INFUSION AND AMBULATORY CARE POLICY AND PROCEDURE MANUAL Full Manual 2012 Edition

Transcription

1 Page 1 of 34 INFUSION AND AMBULATORY CARE POLICY AND PROCEDURE MANUAL Full Manual 2012 Edition Policy & Procedure Manual Table of Contents Effective Date: December 10, 2011 Approved By: Roger S. Klotz, R.Ph., BCNSP, FASCP, FACA, FCPhA The s row is highlighted in PINK in this Table of Contents indicates a new procedure. The numbers highlighted in Green in this Table of Contents indicates that the procedure was reviewed and revised in this release When the name of the procedure or is highlighted in yellow it indicates a title change for that procedure. Within the individual procedures the Yellow highlighted areas indicate revisions to the procedure. Appropriate staff should verify that the organization wants to incorporate these changes into their practice should review these revisions. If the revisions are accepted then the appropriate managers should assure implementation. Module Codes: - anizational Wide Rx - Pharmaceutical RN - Nursing HME - Home Medical Equipment - Patient Education INTRODUCTION: ACHC Home i Scope of Care and Services PC.1.10 DRX 3-1A, DRX 3-2A, DRX3-4C, DRX 6-5A, DRX 4-11D, DRX 6-4A ii anizational Policies and Procedures LD.3.90, L.D.350 DRX 1-3B, DRX 1-3B, DRX 3-4C, HSP 2-5A, HSP 2-6A.01, HSP 2-6B, HH2-3A.01, HH2-4A, HH2-5A Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

2 Page 2 of 34 ACHC Home iii Homecare Operational Flow PC.1.10 DRX 1-6A, DRX 1-6B, HSP 1-6B.01, HH 16A.01 iv Governing Body Structure, Duties, and Accountabilities v Health Care Professional Related Web Sites 1.1 Patient Rights and Responsibilities LD.3.90, LD.3.50 N/A RI.1.10, RI.2.10, RI.2.20, RI.2.30, RI.2.40, RI.2.60, RI.2.70, RI.2.100, RI.2.130, RI.2.210, RI Transfer of Patients RI.2.30, PC.2.130, PC.2.20, PC.8.10, PC.15.10, PC.15.30, IM Do Not Resuscitate (DNR)/ Advanced Directives Orders/Withholding, Withdrawing Life-Sustaining Care 1.4 Agreement and Consent/ Assignment of Benefits (Informed Consent) Refusal Of Services, Treatment, Equipment, Supplies RI.2.80 RI.2.40, RI.2.50 RI.1.10, RI.2.10, RI.2.20, RI.2.40, RI.2.60, RI.2.70, HR Investigational Drugs/Devices RI.2.18, MM.7.40, MM.3.10, M.3.20, MM.4.10, M.4.50, MM.4.60, M.5.20, MM.8.10 DRX 1-1A, DRX 1-1C, DRX 1-2A, DRX 1-2B, DRX 1-2C, DRX 1-7A, DRX 1-8A,DRX 1-10A, HSP 1-1A, HH 1-1A, HH 1-2A, HSP 1-3A.01, HSP 1-3B.01, DRX4-15A DRX 3-2A, DRX 3-2B, DRX 3-5A, DRX 3-3A, HSP 2-3A, HSP 2-3B, DRX 3-4A, DRX 3-4B, HSP2-5A, HSP 2-5B, HHS 2-5A, HHS 2-5B DRX 6-2A, HH5-2A.01, DRX5-16A, DRX5-16B, DRX5-16C, HH5-15A.01, HH5-7A. DRX5-16C, DRX7-12C, DRX7-12D, DRX5-16D, DRX5-16E, DRX5-16G, DRX5-16H DRX2-6B, DRX2-6C, HH2-6A, HH2-6B, HH2-6B.01 DRX3-2A, DRX3-2B, DRX3-5A DRX3-2A, DRX3-2B, DRX3-5A, DRX2-6A, DRX2-6B, HSP2-5A, HSP2-5B DRX1-7A, HH1-1C, DRX5-7A, DRX7-22B, DRX4-14D, DRX7-11D, HH7-10A.01, DRX5-18A, DRX2-1B 1.6 Patient Grievances/Complaints RI DRX2-4A, DRX2-4B, DRX2-4C, DRX2-4D, DRX2-4E, HH2-4A, HH2-4A.01, HH2-4A.02, HH2-4B Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

3 Page 3 of 34 ACHC Home 1.7 Confidentiality of Information RI.2.130, IM.2.10, IM.2.20, IM Respect of Patient's Property RI DRX2-2A DRX2-5A, DRX2-5B, DRX3-4A, DRX5-1C, DRX4-1A 1.9 Ethical Issues RI.1.10, RI.1.20 DRX1-3A, DRX1-3B, DRX2-9A, DRX4-6A 1.10 Conflict of Interest RI.1.10, RI.1.20, RI Fee Setting RI.1.10, RI.2.10, RI.2.20, RI.2.40, RI.2.60, RI The Proper Use of Network & Software Systems for the Protection of Patient Privacy 1.13 HIPAA Requirements For Security Of Electronic Health Information #9.12 Staff Rights - Not to Participate in Patient Care RI.2.10, RI.2.20, RI.2.100, RI.2.130, IM.2.10, IM.2.20, IM.2.30, IM.3.10 RI.2.180, RI.5.0, RI.6.0, IM.2.10, IM.2.20, IM.2.30, IM.3.10 RI Initial Patient Assessments PC.2.20, PC.2.130, PC.2.150, PC.8.10, IM Rn Initial Nursing Assessment PC.2.20, PC.2.130, PC.3.10, IM.5.10 #2.9 Rn Initial Pediatric Nursing Assessment PC.2.20 PC Rx Initial Pharmacist Assessment PC.2.20, PC PC.3.10, IM.5.10 #2.9.1 Rx Initial Pediatric Pharmacist Assessment Rn\HME Initial Respiratory Therapist Assessment PC.2.20 PC.2.20, PC.2.130, PC.3.10, IM Further Patient Assessments PC.2.20, PC PC.3.10, IM.5.10 DRX1-3A, DRX1-3B DRX3-4A, DRX3-4B, DRX3-4C, DRX3-5A, DRX3-4C DRX5-1A, DRX5-1C, DRX5-1D, DRX5-1E DRX5-1C DRX5-1A DRX7-1A, DRX5-5A DRX5-2A, DRX5-2B, DRX5-3E, HH5-2A.01, HH5-2B, HH5-2C, HH5-2D DRX5-2A, DRX5-2B, DRX5-3E DRX5-1A, DRX5-1C, DRX5-1D, DRX5-1E DRX5-1C DRX5-1A DRX5-2A, DRX5-2B, DRX5-3E DRX5-2A, DRX5-2B, DRX5-3E, DRX5-4E, DRX5-7A, HH5-2D DRX5-13A, HH5-4A, DRX5-7A, HH5-4B.01, HH5-15A.01 Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

4 Page 4 of 34 ACHC Home 2.3 Interdisciplinary Referral PC.2.130, PC Assessing Nutritional Status (Nutritional Screening) In-Depth Nutritional Assessment PC.2.20 PC PC.2.20, PC PC.4.10, PC Rn Assessing Functional Status PC.2.20, PC.2.130, IM.6.20 DRX5-2A, DRX5-2B, DRX5-3E DRX5-2A, DRX5-2B, DRX5-3E, DRX5-4E, DRX5-7A, HH5-2D DRX5-2A, DRX5-2B, DRX5-3E HH5-2A.01, HH5-2B, HH5-2C, HH5-2C.02, HH5-2D, HH5-2E, HH5-2F, HH5-3A, HSP 4-11E 2.6 Victims of Abuse PC.3.10 DRX2-3A, DRX2-3B, HH2-3A.01, HH2-3A Patient Reassessments PC.2.20, PC.2.130, PC DRX5-2A, DRX5-2B, DRX5-3E, DRX5-4E, DRX5-7A, HH5-2D 2.8 Rn Mental Health Assessments PC.2.20, PC DRX5-2A, DRX5-2B, DRX5-3E 2.9 Rn Infants, Children, and Adolescent Assessments Rx Initial Pediatric Pharmacist Assessment 2.10 Rn Intrapartum and Postpartum Assessments Rx Initial Intrapartum/Postpartum Pharmacist Assessment PC.2.20 PC PC.2.20 PC.2.20, PC PC.2.130, PC DRX5-2A, DRX5-2B, DRX5-3E, HH5-2A.01, HH5-2B, HH5-2C, HH5-2D HSP5-11A.01, HSP5-11B.01, HSP5-11C.01, HSP5-11D, HSP5-11E DRX5-2A, DRX5-2B, DRX5-3E, HH5-2A.01, HH5-2B, HH5-2C, HH5-2D DRX5-2A, DRX5-2B, DRX5-3E, HH5-2A.01, HH5-2B, HH5-2C, HH5-2D 2.11 Hospice Assessments PC.2.20, PC DRX5-2B, DRX5-3E, DRX5-4E, DRX5-5A, DRX5-7A, DRX5-7C 2.12 HME Pulmonary Function Assessment PC.2.20 DRX5-2B, DRX5-3E 2.13 HME Oxygen Saturation Assessment PC.2.20 DRX2-3A, DRX2-3B, HH2-3A.01, HH2-3A Rx/RN/ HME Blood Pressure Assessment PC.2.20 DRX5-2A, DRX5-2B, DRX5-3E, DRX5-4E, DRX5-7A, HH5-2D Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

