i TABLE OF CONTENTS ORGANIZATION AND ADMINISTRATION 1 Mission Statement... 2 Policy and Procedure Development and Implementation... 3 Governing Body... 5 Professional Advisory Committee*... 8 PAC and Governing Body Member Orientation... 10 Organizational Structure... 12 Organizational Chart... 14 Compliance/Whistleblower Policy... 15 Conflict of Interest... 18 Public Disclosure... 20 Legal Requirements... 21 Closure/Transfer of Ownership... 23 PERSONNEL AND CONTRACTORS 24 Equal Employment and Affirmative Action... 25 Criminal History, Disclosure, and Background Inquiries... 26 Personnel Selection... 30 Personnel Requirements... 33 Personnel File Content and Management... 35 Orientation to Home Care Agency... 38 Continuing Education... 41 Home Care Agency Resource Materials... 43 Performance Evaluations... 44 Supervision of Basic Personal Care Assistants... 46 Supervision of Homemakers... 48 Corrective Action... 50 Employee Grievances and Complaints... 52 Smoke Free Workplace... 53 Drug and Alcohol-Free Workplace... 55 Drug Testing... 58
ii Intimidation, Discrimination, and Harassment... 60 Ethical Issues... 62 Conditions of Employment... 65 Job Description: Administrator... 67 Job Description: Office Manager... 70 Job Description: Quality Coordinator/Compliance Officer... 73 Job Description: Service Supervisor... 76 Job Description: Basic Personal Care Assistant... 79 Job Description: Homemaker... 83 Job Description: Scheduler/Client Care Coordinator... 86 CLIENT SERVICES POLICIES AND PROCEDURES 88 Scope and Availability of Agency Services... 89 Client Rights and Responsibilities... 91 Advance Directives... 98 Informed Consent... 101 Admission and Assessment... 103 Plan of Care On-Call Services... 107 Basic Personal Care Assistant Services... 108 Homemaker Services... 110 Contracted Services... 112 Coordination of Services... 115 Medication Assistance... 117 Client/Caregiver Education... 120 Communicating With Clients... 122 Behavior Management... 124 Client Transfer and/or Discharge... 126 Client Expiration at Home... 129 CLIENT RECORDS/INFORMATION MANAGEMENT 131 Information Management Plan... 132 Record Retention And Disposal... 137 Notice of Privacy Practices... 141 HIPAA Compliance for PHI*... 143
iii Release and Disclosure of Client Health Information... 147 Client Requests for Restrictions on Use/Disclosure of PHI... 150 Client Privacy and Security... 152 Client Service Record: Non-Skilled... 155 PERFORMANCE IMPROVEMENT 157 Performance Improvement Program... 158 Performance Improvement Initiatives... 163 Performance Improvement Program Monitoring... 169 Client Record Review... 172 Annual Program Evaluation... 175 Client Satisfaction Survey... 179 Client/Family Complaints and Grievances... 181 Risk Management... 183 Mandatory Reporting of Abuse and Neglect... 185 Client/Employee Incident Reporting... 188 Client Self-Administered Medication Errors... 191 Adverse Events... 193 INFECTION CONTROL 196 Tuberculosis Exposure Control... 197 Hepatitis B Prevention/Vaccination... 201 Infection Control/Exposure Plan... 203 Universal Precautions... 209 Employee Exposure to Bloodborne Pathogens... 213 Hazardous Waste Disposal... 216 Reportable Diseases... 218 SAFETY 222 Safety Management... 223 Workplace Safety... 226 Safe Medical Devices Act/Medical Device Tracking... 227 Personnel Safety... 229 Pets In The Home... 231 Food Handling... 232
iv Fall Prevention... 234 Violence in the Workplace... 235 Emergency Care... 237 Emergency/Disaster Preparedness and Procedures... 239 Staff and Client Home Safety... 246 Home Environment and Safety Assessment... 247 OSHA 300/300A/301 Logs... 248 Employee Protective Equipment... 250 FINANCIAL POLICIES 252 Financial Management... 253 Fee Setting and Collections... 256 Liability Insurance... 258 Budget Preparation... 259 Strategic Plan... 260 Financial Monitoring... 262 Chart of Accounts... 263 Claims Submission and Denied Claims Processes... 264 Billing Audits and Annual Financial Review... 268 Accounts Receivable and Accounts Payable... 270 Transportation Reimbursement... 272 Payroll Compensation and Benefits... 273 Petty Cash... 275 Inventory/Fixed Assets... 276 RESOURCE TOOLKIT 277 Compliance Plan Education Elements... 278 Samples of Suspected Home Health Care Compliance Violations... 280 Developing a Client Bill Of Rights... 281 Sample: Individual Statement Regarding Conflict of Interest... 282 Sample: Continuous Service Personnel Orientation... 283 Sample: Complaint Form... 286 Sample: Employee Complaint Form... 288 Sample: Home Care Quality Grid... 290 OSHA Injury and Illness Recordkeeping and Reporting... 292
v Application information and forms 291 Administrative Organization Organizational Structure Criminal Record Statement Criminal Record Exemption Transfer Request Criminal Record Clearance Submission Criminal Background Clearance Transfer request Request for Live Scan Services Guidelines for Community Care Licensing HomeCare Aide Registry Application Registration Intent Form Instructions for Completion of the Medi-Cal Provider Agreement Medi-Cal Provider Agreement