Policies & Procedures Annual Review & Update
Clinical Record TITLE: Protection of EPHI Definitions: Protected Health Information ( PHI ): PHI is individually identifiable health information that is transmitted or maintained in any medium, including oral statements. Authentication: The process that ensures that users are who they say they are. The aim is to prevent unauthorized people from accessing data or using another person's identity to sign documents. Signature: A signature identifies the author or the responsible party who takes ownership of and attests to the information contained in a record entry or document. Electronic signatures are permitted for use by therapists and authorized personnel to allow for a digital signature on patient medical records. At a minimum, the electronic signature must include the full name and credentials of the author and the date and time signed. Electronic signatures must meet standards for data integrity to protect data from accidental or unauthorized change (for example locking of the entry so that once signed no further untracked changes can be made to the entry) and for authentication to validate the correctness of the information and confirm the identity of the signer (for example requiring signer to authenticate with password or other mechanism); Electronic signatures must be affixed only by that individual whose name is being affixed to the document and no other individual. No individual shall share electronic signature keys with any other individual. Countersignatures or dual signatures must meet the same requirements. Policy Effective Date: 01/01/2013 Policy Review:
Medical Record Policy Addendum Title: Therapist Storage of Medical Records Therapists have access to a patient s protected health information and are required to comply with HIPAA regulations and standards to protect the confidentiality of these records. Therapists use clinical record copies with the original/legal medical record maintained onsite by LifeCare of Florida. When therapy is provided in the home, it is understood that therapists must transport copies of pertinent clinical records with them to/from the patient s home. Vehicles, however, are not considered to be secure locations for long- term storage of medical records. Therapists are permitted to take only clinically relevant information for current day patients with them when travelling to a patient s home. Policy Effective Date: 02/01/2013
Medical Record Policy Addendum Title: Use of HICN LifeCare will comply with all standards and regulations related to the protection of personal health information. In order to reduce risk for identify theft, LifeCare will no longer use the patient s HICN on medical records, but will change to a XXX- XX- last 4 digit format. This will provide the necessary identifying information on patient records, but will help protect the HICN from unauthorized use. Policy Effective Date: 02/01/2013 Policy Review: Reference: HIPAA Standards
Personnel Policy Addendum TITLE: Dress Code As representatives of LifeCare, all therapists (both employees and Independent Contractors) will dress in a manner that is appropriate for their profession and job demands. LifeCare recommends professional attire (such as scrubs or light colored pants/polo- type shirt) with closed shoes to be worn at all times when representing LifeCare. LIfeCare lanyards as are also to be worn at all times when representing the company. Policy Effective Date: 02/01/2013 Policy Review: Reference:
Title: Clinical Record/Utilization Review The organization will provide for review of the quality and appropriateness of its programs and services for each person served. By quarterly record review of a sample of patient records; the organization will ensure that: Admission to the program was appropriate based on patient care policies; The plan of care is appropriate based on diagnosis and treatment goals; The clinical record reflects the rationale for continuing services; The clinical record reflects a program based on the individual needs of the person served. The written records accurately reflect established patient care policies. LifeCare will maintain an active and on- going clinical record review committee to meet this goal. While a portion of charts for the quarterly review are to be random, other charts are selected based on clinical complexities or variations in our routine standard of care. Indicators which may result in clinical record review by the UR Committee include, but are not limited to: Request for Re- Certification of Plan of Care by the therapist; Clinical complexities or conditions that affect patient progress; Medicare claim denial or appeal. The clinical record review will be conducted by the OPT s Core Team which consists of a physician and professionals representing each therapy discipline. Corrective action is assigned to appropriate program personnel based on the identified area of need. Minutes are to be maintained. Policies related to clinical record review will be reviewed annually. Effective Date: January, 2012 Reference I- 169 485.729(a) Standard: Clinical Record Review