5 Page 5 of RN, Rx, HME Initial Pain Assessment / Pain Management 2.16 Rx Medication Therapy Management (MTM) 2.17 Rx Dose and Dosing Interval Assessment Interdisciplinary Care Planning Process HME Care Planning - Home Medical Equipment Only PC.2.20,, PI.1.10, RI PC.2.20, PC PC.3.10, IM.5.10 PC.2.20, PC PC.3.10, IM.5.10 PC.4.10, PC.5.60 PC.5.70, MM.6.10 IM.6.20 PC.2.20, PC.2.130, C.4.10 ACHC Home DRX5-2A, DRX5-2B, DRX5-3E DRX5-2A, DRX5-2B, DRX5-3E, HH5-2A.01, HH5-2B, HH5-2C, HH5-2D HSP5-11A.01, HSP5-11B.01, HSP5-11C.01, HSP5-11D, HSP5-11E DRX5-2A, DRX5-2B, DRX5-3E, HH5-2A.01, HH5-2B, HH5-2C, HH5-2D DRX4-5C # Nutrition Care Planning PC.4.10 DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4C, DRX5-4B, DRX5-4D, DRX5-4E Physician/Prescriber Oders/Prescriptions # # Physician Licensure Verification IM.6.10, PC.5.10, PC.5.20, MM.1.10, MM.3.20, M.4.10, MM TX DRX5-1A, DRX5-7A DRX5-7C, DRX5-11A,HH5-1A.01, HH5-3A, HH5-3B DRX5-1A, DRX5-7A, DRX5-7C, DRX5-11A, HH5-1A.01, HH5-3A, HH5-3B Nutrition Orders TX , 1704-A, 1704-B, C, 1704-D, 1704-E, 1704-F, 1704-G Rx Pharmacy Orders: The Prescription/Ancillary Prescription Rn Nursing Orders: Physician s Orders PC.5.20, IM.6.20 PC.5.20, IM.6.20 DRX5-7A, DRX7-22B, DRX7-22A DRX5-18A Rn Nursing Orders: Plan of Care PC.5.20, IM.6.20 DRX 5-18a, DRX 4-13B, DRX 7-11D, DRX 5-7A, DRX 5-7C HME Home Medical Equipment: Physician Orders PC.5.20, IM.6.20 DRX 1-1A, DRX 1-7B Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

6 Page 6 of 34 ACHC Home HME Oxygen and Respiratory Care Orders: Physician Orders Certification for Parenteral/Enteral Nutrition Dietary Orders: Physician Orders Rx Standards of Professional Practice: The Pharmacist s Role In Clinical Monitoring PC.5.20, IM.6.20 PC.5.20, IM.6.20 PC.5.20, IM.6.20 PC.4.10, PC.5.10, HR.1.10, HR.1.20 DRX 1-1A, DRX 1-7B, DRX 1-7C, DRX 5-2C, DRX 5-2E, DRX 5-2D, DRX 5-3A, DRX 5-3C DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4C, DRX5-4B, DRX5-4D, DRX5-4E DRX5-7A, DRX7-22B, DRX7-22A DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4C, DRX5-4B, DRX5-4D, DRX5-4E Standards of Practice PC.5.10 DRX4-14A, DRX4-12A, DRX4-14B, DRX4-14C, DRX4-9D, DRX5-4A, DRX5-4B, DRX5-4D, DRX5-4E End of Life Care PC.4.10, PC.5.10, PC.8.70, PC Patient Clinical Monitoring MM.2.10, M.3.10, MM.3.20, M.4.10, MM.6.10, M.6.20, MM.7.10, M PC HME Equipment Clinical Care Services (Follow-Up Services) PC.4.10, MM.6.10 IM Clinical Laboratory Monitoring PC.4.10, MM.5.10, IM Rn Measuring Intake and Output PC.4.10, MM.6.10 HR.1.10, HR Progress Reports To The Responsible Physician & PC.5.60, PC.5.70 Other Providers Involved In The Patient s Care Rx Inventory of Medications (Drug Accountability) Rx Selecting and Procuring Medications and Supplies MM.2.10 MM.2.10 DRX1-1B, DRX4-14A DRX2-2A, DRX2-2B, DRX2-6A, DRX2-6B DRX 1-1A, DRX 1-7B, DRX 4-5C DRX 5-2B, DRX 5-3E, DRX 5-4B, DRX 5-4D, DRX 5-4E HH 5-2A.01, HH 5-2E, HH5-3A DRX 5-2B, DRX 5-3E, DRX 5-4B, DRX 5-4D, DRX 5-4E DRX4-13B, DRX5-18A, DRX 7-9A, HH4 4-10A DRX4-13B, DRX5-18A, HH4 4-10A Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

7 Page 7 of 34 ACHC Home Rx/Rn Receiving, Storing, Dispensing, and of Controlled Substances #1.5 MM.2.10, M.2.20, MM.2.30, M.2.40, MM.4.20, M.4.70, MM.7.10, M.7.40 Investigational Drugs/Devices RI.2.180, M.3.10, M.3.20, MM.4.10, M.4.50, MM.4.60, M.5.20, MM.7.40, M.8.10 DRX 4-13B, DRX 5-18A, HH A, HH 4-11C DRX 5-7A, DRX 5-18A, DRX 4-13B, DRX 7-11D Rx Emergency Medication Supply MM.2.10 DRX 2-1A, DRX 2-10A, DRX 4-9D Rx Temperature Control - Pharmaceuticals MM Rx Outdated Drugs MM.2.20, M.2.40, MM.4.40, M.4.70, MM Drug/Product/Device Recall MM.4.70, EC.9.10, EC Rx Prescription Transfer to Another Pharmacy Rx Clean room and Clean Environment - The Environment Control of the Aseptic Compounding Area Rx Cleaning of the Aseptic Compounding Area Rx Clean Air Center/Class 100 Laminar Air Flow Hood Maintenance Rx Compounding Device Calibration and Maintenance PC.5.20, MM.2.10, MM.4.40 MM.4.20 MM.4.20, PI.1.10 MM.4.20, PI.1.10, EC.3.10, EC MM.4.20, PI.1.10 EC Rx Compounding Record MM.2.20, MM.4.20 DRX 7-9A, DRX 7-9B, DRX 7-9C, DRX 7-9D DRX 2-6, DRX 7-7A, DRX 7-7C, DRX 7-9A, DRX 7-9B, DRX 7-9C, DRX 7-9D DRX 7-9A, DRX 7-9B, DRX 7-9C DRX 7-9A, DRX 7-9B, DRX 7-9C, DRX 7-9A, DRX 7-9B, DRX 7-9C DRX 7-8A, DRX 7-8D, DRX 7-8D, DRX 4-14E, DRX 7-9D DRX 7-8A, DRX 7-8D, DRX 7-8D, DRX 4-14E, DRX 7-9D DRX 7-8A, DRX 7-8D, DRX 7-8D, DRX 4-14E, DRX 7-8B DRX 7-8A, DRX 7-8B, DRX 4-14E, DRX 7-8B DRX 7-8A, DRX 7-8B, DRX 7-8D, DRX 4-14E Rx Staging MM.4.20 DRX 7-8A, DRX 7-8B, DRX 7-8D Rx Gowning for the Aseptic Compounding Area MM.4.20, IC.1.10, IC.4.10 DRX 7-8A, DRX 7-8B, DRX 7-8D, DRX 4-14E, DRX 7-8B Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

