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HOME HEALTH POLICY AND PROCEDURE MANUALS

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Aministrative Policies

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Patient Care Policies

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Financial Management Policies

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Personnel Policies

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Infection Control

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Emergency Disaster Plan

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Safety Management

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Outcome Based Quality Improvement Plan

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Performance Evaluations

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Job Descriptions

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ADMINISTRATIVE POLICIES LABELED (SEC 1.0) - Top

1.1	INTRODUCTION
1.2	TABLE OF ORGANIZATION
1.3	MISSION STATEMENT
1.4	PHILOSOPHY
1.5	MAINTENANCE OF POLICIES AND PROCEDURES
1.6	NON‐DISCRIMINATION/AFFIRMATIVE ACTION POLICY
1.7	GOALS AND OBJECTIVES
1.8	ACCOMMODATIONS POLICY
1.9	ORGANIZATIONAL GUIDELINES
1.10	GOVERNANCE
1.11	PUBLIC DISCLOSURE
1.12	STAFF CONFLICT OF INTEREST
1.13	STATEMENT OF PRINCIPLE RELATING TO DISCLOSURE OF CONFLICT OF INTEREST
1.13(A)	CODE OF ETHICS
1.14	COMMITTEES
1.15	PROFESSIONAL ADVISORY COMMITTEE
1.16	ANNUAL EVALUATION
1.17	STATE REGULATORY REQUIREMENTS
1.18	AGENCY SUPERVISION
1.19	PERSONNEL POLICIES
1.20	FEES-FOR-SERVICE CONTRACTS
1.21	CLINICAL RECORDS
1.22	AGENCY BUDGET
1.23	FISCAL AND STATISTICAL POLICIES
1.24	PARLIAMENTARY AUTHORITY
1.25	RATES AND SERVICES
1.26	INFORMATION MANAGEMENT SYSTEMS
1.27	LEGAL REQUIREMENTS
1.28	AGENCY ADMINISTRATION
1.29	POLICY DURING THE ABSENCE OF THE ADMINISTRATOR / DIRECTOR OF NURSING
1.30	ASSIGNMENTS AND STAFFING
1.31	PATIENT / CLIENT ACCEPTANCE / STAFF ASSIGNMENT
1.32	SUPERVISION AND EVALUATION OF STAFF
1.33	ADMINISTRATIVE RECORDS AND REPORTS
1.34	SERVICES UNDER CONTRACT
1.35	PATIENT / CLIENT GRIEVANCE PROCEDURE
1.36	DISCIPLINARY ACTIONS
1.37	EMPLOYEE SEPARATION RECORD
1.38	COMPLAINT / ACTION
1.38A	INCIDENT REPORT
1.39	RECORD POLICIES / CONFIDENTIALITY / RELEASE OF INFORMATION
1.40	PATIENT / CLIENT RIGHTS AND RESPONSIBILITIES
1.41	CLIENT BILL OF RIGHTS AND RESPONSIBILITIES
1.42	ABUSE, NEGLECT AND EXPLOITATION
1.43	CONSENT PRACTICES
1.44	REFUSAL OF CARE
1.45	DISASTER PLAN
1.46	EMERGENCY AND DISASTER PROCEDURES
1.47	PUBLIC INFORMATION
1.48	HIPAA‐PRIVACY COMPLIANCE