Title: Exposure Control Plan LifeCare of Florida is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this goal, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens. The ECP is a key document to assist our organization in implementing and ensuring compliance with the standard, thereby protecting our Team. By the term, Team, we include our employees (part and full time) and contractors. This ECP includes: A. Determination of staff exposure; B. Implementation of various methods of exposure control, including: i. Universal precautions ii. Engineering and work practice controls iii. Personal protective equipment iv. Housekeeping C. Hepatitis B vaccination D. Post- exposure evaluation and follow- up E. Communication of hazards to Team members and training F. Recordkeeping G. Procedures for evaluating circumstances surrounding exposure incidents Implementation methods for these elements of the standard are discussed in the subsequent pages of this ECP. Program Administration: The Director of Safety is responsible for implementation of the ECP. The Director of Safety will maintain, review, and update the ECP at least annually, and whenever necessary to include new or modified tasks and procedures. Follow- up is the responsibility of the OPT Administrator. Those Team members who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP. The Director of Safety will provide and maintain all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. Exposure Control Plan Page 1 of 6
This individual will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes. The OPT Administrator will be responsible for ensuring that all medical actions required by the standard are performed and that appropriate health and OSHA records are maintained. The Director of Safety will be responsible for training, documentation of training, and making the written ECP available to Team members, OSHA, and NIOSH representatives. Team Exposure Determination: OSHA requires employers to perform an exposure determination concerning which Team members may incur occupational exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment (i.e. employees are considered to be exposed even if they wear personal protective equipment.). An employer is required to list all job classifications in which employees may be expected to incur an occupational exposure, regardless of frequency. At this facility, exposure risk is: LOW. The potential risk would be for those individuals who may work with a patient/client/visitor in an emergency situation. These individuals would be: Position Physical Therapist Occupational Therapist Speech Pathologist Job Task/Possible Exposure Incident Patient Contact (emergency situation) Patient Contact (emergency situation) Patient Contact (emergency situation) Other Team members not expected to have occupational exposure are listed as follows: Position OPT Administrator Administrative Staff Job Task/Possible Exposure Incident No Contact Anticipated No Contact Anticipated Methods of Implementation and Control: Universal Precautions: Universal precautions will be observed at this facility in order to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual. Exposure Control Plan Page 2 of 6
Exposure Control Plan Team members covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial orientation. It will also be reviewed in their annual update. All Team members can review this plan at any time during their work shifts by contacting the Director of Safety or through access to the documents on LifeCare s website. Whenever requested, we will provide a Team Member with a copy of the ECP free of charge and within 15 days of the request. The Director of Safety is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures that affect occupational exposure and to reflect new or revised employee positions with occupational exposure. Engineering & Work Practices Engineering and work practice controls will be utilized to eliminate or minimize exposure to employees at this facility. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be utilized. The controls will be examined and maintained on a regular schedule. The controls used and the schedule for reviewing the effectiveness of the controls is as follows: Engineering Control Schedule for Review Responsible for Review Handwashing Facilities Daily for Supplies Housekeeping Heavy Cardboard Containers Bi- Monthly Contract with Red Bags Gloves Replace as Needed Housekeeping Other PPE Replace as Needed Housekeeping Infection Control Policies Annual OPT Administrator Handwashing facilities are available to employees and staff who incur exposure to blood or other potentially infectious materials. OSHA requires that these facilities be readily accessible after incurring exposure. At this facility, handwashing facilities are located: in exam rooms, physical therapy, gym, and facility bathrooms. After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water. If employees incur exposure to their skin or mucous membranes than those areas shall be washed or flushed with water as appropriate as soon as feasible following contact. Needles/Sharps LifeCare of Florida does not expect staff to have exposure to needles or sharps. Exposure Control Plan Page 3 of 6