8 Page 8 of 34 ACHC Home Rx Hand Washing as Part of Aseptic Technique Rx Gloving as Part of Aseptic Technique Rx Product Introduction and Removal to and from the Aseptic Compounding Area/Buffer Room MM.4.20, IC.1.10, IC.4.10 MM.4.20, IC.1.10, IC.4.10 MM.4.20, IC.1.10, IC Rx Aseptic Technique MM.4.20, IC.1.10, IC Rx Compounding Versus Manufacturing (Medication Preparation) Rx Total Parenteral Nutrition (TPN) Compounding (General) MM.4.20, LD.1.30 MM.4.20 DRX 7-8A, DRX 7-8D, DRX 4-14E DRX 7-8A, DRX 7-8D, DRX 4-14E DRX 7-8A, DRX 7-8B, DRX 7-8D, DRX 4-14E, DRX 7-8B DRX 7-8A, DRX 7-8D, DRX 4-14E DRX 7-8A, DRX 7-8D, DRX 7-8B DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B Rx TPN Compounding: 3-IN-1 MM.4.20 DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B Rx Compounding - Medications and Large-Volume Parenterals (LVP) Rx Compounding - Medications in an Elastomeric Infusion System Rx Compounding - Terbutaline Syringes Rx Compounding of Preservative- Free Morphine Rx Compounding of Antineoplastics & Other Hazardous Drugs/Chemicals MM.4.20 MM.4.20 MM.4.20 MM.4.20 DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B MM.4.20, EC.3.10 DRX7-8A, DRX 7-8B Rx Compounding Enterals PC.7.10, MM.4.20 DRX 7-8A, DRX 4-14E, DRX 7-8B, DRX 7-12C, DRX 712D, DRX 7-12H, DRX 7-12E, DRX7-12H Rx Compounding of Parenteral Medications from Non-Sterile Powders Rx/Rn Compounding Personnel Training Rx Ongoing Validation - Sterile Compounding MM.4.20 MM.4.20 MM.4.20 DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

9 Page 9 of 34 ACHC Home Rx Sterilizing Filter Integrity Testing After Compounding (Bubble Point Integrity Testing) MM.4.20, PI.1.10 DRX 5-7A, DRX 7-8A, DRX 4-14E, DRX 7-8B Rx Labeling MM.4.30 DRX 5-7A, DRX 7-22B Rx Packaging Finished Products MM.4.40 DRX 7-9A, DRX 7-9C, DRX 7-9D Rx/Rn Storage and Delivery of Products MM.4.40 DRX 7-9A, DRX 7-9C, DRX 7-9D Rx/Rn Patient Supply Ordering MM.2.10 DRX 5-2B, DRX 5-4C, DRX 5-4B Rx/Rn The Shipping Bill (Medication Dispensing Control and Accountability/Refills) Rx Medication Storage (Security for Pharmacies) Rx Medication Storage - Security for Pharmaceuticals in anizations Outside of the Pharmacy (Night Locker) Rx Medication Storage in Clinical Staff s Possession Medication Protocols - Drugs and/or Drug Classes Rx Compounding of Antineoplastics & Other Hazardous Drugs/Chemicals MM.2.10, IM.6.10 DRX 5-2B, DRX 5-4C MM.2.20, M.240, MM.7.10, M.7.40 MM.2.20, M.2.30 MM.2.20, M.2.30, LD.1.30 MM.5.10 MM.4.20, EC.3.10 DRX 4-14B, DRX 4-14C, DRX 5-7A, DRX 7-9A, DRX 7-9B, DRX 7-10A DRX 5-7A, DRX 7-7A, DRX 7-9A, DRX 7-9B DRX 2-1B, DRX 5-7A, DRX 7-22B, DRX 4-14D DRX 5-2B, DRX 5-2C, DRX 5-2E, DRX 5-5B DRX 7-6A, DRX 7-6B, DRX 7-8C Rx/Rn Pump and Controller Selection MM.5.10, EC.6.30 DRX 7-11D, HSP 5-10A.01, DRX 5-18A, DRX K5-7A, DRX 7-11D, DRX 7-22A Rx/Rn First Dose MM.3.10, M.4.10, MM.5.10, M.5.20, MM.6.20, M.7.10, MM.8.10, PC DRX 7-11D Rx/Rn Anaphylaxis MM.5.10 DRX 7-11D Rx/Rn Extravasations MM.5.10 DRX 5-18A, DRX 7-11D, DRX 5-7A, DRX 7-11D Rn Medication Verification MM.5.10 DRX 7-11D Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

10 Page 10 of 34 NO. MODULE TITLE ACHC Home Rx Assurance of Medication Stability/Compatibility MM.2.20, M.4.30, MM.5.10 DRX 7-9A, DRX 7-9B, DRX 7-9C, DRX 7-9D, DRX 7-10A Medication Profile IM.6.20 DRX 5-7A, DRX 7-11D Rx/Rn Medication Contraindications (Allergies and Interactions) MM.5.10 DRX 5-2B, DRX 5-5A, DRX 5-7A. DRX 7-11D, DRX 7-22A Rx/Rn Patient In-Line IV Filters MM.5.10 DRX 5-6A, DRX 7-12A, DRX 5-7A Rn/Rx Medication Infection Control Measures - Hand Washing Rn/Rx Medication Infection Control Measures - Gloving Rn/Rx Medication Infection Control Measures - Gowning Rx/Rn Needless/Needle-Free IV Access Systems Rx/Rn Flushing with Heparin and Saline IC.1.10, IM.6.20 IC.1.10 IC.1.10 MM.5.10 MM.5.10 DRX 4-13B, DRX 7-7A, DRX 7-8A, DRX 7-8D DRX 4-13B, DRX 7-7A, DRX 7-8A, DRX 7-8D DRX 4-13B, DRX 7-7A, DRX 7-8A, DRX 7-8D DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 7-11D DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 7-11D Rx/Rn Clearing Catheter Occlusions MM.5.10 DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 7-11D Rn/Rx Initiation of a Peripheral Intravenous (IV) Access Rn/Rx Discontinuation of a Peripheral Intravenous (IV) Access Rn/Rx Insertion of a Peripherally Inserted Central Catheter (PICC) MM.5.10, MM.6.20 MM.5.10 MM.5.10 DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B Rn Insertion of a Midline Catheter MM.5.10 DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B Rn Peripheral IV Site/Heparin Lock Catheter Care Rn Peripherally Inserted Central Catheter (PICC) and Midline Site Care MM.5.10 MM.5.10 DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B Rn Central Line Catheter Care MM.5.10 DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

11 Page 11 of 34 ACHC Home Rn Epidural Catheter Care MM.5.10 DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B Rn Continuous Ambulatory Peritoneal Dialysis (CAPD) Catheter Care MM.5.10 DRX 4-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B Rn Implanted Port Catheter Care MM.5.10 DRX 4-13a, DRX 4-14A, DRX 5-18A, DRX D Rn Intermittent Medication Rn Total Parenteral Nutrition (TPN) Rn Continuous Medication Rn of Hazardous Drugs/Chemicals and Vesicants Rn/Rx Intramuscular (IM) Medication Rn/Rx Subcutaneous (SQ) Medication Rn Epidural Medication Rn Implantable Drug Systems (Synchromed7 - Medtronic) Rn/HME Aerosolized Medication Rn/HME Aerosolized Pentamidine MM.5.10, PC.5.20, MM.2.20, M.4.30, MM.5.10, M.6.10., PC.5.20, MM.2.20, M.4.30, MM.5.10, M.6.10., PC.5.20, MM.2.20, M.4.30, MM.5.10, M.6.10., PC.5.20, MM.2.20, M.4.30, MM.5.10, M.6.10., PC.5.20, MM.2.20, M.4.30, MM.5.10, M.6.10., PC.5.20, MM.2.20, M.4.30, MM.5.10, M.6.10., PC.5.20, MM.2.20, M.4.30, MM.5.10, M.6.10., PC.5.20, MM.2.20, M.4.30, MM.5.10, M.6.10., PC.5.20, MM.2.20, M.4.30, MM.5.10, M Rn Enteral Nutrition, PC.5.20, MM.2.20, M.4.30, MM.5.10, M DRX 4-13a, DRX 4-14A, DRX 5-18A, DRX D HH 5-1A.O1, DRX 4-13A, DRX 4-14A, DRX 5-18AM DRX 4-13B, DRX 7-11C, DRX 5-7A, DRX 7-11D DRX 4-14A, DRX 5-18A, DRX 7-11D, DRX 7-11C, HH 7-6A.01 HH 7-6B.01 DRX 4-14A, DRX 5-18A, DRX 7-11DK DRX 7-11C, HH 7-6A.01, HH 7-6B.01 DRX 5-18A, DRX 4-13B DRX 7-11C, DRX 5-7A, DRX 7-11D DRX 4-14A, DRX 5-18A, DRX 7-11D, DRX 7-11C DRX 4-14A, 1DRX 5-18A, DRX 7-11D, DRX 1-1B DRX 4-14A, 1DRX 5-18A, DRX 7-11D, DRX 1-1B DRX 4-14A, 1DRX 5-18A, DRX 7-11D, DRX 1-1B DRX 4-14A, DRX 5-18A, DRX 7-11D, DRX 7-11C, HH 7-6A.01, HH 7-6B.01 DRX 4-14A, DRX 5-18A, DRX 7-11D, DRX 7-11C Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