PATIENT CARE POLICIES LABELED(SEC 2.0) - Top

2.1	POLICIES GOVERNING THE PROVISION OF SERVICES
2.1 A	POLICIES ON THE PRONOUNCEMENT OF DEALTH BY A REGISTERED NURSE (TEXAS ONLY)
2.2	SERVICES PROVIDED
2.2A	RESEARCH PARTICIPATION
2.3	ON-CALL POLICY
2.4	SERVICE POLICIES NURSING SERVICE
2.5	GUIDELINES FOR ASSESSMENT
2.6	CARE PLAN
2.7	SERVICE POLICIES - OTHER HEALTH CARE PROFESSIONAL SERVICES
2.7A	SUBMISSION OF CLINICAL RECORDS VISIT
2.8	DELEGATION OF TASKS TO UNLICENSED PERSONNEL
2.9	REFERAL AND ACCEPTANCE OF PATIENTS / CLIENTS
2.10	CASE MANAGEMENT AND ASSIGNMENTS
2.11	STAFFING PLAN
2.12	SERVICES UNDER CONTRACT
2.13	ELIGIBILITY CRITERIA
2.14	DISCHARGE/TRANSFER POLICY
2.15	FIELD SAFETY MEASURES
2.16	NON COVERED SERVICES
2.17	MEDICAL RELATIONSHIP POLICIES
2.18	PHYSICIAN'S PLAN OF TREATMENT
2.18A	PHYSICIAN'S FACE-TO-FACE ENCOUNTER
2.19	ORDERS FROM OTHER THAN A MEDICAL DOCTOR
2.20	PHYSICIAN RESPONSIBILITIES
2.21	CASE PRIORITIZING GUIDELINES
2.22	PATIENT/CLIENT INVOLVEMENT IN CARE PLANNING
2.23	PATIENT/CLIENT NOTIFICATION OF CHANGES
2.24	CONSENT PRACTICES
2.25	REFUSAL OF CARE
2.26	PATIENT CARE GUIDELINES
2.27	CONTINGENCY PLAN
2.28	GENERAL MEDICAL CARE POLICIES
2.28A	VACCINATIONS
2.29	WOUND PHOTOGRAPHY
2.30	COORDINATION OF SERVICES
2.31	CASE CONFERENCES
2.32	SAFETY‐PATIENT / CLIENT SETTING
2.33	HOME SAFETY GUIDELINES
2.34	HOME SAFETY ASSESSMENT
2.35	PRIVACY, SECURITY, AND RESPECT OF PROPERTY
2.36	COMMUNICATION BARRIERS AND CULTURAL CONSIDERATIONS
2.37	CLINICAL RECORD CONTENTS
2.38	COPYING THE CLINICAL RECORD
2.39	FACSIMILE AND CELLULAR TRANSMISSIONS
2.40	OUTCOME AND ASSESSMENT INFORMATION SET (OASIS)
2.40A	FORMS AND DEVELOPMENT
2.41	USE OF APPROVED ABBREVIATIONS AND SYMBOLS
2.42	CLINICAL RECORD DESTRUCTION / DISPOSAL
2.43	INTERAGENCY COMMUNICATION
2.44	SKILLS COMPETENCY
2.45	SUPERVISION AND EVALUATION OF STAFF
2.46	STAFF EDUCATION POLICY
2.46A	CONTINUING EDUCATION REQUIREMENTS FOR ADMINISTRATOR / ALTERNATE ADMINISTRATOR (TEXAS ONLY)
2.47	PATIENT/CLIENT EDUCATION
2.48	HOME HEALTH AIDE SERVICE
2.49	HOME HEALTH AIDE SUPERVISORY VISITS
2.50	GUIDELINES FOR AIDE PERFORMANCE EVALUATIONS
2.51	MEDICATION ADMINISTRATION
2.52	POSSESSION OF STERILE WATER OR SALINE CERTAIN VACCINES OR TUBERCULIN AND CERTAIN DANGEROUS DRUGS
2.53	MEDICATION PROFILE
2.54	ADMINISTRATION OF MEDICATION
2.55	LABELING AND STORAGE OF MEDICATION
2.56	DRUGS APPROVED FOR ADMINISTRATION
2.57	MEDICATION ADMINISTRATION GUIDELINES
2.58	MEDICATION REFRIGERATOR
2.59	MEDICATION ERRORS
2.60	ADVERSE MEDICATION REACTION
2.61	CONTROLLED SUBSTANCES
2.62	CONSENT FOR ADMINISTRATION OF POTENTIALLY DANGEROUS OR EXPERIMENTAL DRUG
2.63	SUICIDE POLICY
2.64	EXPIRATION POLICY
2.65	CARE OF THE DYING PATIENT / CLIENT
2.66	EMERGENCY RESUSCITATION
2.67	CLIA CERTIFICATE OF WAIVER FOR GLUCOMETER TESTING
2.68	POLICY FOR WHOLE BLOOD GLUCOSE MONITORING POLICY UNDER CLIA WAIVER
2.69	OBTAINING AND TRANSPORTING LABORATORY SPECIMENS
2.69A	PROTHROMBIN TIME TESTING IN THE HOME
2.70	MECHANICAL VENTILATOR PATIENTS / CLIENTS
2.71	OTHER TREATMENTS AND TECHNIQUES
2.72	STANDING ORDERS
2.73	TELEMEDICINE
2.74	USE OF RESTRAINTS
2.74A	CHEST RESTRAINT PROCEDURES
2.75	ETHICAL ISSUES
2.76	ABUSE, NEGLECT AND EXPLOITATION
2.77	PATIENT / CLIENT SATISFACTION SURVEY
2.77A	PATIENT SATISFACTION FOR AGENCIES ADMITTING OVER 60 PATIENTS IN ONE YEAR
2.78	BAG TECHNIQUE
2.79	HAND WASHING POLICY
2.80	EQUIPMENT MANAGEMENT SERVICES
2.81	CARE OF REUSABLE AND DISPOSABLE EQUIPMENT
2.82	ADVERSE EVENTS / INCIDENTS AND UNUSUAL OCCURRENCES
2.83	DO NOT RESUSCITATE (DNR)
2.84	FOREGOING LIVE SUSTAINING MEASURES
2.85	ADVANCE DIRECTIVES
2.86	MEDICARE/MEDICAID REQUIREMENTS FOR ADVANCE DIRECTIVES

