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Home Health Policy and Procedure Manual

MCN Healthcare’s Home Health Policy and Procedure Manual provides over 400 policies and procedures addressing administration, emergency management, human resources, medical records, infection control, safety and security, equipment management, medication management, performance improvement, patient rights and responsibilities, waived testing as well as patient care. The Home Health Policy and Procedure Manual is cross referenced to CMS regulations, TJC, ACHA, and CHAP standards.

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Changes

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Table of Contents - TJC Standards, CMS Regulations Table of Contents - ACHC Standards, CMS Regulations Table of Contents - CHAP Standards, CMS Regulations Copyright Disclaimer Approval/Signature Sheet Introduction

SECTION 01 - EMERGENCY MANAGEMENT

1001 - Emergency Operations Plan 1002 - Hazard Vulnerability Analysis (HVA)1003 - Emergency Management - Hazard Vulnerability Analysis Worksheet - Example 1004 - Command Structure and Staffing 1005 - Communications Processes During an Emergency/Disaster 1006 - Emergency Management Call-Back Tree Sample 1007 - Emergency Management Responder List 1008 - Communications - Patients and Families 1009 - Patient and Family Education Handout - Emergency Management 1010 - Equipment and Supplies 1011 - Utilities - Emergency Management 1012 - Emergency Procedures for Utility System Failure/Disruption 1013 - Managing Patients During an Emergency/Disaster 1014 - Emergency Response Exercise - Exercises and Improvement Plans 1015 - Bomb Incident Plan 1016 - Detecting Suspicious Packages/Letters 1017 - Bomb Threat Report Form 1018 - Natural Disaster Management Plan 1019 - Terrorism Response Plan

SECTION 02 - ENVIRONMENT OF CARE

2001 - Environmental Safety 2002 - Letter of Appointment - Safety Director 2003 - Duties of Safety Director 2004 - Duties of Department Manager in Safety Program 2005 - Safety - Hazard Surveillance Program 2006 - Home Hazard Analysis Checklist Form 2007 - Initial Home Safety Evaluation and Instruction Form 2008 - Safety Education 2009 - Safety and Security Training for Home Health Staff 2010 - Body Mechanics Training 2011 - Security Plan 2012 - Security Education 2013 - Staff Safety Information Form 2014 - Employee Photo Identification Badge 2015 - Hazardous Materials and Waste Plan 2016 - Safety Precautions When Using Oxygen in the Home 2017 - Antineoplastic Waste Management 2018 - Chemotherapy Liquid Spills 2019 - Fire Safety Plan 2020 - Fire Drill Evaluation Form 2021 - Utility Systems Management Plan

SECTION 03 - EQUIPMENT MANAGEMENT

3001 - Medical Equipment Used by Staff 3002 - Infusion Pump Safety 3003 - Durable Medical Equipment 3004 - Equipment Delivery and Set-Up 3005 - Safe Medical Devices - Home Health 3006 - Medical Device Problem and Recall