12 Page 12 of 34 ACHC Home Rn Oral (PO) Medication Rn Continuous Ambulatory Peritoneal Dialysis (CAPD) Rn/Rx Obtaining Blood Specimens for Laboratory Analysis See: # See # # # # # # # #5.6, PC.5.20, MM.2.20, M.4.30, MM.5.10, M.6.10., PC.5.20, MM.2.20, M.4.30, MM.5.10, M PC.5.20, PC.16.30, PC.16.40, M DRX 4-14A, DRX 5-18A, DRX 7-11D, DRX 7-11C DRX 4-14A, DRX 5-18A, DRX 7-11D, DRX 7-11C DRX 4-13A, DRX 4-14A, DRX 2-1A. DRX 2-10A Clinical Laboratory Monitoring PC.4.10, IM.6.20 DRX 4-13A, DRX 4-14A, DRX 2-1A. DRX 2-10A Rn Measuring Intake and Output PC.4.10, MM.6.10, IM.5.10 DRX 4-13A, DRX 4-14A, DRX 2-1A. DRX 2-10A Patient Clinical Monitoring PC.4.10, MM.6.10 DRX5-2A, DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4B, DRX5-4C, DRX5-4D, DRX5-4E, HH5-3A, HH5-3B, HH5-4A, HH5-5A, HH5-5B Interdisciplinary Care Planning Process Interdisciplinary Care Planning Process Medication Effectiveness Monitoring Medication Monitoring Collaboration PC.4.10, PC.5.60, PC.5.70, MM.6.10, IM.6.20 PC.4.10, PC.5.60, PC.5.70, MM.6.10, IM.6.20 PC.4.10, PC.5.60, PC.5.70, MM.6.10, IM.6.20 PC.4.10, PC.5.60, PC.5.70, MM.6.10, IM.6.20 DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4C, DRX5-4B, DRX5-4D, DRX5-4E DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4C, DRX5-4B, DRX5-4D, DRX5-4E DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4C, DRX5-4B, DRX5-4D, DRX5-4E DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4C, DRX5-4B, DRX5-4D, DRX5-4E Medication Continuation PC.8.70 DRX2-2A, DRX2-2B, DRX2-6A, DRX2-6B Care Coordination (Patient Care Conference) PC.5.50, PC.5.60, PC.5.70, MM.6.10, IM.3.10 DRX 5-2B, DRX 5-4D, DRX 5-3E, DRX 5-4D, DRX 5-4E Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

13 Page 13 of 34 ACHC Home # Patient Compliance IM.6.20 DRX 5-18A, DRX 5-7A Medication Record (MAR) #5.11 # Guidelines for Physician Notification Progress Reports to the Responsible Physician PC.5.10, PC.5.20,, PC.7.10, MM.3.10, M.3.20, MM.4.10, M.4.30, MM.4.40, M.5.10, MM.5.20, M PC.5.50, PC.5.60, PC.5.70 PC.5.50, PC.5.60, PC.5.70 DRX 5-7A, DRX 5-7C, DRX 5-7A DRX 5-4D, DRX 5-4E DRX 5-4D, DRX 5-4E #1.5 Investigational Drugs/Devices RI.2.180, MM.3.10 MM.3.20, M.4.10, MM.4.50, M.4.60, MM.5.20, M.7.40, MM Adverse Drug Reaction (ADR) Reporting PI.2.20, PI.2.30, MM.4.20, M.4.30, MM.4.40, M.5.10, IM Medication Errors PI.2.20, PI.2.30, MM.4.20, M.4.30, MM.4.40, M.5.10 DRX 5-18A, DRX 7-11D, DRX 7-18A, DRX 5-7A, DRX 7-11D DRX 5-18A, DRX 7-11D, DRX 5-7A DRX 7-2A, DRX 7-2A, DRX 7-2C, HSP 6-5D, DRX 7-11C, DRX 7-22A Rx/Rn Phlebitis MM.5.10 HH 7-2C.01, DRX 5-18A, DRX 7-11D #2.4 #2.4.1 Assessing Nutritional Status (Nutritional Screening) In-Depth Nutritional Assessment PC.2.20 PC.2.20, PC.4.10 DRX5-2A, DRX5-2B, DRX5-3E DRX5-2A, DRX5-2B, DRX5-3E Nutrition Care Planning PC.4.10 DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4C, DRX5-4B, DRX5-4D, DRX5-4E Nutrition Orders PC.5.20 DRX5-2B, DRX5-3E, DRX5-4A, DRX5-4C, DRX5-4B, DRX5-4D, DRX5-4E Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

14 Page 14 of 34 ACHC Home Nutrition Preparation, Storage, Dispensing, and PC.4.10, PC.7.10 DRX 5-7A, DRX 7-22B, DRX 7-22A, DRX 7-12C, DRX 7-12D, DRX 7-12H, DRX 7-12E Altered Diet Schedules PC.4.10 DRX 5-2B, DRX 5-2B, DRX 5-3E Nutrition Monitoring PC.4.10 DRX 5-7A, DRX 7-22B, DRX 7-22A, DRX 7-12C, DRX 7-12D, DRX 7-12H, DRX 7-12E Rx/Rn "Waived" CLIA Tests PC HH1-11A, HH4-6C.01, HH7-8A Rx/Rn "Waived" Test Performance Responsibilities Rx/Rn Personnel Who Perform "Waived" Tests PC.16.20, C PC HH1-11A, HH4-6C.01, HH7-8A.01 HH1-11A, HH4-6C.01, HH7-8A Rx/Rn Specimen Collection and Preservation for "Waived" Tests Rx/Rn Instrument Calibration, Quality Control and Remedial Action, Equipment Performance Evaluation and Waived Test Performance Rx/Rn Quality Control Checks for "Waived" Tests Patient Education Process and Planning PC PC PC HH1-11A, HH4-6C.01, HH7-8A.01 HH1-11A, HH4-6C.01, HH7-8A.01 HH1-11A, HH4-6C.01, HH7-8A.01 LD.3.120, IM.6.20 DRX 5-5A, DRX 5-5E Patient Education Resources PC.6.30, LD DRX 5-5A Rx/Rn Patient & Nurse Training for addition to a sterile solution or reconstituting a sterile product # PC 6.30, LD DRX 5-5A Community Resources, PC.15.10, LD.3.120, IM.6.20 Patient/Caregiver Training - General Policy IM.5.10, PC.6.30,, LD DRX 6-2A, HH5-15A.01, HH , HH5-15C.01 DRX 5-5A Adult Learning Principles LD DRX 5-5A Training Checklist IM.6.20 DRX 5-5A Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

15 Page 15 of 34 ACHC Home Patient Medication Therapy Counseling PC.6.30, LD.3.120, IM.6.20 Important Telephone Numbers PC.6.30, LD.3.120, IM.6.20 DRX 5-5A. DRX 5-5E DRXN 3-1A #1.1 Or Rx/Rn/ / Patient Responsibilities Bill of Rights and Responsibilities Agreement and Consent/ Assignment of Benefits RI.1.10, RI.2.10, RI.2.20, RI.2.30, RI.2.40, RI.2.60, RI.2.70, RI.2.100, RI.2.130, RI.2.210, RI.3.10 RI.1.10, RI.2.10, RI.2.20, RI.2.30, RI.2.40, RI.2.60, RI.2.70, RI.2.100, RI.2.130, RI.2.210, RI.3.10, PC.6.30, LD DRX 3-2A, DRX 3-2B, DRX 2-5A, HH2-2A, HH2-2A.01 DRX 3-2A, DRX 3-2B, DRX 3-5A, DRX 3-3A, HH 2-3A.01, HH 2-3A.02, HSP 2-3B, HH 2-3A.03, HSP 2-3C, DRX 3-4A, HH 2-4A.01,HSP 2-4B.01, DRX 3-4C, HH 2-4A, HSP 2-4A.01, HH 2-5A, HSP 2-5A, HSP 2-5A, HSP 2-5B, HSP 2-6A.01, HH 2-6A HH 2-2A, HSP 2-2A, DRX 3-2B, HH 2-2A.01, HSP 2-2B.01, DRX 3-5A, HH 1-2A, HSP 2-2C Patient Concerns/Grievances, PC.6.30 DRX 3-3A, HH 2-3A.02, HSP 2-3A, HH 2-3A.01, HSP 2-3A Needleless/Needle-Free Intravenous (IV) Access System Patient/Caregiver Instructions for:, PC.6.30, LD Hand Washing, PC.6.30 IC.1.10, LD Pated - Gloving, PC.6.30, IC.1.10, IC.1.40, LD DRX 3-13A, DRX 4-14A, DRX 5-18A, DRX 4-13B, DRX 7-11D, DRX 7-11C HH 7-1A.01, HH 7-1B.0, HH 7-1C.01, HH 7-1D.01, HSP 7-1C, DRX 7-8D, DRX 4-14E HH 7-1A.01, HH 7-1B.0, HH 7-1C.01, HH 7-1D.01, HSP 7-1C, DRX 7-8D, DRX 4-14E Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

