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TABLE OF CONTENTS ORGANIZATION AND ADMINISTRATION 1 Mission Statement... 2 Policy and Procedure Development and Implementation... 3 Governing Body... 6 Professional Advisory Committee... 10 Orientation for Governing Body and PAC Members... 12 Organizational Structure... 14 Organizational Chart... 16 Compliance/Whistleblower Policy... 17 Medicare/Medicaid Fraud and Abuse... 20 Conflict of Interest... 22 Public Disclosure... 24 Legal Requirements... 25 Closure/Transfer of Ownership... 27 PERSONNEL, VOLUNTEERS, AND CONTRACTORS 29 Equal Employment and Affirmative Action... 30 Criminal History, Disclosure, and Background Inquiries... 31 Personnel Selection... 34 Personnel Requirements... 37 Home Health Aide Training (Optional)... 39 Physician Licensure Verification... 43 Personnel File Content and Management... 44 Conditions of Employment... 47 Orientation to Agency... 49 Continuing Education... 52 Agency Resource Materials... 54 Performance Evaluation... 55 Supervision of Clinical Staff... 57 Supervision of Non-Clinical Staff... 60 Supervision of Home Health Aides... 62
Supervision of Homemakers... 64 Corrective Action... 66 Personnel Grievances and Complaints... 68 Smoke Free Workplace... 69 Drug and Alcohol Free Workplace... 71 Drug Testing... 74 Intimidation, Discrimination, and Harassment... 76 Ethical Issues... 78 Job Description: Administrator... 81 Job Description: Director of Clinical Services... 85 Job Description: Office Manager... 88 Job Description: Quality Coordinator/Compliance Officer... 91 Job Description: Clinical Supervisor... 94 Job Description: Registered Nurse Case Manager... 97 Job Description: Licensed Vocational Nurse... 100 Job Description: Physical Therapist... 103 Job Description: Physical Therapy Assistant... 107 Job Description: Occupational Therapist... 110 Job Description: Occupational Therapist Assistant... 113 Job Description: Speech Language Pathologist... 116 Job Description: Masters-Prepared Social Worker... 119 Job Description: Bachelors-Prepared Social Worker/Social Work Assistant... 122 Job Description: Dietitian... 125 Job Description: Home Health Aide... 128 Job Description: Scheduler/Patient Care Coordinator... 132 PATIENT CARE POLICIES AND PROCEDURES 134 Scope and Availability of Home Health Care Services... 135 Patient Rights and Responsibilities... 137 Advance Directives... 145 Eligibility and Covered/Non-Covered Services... 148 Certification/Re-Certification/Face-To-Face Process... 151 Informed Consent... 153 OASIS Comprehensive Assessment... 155
Admission... 158 On-Call Services... 161 Skilled Nursing Services... 163 Physical Therapy Services... 165 Occupational Therapy Services... 167 Speech Therapy Services... 169 Medical Social Worker Services... 171 Home Health Aide Services... 173 Homemaker Services... 175 Dietary Counseling Services... 177 Laboratory Services... 179 Telemedicine Policy... 180 Durable Medical Equipment and Supply Services... 182 Contracted Services... 184 Coordination of Care... 188 Case Conferences... 191 Patient/Caregiver Education... 193 Communicating with Patients... 195 Pain Management... 197 Physician Plan of Care Orders... 200 Behavior Management... 204 Use of Restraints... 206 Medication Administration... 208 Medication Assistance... 212 Medication Disposal... 215 Advance Beneficiary Notices... 217 Patient Transfer... 224 Patient Discharge... 227 Patient Expiration at Home... 230 CLINICAL RECORDS/INFORMATION MANAGEMENT 233 Information Management Plan... 234 Record Retention and Disposal... 239 Notice of Privacy Practices... 244
HIPAA Compliance for PHI*... 246 Release and Disclosure of Patient Health Information... 250 Patient Request for Restrictions on Use/Disclosure of PHI... 253 Patient Privacy and Security... 255 Patient Clinical Record... 258 Patient Charting... 261 PERFORMANCE IMPROVEMENT 263 Performance Improvement Program... 264 Performance Improvement Initiatives... 269 Performance Improvement Monitoring... 275 Clinical Record Review... 278 Annual Program Evaluation... 281 Research... 285 Patient Satisfaction Survey... 286 Patient/Family Complaints and Grievances... 288 Risk Management... 290 Mandatory Reporting of Abuse and Neglect... 292 Patient/Personnel Incident Reporting... 295 Adverse Drug Reactions... 298 Medication Errors... 304 Adverse Events... 306 INFECTION CONTROL 309 Tuberculosis Exposure Control... 310 Hepatitis B Prevention/Vaccination... 314 Infection Control/Exposure Plan... 316 Universal Precautions... 322 Employee Exposure to Bloodborne Pathogens... 326 Disposal of Needles, Syringes, and Sharps... 329 Hazardous Waste Disposal... 331 Reportable Diseases... 334 SAFETY 338
Safety Management... 339 Workplace Safety... 342 Safe Medical Devices Act/Medical Device Tracking... 343 Personnel Safety... 346 Pets in the Home... 348 Food Handling... 349 Fall Prevention... 351 Violence in the Workplace... 352 Emergency Care... 354 Emergency/Disaster Preparedness and Procedures... Error! Bookmark not defined. Staff and Patient Home Safety... 356 Home Environment/Safety Assessment... 365 OSHA 300/300A/301 Logs... 366 Employee Protective Equipment... 368 FINANCIAL POLICIES 370 Financial Management... 371 Fee Setting and Collections... 374 Liability Insurance... 377 Budget Preparation... 378 Strategic Plan... 379 Financial Monitoring... 381 Chart of Accounts... 383 Claims Submission and Denied Claims Processes... 384 Billing Audits and Annual Financial Review... 388 Accounts Receivable and Payable... 390 Transportation Reimbursement... 392 Payroll Compensation and Benefits... 393 Petty Cash... 395 Inventory/Fixed Assets... 396 RESOURCE TOOLKIT 397 Compliance Plan Education Elements... 398 Samples of Suspected Home Health Care Compliance Violations... 400
Developing a Patient Bill of Rights... 401 Sample: Individual Statement Regarding Conflict of Interest... 402 Sample: Continuous Care Personnel Orientation... 403 Sample: Physician License Verification Request Form... 406 Sample: Complaint Form... 407 Sample: Employee Complaint Form... 409 Sample: Patient Medication Disposal Form... 411 Sample: Home Health Quality Grid... 412 OSHA Injury and Illness Recordkeeping and Reporting... 414 Research Informed Consent Form... 415 Research Documentation... 416 California Title 22 Definitions... 417 California License Requirements Title 22/Division 5/Chapter 6... 421 California Title 22 Division 5 Chapter 6 Plans of Correction Requirements... 428