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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Table of Contents - TJC Standards, CMS RegulationsTable of Contents - ACHC Standards, CMS RegulationsTable of Contents - CHAP Standards, CMS RegulationsCopyrightDisclaimerApproval/Signature SheetIntroduction
SECTION 04 - HUMAN RESOURCES
4001 - Staffing - General4002 - Qualifications and Competency - HHA4003 - Licensure, Certification and Registration Verification and Control Systems4004 - Criminal Background Checks4005 - Criminal Background Check Release of Information Authorization Form - Sample4006 - Reference Checking4007 - Physician Licensure Verification4008 - Orientation Program4009 - Orientation - Certified Home Health Aide Services4010 - Performance Evaluations4011 - Employee Education Programs4012 - Continuing Education/Inservice Attendance Record Form4013 - Monitoring of CHHA and CNA Inservice Hours4014 - Position Description/Performance Evaluation - Home Health Administrator4015 - Annual Competency Clinical Skills Assessment - Home Health Administrator4016 - Position Description/Performance Evaluation - Home Health Patient Care Services Director4017 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Patient Care Services Director4018 - Annual Competency Clinical Skills Assessment - Home Health Patient Care Services Director4019 - Position Description/Performance Evaluation - Home Health Intake Nurse4020 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Intake Nurse4021 - Annual Competency Clinical Skills Assessment - Home Health Intake Nurse4022 - Position Description/Performance Evaluation - Home Health Clinical Supervisor4023 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Clinical Supervisor4024 - Annual Competency Clinical Skills Assessment - Home Health Clinical Supervisor4025 - Position Description/Performance Evaluation - Home Health Case Manager4026 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Case Manager4027 - Annual Competency Clinical Skills Assessment - Home Health Case Manager4027A - Position Description/Performance Evaluation - Home Health RN4027B - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health RN4027C - Annual Competency Clinical Skills Assessment - Home Health RN4028 - Position Description/Performance Evaluation - Home Health LPN/LVN4029 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health LPN/LVN4030 - Annual Competency Clinical Skills Assessment - Home Health LPN/LVN4031 - Position Description/Performance Evaluation - Home Health Physical Therapist4032 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Physical Therapist4033 - Annual Competency Clinical Skills Assessment - Home Health Physical Therapist4034 - Position Description/Performance Evaluation - Home Health Occupational Therapist4035 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Occupational Therapist4036 - Annual Competency Clinical Skills Assessment - Home Health Occupational Therapist4037 - Position Description/Performance Evaluation - Home Health Speech-Language Pathologist4038 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Speech-Language Pathologist4039 - Annual Competency Clinical Skills Assessment - Home Health Speech-Language Pathologist4040 - Position Description/Performance Evaluation - Home Health Medical Social Worker4041 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Medical Social Worker4042 - Annual Competency Clinical Skills Assessment - Home Health Medical Social Worker4043 - Position Description/Performance Evaluation - Home Health Aide4044 - Performance Evaluation - Population-Specific/Age-Related Competency - Home Health Aide4045 - Annual Competency Clinical Skills Assessment - Home Health Aide4046 - Annual Competency - Joint Commission National Patient Safety Goals - Home Health/Hospice4047 - Employment of Certified Home Health Aides/Nursing Assistants4048 - Home Health Aide Training4049 - Certified Home Health Aide - Competency4050 - Certified Home Health Aide Competency Evaluation Program4051 - Certified Home Health Aide Competency Checklist Form4052 - Certified Home Health Aide Supervision4053 - Supervision Checklist Form4054 - Equal Opportunity Employment4055 - Applications for Employment4056 - Attendance and Tardiness4057 - Change in Personal Information4058 - Classification of Employees4059 - Disciplinary Action4060 - Dress Regulations4061 - Employee Assistance Program4062 - Employee Communications4063 - Employee Handbook4064 - Employee Requests for Time Off4065 - Employment of Foreign Applicants4066 - Employment of the Disabled4067 - Employment of Relatives4068 - Exit Interviews4069 - Exit Interview Form - Sample4070 - Garnishment of Wages4071 - Holiday Policy4072 - Payroll Distribution/Time Verification4073 - Personnel Files - Contents and Originations4074 - Procurement of Employees4075 - Personnel Requisition Form - Sample4076 - Re-Employment4077 - Sick Leave Policy4078 - Termination of Employment4079 - Staff Recruitment, Retention and Education4080 - Vacation Policy4081 - Workers' Compensation
SECTION 05 - INFECTION PREVENTION AND CONTROL