16 Page 16 of 34 ACHC Home or # #1.2 Pated - Aseptic Technique, PC.6.30, IC.1.10, IC.4.10, LD Infection Control, PC.6.30, IC.1.10, LD Rx/Rn/ - Basic Home Safety, PC.6.30, LD.3.120, IM Emergency Preparedness, EC.1.10, EC.1.20, EC Transfer/Discharge of Patients RI.2.30, PC.2.130, PC.15.10, PC.15.30, IM.6.20 HH 7-1A.01, HH 7-1B.0, HH 7-1C.01, HH 7-1D.01, HSP 7-1C, DRX 7-8D, DRX 4-14E HH 7-1A.01, HH 7-1B.0, HH 7-1C.01, HH 7-1D.01, HSP 7-1C, DRX 7-8D, DRX 4-14E HH 7-1A.01, HSP 7-1A, HH 7-1B.01, HSP 7-1BM HH 7-2A.01, HH 7-2B.01, HH 7-2C.01, HSP 7-2C.01 HH 7-1A.01, HSP 7-1A, HH 7-1B.01, HSP 7-1BM HH 7-2A.01, HH 7-2B.01, HH 7-2C.01, HSP 7-2C.01702, HH 7-3A.01, HH 7-4A.01,HH 7-5A.01, HH 7-5B.01 DRX 6-2A, HH 5-15A.01, HSP 5-11D, DRX 5-16A, DRX 5-16B, DRX 5-16A, DRX 5-16B, DRX 5-16C Rx/Rn - Understanding the Use of Restraints #5.8 # # a b - Hours of Normal Operation RI.2.10, RI.2.20, I.2.60, PC.1.10, PC.5.70 Patient/Caregiver Instructions for: - On-Call (After Hours Care) RI.2.10, RI.2.20, PC.1.10, PC.5.70 DRX 7-22A DRX 3-1A, HH 2-1A.01, HSP 2-1B.01 DRX 3-1A, HH 2-1A.01, HSP 2-1B.01 - Waste Disposal HH 7-1A.01, HSP 7-1A, HH 7-1B.01, HSP 7-1B, HH 7-6A.01, HH 7-6B.01 HME - Storage and Handling of Medical Gases and Related Supplies HH 72A.01, HH 7-2C.01, HH 7-6A.01, HH 7-6B.01 - Storage of Medication DRX 7-9A, DRX 7-9D - Preparation of Medication from a Vial DRX 7-8A, DRX 7-9D Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

17 Page 17 of c a b a b Preparation of Medication from an Ampoule - Ordering Supplies - Medication Record (MAR) Recording - Medication Record (MAR) Form - Total Parenteral Nutrition (TPN) Medication Record (MAR) Forms ACHC Home DRX 7-8A, DRX 7-9D DRX 7-8A, DRX 7-9D DRX 5-4C, DRX 5-4B, DRX 5-4E DRX 5-4C, DRX 5-4B, DRX 5-4E DRX 5-4C, DRX 5-4B, DRX 5-4E - Anaphylaxis Care DRX 7-11D, DRX 7-11D - Measuring Intake and Output DRX 5-2B, DRX 5-2B, DRX 5-3E - Daily Intake and Output Form DRX 5-2B, DRX 5-2B, DRX 5-3E - Fluid Conversions/Measurement Equivalents Chart Patient/Caregiver Instructions for: - Flushing With Heparin and Saline - Peripheral IV Site/Heparin Lock Catheter Care DRX 7-22A - Central Line Catheter Care - Peripherally Inserted Central Catheter (PICC) or Midline Site Care - Epidural Catheter Care - Central Line - Catheter Complications - Implanted Port Catheter Care Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

18 Page 18 of :00: Patient/Caregiver Instructions for: - Intermittent Intravenous (IV) Medication - Continuous Intravenous (IV) Medication - Minibag Medication Intravenous (IV) - Syringe Pump Medication Intravenous (IV) - Total Parenteral Nutrition (TPN) - Elastomeric Infusion Device - Intramuscular (IM) Medication - Continuous Subcutaneous (SQ) Medication - Epidural Medication - Aerosolized Medication - Oral (PO) Medication Hand Washing 22:00.02 Gloving Aseptic Technique Infection Control Basic Home Safety Waste Disposal Storage of Medication ACHC Home Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

19 Page 19 of V S Ordering Supplies Preparation of Medication from a Vial Preparation of Medication from a Ampoule Medication Record (MAR) Anaphylaxis Care Flushing with Heparin & Saline Needless Version Flushing with Heparin & Saline -Vial Sheet: Flushing with Heparin & Saline - Syringe Peripheral site/heparin Lock Catheter Care Central Line Catheter Care Peripherally Inserted Central Catheter (PICC), Midclavicular, or Midline Site Care Epidural Catheter Care Central Line - Catheter Complications Implanted Port Catheter Care Intermittent IV Medication Continuous IV Medication TPN Needless Version ACHC Home Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

20 Page 20 of N # Rx/Rn Syringe Pump Medication IV Syringe Pump Medication IV Needless Version TPN Needless Version Elastomeric Infusion Device IM Medication Continuous Subcutaneous Medication Epidural Medication Aerosolized Medication Oral (PO) Medication - Understanding the Use of Restraints ACHC Home DRX 7-22A Philosophy/Mission Statement PC.1.10, LD.1.20 DRX 1-7A, DRX 1-8A, HSP 1-3A.01, DRX 1-10A,HSP 1-3B Patient Acceptance Process (Patient Admission Criteria) PC.1.10 DRX 6-5A, DRX 4-11D, HH 5-13A.01, HSP 5-11A.01, DRX 6-1A, DRX 6-3F, HH 5-14A.01, DRX 6-1A, DRX 6-3B, DRX 6-1A, DRX 6-3G, DRX 6-3C Scope of Care and Services PC.1.10, LD.3.40 DRX 3-1A, HH 21A.01, HSP 2-1B.01, DRX 3-1B, HH 2-1A.02, HSP 2-1A Intake Referral (Entry Process) PC.1.10 DRX 3-1A, HH 21A.01, HSP 2-1B.01, DRX 3-1B, HH 2-1A.02, HSP 2-1A Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