FINANCIAL MANAGEMENT POLCIES LABELED (SEC 3.0) - Top

3.1	FINANCIAL MANAGEMENT
3.2	RESPONSIBILITY FOR FINANCIAL PLANNING
3.3	BUDGET POLICY
3.4	DEVELOPMENT OF BUDGET
3.5	CAPITAL EQUIPMENT BUDGET
3.6	CAPITALIZATION, DEPRECIATION AND AMORTIZATION
3.7	CAPITALIZATION POLICY
3.8	CHART OF ACCOUNTS
3.9	CHARGE DETERMINATION
3.10	FEE SETTING AND COLLECTION POLICY
3.11	FINANCIAL ELIGIBILITY CRITERIA
3.12	INSURANCE CASES AND PRIVATE PAY
3.13	REDUCED AND NO-FEE SERVICES
3.14	BILLING FOR SERVICE
3.15	INVENTORY/FIXED ASSESTS
3.16	INSURANCE AND BONDING
3.17	FINANCIAL MONITORING
3.18	REVIEW OF FINANCIAL AND BUDGET REPORTS
3.19	REIMBURSEMENT FOR SERVICES
3.20	PROCEDURE TO ENSURE ACCURATE BILLING AND INSURANCE CLAIMS
3.21	NON‐COVERAGE OF SERVICES
3.22	PAYMENT RECEIPT AND VERIFICATION
3.23	BILLING, PAYROLL AND INVOICE INPUT
3.24	REVIEW AND COLLECTION OF ACCOUNTS RECEIVABLE
3.25	ACCOUNTS RECEIVABLE RECONCILIATION
3.26	FEE SETTING AND COLLECTION POLICY
3.27	REFUNDS
3.28	INSURANCE AND BONDING
3.29	DENIED CLAIMS
3.30	COMPUTER FILES BACKUP
3.31	PURCHASING
3.32	PETTY CASH