5001 - Infection Prevention and Control Program - Home Health5002 - Infection Prevention and Control Plan - Home Health5003 - Infection Prevention and Control Committee5004 - Infection Report Form5005 - Infection Surveillance Sheet5006 - Patient Infection Control Log Form5007 - Summary of Monthly Infection Control Data Form5008 - Reporting Patient Infections5009 - Nationally Notifiable Infectious Diseases5010 - Standard Precautions5011 - Hand Hygiene - CDC Guidelines5012 - Hand Hygiene/Glove Use Observation Form5013 - Respiratory Hygiene/Cough Etiquette in Healthcare Settings5014 - Transmission-Based Precautions (Isolation Precautions)5015 - Aseptic Practices5016 - Nursing Bag Techniques5017 - Personal Protective Equipment5018 - Personal Protective Equipment - Training5019 - Management of Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings5020 - AIDS/HIV Positive Guidelines5021 - Guidelines for Prevention of Tuberculosis Transmission in the Home5022 - Tuberculosis Training Program Outlines5023 - Influenza Vaccination - Home Health5024 - Influenza Immunization Program for Healthcare Staff - Monthly Implementation Checklist5025 - Influenza Vaccination Program for Healthcare Staff5026 - HHA Plan and Response to a Potential or Actual Influenza Pandemic Outbreak5027 - Pandemic Risk Assessment Tool for Home Care Organizations5028 - CDC - Home Healthcare Services Pandemic Influenza Planning Checklist5029 - Exposure Control Plan5030 - Sharps Injury Protection Plan5031 - Sharps Injury Log Form5032 - Employee Exposure to Blood and Body Fluids - Sample Form5033 - Infectious Waste Management Plan
SECTION 07 - LEADERSHIP
7001 - CMS Definitions7002 - Organization and Structure7003 - Governance - Board of Directors/Management Company7004 - Governance - Sole Proprietorship7005 - Professional Advisory Committee7006 - Organization Chart - Example7007 - Licensure7008 - Mission Statement7009 - Philosophy7010 - Non-Discrimination Policy7011 - Compliance with Federal, State and Local Laws7012 - Fiscal Planning7013 - Annual Operating Budget7014 - Communication Process - Staff, Patients and Community7015 - Agency Supervision7016 - Supervision of Care, Treatment and Services7017 - Supervising Physician or Registered Nurse7018 - Guidelines for Medical Management and Physician's Responsibilities7019 - Scope of Services7020 - Professional Standards and Principles7021 - Staff Under Hourly or Per Visit Contracts7022 - Contracted Services7023 - Policies and Procedures7024 - Role of HHA Leadership in Performance Improvement7025 - Annual Agency Evaluation7026 - Code of Ethics7027 - Code of Ethics (Sample)7028 - Standards of Conduct7028A - Care and Service Rates7029 - Financial Incentives/Clinical Decision Making7030 - Billing Practices7031 - Marketing Practices7031A - Financial Records - Maintenance of7032 - Conflict of Interest7033 - Conflict of Interest Disclosure Letter - Sample7034 - Ethics Committee7035 - Culture of Safety and Quality7036 - Code of Conduct - Sample7037 - Disruptive and Inappropriate Behavior7038 - Examples of Survey Tools to Survey a Culture of Safety and Quality7039 - Your Organization's Culture of Safety and Quality Survey7040 - Survey Assessment Tools7041 - Staff Rights and Ethical Dilemmas in Patient Care7042 - Patient Safety Plan7043 - Components of a Patient Safety Program - Patient Safety Program Checklist7044 - Sentinel Event7045 - Corporate Compliance Plan7046 - The OIG Work Plan - 2013 - Home Health7047 - Change in Ownership
SECTION 10 - PROVISION OF CARE, TREATMENT AND SERVICES
SECTION 12 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL
12001 - Notice of Rights12002 - Home Care Patient Rights and Responsibilities12003 - OASIS Privacy Act Statement Policy12004 - 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)12009A - CMS Home Health Beneficiary Notices - Home Health Change of Care Notice and Advance Beneficiary Notice of Noncoverage (ABN)12010 - Patient Information Packet12011 - Advance Directives12012 - Advance Directive Information Form12013 - Patient Information on Advance Directives12014 - Formats for Patient Directives12015 - Durable Power of Attorney for Healthcare12016 - Withholding or Withdrawal of Life-Sustaining Measures12017 - Declaration to Withdraw/Withhold Treatment12018 - Do Not Resuscitate/Do Not Intubate (DNR/DNI)12019 - Do Not Resuscitate and/or Do Not Intubate Request Form12020 - Patient Liability for Payment12021 - Privacy and Confidentiality of Information12022 - Staff Confidentiality Statement Form12023 - Release of Patient Identifiable OASIS Information12024 - Uses and Disclosures for Which an Authorization is Required12025 - Consent for Uses or Disclosures to Carry Out Treatment, Payment or Healthcare Operations12026 - Auxiliary Aids and Services for Persons with Disabilities12027 - Patient Informed Decision Making12028 - Authorization to Treat/Informed Consent12029 - Patient Consents and Authorizations - Sample Form12030 - Authorization/Agreement for Services - Sample Form12031 - Consent to Blood/Blood Product Transfusion(s) Form12032 - Recording/Filming Patients12033 - Authorization and Consent Form - Recordings, Films or Other Images, and Publication12034 - Patients with Special Communication Needs12035 - Patient Concerns/Grievances12036 - Patient Concerns/Grievance Process Flowchart12037 - About the Right to Express Grievances12038 - Patient Complaint Form