21 Page 21 of 34 ACHC Home Staff Assignments PC.1.10, PC.5.60, PC.5.70, PC.15.10, PC.15.30, IM.6.20 DRX 4-12A, DRX 4-12B, DRX 4-14B, DRX 4-14C #2.3 #10.21 Interdisciplinary Referral PC.2.20, PC.2.130, PC.15.10, PC Community Resources, PC Care Coordination (Patient Care Conference) 5.7 Contracted Services/Written Agreements LD.3.120, IM.6.20 PC.5.50, PC.5.60, PC.5.70, PC.15.10, IM.3.10 PC.5.60, PC.5.70, PC.15.10, LD.3.50, IM Hours of Normal Operation RI.2.10, RI.2.20, RI.2.60, PC.1.10, PC On-Call (After Hours Care) RI.2.10, RI.2.20, RI.2.60, PC.1.10, PC.5.70 DRX 5-2B, DRX 5-4A, DRX 5-16A, DRX 5-16B, DRX 5-4E, DRX 5-16C DRX 6-4A, HH5-15A.01, HH5-5B.01 DRX 5-2B, DRX 5-4A, DRX 5-16A, DRX 5-16B, DRX 5-4E, DRX 5-16C Hh1-10A, HH1-10B, HH1-10C.01, HH1-10D.01 DRX 3-1A, HH2-1A.01, HH2-1A.02M, DRX 4-9D, DRX 2-11D, DRX 4-9D DRX 3-1A, HH2-1A.01, HH2-1A.02M, DRX 4-9D, DRX 2-11D, DRX 4-9D 5.10 Home Care Visit PC.5.60 DRX 5-3E, DRX 5-4C, DRX 5-18A 5.11 Physician Notification PC.5.50, PC.5.60, PC.5.70 DRX 5-2B, DRX 5-4A, DRX 5-16A, DRX 5-16B, DRX 5-4E, DRX 5-16C 5.12 Patient Abandonment RI.1.10, PC DRX 5-16A, DRX 5-16B, DRX 5-16C #10.10 Aggregation of Data and Information 6.1 Improving anizational Performance (IOP) Plan New Governing Body Member Orientation PI.1.10, PI.2.10, IM.3.10, IM.6.10 PI.2.3, PI.3.10, LD.3.10, LD.4.10, LD.4.50, LD.4.60, LD.4.70, LD.1.10, LD.1.20 DRX 2-1B, DRX 7-2A, DRX 7-2C, HH6-2A, HH6-4A.02, HH6-4A6.03, HH6-4A.04, HH6-4A.05 DRX 7-1A, DRX 7-1B, DRX 7-1C, DRX 7-2A, DRX 7-2C, DRX 7-2ª, HSP6-4A, HSP6-3A, HSP6-3B, HH6-2ª, HH6-4A, HH6-4A.02, HH6-2A, HH6-4A.03,HH6-4A.04, HH6-4A.05, DRX 7-4A, DRX 7-4B DRX 1-2A, DRX 1-2B, DRX 1-2C, HH1-2A, HH1-2A.03 Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

22 Page 22 of 34 ACHC Home anization-wide Planning Process LD.1.20, LD.3.10, LD.4.10 DRX 1-3B, HH1-3A, HH1-3A.02, HH1-3A.01, HH1-3B, DRX 7-1A, DRX 7-1B, DRX 7-1C Operating Budget LD.3.10, LD.4.20 DRX 4-2I, DRX 3-3A, HH3-1A, HH3-1C, HH3-1B, HH3-1D Policy Decision Process LD.2.10, LD.4.20 DRX 1-2A, DRX 1-2B, DRX 1-2C, DRX 1-3B, HH1-3A #5.1 Philosophy/Mission Statement PC.1.10, LD.1.20 DRX 1-7A, DRX 1-8A, DRX 1-10A /Rn Professional Advisory Committee (Program Evaluation) #5.2 LD.1.20 DRX 1-3B, HH1-3A, HH1-3A.01, HH1-3A.O2 Scope of Care and Services PC.1.10, LD.3.40 DRX 3-1A, HH2-1A Level of Care Equity LD.3.20 DRX 7-2A, HH6-2A, HH6-4A Patient Satisfaction Survey LD.2.10 DRX 7-2A, HH6-2A, HH6-4A Referral/Physician Satisfaction Survey PI.1.10, LD.3.10 DRX 7-2A, HH6-2A, HH6-4A Staff Satisfaction Survey PI.1.10 DRX 7-2A, HH6-2A, HH6-4A Lines of Responsibility LD.2.10, LD.2.20, LD.3.30, LD.4.10, LD.4.20, LD.4.70 DRX 1-6A, DRX 1-6B, DRX 1-7B, HH1-6A, HH1-6A.01 #5.7 Contracted Services (Written Agreements) PC.5.60, PC.5.70, LD.1.20, LD.3.50, IM.6.20 HH1-10A, HH1-10B, HH1-10C.01, HH1-10D.O Rx Pharmacy License LD.1.30 DRX 1-1A, HH1-1A, DRX 4-14A, DRX 1-1B Rn Home Care Agency License LD.1.30 HH 1-1A, DRX 1-1A HME Home Medical Equipment Dealer License LD.1.30 HH 1-1A, DRX 1-1A Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

23 Page 23 of 34 ACHC Home #6.1 Performance Improvement Planning Process - Leader s Role Safety Hazards Program EC.1.10 EC HME Environmental/Safety Policy Waiver HME Complimentary Basic Residential Safety Review PI.3.10, LD.3.10, LD.3.70, LD.3.80, LD.3.120, LD.4.10, LD.4.20, LD.4.40, LD.4.50, LD.4.60, LD.4.70 EC.1.10, EC.2.10 EC.1.10, EC.2.10 DRX 1-5A, DRX 1-5B, HH1-5A, HH1-5A.01, HH1-5B, DRX 1-6A, DRX 1-6B, DRX 1-7B, HH1-6A, DRX 7-1A, DRX 7-1B, DRX 7-1C, HH6-1A.01,HH6-1B.01, HH6-1C.01, DRX 7-2A, DRX 7-2C, DRX 7-2A, HH6-2A, HH6-4A, HH6-4A.01, HH6-4A.03, HH6-4A.04, HH HH7-1B.01, HH7-1D.01, HH7-2A.01, HH7-2B.01. HH7-3A.01, HH7-4A.01, HH7-5A.01, HH7-5B.01, HH7-6A.01 HH 7-5A.01, HH 7-5B.01, HH 7-6A.01, HH 7-6B.01, HH 7-7A.01 HH 7-2B.01, HH 7-2C Staff Security and Safety EC.1.10, EC.2.10 HH7-2A.01, HH7-2B.01, HH7.2C.01, HH7-4A.01, HH7-5A.01, DRX7-9A The Warehouse Area EC.1.10, EC.2.10, EC.5.10, EC.5.20, EC.5.50, EC Offices/Patient Services Area EC.1.10, EC.2.10, EC.5.10, EC.5.20, EC.5.50, EC Hazardous Materials and Waste Handling and Disposal Management Rx/Rn Hazardous Drugs/Chemicals Spill Management EC.3.10 EC.4.10, EC Fire Safety EC.5.10, EC.5.20, EC Utilities Management EC.6.50, EC.7.10, EC.7.30 DRX7-9A, DRX7-9B, HH7-4A.01, HH7-5A.01, HH7-5B.01, HH7-6A.01, HH7-6B.01 HH7-2A.01, HH7-2C.01, HH7-4A.01, HHT-5A.01, HH7-5B.01 DRX7-6A, DRX7-6B, HH7-6A.01, HH7-6B.01 DRX7-6A, DRX7-6B, HH7-6A.01, HH7-6B.01 DRX 4-8A, HH 7-5A.01, HH 7-5B.0, 1HSP 7-3A.01 HH7-4A Emergency Preparedness Plan EC.4.10, EC.7.30 HH7-3A.01, HH7-3B.01 Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

24 Page 24 of 34 ACHC Home Incident/Unusual Occurrence System # s 1.5, , , , # s , # #5.2 /Rx/ Rn Rx Medications and Nutritional Therapy Solutions Storage Medications and Nutritional Therapy Solutions Preparation EC.9.10, EC.9.20 EC.9.30 MM.2.10, M.2.20, MM.3.10, M.3.20, MM.4.10, M.4.50, MM.4.60, M.5.20, MM.7.40, M.8.10 MM.4.20 HH7-7A.01, HH7-7B.01 DRX 7-9A, DRX 7-9B, DRX 7-9C, DRX 7-9D, DRX 7-12C, DRX 7-12D, DRX 7-12H, DRX 7-12-E, DRX 7-12H DRX 7-9A, DRX 7-9B, DRX 7-9C, DRX 7-9D, DRX 7-12C, DRX 7-12D, DRX 7-12H, DRX 7-12-E, DRX 7-12H Rx/Rn Pump and Controller Selection MM.2.10, M.5.10 DRX 5-18A, DRX 5-17AM DRX 7-11D, DRX 7-22A Scope of Care and Services PC.1.10, LD.3.40 DRX 3-1A, DRX 3-1B Home Medical Equipment: HME Staff Setup Competencies EC.6.30, EC DRX 1-1A, DRX 1-7B, DRX 2-11A, DRX 2-11C, DRX 5-16D, DRX 5-16E HME Patient Selection EC.6.30, EC DRX 4-5C HME Delivery and Setup EC.6.30, EC.6.50, EC DRX 5-16g HME Patient/Caregiver Training DRX 5-2C, DRX 5-4D, DEX 5-4F, DRX 4-4G HME Home Medical Equipment: Follow-Up Care Oxygen: PC.2.150,, EC.6.30 DRX 4-5C HME Type II & III Equipment Setup EC.6.30 DRX 2-10B, DRX 5-2C, DRX 4-15A, HME Oxygen Therapy EC.6.30, EC.6.50, DRX 5-16D, DRX 5-16E, EC EC.6.30 DRX 2-11A, DRX 2-11C, # HME Staff Setup Competencies HR HME Oxygen Therapy: Patient Selection HME Oxygen Therapy: Patient/Caregiver Training EC.6.30, EC DRX 4-5C DRX 5-2C Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