SECTION 04 - HUMAN RESOURCES

4001 - Staffing - General 4002 - Qualifications and Competency - HHA 4003 - Licensure, Certification and Registration Verification and Control Systems 4004 - Criminal Background Checks 4005 - Criminal Background Check Release of Information Authorization Form - Sample 4006 - Reference Checking 4007 - Physician Licensure Verification 4008 - Orientation Program 4009 - Orientation - Certified Home Health Aide Services 4010 - Performance Evaluations 4011 - Employee Education Programs 4012 - Continuing Education/Inservice Attendance Record Form 4013 - Monitoring of CHHA and CNA Inservice Hours 4014 - Position Description/Performance Evaluation - Home Health Administrator 4015 - Annual Competency Clinical Skills Assessment - Home Health Administrator 4016 - Position Description/Performance Evaluation - Home Health Patient Care Services Director 4017 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Patient Care Services Director 4018 - Annual Competency Clinical Skills Assessment - Home Health Patient Care Services Director 4019 - Position Description/Performance Evaluation - Home Health Intake Nurse 4020 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Intake Nurse 4021 - Annual Competency Clinical Skills Assessment - Home Health Intake Nurse 4022 - Position Description/Performance Evaluation - Home Health Clinical Supervisor 4023 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Clinical Supervisor 4024 - Annual Competency Clinical Skills Assessment - Home Health Clinical Supervisor 4025 - Position Description/Performance Evaluation - Home Health Case Manager 4026 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Case Manager 4027 - Annual Competency Clinical Skills Assessment - Home Health Case Manager 4028 - Position Description/Performance Evaluation - Home Health LPN/LVN 4029 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health LPN/LVN 4030 - Annual Competency Clinical Skills Assessment - Home Health LPN/LVN 4031 - Position Description/Performance Evaluation - Home Health Physical Therapist 4032 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Physical Therapist 4033 - Annual Competency Clinical Skills Assessment - Home Health Physical Therapist 4034 - Position Description/Performance Evaluation - Home Health Occupational Therapist 4035 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Occupational Therapist 4036 - Annual Competency Clinical Skills Assessment - Home Health Occupational Therapist 4037 - Position Description/Performance Evaluation - Home Health Speech-Language Pathologist 4038 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Speech-Language Pathologist 4039 - Annual Competency Clinical Skills Assessment - Home Health Speech-Language Pathologist 4040 - Position Description/Performance Evaluation - Home Health Medical Social Worker 4041 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Medical Social Worker 4042 - Annual Competency Clinical Skills Assessment - Home Health Medical Social Worker 4043 - Position Description/Performance Evaluation - Home Health Aide 4044 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Aide 4045 - Annual Competency Clinical Skills Assessment - Home Health Aide 4046 - Annual Competency - Joint Commission National Patient Safety Goals - Home Health/Hospice 4047 - Employment of Certified Home Health Aides/Nursing Assistants 4048 - Home Health Aide Training 4049 - Certified Home Health Aide - Competency 4050 - Certified Home Health Aide Competency Evaluation Program 4051 - Certified Home Health Aide Competency Checklist Form 4052 - Certified Home Health Aide Supervision 4053 - Supervision Checklist Form 4054 - Equal Opportunity Employment 4055 - Applications for Employment 4056 - Attendance and Tardiness 4057 - Change in Personal Information 4058 - Classification of Employees 4059 - Disciplinary Action 4060 - Dress Regulations 4061 - Employee Assistance Program 4062 - Employee Communications 4063 - Employee Handbook 4064 - Employee Requests for Time Off 4065 - Employment of Foreign Applicants 4066 - Employment of the Disabled 4067 - Employment of Relatives 4068 - Exit Interviews 4069 - Exit Interview Form - Sample 4070 - Garnishment of Wages 4071 - Holiday Policy 4072 - Payroll Distribution/Time Verification 4073 - Personnel Files - Contents and Originations 4074 - Procurement of Employees 4075 - Personnel Requisition Form - Sample 4076 - Re-Employment 4077 - Sick Leave Policy 4078 - Termination of Employment 4079 - Staff Recruitment, Retention and Education 4080 - Vacation Policy 4081 - Workers' Compensation

SECTION 05 - INFECTION PREVENTION AND CONTROL

5001 - Infection Prevention and Control Program - Home Health 5002 - Infection Prevention and Control Plan - Home Health 5003 - Infection Prevention and Control Committee 5004 - Infection Report Form 5005 - Infection Surveillance Sheet 5006 - Patient Infection Control Log Form 5007 - Summary of Monthly Infection Control Data Form 5008 - Reporting Patient Infections 5009 - Nationally Notifiable Infectious Diseases 5010 - Standard Precautions 5011 - Hand Hygiene - CDC Guidelines 5012 - Hand Hygiene/Glove Use Observation Form 5013 - Respiratory Hygiene/Cough Etiquette in Healthcare Settings 5014 - Transmission-Based Precautions (Isolation Precautions)5015 - Asepsis 5016 - Nursing Bag Techniques 5017 - Personal Protective Equipment 5018 - Personal Protective Equipment - Training 5019 - Management of Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings 5020 - AIDS/HIV Positive Guidelines 5021 - Guidelines for Prevention of Tuberculosis Transmission in the Home 5022 - Tuberculosis Training Program Outlines 5023 - Influenza Vaccination - Home Health 5024 - Influenza Immunization Program for Healthcare Staff - Monthly Implementation Checklist 5025 - Influenza Vaccination Program for Healthcare Staff 5026 - HHA Plan and Response to a Potential or Actual Influenza Pandemic Outbreak 5027 - Pandemic Risk Assessment Tool for Home Care Organizations 5028 - CDC - Home Healthcare Services Pandemic Influenza Planning Checklist 5029 - Exposure Control Plan 5030 - Sharps Injury Protection Plan 5031 - Sharps Injury Log Form 5032 - Employee Exposure to Blood and Body Fluids - Sample Form 5033 - Infectious Waste Management Plan