PERSONNEL POLICIES LABELED SEC 4.0) - Top

4.1	WELCOME TO OUR HOME HEALTH AGENCY
4.2	MISSION
4.3	PHILOSOPHY
4.4	EQUAL OPPORTUNITY
4.5	SEXUAL HARASSMENT
4.6	PERSONNEL POLICIES
4.7	GENERAL STATEMENTS
4.8	ORIENTATION ‐ STAFF
4.9	SCREENING AND HIRING
4.10	CRIMINAL HISTORY CHECK
4.11	REASONABLE ACCOMMODATIONS FOR HANDICAPPED EMPLOYEES
4.12	EMPLOYEE QUALIFICATIONS
4.13	PERSONNEL RECORDS
4.14	ORIENTATION OF NEW HOME CARE STAFF
4.15	ORIENTATION
4.16	HOURS OF OPERATION
4.17	PAYDAYS
4.18	TRANSPORTATION
4.19	RECEIVING GIFTS/MONEY FROM PATIENTS
4.20	WORKING CONDITIONS/EMPLOYEE SAFETY
4.21	SITUATIONS INVOLVING GUNS IN THE HOME
4.22	GARNISHES AND WAGE ASSIGNMENTS
4.23	TOBACCO‐FREE WORK PLACE
4.24	ALCOHOL AND DRUG‐FREE WORK PLACE
4.25	CITIZENSHIP
4.26	DEMOTIONS
4.27	RESIGNATIONS
4.28	TERMINATIONS / DISCIPLINARY ACTIONS
4.29	REHIRES
4.30	PROFESSIONAL RESPONSIBILITIES
4.31	SUPERVISION
4.32	EVALUATION OF SUPERVISORY FUNCTIONS
4.33	EVALUATIONS
4.34	EXIT INTERVIEWS
4.35	STAFF RIGHTS
4.36	GRIEVANCE PROCEDURES
4.37	CLIENT GRIEVANCE POLICY
4.38	PAYROLL PROCEDURES
4.39	OVERTIME
4.40	LUNCH BREAKS
4.41	ATTENDANCE
4.42	CONFERENCE AND TRAVEL EXPENSES
4.43	EMPLOYEE BENEFITS
4.44	EMPLOYEE SUGGESTIONS
4.45	SALARY PLAN
4.46	TRANSPORTATION REIMBURSEMENT
4.47	STAFF DEVELOPMENT
4.48	HOME HEALTH AIDE TESTING AND COMPETENCY
4.49	CONDUCT AND CONFIDENTIALITY
4.50	ACCIDENTS AND INJURIES
4.51	OPTIONAL BACK BRACE POLICY
4.52	EMERGENCIES AND DISASTERS
4.53	SOLICITATION AND DISTRIBUTION OF LITERATURE
4.54	FIELD EMPLOYEE STANDARDS AND PROCEDURES
4.55	CONFIDENTIALITY AND NON‐COMPETITION AGREEMENT
4.56	EMPLOYEE POLICIES AND PROCEDURES
4.57	CRIMINAL HISTORY AFFIDAVIT
4.58	PERSONAL PROTECTIVE EQUIPMENT FOR SAFETY AND INFECTION CONTROL
4.59	ACKNOWLEDGMENT

INFECTION CONTROL (LABELED (SEC 5.0) - Top

5.1	OSHA REGULATIONS/INFECTION CONTROL/EXPOSURE CONTROL PLAN
5.2	DEFINITIONS5.3 EXPOSURE CONTROL PLAN
5.3	INFECTION CONTROL EDUCATION/TRAINING
5.4	INFECTION CONTROL TRAINING OUTLINE
5.5	STANDARD PRECAUTIONS FOR ALL HEALTH CARE WORKERS
5.6	GUIDELINES FOR PATIENTS KNOWN TO BE HIV‐POSITIVE
5.7A	CONTROL OF ANTIBIOTIC RESISTANT (MRSA) AND (VRE) ORGANISMS IN HOME SETTINGS
5.8	GUIDELINES FOR EMPLOYEES KNOWN TO BE HBV INFECTED
5.9	EMPLOYEE HEALTH REQUIREMENTS/HEPATITIS B VACCINATION
5.10	HEPATITIS B FACT SHEET
5.11	INFORMATION ON VOLUNTARY AUTHORIZATION FOR THE ADMINISTRATION OF HEPATITIS B VACCINE
5.12	HEPATITIS B VACCINE DECLINATION
5.13	POST EXPOSURE EVALUATION AND FOLLOW‐UP PROCEDURES
5.14	CONSENT FOR HIV ANTIBODY BLOOD TEST AND RELEASE OF INFORMATION
5.15	POST OCCUPATIONAL EXPOSURE TO BLOOD BORNE PATHOGEN EVALUATION
5.16	EMPLOYEE EXPOSURE INCIDENT
5.17	REFERRAL FOR EVALUATION
5.18	EMPLOYEE EXPOSURE TO AN INFECTIOUS DISEASE
5.19	HIGH RISK EMPLOYEES
5.20	EXPOSURE DETERMINATION
5.21	DISEASES USUALLY CONSIDERED REPORTABLE
5.22	MEDICAL LABORATORY SERVICES
5.23	EMPLOYEE PROTECTIVE EQUIPMENT
5.24	DISPOSAL OF NEEDLES, SYRINGES AND SHARP ITEMS
5.25	HAZARDOUS WASTE DISPOSAL
5.26	RESPIRATORY PROTECTION PLAN
5.27	TB PROTOCOL FOR QUALITATIVE FIT TEST