25 Page 25 of 34 ACHC Home HME Oxygen Therapy: Setup EC.6.30, EC.6.50, EC HME Oxygen Therapy: Follow-Up Care HME Oxygen Therapy: Troubleshooting Nebulization and Aerosol Equipment: HME Nebulization & Aerosol Equipment # HME Staff Setup Competencies PC.2.150,, EC.6.30 EC.6.30, EC HR.1.20 EC.6.30 EC.6.30, EC.6.50, EC EC.6.30 HR.1.20 DRX 2-10B, DRX 5-2C, DRX 5-16D, DRX 5-16E, DRX 4-5C HME Patient Selection EC.6.30, EC DRX 4-5C HME Patient/Caregiver Training DRX 5-2C HME Setup EC.6.30, EC.6.50, EC HME Nebupent Setup EC.6.30, EC.6.50, EC HME Follow-Up Care PC.2.150,, EC HME Troubleshooting EC.6.30, EC.6.100, HR HME Nasal CPAP/BiPAP: EC.6.30 # HME Nasal CPAP/BiPAP: Staff Setup Competencies HME Nasal CPAP/BiPAP: Patient Selection HME Home Care Nasal CPAP/BiPAP: Patient/Caregiver Training EC.6.30, HR.1.20 DRX 5-16D, DRX 5-16E, DRX 4-5D, DRX 16D, DRX 5-16E, DRX 16G DRX 2-10B, DRX 5-2C, DRX 5-16D, DRX 5-16E, DRX 2-10B, DRX 5-2C, DRX 5-16D, DRX 2-10B, DRX 5-2C, DRX 5-16D, DRX 4-5C EC.6.30, EC DRX 4-5C DRX 5-2C HME Nasal CPAP/BiPAP: Setup EC.6.30, EC.6.50, EC HME Nasal CPAP/BiPAP: Follow-Up Care HME Nasal CPAP/BiPAP: Troubleshooting PC.2.150,, EC.6.30 EC.6.30, EC.6.100, HR.1.20 DRX 5-16D, DRX 5=16E, DRX 4-5D, DRX 5-16D, DRX 5-16E, DRX 2-10B, DRX 5-2CM DRX 5-16D, DRX 5-16E, DRX 2-10B, DRX 5-2CM DRX 5-16D, DRX 5-16E, DRX 4-5C DRX 5-16DX, DRX 5-16EM Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

26 Page 26 of 34 ACHC Home Mechanical Ventilator: HME Mechanical Ventilator HME Mechanical Ventilator: Staff Setup Competencies HME Mechanical Ventilator: Patient Selection HME Mechanical Ventilator: Patient/Caregiver Training EC.6.30, EC.6.50, EC EC.6.30, HR.1.20 EC.6.30, EC DRX 4-5C DRX 5-2C HME Mechanical Ventilator: Setup EC.6.30, EC.6.50, EC HME Mechanical Ventilator: Follow- Up Care HME Mechanical Ventilator Troubleshooting PC.2.150,, EC.6.30 EC.6.30, EC.6.100, HR.1.20 DRX 4-5D, DRX 5-16D, DRX 5-16E, DRX 2-10B, 2DRX 5-2C, DRX 5-16D, DRX 5-16E, DRX 2-10B, DRX 5-2CM DRX 5-16D, DRX 5-16EM DRX 4-5C DRX 5-16D, DRX 5-16E, HME Mechanical Ventilator Tracking EC DRX 5-16D, DRX 5-16E EC.6.30 DRX 4-5D, DRX 5-16D, HME Suction Equipment: DRX 5-16E, EC.6.30, HR.1.20 DRX 2-10B, DRX 5-2C, HME Staff Competencies DRX 5-16D, # HME Suction Equipment: Patient Selection HME Suction Equipment: Patient/Caregiver Training EC.6.30, EC DRX 4-5C DRX 5-2C HME Suction Equipment: Setup EC.6.30, EC.6.50, EC HME Suction Equipment: Follow-Up Care HME Suction Equipment: Troubleshooting # HME Chest Physical Therapy: Staff Competencies HME Chest Physical Therapy: Patient Selection HME Chest Physical Therapy: PC.2.150,, EC.6.30 EC.6.30, EC HR.1.20 EC.6.30 HR.1.20 DRX 2-10B, DRX 5-2C, DRX 5-16D, DRX 5-16E DRX 4-5C EC.6.30, EC DRX 4-5C EC.6.30 DRX 5-16D, DRX 2-10B, DRX 5-2C. DRX 5-16D, DRX 5-16E, DRX 4-5D, DRX 5-16D, Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

27 Page 27 of 34 ACHC Home HME Chest Physical Therapy: Patient/Caregiver Training ORG Sentinel Events/Root Cause Analysis HME Phototherapy: # HME Phototherapy: Staff Setup Competencies DRX 5-2C LD.4.10, LD.4.50, D.4.60, LD PI.1.10, PI.2.20, PI.2.30, PI.3.10, PI.3.20 EC.6.30 EC.6.30, HR.1.20 HH7-7A HME Phototherapy: Patient Selection EC.6.30, EC DRX 4-5C HME Phototherapy: Patient/Caregiver Training DRX 5-2C HME Phototherapy: Setup EC.6.30, EC.6.50, EC HME Phototherapy: Follow-Up Care PC.2.150,, EC HME Phototherapy: Troubleshooting EC.6.30, EC HR HME Apnea Monitor: EC.6.30 # HME Staff Setup Competencies HME Apnea Monitor:Patient Selection HME Apnea Monitor:Patient/Caregiver Training EC.6.30, HR.1.20 DRX 4-5D, DRX 5-16DM DRX 5-16E, DRX 5-16D, DRX 5-16E, DRX 2-10B, DRX 5-2C, DRX 5-16D, DRX 5-16E, DRX 4-5C EC.6.30, EC DRX 4-5C DRX 5-2C HME Apnea Monitor:Setup EC.6.30, EC.6.50, EC HME Apnea Monitor:Troubleshooting EC.6.30, EC HR HME Apnea Monitor:Follow-Up Care PC.2.150,, EC.6.30 DRX 5-16D, DRX 5-16E, DRX 4-5D, DRX 5-16E, DRX 2-10B, DRX 5-2C, DRX 5-16D, DRX 5-16E, DRX 2-10B, DRX 5-2C, DRX 5-16D, DRX 5-16EM DRX 5-16D, DRX 5-16EM DRX 4-5C ORG Delivery Vehicle Maintenance EC.6.40 HH 7-2B.01, HH 7-2C.01, HH 7-5A HME Delivery Vehicle Stock EC.6.40 DRX 6-16D, DRX 5-16EM DRX 16-G Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

28 Page 28 of 34 ACHC Home HME Daily Load Manifest and Checklist ORG Medical Equipment Backup EC.6.70, EC.6.80, EC ORG Tracking of Life-Sustaining or Life-Supporting Devices HME Separation of Unsafe Compressed Medical Gas Cylinders EC.6.40 DRX 5-16D, DRX 5-16E EC.6.70, EC.6.80, EC.6.90, EC ORG Equipment Status Tag EC.6.100, EC ORG Medical Equipment Inspection EC.6.60, EC.6.100, EC # HME Equipment Hazards/Defects/Records HME Oxygen Lot Number Assignment Log HME Oxygen Concentrator Master Service DRX 5-16D, DRX 6-16E EC.1.10 DRX 5-16D, DRX 6-16E DRX 5-16D, DRX 6-16E DRX 5-16D, DRX 5-16E EC.9.10 DRX 5-16D, DRX 5-16E LD.1.30, EC DRX 5-16D, DRX 5-16E LD.1.30, EC.6.60 DRX 5-16D, DRX 5-16E HME Oxygen Analyzer Calibration LD.1.30, EC.6.60 DRX 5-16D, DRX 5-16E HME Compressed Medical Gas Transfill Log LD.1.30, EC DRX 5-16D, DRX 5-16E HME Certificate of Oxygen Analysis LD.1.30, EC.6.60 DRX 5-16D, DRX 5-16E HME Liquid Oxygen Platform Scale: Daily Calibration LD.1.30, EC.6.60 DRX 5-16D, DRX 5-16E HME Respiradyne II Calibration LD.1.30, EC.6.60 DRX 5-16D, DRX 5-16E HME Paramagnetic Analyzer Calibration LD.1.30, EC.6.60 DRX 5-16D, DRX 5-16E HME CPAP/BiPAP Master Service LD.1.30, EC.6.60 DRX 5-16D, DRX 5-16E # # Rx Clean Air Center/Class 100 Laminar Airflow Hood Maintenance Rx Compounding Device (Compounder) Calibration and Maintenance Rx Sterile Compounding Quality Control Audit MM.4.20, PI.1.10, LD.1.30, EC MM.4.20, PI.1.10, LD.1.30, EC PI.1.10 DRX 4-13B, DRX 5-18A, HH A, HH 4-11C DRX 2-1A, DRX 2-10A, DRX 4-9D HH4-7C.01, DRX 7-2A, DRX 7-2C, DRX 7-2A, HSP6-5D, HSP6-5D, HSP6-5F.01 Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