Employee Health

5101 - Employee Health Program 5102 - Tuberculosis Screening Program 5103 - Health Questionnaire for Positive Tuberculosis Skin Test Reactions 5104 - Employee Health - Immunizations 5105 - Hepatitis B Vaccine Program 5106 - Informed Consent for Hepatitis B Vaccine Form 5107 - Hepatitis B Vaccine Declination Form 5108 - Workplace Injury, Illness or Fatality Reporting 5109 - Employee Health - Employee Illnesses 5110 - Employee Absence Report Form 5111 - Exposure to HIV

SECTION 06 - INFORMATION MANAGEMENT

6001 - Information Management Plan - Home Health 6002 - Interruptions to Electronic Health Information 6003 - Confidentiality of Information - General Issues 6004 - Confidentiality of Information - Electronic Health Records 6005 - Electronic Signature Authorization/Confidentiality Form 6006 - Confidentiality of the Medical Record 6007 - Uses and Disclosures of Protected Health Information - General Rules 6008 - Uses and Disclosures of Protected Health Information Subject to an Agreed-Upon Restriction 6009 - Restriction Agreement - Release of Patient Protected Health Information Consent Form 6010 - Release of Medical Information 6011 - Release of Patient Information Consent Form 6012 - Patient Medical Record Access Form 6013 - Reporting OASIS Information 6014 - Documentation and the Use of Abbreviations, Acronyms and Symbols 6015 - Unacceptable Abbreviation and Symbol List 6016 - Knowledge-Based Information 6017 - Utilization of the Facsimile Machine 6018 - Guidelines for the Use of Electronic Mail

SECTION 07 - LEADERSHIP

7001 - CMS Definitions 7002 - Organization and Structure 7003 - Governance - Board of Directors/Management Company 7004 - Governance - Sole Proprietorship 7005 - Professional Advisory Committee 7006 - Organization Chart - Example 7007 - Licensure 7008 - Mission Statement 7009 - Philosophy 7010 - Non-Discrimination Policy 7011 - Compliance with Federal, State and Local Laws 7012 - Fiscal Planning 7013 - Annual Operating Budget 7014 - Communication Process 7015 - Agency Supervision 7016 - Supervision of Care, Treatment and Services 7017 - Supervising Physician or Registered Nurse 7018 - Guidelines for Medical Management and Physician's Responsibilities 7019 - Scope of Services 7020 - Professional Standards and Principles 7021 - Staff Under Hourly or Per Visit Contracts 7022 - Contracted Services 7023 - Policies and Procedures 7024 - Role of HHA Leadership in Performance Improvement 7025 - Annual Agency Evaluation 7026 - Code of Ethics 7027 - Code of Ethics (Sample)7028 - Standards of Conduct 7028A - Care and Service Rates 7029 - Financial Incentives/Clinical Decision Making 7030 - Billing Practices 7031 - Marketing Practices 7031A - Financial Records - Maintenance of 7032 - Conflict of Interest 7033 - Conflict of Interest Disclosure Letter - Sample 7034 - Ethics Committee 7035 - Culture of Safety and Quality 7036 - Code of Conduct - Sample 7037 - Disruptive and Inappropriate Behavior 7038 - Examples of Survey Tools to Survey a Culture of Safety and Quality 7039 - Your Organization's Culture of Safety and Quality Survey 7040 - Survey Assessment Tools 7041 - Staff Rights and Ethical Dilemmas in Patient Care 7042 - Patient Safety Plan 7043 - Components of a Patient Safety Program - Patient Safety Program Checklist 7044 - Sentinel Event 7045 - Corporate Compliance Plan 7046 - The OIG Work Plan - 2013 - Home Health 7047 - Change in Ownership

