CI.5e 285 Plan CII.7i Contaminated Reusable Materials CII.7e 286 Disposition Contaminated Waste Disposal CII.7e Therapy Bag Techniques Multidrug-Resistant Organisms Communication of Hazards to Personnel CII.7j Hepatitis B Vaccination CII.7f,h Information & Training CI.5g CII.7h Evaluating & Maintaining Records of infections CII.7h 285
7 Page SAFETY/INFECTION CONTROL Cont Reporting of Communicable CI.5e,g 285 Diseases/Infections Record Keeping CI.5e,h CII.7h Medical Equipment Malfunction CI.5f CII.7m Hazardous Waste Handling CII.7e OSHA Bloodborne Pathogen CII.7g 285 Training Incident/Accident Reporting Agency Personnel Safety,c 281 Personal Safety Agency Personnel Safety/ Unsafe Home Visits,c Accidental Exposure,c Accidental Prevention,c Fall Prevention,c CII.7k,l Car Accident Reporting,c Disaster/Emergency Preparedness CI.5c CII.3a,b,c Material Safety Data Sheet Fire Safety Utilities/Equipment Management Evacuation Assistance 256 Page QUALITY MANAGEMENT Quality Assessment/Performance CI.5g 287 Plan CII.6a-h CIII.1d Patient Satisfaction Survey CII.5f Non Patient Satisfaction Survey 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 303
Table of Contents. PD1-6A PD1-6B Services Offered PD2-1A
Table of Contents Page ADMINISTRATIVE 1.001.1 Definition of Organization PD1-1A 400.471 408.804 1.001.2 Mission Statement, Goals, and Philosophy PD1-6A PD1-6B 1.002.1 Services Offered PD2-1A 59A-8.008
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Table of Contents Page ADMINISTRATIVE 1.001.1 Definition of Organization LD.04.01.01 040(b) 1.001.2 Mission Statement, Goals, and LD.02.01.01 Philosophy 1.002.1 Services Offered LD.01.03.01 LD.04.01.05
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