Personal Protective Equipment (PPE) All personal protective equipment used will be provided without cost. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employees' clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used. The following situations require that such protective clothing be utilized: EMERGENCY ONLY: Protective clothing will be used by the Team in the following manner: Personal Protective Equipment Gloves Lab Coat Face Shield Clinic jacket Protective eyewear (with solid side shield) Surgical Gown Shoe Covers Utility Gloves Task Open wounds Open wounds Not necessary for routine tasks Not necessary for routine tasks Not necessary for routine tasks Not necessary for routine tasks Not necessary for routine tasks Equipment decontamination All personal protective equipment will be cleaned, laundered, and disposed of by the employer at no cost to staff. All garments which are penetrated by blood shall be removed immediately or as soon as feasible. All personal protective equipment will be removed prior to leaving the work area and disposed of in provided red bags. Masks in combination with eye protection devices, such as goggles or glasses with solid side shield, or chin length face shields, are required to be worn whenever splashes, spray, splatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonable be anticipated. Situations at this facility which would require such protection are as follows: no routine situations emergency use only. This facility will be cleaned and decontaminated according to the following schedule: Decontamination will be accomplished by utilizing bleach solutions or EPA registered germicides. Any broken glassware which may be contaminated will not be picked up directly with the hands. The following procedures will be used: heavy utility gloves are to be worn and broom and dust pan are to be used. Broom and dustpan are to be decontaminated after use. Exposure Control Plan Page 4 of 6
Regulated Waste Disposal LifeCare of Florida will maintain an agreement for regulated waste disposal. Laundry Procedures Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be placed in appropriately marked bags at the location where it was used. Such laundry will not be sorted or rinsed in the area of use. All staff who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious materials. Laundry at this facility will be disposable or cleaned onsite. Contaminated laundry is to be disposed of as regulated waste disposal. Hepatitis B Vaccine: All employees who have been identified as having exposure to blood or other potentially infectious materials will be offered the Hepatitis B vaccine, at no cost to the employee. The vaccine will be offered within 10 working days of their initial assignment to work involving the potential for occupational exposure to blood or other potentially infectious materials unless the employee has previously had the vaccine or who wishes to submit to antibody testing which shows the employee to have sufficient immunity. If an employee declines the vaccination, the employee must sign a declination form. Employees who decline may request and obtain the vaccination at a later date at no cost. Documentation of refusal of the vaccination is kept within the Personnel Record. Employees who initially decline the vaccine but who later wish to have it may then have the vaccine provided at no cost. Post- Exposure Evaluation and Follow- up When the employee incurs an exposure incident, it should be reported to the OPT Administrator. All employees who incur an exposure incident will be offered post- exposure evaluation and follow- up in accordance with the OSHA standard. This follow- up will include the following: - - Documentation of the route of exposure and the circumstances related to the incident; If possible, the identification of the source individual and, if possible, the status of the source individual. The blood of the source individual will be tested (after consent is obtained) for HIV/HBV infectivity. Exposure Control Plan Page 5 of 6
- Results of testing of the source individual will be made available to the exposed employee with the exposed employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual. The employee will be offered the option of having their blood collected for testing of the employees HIV/HBV serological status. The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status. However, if the employee decides prior to that time that testing will or will not be conducted then the appropriate action can be taken and the blood sample discarded. Exposure Control Plan Page 6 of 6
Title: Onsite Emergency Evacuation LifeCare will evacuate and/or assist in the evacuation of all persons onsite in the event of an internal or external disaster. A minimum of two staff persons will be onsite at all times when a patient is being treated. In accord with our policy to test various aspects of the Emergency Plans, LifeCare will conduct emergency evacuations at a minimum of once per year. Results of the test of the emergency evacuation are to be submitted, in writing, to Administration. Corrective action, if indicated, is the responsibility of Administration. Procedure: In the event that a full evacuation is required, staff are to assemble the patients in the parking area in front of the Center. In the event that staff and patients cannot return to the Center, Tamarac Elementary School will be the designated shelter area. Staff are responsible to coordinate transportation for patients and clients. Staff will remain onsite until the disposition of patients is completed. Policy Effective Date: 01/01/2012 Reference 485.727 Disaster Preparedness Standards for Accreditation of Rehabilitation Agencies