SECTION 08 - MEDICATION MANAGEMENT

8001 - Medication Management - Patient Information 8002 - HHA Medication Reconciliation/Verification Form - Sample 8003 - Medication Profile Form "A" - Sample 8004 - Medication Profile Form "B" - Sample 8005 - Medication Transfer Communication 8006 - High Alert Medication Management 8007 - Look-Alike, Sound-Alike Medication Management 8008 - Selection of Medications 8009 - Safe Storage of Medications in the Patient's Home 8010 - Emergency Medications 8011 - Prescribing/Ordering - General Practices 8012 - Telephone/Verbal Orders 8013 - Physician Telephone/Verbal Orders Form 8014 - Contracted Pharmacy and On-Call Pharmacist 8015 - Medication Orders and Administration 8016 - Patient Self-Administration of Medication 8017 - Influenza and Pneumococcal Vaccine Standing Orders 8018 - Use of Investigational Treatments/Trials 8019 - First Dose Home IV Antimicrobial Administration and Management of Anaphylaxis 8020 - Medication Monitoring 8021 - Controlled Drug Disposal 8022 - Disposal of Controlled Substance Patches in the Home 8023 - Reducing Medication Errors 8024 - Medication Errors 8025 - Medication Inadvertent Incident Report Form 8026 - Performance Improvement Analysis - Medication Inadvertent Incident Form 8027 - Adverse Drug Reaction Reporting 8028 - Adverse Drug Reaction Reporting Form (Internal)8029 - Medication Management Program

SECTION 09 - PERFORMANCE IMPROVEMENT

9001 - Organizational Performance Improvement Plan 9002 - Performance Measurement 9003 - Problem Conclusion 9004 - Action Plan Monitoring 9005 - Conducting Root Cause Analysis 9006 - A Framework for a Root Cause Analysis and Action Plan in Response to a Sentinel Event 9007 - Root Cause Analysis Flowchart 9008 - Incident Reports 9009 - Incident Report Form 9010 - Home Health PI Monitoring and Evaluation Plan 9011 - Home Health PI Trending Sheet 9012 - Home Health PI Outcome Evaluation 9013 - Home Health PI Volume Measures/Statistics 9014 - Home Health Service Questionnaire Form 9015 - Incident Reporting Staff Questionnaire Form

SECTION 10 - PROVISION OF CARE, TREATMENT AND SERVICES

Admission/Assessments

10001 - Acceptance/Admission of Patients 10002 - Intake Service 10003 - Intake/Referral Form - Sample 10004 - Plan of Care (Plan of Treatment)10005 - Orders for Service Form - Sample 10006 - Initial Certification for Home Health Services - Face-to-Face Encounter 10007 - Completion of the Comprehensive Assessment 10008 - Assessment - Nursing 10009 - Nursing Assessment Form 10010 - Interdisciplinary Patient Assessments and Reassessments 10011 - Fall Assessment and Prevention 10012 - Pain Assessment, Reassessment and Management 10013 - Pain Management Education 10014 - Nutritional Assessment 10015 - Nutritional Assessment Form 10016 - Patient Abuse, Neglect or Exploitation - Training Program 10017 - Patient Abuse, Neglect or Exploitation - Adult 10018 - Patient Abuse, Neglect or Exploitation - Child 10019 - Care Planning - Home Health 10020 - Care Plan Implementation 10021 - Coordination of Patient Services 10022 - Skilled Nursing Plan of Care Form - Sample 10023 - Nursing Progress Report Form - Sample 10024 - Monthly Medical Update - Sample Form

Patient Care

10101 - Administration of Blood/Blood Components 10102 - Blood/Blood Components - Transfusion Reactions 10103 - Emergency Intervention 10104 - End-of-Life Care 10105 - Patient Identification 10106 - Scheduling Patient Visits 10107 - On-Call Coverage 10108 - Photographing Pressure Ulcers/Suspected Physical Abuse 10109 - Reporting of Critical Results of Tests and Diagnostic Procedures 10110 - Resumption of Care 10111 - Seizures - Nursing Management 10112 - RN Supervisory Visits 10113 - Licensed Practical/Vocational Nurse Supervision 10114 - LPN/LVN Supervisory Visit Note 10115 - Home Health Aide - Supervision Form

Patient/Family Education

10201 - Patient/Family Education 10202 - Multidisciplinary Patient Education 10203 - Patient/Family Education Record - Sample Form 10204 - Personal Care Instructions 10205 - Personal Care Instructions Form 10206 - Patient Education - Anticoagulation Therapy - Home Health 10207 - Patient Education - Medical Equipment 10208 - Patient and Family Education Handout - Home Safety 10209 - Patient and Family Education Handout - Hazardous Materials and Waste Disposal 10210 - Patient and Family Education Handout - Infection Prevention and Control 10211 - Patient and Family Education Handout - Use of Restraint Devices 10212 - Patient and Family Education Handout - Oxygen Safety Rules 10213 - Patient and Family Education Handout - Crutch Ambulation for Stairs - Weight Bearing as Tolerated (WBAT)10214 - Patient and Family Education Handout - Crutch Ambulation for Stairs - Non-Weight Bearing (NWB)10215 - Patient Instruction Sheet - Oxygen Cylinder Set-Up 10216 - Patient Instruction Sheet - Oxygen Concentrator 10217 - Patient Instruction Sheet - Canes and Quad Canes 10218 - Hoja de Instruccion del Paciente - Los Bastones y Los Bastones de Cuadrangulo 10219 - Patient Instruction Sheet - Walker 10220 - Hoja de Instruccion del Paciente - Andador 10221 - Patient Instruction Sheet - Bedside Commode Procedure 10222 - Hoja de Instruccion del Paciente - Procedimiento de la Comoda del Lado de la Cama