29 Page 29 of 34 ACHC Home Rx Quality Control Notebook PI.1.10 DRX 7-2A, DRX 7-2C, DRX 7-2A, HSP6-5D, HSP6-5F.01D HME Home Respiratory Care Equipment Disinfection Procedure HME Equipment/Supplies Hazard, Defect, Recall and Product Liability Policy PI.1.10 EC.6.60 DRX 5-16D, DRX 5-16E PI.1.10, EC.9.10 DRX 5-16D, DRX 5-16E HME/Rx Therapeutic Shoe Fitter Services DRX 1-1A, DRX 1-7E, DRX 4-5B, DRX 2-1A, DRX 2-11C, DRX 4-5C, DRX 5-2C, DRX 5-2D, DRX 5-3A, DRX 5-31, DRX 5-4C, DRX 5-4F, DRX 5-4G 9.1 ORG Hiring of Personnel and Job Descriptions Job Description: Rx/HME - Biomedical/Maintenance Personnel LD.3.70, HR.1.10, HR.1.20, HR.3.20 DRX 5-1A, DRX 5-1B, DRX 2-6B, DRX 5-1D, DRX 5-9A, DRX 5-13A, DRX 5-13B, HH4-2B HR.3.20 DRX 5-9A, DRX 5-9B Rn - Certified Home Health Aide HR.3.20 HH 4-2E.0, HH 4-2A.01, HH 4-2BM HH 4-2C Rn - Clergy/Bereavement Coordinator HR.3.20 HH 4-2E.0, HH 4-2A.01, HH 4-2BM HH 4-2C Clerical Staff HR.3.20 DRX 5-9A, DRX 5-9B Dietician HR.3.20 DRX 5-9A, DRX 5-9B Rn - Director of Nursing HR.3.20 DRX 5-9A, DRX 5-9B Rn - Director of Patient Services/ Administrator Rx/HME - Equipment/Service Technician General Manager (Operations Manager) Governing Body Member (Chief Operating Officer) HR.3.20 DRX 5-9A, DRX 5-9B HR.3.20 DRX 5-9A, DRX 5-9B HR.3.20 LD.1.20 HR Rn - Homemaker HR.3.20 HH 4-2E.01 DRX 1-5A, DRX 1-5B, DRX 5-9A DRX 1-5A, DRX 1-5B, HH1-5A, HH1-5A.01, DRX 5-9A Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

30 Page 30 of 34 ACHC Home Rx/HME - Home Service Representative/ Driver (Customer Service Representative) Intake Coordinator (Patient Service Coordinator) HR.3.20 DRX 5-9A, DRX 5-9B HR.3.20 DRX 5-9A, DRX 5-9B Rx - Laboratory Technician HR.3.20 DRX 5-9A, DRX 5-9B Rn - Licensed Vocational Nurse HR , 401-A, 402-A, 402-B, 403-A, 403-B, 403-C Marketing Representative HR.3.20 DRX 5-9A, DRX 5-9B Rn - Medical Social Worker HR.3.20 HH 4-2E Rn - Nurse Case Manager HR.3.20 HH 4-2E Rn - Nursing Supervisor HR.3.20 HH 4-2E Rn - Occupational Therapist HR.3.20 HH 4-2E Rx/Rn - Patient Care Coordinator HR.3.20 DRX 5-9A, DRX 5-9B Rx - Pharmacist HR.3.20 DRX 5-9A, DRX 5-9B Rx - Pharmacist-In- Charge/Pharmacy Manager HR.3.20 DRX 5-9A, DRX 5-9B, DRX 4-14A, DRX 4-14B, DRX 4-14C Rx - Pharmacy Technician HR.3.20 DRX 5-9A, DRX 5-9B Rn - Physical Therapist HR.3.20 HH 4-2E Quality Improvement Coordinator HR.3.20 DRX 5-9A, DRX 5-9B Rn - Registered Nurse HR.3.20 HH 4-2E Reimbursement Specialist HR.3.20 DRX 5-9A, DRX 5-9B Rn/HME - Respiratory Therapist HR.3.20 DRX 5-9A, DRX 5-9B, DRX 5-9A, HH 4-2E.01, HH 4-2A.01, DRX 13-A, DRX 13- B, HH 4-2C.01, HH 4-2D Rn - Speech Therapist HR.3.20 HH 4-2E HME - Clinical Respiratory Care Manager HR.3.20 DRX 5-9A, DRX 5-9B, DRX 5-9A, HH 4-2E.01, HH 4-2A.01, DRX 13-A, DRX 13- B, HH 4-2C.01, HH 4-2D HME - Clinical Associate HR.3.20 DRX 5-9A, DRX 5-9B, DRX 5-9A, HH 4-2E.01, HH 4-2A.01, DRX 13-A, DRX 13- B, HH 4-2C.01, HH 4-2D.01 Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11

31 Page 31 of 34 ACHC Home HIPAA Chief Compliance Officer HR.3.20 DRX 105A, DRX 1-5B, DRX 5-9A, DRX 5-9B HME/Rx Therapeutic Shoe Fitter DRX 1-1A, DRX 1-7E, DRX DRX 4-5B 9.2 Personnel Files HR.3.20 DRX 5-9A, HH4-2C.01, HSP4-1A.01, HH4-1A.01, HH4-1A.02, HH4-5A.01 HH4-6A.01, HH4-8A 9.3 Staffing Ratios HR.1.10, HR.1.20, HR.3.10 #5.5 Staff Assignments PC.1.10, PC.5.60, PC.5.70, PC.15.10, PC.15.30, IM Staff Competency LD.2.10, HR.1.20, HR.2.30, HR Employee Orientation and Ongoing In-Services HR.2.10, HR.2.20 HR.2.30, HR Staff Proficiency Testing HR.1.10, HR.1.20 HR.2.30, HR Rx Validation-Initial Compounding HR.1.10, HR.1.20 HR.2.30, HR Patient Acceptance Process (Patient Admission Criteria) Rn/Rx Peripherally Inserted Central Catheter (PICC) and Midline Nurse/Pharmacist Certification Requirements PC.1.10 HR.1.20, HR.2.10, HR.2.20, HR.2.30, HR Rn Personal Care Staff Training HR.3.10 HH 4-8A Rx Marketing Pharmaceutical Care (Cognitive Services) HR.1.10, HR.1.20, HR.2.30, HR.3.10 HH4-7A.01, HSP4-7A.01, HSP4-7B HH4-7A.01, HSP4-7A.01, HSP4-7B HH4-7A.01, HSP4-7A.01, HSP4-7B HH4-5A.01, HH4-5A.01, HH4-5C.01, HH4-6A.01, HH4-6B.01, HSP4-8A.01, HSP4-8C HH4-6A, HH4-6B.01 HH4-7C.01 HH4-6A, HH4-6B.01 HH4-7C.0, DRX 7-8A, DRX 4-14E DRX 6-5A, DRX 4-11D, DRX 6-1A, DRX 6-3F, DRX 6-3B, DRX 6-3G, DRX 6-3C HH4-6A.01, HH4-6B.01, HH4-7C.01, HH4-2J, HH409A.01 DRX 3-4A, DRX 5-13A, HH46A Performance Evaluations HR.3.20 HH4-7C.01, HH4-2J, HH4-9A HME Employee Daily Work Log HR.1.10, HR.3.10 HH 4-7C.01HH 4-2J 9.10 Employee Exit Interview Check Out Form HR.3.10, HR.3.20 HH4-7C.01, HH4-9A.01 Infusion & Ambulatory Care Manual Copyright 2011 Care Partners Consulting Pharmacists, LLC. All Rights Reserved 12/10/11