EMERGENCY DISASTER PLAN (LABELED (SEC 6.0) - Top

6.1	EMERGENCY PREPAREDNESS
6.2	TYPES OF EMERGENCIES
6.3	TYPES OF DISASTERS
6.4	EMERGENCY AND DISASTER PROCEDURES
6.5	HURRICANES
6.6	SPECIFIC PROCEDURES REGARDING HURRICANES
6.7	FIRE IN THE BUILDING
6.8	BOMB THREAT
6.9	VERBALLY/PHYSICALLY ABUSIVE STAFF/VISITOR
6.10	SITUATIONS INVOLVING GUNS IN THE HOME
6.11	HAZARDOUS MATERIAL INCIDENT
6.12	TRANSPORTATION EMERGENCY
6.13	EMERGENCY POLICY
6.14	ABUSE AND NEGLECT
6.15	EPIDEMICS
6.16	TORNADOES
6.17	FLASH FLOODS
6.18	EARTHQUAKES
6.19	SEVERE WEATHER
6.20	CASE PRIORITIZING GUIDELINES
6.21	EMERGENCY MANAGEMENT PLANNING CRITERIA FORHOME HEALTH AGENCIES

SAFETY MANAGEMENTLABELED 7.0 - Top

7.1	INTRODUCTION
7.2	FUND LOSS CONTROL PROGRAM PROCEDURES
7.3	VOLUNTARY OSHA GUIDELINES FOR HEALTH CARE WORKER SAFETY PROGRAM MANAGEMENT
7.4	SAFETY POLICY
7.5	SAFETY COMMITTEE
7.6	SAFETY RESPONSIBILITIES
7.7	EMPLOYEE SAFETY RESPONSIBILITIES
7.8	EMPLOYEE SAFETY EDUCATION
7.9	NEW EMPLOYEE HIRING PRACTICES
7.10	PERSONNEL SAFETY
7.11	EQUIPMENT AND SUPPLIES
7.12	EMPLOYEE ORIENTATION AND TRAINING
7.13	FIRE SAFETY PLAN: ADMINISTRATIVE AND OFFICE STAFF
7.14	FIRE DRILLS
7.15	FIRE DRILL EVALUATION
7.16	HOME FIRE SAFETY PLAN
7.17	GENERAL INFORMATION ON FIRES
7.18	ACTIONS IN CASE OF FIRE
7.19	MEDICAL DEVICE/SAFETY HAZARDOUS DEVICE REPORTING
7.20	EMPLOYEE SAFETY CHECKLIST
7.21	ACCIDENT INVESTIGATION PROCEDURES
7.22	OCCUPATIONAL INJURY/ILLNESS REPORTING
7.23	INJURY REPORTING PROCEDURES
7.24	GENERAL & DEPARTMENTAL SAFETY RULES
7.25	SAFETY RULES
7.26	HOW TO PREVENT ACCIDENTS

OUTCOME BASED QUALITY IMPROVEMENT PLAN
(LABELED SEC 8.0) - Top

8.1	SCOPE OF SERVICES
8.2	OBJECTIVES OF OUTCOME BASED QUALITY IMPROVEMENT (OBQI)
8.3	ACTIVITIES FOR MONITORING AND EVALUATION
8.4	RESPONSIBILITY
8.5	COMMITTEE RESPONSIBILITIES
8.6	OUTCOME BASED QUALITY IMPROVEMENT INITIATIVES
8.7	OUTCOME BASED QUALITY IMPROVEMENT PHILOSOPHY
8.8	RESOLUTION OF IDENTIFIED PROBLEMS
8.9	ACTIONS FOR PROBLEM RESOLUTION AND IMPROVEMENT OF CARE
8.10	CONFIDENTIALITY
8.11	COLLECTION AND ORGANIZATION OF DATA
8.12	EVALUATION OF FINDINGS AND IMPROVING PERFORMANCE
8.13	ASSESSMENT OF EFFECTIVENESS OF ACTIONS
8.14	PRIORITIZING QUALITY IMPROVEMENT ACTIVITIES
8.15	ACTION PLAN
8.16	ASSESSING EFFECTIVENESS
8.17	REPORTING OF INFORMATION
8.18	QUALITY CONTROL
8.19	IMPROVEMENT SCHEDULE/TIMETABLE
8.20	CASE CONFERENCES
8.21	CONTINUING REVIEW
8.22	CLINICAL RECORD REVIEW
8.23	RECORD REVIEW PROCEDURES
8.24	REVIEW OF RECORDS REQUESTED BY PEER REVIEW
8.25	PATIENT EDUCATION GUIDELINES
8.26	INTERMEDIARY REQUESTS FOR INFORMATION/DENIAL NOTIFICATION
8.27	ROLE OF THE QUALITY IMPROVEMENT TEAM ININFECTION CONTROL
8.28	RISK MANAGEMENT
8.29	ANNUAL PROGRAM EVALUATION
8.30	OUTCOME BASED QUALITY IMPROVEMENT INDICATORS