Discharge/Transfer

10301 - Discharge/Transfer/Referral of Patients 10302 - Discharge Summary 10303 - Skilled Nursing Discharge Summary Form 10304 - Discharge Summary Plan/Transfer Form 10305 - Physician Discharge Summary Form 10306 - Patient Discharge Instructions Form 10307 - Discontinuance of Service Against Medical Advice Form

SECTION 11 - RECORD OF CARE, TREATMENT AND SERVICES

11001 - Medical Record Content Policy 11002 - Entries in the Medical Record 11003 - Physician Signature Requirements 11004 - Corrections to the Paper Medical Record 11005 - Access and Maintenance of the Electronic Health Record 11006 - Late Entries to the Electronic Health Record 11007 - Addendum to the Electronic Health Record 11008 - Amendment to the Electronic Health Record 11009 - Legibility of Medical Record Documentation 11010 - Maintenance and Retention of Clinical Records 11011 - Auditing of Medical Records 11012 - Quarterly Clinical Record Review 11013 - Home Health Medical Records Audit Form 11014 - Home Health Documentation Form

SECTION 12 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

12001 - Notice of Rights 12002 - Home Care Patient Rights and Responsibilities 12003 - OASIS Privacy Act Statement Policy 12004 - OASIS Statement of Patient Privacy Rights - English (CMS)12005 - OASIS Statement of Patient Privacy Rights - Spanish (CMS)12006 - OASIS Privacy Act Statement - English (CMS)12007 - OASIS Privacy Act Statement - Spanish (CMS)12008 - OASIS Notice About Privacy for Patients Who Do Not Have Medicare or Medicaid Coverage - English (CMS)12009 - OASIS Notice About Privacy for Patients Who Do Not Have Medicare or Medicaid Coverage - Spanish (CMS)12010 - Patient Information Packet 12011 - Advance Directives 12012 - Advance Directive Information Form 12013 - Patient Information on Advance Directives 12014 - Formats for Patient Directives 12015 - Durable Power of Attorney for Healthcare 12016 - Withholding or Withdrawal of Life-Sustaining Measures 12017 - Declaration to Withdraw/Withhold Treatment 12018 - Do Not Resuscitate/Do Not Intubate (DNR/DNI)12019 - Do Not Resuscitate and/or Do Not Intubate Request Form 12020 - Patient Liability for Payment 12021 - Privacy and Confidentiality of Information 12022 - Staff Confidentiality Statement Form 12023 - Release of Patient Identifiable OASIS Information 12024 - Uses and Disclosures for Which an Authorization is Required 12025 - Consent for Uses or Disclosures to Carry Out Treatment, Payment or Healthcare Operations 12026 - Auxiliary Aids and Services for Persons with Disabilities 12027 - Patient Informed Decision Making 12028 - Authorization to Treat/Informed Consent 12029 - Patient Consents and Authorizations - Sample Form 12030 - Authorization/Agreement for Services - Sample Form 12031 - Consent to Blood/Blood Product Transfusion(s) Form 12032 - Recording/Filming Patients 12033 - Authorization and Consent Form - Recordings, Films or Other Images, and Publication 12034 - Patients with Special Communication Needs 12035 - Patient Concerns/Grievances 12036 - Patient Concerns/Grievance Process Flowchart 12037 - About the Right to Express Grievances 12038 - Patient Complaint Form

SECTION 13 - WAIVED TESTING

13001 - Waived Testing 13002 - Glucose Monitor Operator Proficiency Record Form 13003 - Glucose Monitor Quality Control 13004 - Glucose Monitor Quality Control Log 13004A - Fingerstick and Point of Care Blood Testing Devices 13005 - Referring Specimens for Laboratory Testing