Title: Fire Plan Lifecare s immediate interest is to protect the safety of all staff, persons served, and visitors within the facility. Fire/Safety is the responsibility of each and every staff member. All staff are to be aware of the location of the nearest fire extinguisher and are aware to call 911 in the event of a fire or suspected fire. A staff member may attempt to extinguish the fire if it is small and in a controlled area, provided there is no personal risk. Procedure: In the event of a fire or suspected fire (smoke, no flames, or the smell of smoke), the following steps are to be taken. 1. The first person to learn of the fire or threat of fire is responsible for: Setting off fire alarm to begin evacuation procedure. Calling 911 to notify of the threat and our location. 2. All staff, as per policy, will begin evacuation following Evacuation Procedure. 3. OPT Administrator/Assigned Designee is to b ring the appointment/scheduling book prior to exiting the building to allow for a count of persons onsite. Policy Effective Date: 01/01/2012 Reference 485.727 Disaster Preparedness Standards for Accreditation of Rehabilitation Agencies
Title: Natural Disaster Plan In the event of an eminent natural disaster, such as a hurricane, LifeCare will remain closed. In the event of a sudden natural disaster, such as a severe storm or tornado, LifeCare will protect the safety of staff, patients and visitors onsite until the disaster is over and conditions are safe for exit. Procedure: When conditions warrant, as determined by Administration, all patients will be disconnected from electrical equipment and activities are to be conducted away from doors and windows. Telephone use will be restricted to emergencies only. Policy Effective Date: 01/01/2012 Reference 485.727 Disaster Preparedness Standards for Accreditation of Rehabilitation Agencies
Title: Power Failures Power failures are not expected to create an emergency situation given the physical structure of the building, the many outside windows, and the fact that we operate during daytime hours only. LifeCare will provide flashlights available for local lighting and emergency exit lights will be activated if power is disconnected. Procedure: In the event of a power failure, the following procedure will apply: LifeCare will provide flashlights for local lighting. Patients will be disconnected from electrical equipment. Staff will remain onsite as long as patients or visitors are onsite. Patients are to be kept with minimal transfer between areas and supervised. Policy Effective Date: 01/01/2012 Reference 485.727 Disaster Preparedness Standards for Accreditation of Rehabilitation Agencies
Title: Medical Emergency: On- Site LifeCare will attempt to render immediate assistance in the case of a medical emergency. If a physician is onsite, he or she is to be called to the scene immediately. The person administering the first aid is also a primary concern. An accident or emergency scene must always be evaluated to determine if it is safe to enter before making contact with the patient(s). Forgetting to evaluate the safety of a scene will put this individual at risk for becoming a victim himself. Procedure: First Person on Scene: 1. Yell for help. 2. Dial 911. 3. Give way to persons with greater medical knowledge. 4. Obtain emergency medical supplies. Physician/Nurse/First- Aide/CPR Certified Individual will: 1. Conduct a secondary survey. 2. Administer first aide or CPR as appropriate until EMS arrives. Support Staff: 1. Copy necessary forms to accompany person to hospital: For patients, the PIF is to be copied; For staff, the Staff Demographic Sheet will be copied; 2. Help clear way for emergency team and evacuation. An Incident Report is to be completed following the incident. Policy Effective Date: 01/01/2012 Reference 485.727 Disaster Preparedness Standards for Accreditation of Rehabilitation Agencies
Title: Medical Emergency: Off- Site LifeCare staff who are faced with a medical emergency off- site are asked to provide support and assistance within the scope of his/her knowledge and expertise. The safety of the LifeCare staff member is also paramount and personal safety should never be jeopardized. Procedure: In the event of a medical emergency that occurs in the home or offsite with a LifeCare representative present, the following steps are to be taken: Call 911. Stay onsite until paramedics arrive on scene. Notify LifeCare of the incident. Complete Incident Report Policy Effective Date: 01/01/2012 Reference 485.727 Disaster Preparedness Standards for Accreditation of Rehabilitation Agencies
Title: Non- Medical Emergency: Off- Site Therapists may face situations which may not be a medical emergency. This is to be dealt with on a case- by- case basis with the safety of the patient being paramount. Examples of non- medical concerns may be the patient feeling ill or other circumstance when there is a concern, but not a true emergency. Procedure: If a non- medical concern arises with a patient offsite, the following procedure is to be followed: (1) Contact LifeCare or directly contact the patient s physician; (2) Patient s physician will direct the plan of action. (3) Stay with the patient until resolution. (4) Document the incident on daily notes. Policy Effective Date: 01/01/2012 Reference 485.727 Disaster Preparedness Standards for Accreditation of Rehabilitation Agencies