PERFORMANCE EVALUATIONS - Top

CHIEF EXECUTIVE OFFICER

CHIEF FINANCIAL OFFICER

MEDICAL DIRECTOR

ADMINISTRATOR

ALTERNATE ADMINISTRATOR

ADMINISTRATOR/DIRECTOR OF NURSING

ALTERNATE ADMINISTRATOR/ALTERNATE DIRECTOR OF NURSING

DIRECTOR OF NURSING

ALTERNATE DIRECTOR OF NURSING

DIRECTOR OF HUMAN RESOURCES

QUALITY IMPROVEMENT MANAGER

COMMUNITY HEALTH REGISTERED NURSE

COMMUNITY HEALTH PEDIATRIC REGISTERED NURSE

PSYCHIATRIC REGISTERED NURSE

REGISTERED NURSE HI‐TECH DIVISION

NURSING SUPERVISOR

LICENSED PRACTICAL/VOCATIONAL NURSE

MEDICAL SOCIAL WORKER

MEDICAL SOCIAL WORK ASSISTANT

REGISTERED PHYSICAL THERAPIST

PHYSICAL THERAPY ASSISTANT

OCCUPATIONAL THERAPIST

OCCUPATIONAL THERAPY ASSISTANT

SPEECH PATHOLOGIST/AUDIOLOGIST

NUTRITIONIST

HOMEMAKER (Level)

PERSONAL CARE WORKER

HOME HEALTH AIDE

STAFFING COORDINATOR

MEDICAL RECORDS MANAGER

OFFICE COORDINATOR

PAYROLL/BILLING/RECEIVABLES MANAGER

OFFICE MANAGER

BUSINESS/CLERICAL STAFF CLERK COORDINATOR

UNLICENSED INTAKE COORDINATOR COMMUNITY LIAISON

RECEPTIONIST

DATA ENTRY OPERATOR

COURIER/CLERK

JOB DESCRIPTIONS - Top

JOB ACCEPTANCE STATEMENT

CHIEF EXECUTIVE OFFICER

CHIEF FINANCIAL OFFICER

MEDICAL DIRECTOR

ADMINISTRATOR

ALTERNATE ADMINISTRATOR

ADMINISTRATOR/DIRECTOR OF NURSING

ALTERNATE ADMINISTRATOR/DIRECTOR OF NURSING

DIRECTOR OF NURSING

ALTERNATE DIRECTOR OF NURSING

DIRECTOR OF HUMAN RESOURCES

QUALITY IMPROVEMENT MANAGER

COMMUNITY HEALTH REGISTERED NURSE

COMMUNITY HEALTH PEDIATRIC REGISTERED NURSE

PSYCHIATRIC REGISTERED NURSE

REGISTERED NURSE HI‐TECH DIVISION

NURSING SUPERVISOR

LICENSED PRACTICAL/VOCATIONAL NURSE

MEDICAL SOCIAL WORKER

MEDICAL SOCIAL WORK ASSISTANT

REGISTERED PHYSICAL THERAPIST

PHYSICAL THERAPY ASSISTANT

OCCUPATIONAL THERAPIST

OCCUPATIONAL THERAPY ASSISTANT

SPEECH PATHOLOGIST/AUDIOLOGIST

NUTRITIONIST

PERSONAL CARE WORKER

HOME HEALTH AIDE STAFFING

COORDINATOR MEDICAL

RECORDS MANAGER OFFICE COORDINATOR

PAYROLL/BILLING/RECEIVABLES CLERK

OFFICE MANAGER

BUSINESS/CLERICAL STAFF

CLERK COORDINATOR

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